I voted

…after I spent about three hours going through paper and throwing it out… ok, like a total numbskull I mislaid my ballot. Have you mislaid your ballot? FIND IT! VOTE!

” …that government of the people, by the people, for the people, shall not perish from the earth.

When I went across the country as a Mad as Hell Doctor in 2009, we talked to people everywhere. I joined the group in Seattle. I had never met any of them and had only heard about them two weeks before. But we were on the road, talking about health care, talking about single payer healthcare, talking about Medicare for All.

Some people said, “I don’t want the government in healthcare.”

We would ask, “Are you against medicare?” “No!” “Medicaid?” “No!” “Active duty military health care?” “No! We must take care of our active duty!” “Veterans?”  “No! They have earned it!”

…but those are all administered by the government. More than half of health care in the US. So let’s go forward: let’s all join together and have Medicare for ALL! And if you don’t agree… so you don’t think you should vote? Hmmm, I am wrestling my conscience here….

We need one system, without 20 cents of every insurance paid dollar going to health insurance profit and advertising and refusing care and building 500++ websites that really, I do not have time to learn and that change all the time anyhow. How about ONE website? How about ONE set of rules? We are losing doctors. It’s not just me worrying: it’s in the latest issue of the American Academy of Family Practice.

Vote. For your health and for your neighbor’s health.

____________________________________________

Physicians for a National Healthcare Progam: http://pnhp.org/

Healthcare Now: https://www.healthcare-now.org/

I can’t credit the photograph, because I don’t remember who took it…. or if it was with my camera or phone or someone else’s! But thank you, whoever you are!

Eeeeeee

My theme is happy things, though sometimes they are things where I am trying to find the perspective to love what is happening.

When my son was little, I had Dr. Suess’s ABCs memorized: Ear, egg, elephant, E, e, e!

My words today are everybody, embody and evening.

E for Everybody. Everybody in, nobody out! This is one of the calls for Healthcare for all, and I am still a Mad as Hell Doctor, working for single payer.

Our state representative was here a year ago and said that there is not a mandate for healthcare for all. I said, “I politely disagree. We already have a law in place that emergency rooms cannot turn anyone away. They cannot refuse to treat a person. This is a mandate for care. Unfortunately, the emergency room is the most expensive and inefficient care, unless you are about to die. The emergency room cannot do chronic care: it cannot help people stop smoking, help lower blood pressure, help people with chronic illness such as diabetes, do preventative care like pap smears and checking kidney function to stave off renal failure. We have the mandate: now we need the political will to change to a single payer system that gives good care. A patient can see me in my family practice clinic a dozen times for the cost of one emergency room visit.” S o, everybody in, nobody out. The law that insurance companies can ONLY keep 20 cents of every dollar does not comfort me: I want my dollar to go to health care for everyone and not 1/5 to profit!

Embody: what do I embody? What do you embody? Do you treat your body well? Do you thank it? What is it carrying?

I see people so fixed on success and progress and getting goals, that sometimes we don’t pay any attention to our bodies. We treat the body like a tool, like a hammer or a wrench, use and abuse it, try to make it conform to some idea of external beauty, get angry when it breaks down. Fix me back to where I was three years ago, when I could work 12 hours a day and never ever paid attention to my body. Bad food, tobacco, alcohol, marijuana, gallons of caffeine, energy drinks, sugar, illegal drugs, no exercise… and then we are surprised when it breaks down? Even exercise is seen as an inconvenient and necessary job, like buying new tires for the car. When people say get me back to where I was, I ask, “Back to working the 12 hours a day that caused this damage? Do you think that is a good idea?

And I include myself in that! I have had pneumonia with sepsis symptoms twice. The second time I thought, how dumb I am! My father died and I did not take any time off. I just kept working and added executor to my jobs and cried daily. Is it any surprise that after a year of that I became ill? Now my goal is to not do medicine for more than forty hours a week and to listen to my body and to take breaks!

Evening: the sunset. I am so grateful for the day, for the night, for the light changing and the world turning, for the stars and the moon and the sun and the glorious, gorgeous, generous world.

E

This is an evening photograph from Mauna Loa last week.

bust

I took this in 2011, as a Mad as Hell Doctor, traveling around California talking about single payer.

We are losing more and more physicians. Our three counties, 450,000 people, are down from 8 neurologists ten years ago, to 2. The last one standing in the county of 350,000 says that he is really tired.

Single payer, medicare for all….. because I dream of other countries, civilized countries, countries where there is one set of rules, I can take care of any person who comes to me, I know what is covered and what is not, and I actually get paid….

 

cancer pen

A patient told me about the “cancer pen” yesterday. I promptly pictured  Star Trek’s Bones holding his device over patients, but no, this has to touch tissue…aka a piece of you…and do a chemical evaluation. It is to be used during surgery.

Here: http://www.bbc.com/news/health-41162994

This is neat new technology… but. I can hear my sister saying, “Uh, so what about PREVENTION?”

This is technology to remove cancer after it’s already grown. And presumably metastasized. So this is stage II, stage III, stage IV cancer.

Cancer deaths are the second biggest cause of death in the US. Around 23% of yearly deaths and that does not count the people who survive cancer. At present we do not have many screening tests for cancer: pap smears continue to evolve, and now the recommendation is an HPV test or pap smear every five years AND we have a vaccine for the high risk HPV.
We can screen for colon cancer.
Mammograms for breast cancer.
The screen for prostate cancer sucks.
We can do skin checks.
The screen for lung cancer is now a low dose CT in a certain population that is high risk, that is, smokers. The recommendations have not addressed smoking marijuana.
Recommendations in the US are here: https://www.uspreventiveservicestaskforce.org/.

There are lots of cancers that we don’t have screens for…. yet.

Proteomics is on the horizon. Genomics is looking at the genes, but it turns out that lots of cancers and infections and other illnesses have particular protein patterns. There is TONS of research in this area. Someday we may have protein tests: put a drop of blood or urine on it and say, “Hmmm. Looks like you have a positive test, probable lung cancer.”

That in turn creates problems. Initially we may be able to diagnose a cancer but not FIND it. Also not know how to treat it. The first big study trying to set up lung cancer screening had over 600 worrisome CT scans out of 1000. How many lung cancers did they find? Nine. And half of the nine had symptoms and could be found on chest xray by the time they did repeat CTs. Think of the anxiety of the 600 people who might have cancer and “We will repeat the CT scan in four months. Don’t worry too much.” Also there were complications from biopsying the lungs, like bleeding and pneumonia….

The best bet to avoid cancer is still living in a healthy way: don’t smoke anything, avoid addictive substances, eat good food, exercise, have friends and loved ones, work for yourself and your community, do some things you love…..

 

I took the photograph of my sister in 2011. She died of breast cancer in 2012. Her blog is here: butterfly soup.

For the Daily Prompt: strut. Struts support things: airplane wings, cars, things that move. How do we as a culture support people to live healthy lives?

Health and teeth

For the Daily Prompt: toothbrush.

Here is a young rabbit. Their front teeth grow and get worn down eating. Their nails keep growing too and need to be worn down or clipped if they are pets.

In my county there are no dentists who take the state Medicaid for dental. And in some states Medicaid covers orthodontia for children but not in mine. Teeth are not covered on Washing ton State for my Medicare or Medicaid. And there are still battles going on about covering mental health including addiction. Is mental health not part of health? Are teeth not part of health? Why do we put health insurance profitable before basic life saving health coverage that covers all of us?

Health care should be like a toothbrush. We all need it. We all should have it.

 

Templates and the death of medicine

One of the many problems that are killing medicine in the US and especially primary care is templates.

Templates are a nightmare.

Why?

In a template, for back pain, there is a list of questions and in some there is also a list of answers. The “provider” asks the questions on the list and then checks off the answers. This is absolutely terrible brainless stupid failure of medicine. Because the most important answer that the patient gives is the one that does not fit the routine pattern of back pain or ear pain.

For example, I saw a woman for a new patient visit for back pain. Years ago. Half way through the questions about back pain I say, “How long have you been hoarse?”

She stops. She has to think about it. “Three months.”

“Continuously or does it come and go?”

Again, thought. “Continuously.”

On with the back pain. But she gets TWO referrals, one to an otolaryngologist. I ask other voice and throat questions.

When she returns she thanks me. Continuous hoarseness is worrisome for vocal cord cancer. You have to rule it out. She did not have vocal cord cancer. She did have vocal cord polyps and was going to have laser surgery.

But as a physician or “provider” you have to PAY ATTENTION. And ignoring the thing that doesn’t “fit” or isn’t relevant or isn’t on the god damned template — just don’t do it.

Another new patient. Back pain. Routine, routine, routine, one in four people get it in their lives. All the questions indicating that it’s musculoskeletal, not a disc, 99% are not discs, until:

“Sometimes my leg goes numb from the knee down.”

I stop. “How often? The whole leg?”

“Whole leg, yes.” She doesn’t know how often.

“If that happens I want to see you right away. Call.”

…because that is not a disc and it’s not musculoskeletal. And people say that but usually it can’t be confirmed on exam.

She calls. “Both legs are numb from the knee down.”

“Get in here.”

On exam she is not only numb but the muscles of her feet and ankles are weak and the reflexes don’t work right. I call neurology, anxious. “MRI from her head to her tailbone.”

She has multiple sclerosis lesions, more than one, in her brain. And a normal brain MRI from a few years before when she also had weird symptoms….

So it is NOT the template, the routine questions, that diagnose odd things in medicine. It’s the off hand comment, the puzzle piece that doesn’t fit, the symptom or sign that I notice and that gets my attention.

I hate the templates when we first get an electronic medical system. It sucks. It generates unreadable generic sentences: “The patient has ear pain. The quality of the ear pain is sharp. The ear pain has gone on for 6 weeks. The level of the ear pain is high.” Etc. Ok, that patient sounds like a robot. I quickly figure out how to type into the stupid boxes and avoid the templates as much as possible. I also start offering additions to the templates. “Ok, add this to quality of ear pain: It feels like being kicked over and over with the metal pointed tip of a cowboy boot.” Also to tachycardia: “It feels like a salmon is swimming upstream in my chest.”

See patients for one thing only. That would have really helped the hoarse woman, right?  Do the template. Do 10, 15, or 20 minute visits. The best doctors are rebelling and quitting, especially in primary care, because this is killing medicine. Why see people for one thing only? MONEY. MONEY MONEY MONEY. No. I like to work in medicine and I like to dig down, pay attention, listen and watch for the little details that stick out, the puzzle pieces that don’t fit….

….because that is what real medicine is. Not template robot medicine.

bye bye doctors

stop this healthcare bill… until there is transparency… or this will get worse.

 

I am grieving, watching doctors leave.

I have been in my rural county, 27,000 people, for 17 years.

Doctors are leaving. Wake up, United States.

The trend when I got here was that we had 14 primary care doctors and 5 midlevels. For years, we lost one primary care doctor a year. I would grieve and it would mean more work, every year. We would get a new doctor, but often there would be a gap… I made up a game to help cope with grieving. I call it “Local Doctor Survivor”. I would bet on the next doctor to leave and also on their trajectory. One of three: nice doctor, angry doctor, doctor labeled nuts. Burn out.

But…in 2015 it jumped. Suddenly we had 3 primary care doctors and two midlevels leave. Uh-uh. One was a husband and wife, doctor and nurse practitioner. One switched to being a hospitalist. Another left. And another midlevel. By then, we still had 14 primary care doctors, but the number of midlevels, nurse practitioners and physicians assistants had risen to 12. Ok, 12 plus 14 is 26. One fifth left. That is a bad trend.

In 2016 another physicians assistant retired. One of the best. I stopped counting who was leaving. Until another doctor announced they were leaving in February 2017. One of the best. That doctor said that a 20 minute visit generates 1 hour of paperwork. If one works “full time” the quota of patients is 18 per day, 72 in the four day week, and that is 32 hours four days a week of 20 minute visits. Generating 72 additional hours paperwork. That is 104 hours a week. Unsustainable.

The 2016 salary information is out for primary care. The “median” family practice physician in the US makes $168,000. Ok. But every doctor given as an example works 60-70 hours a week. Maybe that salary is not as good as you think. Because they are quitting.

Our neurologist retired, in about 2010. I was bummed. The county north of us has 75,000 people. They had two neurologists. Both left in the last two years. The county south of us has 350,000 people. They had five neurologists. Two have left, including my current favorite. For the first time in 17 years I have a neurology referral refused: and not one, but two. Send them to the big city, says one. The other just says no.

I call ENT and he bemoans that now they are down to three in the county. Another left. Three there, one on the county north of me, great, we have 4 for 450,000 people.

I get a letter from one of the two neurosurgeons in Seattle that I like best. In 2016. He is leaving to go do medical administration in another country.

Our three counties are down three dermatologists. One sent a letter. “I am quitting on October 1, 2016, unless ICD-10 is cancelled.” ICD-10 is the new manual of diagnostic codes. It was not cancelled so that dermatologist quit. We have to code every diagnosis. ICD-9 had 14,000 codes. ICD-10 has 48,000. I am memorizing the new ones. I10 is hypertension. E11.65 is type II diabetes in poor control. I used to be able to write a prescription for diabetic supplies, lancets and glucose strips. Now I have to include the ICD-10 code on the prescription and often the pharmacy cites medicare and demands that I fax proof that I have seen the patient and that the patient does indeed need the prescription. I frankly have better use for my brain than memorizing the ICD-10 codes, but whatever.

Another clinic closed in the county north of us and our county. Then the main clinic closed in the county south of us. Within two weeks. 3500 patients needing primary care providers and refills and we can’t get old records because the rumor mill says it was a “hostile takeover”. That is, the person who owned the clinics quit paying the bills, so the electronic medical company won’t release the records. Great.

I have been absorbing about one new patient per day worked since March, but I am getting tired and will have to back off.

Meanwhile, our county hospital has been hiring specialists. Gynecology, new orthopedists, dermatology. Great, right? But currently most specialists won’t take a new patient without the patient having a primary care doctor. Why? Well, one of the new trends is that the specialist says the patient needs something but that I should order it. Yep. Had one of those yesterday. The specialist says I should order it. It’s a veteran. So I get to fill out the VA authorization paperwork with the ICD-10 codes and the CPT code for the study, fax that to the VA, call the patient and remind him to call triwest, because if the patient doesn’t call then triwest throws the authorization paperwork out. And the specialist makes more than 5 times the amount I do. Maybe I should retrain. I am a specialist: family practice, three year residency, board certified, board eligible. But….. I have little value in the United States.

We are seeing Veterans in spite of the extra paperwork. Triwest is sending us 5 from Whidby Island. They have to take a ferry to see me. Because no one on Whidby is taking veterans. My receptionist complains to triwest about all the doctors leaving the Olympic Peninsula.

“No,” says the triwest person. “Not just the Olympic Peninsula. The whole west coast of the US.”

 

http://www.aafp.org/news/government-medicine/20170620senatespeakout.html

greed

Virtues and views, 7 sins and friends, Blogging from A to Z. Last year I chose gluttony for the letter g, but greed is also there. Charity is listed as the virtue to oppose the sin of greed. How interesting, because I did not have those paired! I think of generosity as the opposite of greed, but I do understand placing charity there.

Webster 1913 Greed:

An eager desire or longing; greediness; as, a greed of gain.

Dictionary.com 2017 Greed:

noun

1. excessive or rapacious desire, especially for wealth or possessions.

Webster 1913 Charity

1. Love; universal benevolence; good will.

Now abideth faith, hope, charity, three; but the greatest of these is charity. 1. Cor. xiii. 13.

They, at least, are little to be envied, in whose hearts the great charities . . . lie dead. Ruskin.

With malice towards none, with charity for all. Lincoln.

2. Liberality in judging of men and their actions; a disposition which inclines men to put the best construction on the words and actions of others.

The highest exercise of charity is charity towards the uncharitable. Buckminster.

3. Liberality to the poor and the suffering, to benevolent institutions, or to worthy causes; generosity.

The heathen poet, in commending the charity of Dido to the Trojans, spake like a Christian. Dryden.

4. Whatever is bestowed gratuitously on the needy or suffering for their relief; alms; any act of kindness.

She did ill then to refuse her a charity. L’Estrange.

5. A charitable institution, or a gift to create and support such an institution; as, Lady Margaret’s charity.

6. pl. Law Eleemosynary appointments [grants or devises] including relief of the poor or friendless, education, religious culture, and public institutions.

The charities that soothe, and heal, and bless, Are scattered at the feet of man like flowers. Wordsworth.

_____________________

So why is charity the virtue to balance greed? I am thinking of the Buddhist prayer: may all beings be safe. May all beings be peaceful. May all beings experience loving kindness. May all beings be free.

All beings. Not just the virtuous, not just the good, not the people of one race or one religion or one country. All beings and I think that is what charity and love really are. When we say “Not those kind of people!” we are separating and discriminating and labeling and we choose to keep charity from them: that is greed, too. More for us, less for them. They are bad, wrong, different, so we don’t have to share with them.

The Buddhist prayer is to be practiced towards a loved one, then a friend, then an acquaintance, then a stranger, someone we dislike, some one who has hurt us, and someone that we think (and here is gossip) is evil….progressively harder.

But what if someone HAS hurt us? How do we practice charity there?  Do we have to?

I return to a sermon on forgiveness: here, by Reverend Bruce Bode:

“Says Dr. Lewis Smedes in his book, Forgive and Forget:

When you forgive, you heal your hate for the person who created that reality. But you do not change the facts. And you do not undo all of their consequences. The dead stay dead; the wounded are often still crippled.”

Reverend Bode goes on to say:

“While I’m talking about what forgiveness is not, let me also make a distinction between forgiveness and reconciliation. The distinction is this: forgiveness opens the possibility of reconciliation with another, but it does not necessarily lead to reconciliation, and it is certainly not the same thing as reconciliation.

One can forgive and not reconcile. This is because reconciliation demands something from the other side, whereas forgiveness has to do with an internal process within a person.”

Charity, then, is more complicated than generosity, than romantic love, than love for one’s family and friends and community. It is the ideal of loving everyone, even those who have harmed us. Our ideal is for charity and forgiveness: and a hope for reconciliation. Charity is the opposite of greed.

Doctors don’t charge for phone calls

Doctors don’t charge for phone calls.

Attorneys do: they charge in fifteen minute increments.

Doctors don’t charge for phone calls: oh, but actually that is a myth. And it’s raising the cost of health care in the US because the insurance companies are using this myth to their advantage. Not only is this costing every one of us more money, but it is driving doctors out of practice. And it’s making patients bitter and angry at the doctor, when it is the insurance that should bear the blame…

Why do I say this?

A patient calls their health insurance. “I need x.”

The health insurance says, “Have your doctor’s office call for a prior authorization.” Now, we are definitely paying the health insurance to have someone say that to the patient.

The patient calls the doctor’s office and requests the prior authorization. There, a second person is being paid to get that phone call.

The doctor’s staff runs it by the doctor. The doctor says, yes, the patient needs that or no, I would like a visit to discuss this. More time that we pay for.

If the doctor says yes, the doctor’s office contacts the insurance by phone or on line to do a prior authorization. This means a different website for every one of 1300 insurance companies in the US. We are paying the doctor’s office staff to be on the phone and on the computer to fill out prior authorization forms to get permission from the insurance if your doctor agreed that you need x or that x would be helpful. We also are paying for all of those websites that the insurance companies have to slow down giving the patient care.

I don’t have an office staff to do this. I have a bare bones clinic so that I can spend more time with patients. I call the insurance myself with the patient in the room.

More than half the time the insurance company says that x is not covered under the patient’s plan.

But wait. The patient already called the insurance to ask if they could get x. And the insurance said have your doctor get prior authorization. So in the usual office, the patient is called and told that x is not covered. The patient is angry, because they think that the doctor’s office has messed up the prior authorization. The insurance does not want to tell the patient it is not covered. So our costs spiral up and up and up, because the insurance has realized that they would rather have the patient angry at the doctor’s office, not the insurance.

And we all are paying for it with our health care dollars…..