Category Archives: single payer

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Bolster meaning

It did not even occur to me that yesterday’s dream could be taken as complaints about patients! That was not my meaning!

I wrote the dream out because I wanted to know what it was trying to tell me. And I look at it from the perspective of all the people in the dream being aspects of myself.

So who is the whiny guy (me) who won’t cooperate with authority (me) and who wants attention and is difficult? That’s not a very nice aspect of myself!

First of all, he reminds me of my father. My father really did not like authority and did not like most men. When I was quite small, I announced that he would have to die first, because he couldn’t live without my mother, but she could live without him. I was wrong as well as being an awkward child. My father’s dislike of authority interfered with his employment and he was mostly underemployed. He finished a Master’s in Mathematics, but never wrote the thesis for his PhD. I asked him why once and he said, “I was bored.” I don’t know how much alcohol interfered with his working.

I am not brilliant with authority either, though I am trying. I notice systems and often annoy authority by asking why something is run a certain (foolish and unproductive) way. I used to study whatever system I was in and then say, “Here, I’ve thought up a solution for this problem.” Then I would get in trouble for suggesting that there was a problem and I would be the problem. I learned to go to authority first and ask, “So is this (huge problem) a problem? I find it difficult. What is your advice?” Priming the pump, so to speak.

As a temp, the authority problem is weirder. I am an outsider, short term, no one really has to be nice to me. That fast trip home and back made me realize that I am lonelier in a group clinic than I was in a solo clinic. In my solo clinic there was me, my receptionist and the patients. In this group clinic I have less people to talk to and it is lonely. My problem, not theirs. They are about to move me to another clinic and I will see what approach I can take to this. The system might have a Balint Group or I may be able to start one.

What about the frozen looking spouse? Ha, I think that’s the part of me that is trying to keep my mouth shut with authority. The kids? Some days I want to pull the system apart and fix it, but I am not in authority to do that here. The grumpy nurse? I am running behind and I can’t fix everyone. Some people don’t want to be fixed, including me.

I could go home and try another place. However, I think that the cracks in the US medical system are in the whole system. As a country, we built this. I hope that I see single payer healthcare in my lifetime, but I may not. And Martha is right too: I thought that this place was doing better handling a chronic illness than where I worked in 2021, but they aren’t, really. They apply a formula, but the patients don’t get much out of it. They just get shuffled in once every three months. I did upset that apple cart by spending more time with those people and talking to them, but I do not know what the next physician will do. Sigh. The patients are already my patients and are saying goodbye.

For the Ragtag Daily Prompt: meaning.

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Staying the course

Have you ever started talking to someone, only to find out that they throw amazing accusations and lies at you? I have had a patient say “You are FORCING me to use heroin.” It’s a bit disconcerting.

Imagine this in a debate. I can leave the room and end things in clinic. I can ignore family members that tell made up stories about me over and over. They want to believe what they want to believe. They don’t fact check. Aren’t you glad I don’t do that with people in clinic? Make stuff up? I don’t want a doctor who does that nor a president.

I don’t find it “presidential” to spend an hour and a half snarling lies, false blame and accusations. That is not leadership.

I am not voting for the biggest liar on the block.

For the Ragtag Daily Prompt: serenity.

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Hi ho, hi ho

This is zoomed in to the Colorado National Monument in the early morning. The light and shadows are wonderfully dramatic and change by the minute.

I won’t trudge to work today. I was mildly sick the last two days and am better today, so I am happy to go. Hoorah for feeling better.

For the Ragtag Daily Prompt: trudge.

And two songs from The Yes Yes Boys, 2004, here.

I do just what I please:

Make it easy:

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Double standard: AI technology can take jobs but improving healthcare can’t

The United States could go to single payer healthcare, but one objection has been “People will lose their jobs with health insurance companies.” Yet no one seems to object to AI, Artificial Intelligence taking jobs. It’s technology so it’s fine! The wave of the future! Coming whether we like it or not!

One form of single payer healthcare is medicare for all. Expand medicare so that it covers everyone. At first, it only covered retired female teachers. Women were only considered for teaching jobs if they were single. A married woman was expected to work in the home. The teaching pay was low. Men were expected to be supporting a family, so they got more. Women were often supporting parents or children if spouses died or divorced or abandoned a family or were disabled. Early census information was a finagle: any male in the household was listed as “head” even if it was an elderly disabled father or a boarder or a teen. So the true numbers of women as head of households were obscured.

Single payer would improve healthcare. There would be ONE set of rules. Physicians would know if something was covered. Right now there are over 500 health insurance companies and they each have multiple different policies. Not only that, but the policies can change monthly in what they cover. Did you know that? I would get monthly postcards from multiple companies saying that I could go on line to one of the 500 different websites and see what they had changed and were no longer covering. I found little time to learn 500 websites. We spend enormous amounts of healthcare money on communication back and forth from insurance companies to hospitals and clinics. Trying to prior authorize CT scans, MRIs, surgeries, referrals, medications (even old cheap ones!) and then attempting to get the health insurance companies to pay for the care. Remember that the insurance companies are allowed a 20% profit: so for 1 million dollars of healthcare money, $200,000 can go to profit. The people and computer work is not in that profit, so what percentage of your healthcare dollar goes to attempting to prior authorize and get paid? How much of your healthcare dollar would you like to go to healthcare?

Medicare’s overhead is either 1.4% or 6%, instead of that 20% profit and the prior auth/collection effort. There are two different estimates (from here):

1. There are two different measures of Medicare’s administrative costs. One figure comes from the Medicare Board of Trustees’ annual report, while the other comes from CMS’ National Health Expenditure Accounts. According to the latest trustees’ report, Medicare’s overhead represented 1.4 percent of its total expenditures. According to the latest NHEA, Medicare’s overheard was 6 percent of expenditures.

2. The discrepancy between the two figures is due to Medicare Parts C and D. Mr. Sullivan wrote that the difference between the trustees’ measure of overhead and the NHEA measure β€œis due almost entirely to the fact” that the NHEA figure includes administrative expenses incurred by health insurers that participate in Medicare Advantage (Part C) and Medicare’s prescription drug program (Part D). In essence, the overhead associated with the private insurers involved with Medicare raise the program’s overhead by almost 5 percent, or $24 billion in 2010.

People worry about “socialized medicine” but really, the closest system to socialized medicine is the Veterans Administration. I don’t think anyone wants to take their healthcare away, and some of it is specialized depending on where they were deployed and what they were exposed to. I saw veterans in my clinic because we were more than 30 miles by car from a VA hospital.

What about medicare fraud? I saw way more fraud with the insurance companies. Companies will maximize revenue by sending equipment at the exact interval insurance allows (like sleep apnea equipment and diabetes glucometers). It doesn’t matter to them if it’s being used or not. After my father died, there were 16 full oxygen tanks full in his house. The company was happy to pick them up and no, they did not want to reimburse the payments. A biller told me that often the health insurance companies will pay less then the contracted amount. When challenged, they say, “Oh, that was a computer error! We will fix that!” She said, “I have never once seen the error in the physician’s favor.” When I had cobra insurance, they would not pay my bills and I had to call them every single time to force them to pay. It took enormous amounts of time and again they claimed, “Oh, computer error!” I finally called their counseling line and said, “I want to be counseled for your company refusing to call me back and screwing over this cobra policy, and by the way, I have a family member dying of cancer.” That finally made them fix it.

WHY is our culture ok with technology taking jobs, while improving healthcare can’t? Get rid of the health insurance companies! Medicare for all! If we all had secure health insurance, think of the work innovation in our country!

For the Ragtag Daily Prompt: finagle.

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Not immune

I am attending multiple Zoom conferences on Long Covid and Chronic Fatigue and PANS/PANDAS and fibromyalgia. The speakers are talking hard science, digging in to the immune system to figure out what is wrong. Then they can find a drug to fix it.

Maybe it doesn’t need to be fixed. I think the immune system is smarter than we are and it knows that Covid-19 is a really really bad virus. What the immune system wants is to keep from getting any other infections so it shuts us down. It hits the chronic fatigue button, so we stay home or in bed. It hits the fibromyalgia button so that it hurts to move: we stay home or in bed. It hits the PANS button so that antibodies seriously change our behavior and we stay home or in bed. Anyone see a theme here? I think that the immune “over-response” is not an over-response. It’s not broken. It is trying to reduce exposure and just maybe we should pay attention. I thought that in residency, in the early 1990s, when chronic fatigue patients would interview me to see if I “believed” in chronic fatigue. Heck yeah, I said, but I don’t know what it is or how to fix it. My chronic fatigue patients had something in common: they were all either working 12-14 hour days continuously when they crashed, or they overworked and had insane stress, deaths of loved ones, car wrecks, accused of a crime, something horrible. The workers all wanted “to get back to where I was.” I would ask, “You want to work 12-14 hours a day again?” “Yes!” they’d say, “I want to be just like I was in the past!” “Um, but that’s what crashed you. Do you think maybe your body is not up to that?” “FIX ME.” I would try to improve things, but fix them back to what crashed them? No way and anyhow, that is not really sane.

There are some levels of illness where we have to intervene. In really bad PANDAS, antibodies to the brain are followed by macrophages that destroy brain cells. I was horrified and wanted to run around screaming “NOT MY BRAIN!” when I heard that. Then I thought, don’t be silly, I am in my 60s and if I had brain eating cells it would have happened by now. I consider myself really really lucky to have the mildest version. At least, that’s what it seems to be. (Officially we don’t believe in PANS or PANDAS in adults in the US but we do in Europe and Canada. Ironic.) With that version, especially in children, I am all for intervention, as soon as possible. And it’s not that I do not think we should intervene in these illnesses. I just think we need to step back and think a little and just maybe listen to our bodies and listen to the immune system. Slow down. Breathe. Watch some stupid cat videos. Whatever makes you relax and laugh. Reduce stress. Limit stupid hyper news to 15 minutes a day and not before bed, ok? Reduce the drama.

I am liking movies less and less. The drama bugs and bores me. I might last an hour. I have nearly quit going to our downtown movie house because it’s always “moving” and art films. Bleagh, drama. Also when it’s about illness or addiction, I want to argue with it. Easy lying endings which are nothing like reality. I like cartoons and sometimes superheroines, but it’s all drama too. I am tired of people behaving badly and don’t want to watch it on tv or a movie. There’s enough for me in the real world. I think it’s time to bring back musicals. I would watch them. Maybe. My father’s last movie was Blazing Saddles. He refused to ever go to another movie. I think I understand that now.

None of us are immune to stress or immune to infection. A person might be immune to Covid-19, or they might be immune until the tenth or hundredth strain shows up. I chose Family Practice for my specialty because I wanted to have children and be able to see them. I thought about Obstetrics-Gynecology or General Surgery, because I loved babies and loved surgery, but the Ob-Gyn residency was 4 years and General Surgery was 7 years and I was starting medical school five years out of college. Choose the more flexible and portable specialty and go rural.

Doctors and nurses are burning out because hospitals and administrators “maximize production”. Hospitals and administrators are stupid and destroying medicine. It’s not about money, it’s about helping people and science and healing. Having it be about money is soul-destroying and causes moral injury to any ethical provider. If we’d prefer unethical ones, keep on the present path. Otherwise we need single payer health care so that any physician or nurse can take care of whoever shows up. The system is breaking down more and more and it is hard to watch. Another nail of stress in the coffin of ethical medicine. I suppose when enough people die, change will come.

My working theory is that anyone can get one of these immune system illnesses: chronic fatigue, fibromyalgia, PANS/PANDAS and so forth. Medicine says that Hashimoto’s Thyroiditis, antibodies to the thyroid is the most common autoimmune disorder, but that may change. The evidence is mounting that Long Covid and these other “vague” illnesses are immune system shifts. Immune systems in “Code Red”, let’s not catch anything else. Are they an illness or are they our immune system trying to keep us quiet to protect us? I think the latter. Time may tell. I am listening to the science and listening to my body, both.

The photographs are from 2016, when a flock appeared in my yard. They demanded money to be moved to the next house.

For the Ragtag Daily Prompt: fiddlesticks. Oh, fiddlesticks, we have to figure out the very very complicated immune system. Or listen to it.

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Rebel in clinic

Right before my hospital district informed me that they no longer wanted my services, I was rebelling. The fight from my perspective, was over good patient care. They had set a quota. 18 patients a day. One every 20 minutes and one 40 minute visit. 8 am to noon and 1 pm to 5. I argued and argued and argued. I knew finishing the note in the room took me 25 minutes on the hateful electronic medical record and I had averaged 16 patients a day my whole career. I was not fast but I was super thorough and had just gotten an excellent report on a chart review and had been told that I was a great diagnostician. Which was mostly due to my nearly OCD thoroughness. I was not diplomatic with the hospital administration.

One day I was feeling wicked, just wicked. I had a brainstorm and started whistling softly. The other two doctors and PA were all in the same small office.

One took the bait. “What is that? I know that song.”

“Oh, we are singing it in chorus. For some reason it is in my head today.” So I sang this song.

I did not have the words memorized. I swear that the temperature in the room dropped and the male doctors hunched in their chairs.

“Yeah, don’t know why that one keeps playing in my head.” I said. “I hope you can all come to the concert!”

But answer came there none.

I took the photograph at Quimper Family Medicine, the clinic I opened after the hospital clinic kicked me out. The skeleton was named Mordechai in a contest. This is from 2014. Mordechai lived in our waiting room every October, with different outfits.

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Songs to Raise Girls: three songs

The Ragtag Daily Prompt today is memorize, and oh, what I have memorized! I saw a t-shirt at the Nowhereelse Festival in Ohio that said, “My memory is 80% lyrics.” Yes, me too, a mix of songs, poetry and books that I have read. My sister Chris and I were busily memorizing songs as soon as we could. Here are three very educational songs for young girls. The last one we learned from our cousin, who was a girl scout and a girl scout leader. She was in the calendar one year, making cookies. I was very very impressed and a little jealous.

I bought a four hour recording session at a silent auction and the recordings are me and my sister and my father. We did them in two sessions. We made a list of songs and lost it immediately so we all took turns suggesting songs. My mother had already died of cancer. My sister died in 2012 and my father in 2013. I am so glad to have these recordings. We called it Mocoko for Malcolm Ottaway, Chris Ottaway and Katherine Ottaway. We sang most of them just once and so they are not polished, but I still am happy to have them.

Bridget O’Flynn

I sang Bridget O’Flynn to my daughter when she called me about dancing. “Mom! I love to twirl!” Um, well, yes, your parents met at a contra dance at Glenn Echo Park in Maryland. We love to twirl too.

Late in the evening

A cautionary song, an old barbershop quartet song, that we sang.

Fascinating Lady

I wonder if the girl scouts still sing this.

The photograph is my son scaring me. Ok, that boulder is sitting there balanced BUT! GET OUT OF THERE! Taken in Palm Springs in 2011 up on the mesa. Beautiful.

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from blue to breathe

I attended a medical conference on line yesterday and today and it made me very blue. At first it just frustrated me, because it is about increasing behavioral health access. Isn’t that a good thing? Yes, but they completely missed the biggest barrier for primary care: TIME.

With the current US medical corporate money extracting insurance non-caring system, primary care is increasingly forced into 20 or 15 or 10 minute visits. I fought my hospital district when they said “See patients for one thing only.” I replied “That is unethical and dangerous: if it is a diabetic with an infected toe, I HAVE to check their kidney function, because antibiotic dose must be adjusted if their kidney function is reduced.” And there are at least two and maybe three problems there: infection, and if the diabetes is out of control that worsens the infection, and then kidney function. And actually I have to be sure anyone going on antibiotics has good kidney function or adjust my dose. I am very very good at this, but it takes time. I can work with complex patients, with veterans, with opiate overuse, with depression: but none of this is a simple template slam dunk. A study more than a decade ago says that the “average” primary care patient had 5 chronic illnesses. My patients don’t want to come in for each one separately and anyhow, if they have kidney problems I have to pay attention when I pick medicines for their high blood pressure. None of it can be separated out. That is why medicine is complicated.

Someone asked why can’t I just post the price of a “simple” visit for a sore throat. But a sore throat can be viral, can be strep A, can be a paralyzed vocal cord, can be a throat abscess, can be vocal cord cancer. I can’t tell ahead of time. I can’t. Early on during covid, a patient called and wanted a Zoom visit for abdominal pain that he said was constipation. I said “No, I can’t do abdominal pain over Zoom safely.” I can’t ASSUME it is constipation. It was appendicitis and he had his appendix out that evening. He called from his hospital bed the next day to thank me for making him come in.

The conference made me blue because they ignored my questions about why they were not advocating for primary care to have more time with patients. They claim to be all about change, but changing the US medical system? Nope. Do not want to talk about that. But I do want to talk about it. You can help by letting Congress know: single payer or medicare for all. That insurance company gets 20 cents of every dollar to profit and wastes tons of money forcing doctors’ offices to call for prior authorization. And if we have single payer, think of all the small businesses that will start because the terror about health insurance will disappear! I think it would reduce everyone’s stress, except the insurance CEOs. And they have earned more than enough, goodbye greed.

I am also tired of specialists telling me that primary care needs to do MORE. When I get told that I am not doing enough about hypertension, bladder leakage, depression and stopping smoking, and then 20 other specialists lecture me. Ok, so one minute per topic to fulfill what all of them think I should do? I want a primary care conference where primary care doctors are celebrated: cases are presented where the specialist says what a brilliant job the primary care doctor did.

I received a consult letter from a cancer doctor a few years ago. He wrote that I had diagnosed the earliest case of chronic leukemia that he had ever seen and that he was impressed and the patient would do fine. That’s the conference that I want to go to: where primary care and specialists talk about that and we inspire more doctors to do primary care.

You can learn more and how to talk to your congressperson here: HealthCare Now: https://www.healthcare-now.org/

or at Physicians for a National Healthcare Program: https://pnhp.org

And put your vote and your money towards healthcare, not health insurance.