Why is she really here?

For the Ragtag Daily Prompt: object. I strenuously and loudly object to medicine meaning pills.

During my three months temp job at a nearby Army Hospital in 2010, I wanted to work with residents, Family Practice doctors in training. I finished residency in 1996 and have worked in rural clinics and hospitals for 14 years. I want more rural family practice doctors and I agitated to work with the residents in training.

The Family Practice Department had actually hired me to do clinic. They are swamped and trying to hire temporary and permanent providers as quickly as they can. Six different temp companies called me about the same job, so the word is definitely out.

Initially the department head explained that I was there to do clinic, but she changed her mind. I was cheerful about the electronic medical records. Learning a new electronic medical record is awful, but I was happy to be there, excited about working with residents and in a hospital more than 16 times as big as my usual small town hospital. Most importantly, I was patient with the computer. I have finally realized that computers don’t actually speak English. They speak computer and they are dumb as rocks and they make no effort to understand what I am saying. They don’t care. So it is no use getting mad at the dumb thing when it crashes or when it doesn’t do what I want: I have to go find someone who knows the exact language that the stupid machine will understand.

Since I was cheerful, my department head let me do what I want. I was on the clinic schedule every day, but it was empty. I would arrive and see walk-in active duty people from 6:30 to 8:00. At the same time, I would email the department head and ask what I was doing that day. Half the time, a physician was sick or had a family crisis, so she would move people around and put me with the residents. If not, I would open clinic.

I enjoyed the “Attending Room” duty. Family Practice Residents have their MD but then go through three years of training. The first year residents must precept every clinic patient. That is, they see the person and then come discuss the case with the faculty. Second year residents were required to precept two patients per half day and third year residents had to do one; and all obstetric cases were precepted.

Back when I was in residency and the dinosaurs roamed the earth, no one ever read any of my notes. This has changed. Every note that is precepted must be read by the attending and co-signed. After three years hating the electronic medical record that my small hospital bought, it was very interesting to see a different system. In some ways it was better and in some worse.

We had one or two “Attendings” in the faculty room, no more than three residents per attending. One case stands out, more because of the resident than the patient. He was a first year.

He described an elderly woman in her 80s, there for headaches. Two weeks of headaches, getting a bit worse. History of present illness, past medical history, medicines, allergies, family history, social history and the physical exam. He said, “She’s tried tylonol and ibuprofen, but they aren’t helping that much.” He frowned. “She doesn’t seem to want another medicine.”

“No?” I said.

“No.” he said. “I started to talk about medicines. It doesn’t sound like migraines and she doesn’t have anything that’s really worrisome for a tumor……but she doesn’t seem to want a headache medicine.”

“Why is she really here?”

He looked more confused. “What do you mean?”

“Why is she really here?”

“I don’t know.”

“You already said why. Think about the history.” He frowned. I said, “Ok, you said that she was worried that she was going to have a stroke. Are these headaches likely to be a precursor of a stroke?”


“Right. But that is why she’s here, because that is what she’s worried about. Look at her blood pressure, see what her last cholesterol was, talk to her about what symptoms ARE worrisome for strokes. Find out if a family member or friend has had a recent stroke. She doesn’t need a medicine. She is here for reassurance.”

“Oh.” he said. He left and came back.

“How did it go?”

“She was happy. She didn’t want a medicine. Her blood pressure is great, her cholesterol is great, we talked about strokes and she left.”

“That’s real medicine. Forget the diagnosis if the visit seems confusing. Ask yourself what is your patient worried about? What are they afraid of? Don’t focus on giving people medicine all the time. Ask yourself, why are they really here?”

And that is why I wanted to work with residents. It’s not all diagnosis and treatment. It is people and thinking about what they want and what they are worried about.

Why is she really here?


previously published on everything2.com
According to dictionary.com, precept is a noun. Medical school and residency have verbed it. Hey, get updated, dictionary.com!

Fraud in Medicine: Heartwood

Here in my neck of the woods, people are continuing to quit medicine. Two  managers who have worked in the clinics eaten by the hospital are leaving on the same day, after 30 years. And another woman doctor, around my age, is retiring from medicine. She is NOT medicare age.

Meanwhile, the Mayo Clinic is publishing articles about how to turn older physicians into “heartwood”.


“As trees age, the older cells at the core of the trunk lose some of their ability to conduct water. The tree allows these innermost cells to retire…. This stiffened heartwood core…continues to help structurally support the tree…. Here a tree honors its elderly cells by letting them rest but still giving them something meaningful to do. We non-trees could take a lesson from that.” Spike Carlsen

Oh, wow, let’s honor the elderly. Even elderly physicians. Instead of what, killing them? Currently we dishonor them, right?

But what is the core of the issue? Skim down to “Decreased patient contact”:

“Already, many physicians are choosing to decrease their work to less than full-time, with resultant decreased patient encounters and decreased institutional revenue. Prorating compensation to match full-time equivalent worked will aid in financial balance, but the continued cost of benefits will remain. However, when that benefit expense is compared with the expense of recruiting a new physician (estimated by some to approach $250,000 per physician), the cost of supporting part-time practicing physicians becomes more attractive.”

Ok, so the core of the matter. “Decreased institutional revenue” and the employer still has to pay BENEFITS. NOTHING ABOUT THE QUALITY OF CARE FOR PATIENTS.

Again, the problem is still that you can’t really “do” a patient in twenty minutes, and that full time is really 60 or more hours a week. To be thorough, I  have to absorb the clinical picture for each patient: chief complaint, history of present illness, past medical history, allergies, family history, social history (this includes tobacco, drugs and alcohol), vital signs, review of systems and physical exam. And old records, x-rays, pathology reports, surgical reports, laboratory reports. I fought with my administration about the 18 patient a day quota. I said: ok, I have a patient every twenty minutes for 4 hours in the morning, a meeting scheduled at lunch, four hours in the afternoon. When am I supposed to call a specialist, do refills, read the lab results, look at xray results, call a patient at home to be sure they are ok? The administration replied that I should only spend 8 minutes with the patient and then I would have 12 minutes between patients to do paperwork. I replied that they’d picked the Electronic Medical Record telling us that we could do the note in the room. I could, after three years of practice. But it nearly always took me twenty-five minutes. I would hit send and our referral person had so much experience that she could have the referral approved before my patient made it to the front desk. BUT I felt like I was running as fast as I possibly could all day on a treadmill. Also, the hour lunch meetings pissed me off. I get 20 minutes with a patient and they get an hour meeting? Hell, no! I set my pager for a 20 minute alarm every time I went into a meeting and I walked out when it buzzed. I needed to REST!

After a few weeks of treadmill, I dropped a half clinic day. But of course that didn’t go into effect for another month and I was tired and ran late daily. And every 9 hour clinic day generated two hours of paperwork minimum: nights, weekends, 5 am when I would not get interrupted and could THINK. Do you really want a doctor to review your lab work when they are really tired and have worked for 11 hours or 24 hours? Might they miss something? It might have been best if I had been quiet and just cancelled two people a day, since the front desk knew I was not coming out of any room until I was done, but I argued instead.

The point is, you would like to see a doctor who listens and is thorough. You do not actually want a medical system where there all these other people who read your patient history forms and enter them in to the computer and your doctor tries to find the time to read it, like drinking from a fire hose. If we want doctors and patients to be happy, then doctors need time with patients and we need to off the insurance companies who add more and more and more complicated requirements for the most minimal care. One system, one set of rules, we’ll fight over the details, medicare for all.

Rural medicine crisis: Job offers

One of the signs that we are entering a worse crisis for rural medicine is job offers.

I am starting to keep the email job offers: so far the record is from Texas, a random out of the blue job offer for $500,000 yearly.

One half million dollars for a Family Practice job. I won’t take it. I like my clinic and anyhow, the pace they would set me to work is burning out physicians. They are quitting, though some die instead. A recent article said that this year a physician poll reports the number at burnout this year has risen from 40% to 50%.The job offers roll in. I get phone calls, emails, mailing and now my cat is getting rural family medicine job offers. Really. Desperate times.

Years ago I read that only 30% of family practice doctors are willing to take a rural job and that only 30% of those are willing to do obstetrics in a rural area. I did obstetrics as part of my practice from 1996 to 2009. I stopped when I opened my own practice, because the malpractice price tag is three times as much and my rural hospital was grumpy at me. Starting in my third year of medical school, I did deliveries for 19 years. During my nine years here, the cesarean sections were done by the general surgeons and we did not have an OB-gyn. I called Swedish Hospital Perinatology when I needed help. I got to know them well enough that if I had someone in preterm labor I would call and find out who was on call BEFORE I chose a medicine, because I knew which perinatologist liked terbutaline and which one would rather I would skip it and use procardia. They were fighting out the research: I didn’t know who was right, but it is a huge benefit to have your consultant be happy with your choice if you have to lifeflight the patient by helicopter at 3 am. With a 25 bed rural hospital, we try not to deliver a baby under 35 weeks, and it’s better to fly the baby in mother if you can’t stop the labor.

Back to the numbers: so 33 out of 100 family practice doctors will take a rural job and only 11 of those are willing to do obstetrics. Our first day of medical school, the faculty said, “Shake hands with the person on your right. Shake hands with the person on your left. At least one of the three of you will be sued for malpractice in your career.” Oh, goody, let’s start training with paranoia. Or is it just being realistic and prepared?

I worked for five years between college and medical school and took the GREs first. I thought I was going to get a PhD. However, I did not want to write a thesis and did not want to be one of three world experts in anything. I had a friend who was one of three world experts in honeybee behavior. I asked what happened when they got together. “We argue.” he said. I also did not want to publish or perish, tenure was becoming more of a problem and anyhow, I did not want to be tied to a university. I got a job working as a lab tech in the National Cancer Institute at NIH in Bethesda. Two years there gave me my answer: primary care is the ultimate generalist. I could work anywhere in the world, in a city, in a small town, and there is endless lifelong learning. I took the MCATs and got into medical school, determined to do primary care.

Back to the job offers: 450K for Iowa. 310K, 350K, signing bonus, paid move, 6 weeks “off” (As far as I can tell it’s always unpaid leave. No sick leave, no paid holidays, no paid leave at all. Do factor that in.)Production bonus. No call or phone calls only. Near a city! In a city! Cheap houses! Excellent schools for your children and 6 stellar golf courses! FP job in Texas, 315K, 4 day work week, signing bonus, loan forgiveness!

The most that I’ve made in a year, I think, is less than half the listed average income for family doctors, though that has risen by nearly 1/3 in the last ten years. And that was enough and I didn’t see enough of my two children and the next year I worked less. I have never made the “MGMA average” for what a family doctor makes and it was more than ten years ago. I am below average in income but I think I am above average in personal happiness and way below average in burn out! I made way less last year, because I was out sick for 6 months. Ok, I lost money. However, my clinic still nearly covered expenses and stayed open, with no provider from early June to November 15, thanks to my receptionist, my patients, the PA who stepped in in November and the other independent practitioners in town. The hospital system refused to help except that they took over my 18 patients on controlled substances… after I threatened to complain to the state that they were refusing care. How nice.

I have an old house and old cars. I have a son finishing college and a daughter about to start. More money to retirement seems like a good idea. I now have 25 years as a member of the American Academy of Family Practice and I am an “old” doctor, because I didn’t retire at 50. I told a younger partner at the hospital that I was deliberately being “below average” because I was going for a career with longevity and wanted to avoid burning out. He left town last year….

From the American Academy of Family Practice paper http://www.aafp.org/about/policies/all/rural-practice-paper.html : family practice providers are 15% of physicians in the US, but do 23% of the visits each year. And in rural areas about 42%. “In the U.S. as a whole there is 1 Primary Care physician per 1300 persons while in rural areas the ratio is 1 Primary Care physician per 1910 persons and 1 Family Physician per 2940 persons. In the most rural counties, those with a community of at least 2500 people but no town over 20,000, close to 30,000 additional Family Physicians are needed to achieve the recommended 1:1200 ratio.” I have patients driving from over an hour away because it takes months on the waiting list to see a primary care doctor in their area, and now I am seeing veterans too, because we are more than 40 miles by road from the nearest VA hospital.

This article:  http://doctordrain.journalism.cuny.edu/the-broken-system/family-practice-just-doesnt-pay/ makes me laugh. The student says that 90% of family practice visits are probably coughs and colds. Uh, I would say that less than 5% of mine are. Half of my patients are over 65 and what I do is care for chronic disease with some acute disease thrown in. Diabetes, hypertension, coronary artery disease, rheumatoid arthritis, stage III renal failure, opiate overuse syndrome, depression, PTSD, and the average patient has 4-5 chronic diseases, not one. So the complicated ones have 9 chronic diseases. If they have walking pneumonia and diabetes and are 80, what was their last creatinine so I can adjust the antibiotic dose for their stage three renal failure? My oldest current patient is 98, has diabetes and still is out haying…. rural medicine is never ever boring and some days I think, oh, I would pay to see a simple cold. In the last two months one patient had a four vessel bypass, two have hepatitis C, one has hepatitis B and last month I found one with pertussis: whooping cough. And one has to go to the Big City to see the gynecologist-oncologist….

Rural family medicine is the ultimate generalist. I have to know a little bit of everything and know when to call and ask questions and who to call. Once I had an obstetrics patient with severe and confusing back pain after an epidural. I knew it was something peculiar because we could barely control it with opiates and her back exam was fine. I started calling specialists: ob-gyn didn’t know. The nurse anesthetist. My local internist. An orthopedist. A neurologist, the closest one 90 miles away. Then I got it: I called an anesthesiologist in Denver, 250 miles from where I was. He said it was an inflammatory reaction to the epidural medicine and to give her steroids, which would fix it. It did… but it was my being sure that I had something different on my hands and the stubbornness to keep calling until someone knew the answer….

A friend from college got a PhD in genetics and then went to medical school at the same time as I did. We talked when we picked our specialties. She chose pathology. I chose Family Practice. “Not Family Practice!” she said. “Why not?” I asked. “You can’t know everything!” she said. I said, “Well, no one knows everything. Put three top specialists in a room and they argue about the research. The trick is knowing what you know and what you don’t know.”

We need more primary care physicians and more rural family doctors. And it’s only getting worse.

This blog post helped inspire this article: https://theridiculousmrsh.wordpress.com/2015/11/03/why-i-hope-my-doctor-is-off-having-a-cup-of-tea-as-seen-on-the-huffington-post-yup-actual-huffpost/

The picture is some of the madashell doctors on our first trip stumping for single payer health care in 2009.


The photo is of a synchronized swim trio.

Only one swimmer is really visible. She is being lifted by the other two. They are not allowed to touch to bottom at all. It is all done lifting their own or each other’s bodies out of the water by swimming.

Sychronized swimming is a shrinking sport in the United States, because it is such hard work. My daughter started at age seven and had to swim three laps. She made it one length and then had to hold on to the lane divider to rest during the rest of the laps. She went under three separate times during that first practice. I nearly jumped the divider all three times, but she came up each time.

“How was it?” I asked when she got out.

“I nearly drowned three times.” she said, stomping past me in a rage.

She says that she hated it for the first year and that I made her keep going. If I did, I would feel guilty, except that she loved it so much after that. Seven years of synchronized swimming, until our very small town team folded, and then swim team. She is now a junior. What she wants most in college is to continue to swim on a team.

Back to the photo. To be lifted straight out of the water that far, you must be in the right position, you must have very good core strength, and your two partners must be in the right position underwater and lift correctly. You must practice and practice and practice and practice.

And you do this in time to music.

We need to work as a team in the world to deal with infection, to deal with ebola, to work together. My daughter loved synchronized swimming because it is so challenging and because it is above all, teamwork.

If you have to cry, do it on the boyfriend who wants you to be angry instead of sad

I used to have a temper that could be set off really really easily.

I had a boyfriend right out of college that said that I didn’t get angry “right”. He had a PhD and I was a mere done with undergraduate person, so what did I know? I went into counseling for a year.

Finally I said to him, “The counselor and I have tried presenting anger to you in every possible form and none of it is acceptable. So now she says you need to come to counseling too.”

His response: “What I want is for you to never get angry at me again.”

Mine: “You are dreaming.”

And so he broke up with me. Immediately. And said I was an ogre when I was angry.

I went back to counseling and was depressed for a year. Then I cheered up, met a boyfriend and went to medical school. I worked on my temper, remembering the ogre comment. I did not want to be an ogre. My boyfriend became my husband and he really liked my dark side and my silly side.

My sister was the person who could set me off angry the most easily. She and I fought like pitbulls, like honey badgers. Once we were in Colorado with my husband, her first husband and my parents. The two husbands had an imitation pretend fight acting as me and my sister. They were vicious. It was horribly embarassing and also funny, because they nailed us both.

In residency in Portland, I had a breakthrough. My sister was divorced from the first husband by then, and with the no meat, no dairy, really pain in the butt boyfriend. We were having a big party, lots of people, grilling salmon and cooking in a group. My sister walked in.

“Oh.” I said, “You didn’t RSVP.”

She fired up instantly. “What? Why does that matter? Do you want me to leave?”

I did not fire up. I held my breath and then said, “No. But if you are here with No Meat No Milk, I didn’t make any food for him, because I did not know you were coming. There is lots of food. You are both welcome to stay, but he will have to figure out his own food.” Then I held my breath again.

There was a long pause. My sister had her breath drawn in and held. She looked like she was going to explode. But I had answered quietly. She really had nothing to explode at.

“We will stay then,” she said, grudgingly. And there was No Meat No Milk. I was pretty happy when she ditched him. But I was also happy that I had not exploded back at her.

That was when I really got control of my temper. Not that I never lost it again, but I was no longer an ogre. I could hold it with my sister. My husband could set me off, but when I stepped back and started recording what he said and my responses, I could hold it there too.

After we divorced, I had one boyfriend who moved in. I had joked to a friend that my family had a lot of enablers and enablees, but that the latter lived longer. I said if I had to be one or the other, the latter seemed better for longevity.

And that boyfriend showed up immediately. I had just been “strongly encouraged” by my employer local hospital to open my own private practice. That is, I was not seeing patients. I was writing a business plan. I met him in a bar, salsa dancing. He said I was cute and I said, “No, I’m prickly.” I swear, it was that sentence and my dancing that attracted him. I always grin like a fool when I’m dancing. I love it. It lights me up.

Anyhow, I got mad at him exactly twice before he moved in. Boy did he come down on me for getting mad and punished me very thoroughly. By now you are wondering why I let him move in and frankly I was too. But my intuition was running the show and I just let it.

Well, he had kissed me like crazy at the start of the relationship. He stopped kissing me, almost as he moved in. He had insomnia. He’d fixed up one of the two upstairs bedrooms. He started sleeping with me less and less and sleeping in the other room, on cushions.

I would wake, worry. I started moving too. I moved to the guest room. I moved to the couch. Once I was out of the theoretically shared bed, I could go back to sleep. He protested that I shouldn’t move. Why not? I was getting insomnia from worrying about him leaving more and more.

He said we’d need couples counseling eventually. I said, ok, and scheduled it. He said, “I didn’t mean now!” I said, “Well, seemed like we might as well get it out of the way.”

He told the counselor I needed to either cut my sister off or do what she said, but instead, I was present and disobeidient. My sister had metastatic breast cancer and we came from an alcohol addiction family. Can you say complicated relationship?

I explained to the counselor that I thought many patients with cancer end up in a “cancer bubble”. Everyone tries to do what they say because they have cancer. This isolates them and does damage to the relationship. I was trying to stay present and real. That is, I did not obey. I was getting pressure from other people to obey, because my sister would complain about me. Whatever.

The counselor thought I was reasonable. I brought up the sleep issues. The boyfriend cancelled the counseling, saying that he needed a break.

At six months living together, he was saying that he might need to go back to the city to work. Two hours away. And I still was not doing what he wanted re my sister.

Counseling again. Again my behavior to my sister was examined. Same story. I turned to him. “I hear you saying you may need to return to the city for work. I hear you saying you may need to move there. What I don’t hear you saying is darling, we will get through a long distance relationship. Are you breaking up with me and not telling me?”

Long silence.

The counselor said, “You need to answer her.”

He finally said, “I wasn’t going to tell you until after I moved.”

I cried. We left. I kept crying.

He said, “You are angry and you are going to throw me out on the street.”

“No!” I said, “I am sad! You move out when you are ready! We will remain friends!”

So then I cried buckets. I cried on him, buckets. I cried every time I saw him, I cried daily, I cried about him, about my sister, about alcoholism, about the hospital getting rid of me. I cried about everything. I cried on him daily.

For six months. He kept saying “You are angry. You are throwing me out.” But I didn’t. I just cried more.

He moved out on the weekend I returned from seeing my sister in hospice for the last time. Her birthday was March 23. I saw her last on March 22. My birthday was March 28. She died March 29. He moved out on the 26th and 27th. I was not mad, I just cried and cried and cried.

I think that he was looking for an angry girlfriend. He thought he’d found her when I said I was prickly. He would have been the enabler and I would have been the angry dysfunctional enablee. It turns out that I was not really interested in being an enablee. Now I want a healthy relationship.

So that is my recommendation. If you have to cry, do it on the boyfriend who wants you to be angry instead of sad.

In preparation

I wrote this on 9/26/14 in the midst of much frustration and my lungs still hurting three and a half months after I got sick. I am off from taking care of patients, but still have to try to get my business covered and my patients taken care of. I think there is a component of my vocal cords not working because I am told that I am wrong and to shut up so often.

Favorite example is a Seattle Infectious Disease doctor that I called to ask for help with an infection in our town. He said, “You are a rural Family Practice Doctor. Why would I listen to you?”

I said, “I’m a girl too.” and hung up in frustration. That attitude will not win him any referrals from me. On my permanent stupid moron list, along with an amazing number of specialists. They are either respectful or they aren’t.

Currently I am on no alcohol at all, because I have to do a special diet before a 24 hour urine test. Means no caffeine either, ouch, headache.

In preparation

Today I will start drinking
even though it’s only 9:40
in the am

I will stretch two beers
through the long hours
as the alcohol
blocks the receptors
and numbs my aching heart
and lungs

and I will stay home alone
so that I won’t talk

to rest my voice

in preparation
for the next round
of talk

where I am told
in no uncertain terms
to sit down
and to shut up