stay or go?

For the Ragtag Daily Prompt: migration.

I took this on a beach walk with my aunt and uncle on Sunday. They were visiting from Virginia. They’ve flown back now.

This is taken with the zoom all the way out. I recognized the great blue heron, but in the first picture I can’t tell what the geese are. With a face in profile in this second photograph it’s clear that they are Canada geese.

The geese are migrating but the great blue heron stays and winters over. Most of our hummingbirds migrate, but the Anna’s can winter over. And I have been asked: stay or go? My landlord asks if I will renew my lease for my clinic in February.

I reply that I am waiting on the US Congress. My clinic is more than half medicare patients. 48% are over age 65. Congress is discussing paying a flat fee for medicare visits: about $43.00 dollars. At the moment I do not see how I could keep my small solo clinic open if that goes through. Stay or go? It is stressful. I want to stay. But I may have to migrate like the geese….

I think a frightening number of physicians would either migrate or stop taking medicare patients, opt out of medicare, if Congress passes this bill. The AAFP is fighting it. I contact Congress too, but I am tired of fighting for single payer, medicare for all. Patients spend more on their dogs’ health than their own. How can I do good care and feel valued for $43.00 per clinic visit?

I thought the thing most likely to close my clinic is the cost of my own health insurance. But Congress may close me down by dropping my payments from 48% of what I bill, to less than 25%. Yet they say they want good care for our country….

Message me if you contact Congress to say do not do this. And thank you so much if you do.

The proposal for medicare changes is 1472 pages. So I am supposed to find time to read that and comment on it in addition to taking care of my patients? What sort of insanity is this?

Illness Anxiety Disorder

“Please write something from a medical perspective about anxious people who worry every little thing is some serious disease.” — reQuest 2018

This is quite a brilliant and timely question.

Here: https://www.anxiety.org/hypochondriasis-replaced-by-two-new-disorders-in-dsm-5.

The DSM V was published on May 18, 2013. This is the Diagnostic and Statistical Manual of Mental Disorders version 5,  and it redefines various disorders. For example, opiate dependence has disappeared and so has opiate addiction. Instead, there is one diagnosis: opiate overuse syndrome. Which really combines both opiate addiction and opiate dependence and makes it a spectrum.

The DSM V drops hypochondriasis. Wait, you say, that diagnosis no longer exists? Well, yes, correct. So the diagnoses are made up? Yes, as my daughter says, “All the words are made up.” So psychiatry changes and the diagnosis definitions change and some diagnoses disappear. Medicine is like the Oregon Dunes, really. The information is changing daily. I went into medicine thinking it is like a cookbook, where I just have to learn all the recipes. Nope, sand dunes: the wind and waves and new information change the contours daily. It drives my patients nuts. “My insurance won’t cover the medicine I’ve been on for 26 years.” Um, yeah, sorry, work for single payer and shut down the insurance companies, ok? “This combination of medicines has never killed me yet.” Um, yeah, sorry, but you are in fact getting older and we no longer think that combination is safe and first do no harm: I can’t prescribe combinations that I think may kill you.

Hypochondriasis has been replaced by two diagnoses: Somatic Symptom Disorder and Illness Anxiety Disorder.

From the Mayo Clinic website: https://www.mayoclinic.org/medical-professionals/clinical-updates/psychiatry-psychology/diagnostic-statistical-manual-mental-disorders-redefines-hypochondriasis.

“Patients with illness anxiety disorder may or may not have a medical condition but have heightened bodily sensations, are intensely anxious about the possibility of an undiagnosed illness, or devote excessive time and energy to health concerns, often obsessively researching them. Like people with somatic symptom disorder, they are not easily reassured. Illness anxiety disorder can cause considerable distress and life disruption, even at moderate levels.”

“To meet the criteria for somatic symptom disorder, patients must have one or more chronic somatic symptoms about which they are excessively concerned, preoccupied or fearful. These fears and behaviors cause significant distress and dysfunction, and although patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate.”

So, subtle difference. Broadly, the illness anxiety disorder people are sure they have SOMETHING and are worried about ALL THE SYMPTOMS. The somatic symptom disorder people are worried about A SPECIFIC SYMPTOM OR SYMPTOMS and WHY HAVEN’T YOU FIXED ME.

Some of the people complaining of weird symptoms do have a medical diagnosis that has not been sorted out. Take multiple sclerosis for example. The average time from the start of symptoms to diagnosis is 4-5 years.

Here: http://biketxh.nationalmssociety.org/site/DocServer/Facts-about-MS.pdf?docID=54383).

Also here: https://www.nationalmssociety.org/Symptoms-Diagnosis/Diagnosing-Tools.

Another one is sarcoidosis: https://www.mayoclinic.org/diseases-conditions/sarcoidosis/symptoms-causes/syc-20350358. It’s hard to diagnose, can affect different parts of the body, and it’s still pretty mysterious. Add to that list chronic fatigue, fibromyalgia, chronic pain, and numerous other diagnoses.

With multiple sclerosis, you may be thinking, well, if they had just done the brain MRI sooner, the diagnosis would be made. Not necessarily. I did find a patient with a bunch of MS brain lesions: made the diagnosis. She had had a brain MRI 3-5 years before because of suspicious symptoms during pregnancy. At that time her MRI was entirely normal.

The DSM V does not have a diagnosis called psychophysiological disorder. This is an ongoing discussion:
1. https://pdfs.semanticscholar.org/7f7f/21a9b524fb677d575428bea11aab4c8d70c5.pdf
2. https://thoughtbroadcast.com/2011/01/21/psychosomatic-illness-and-the-dsm-5/
This site: http://www.stressillness.com/ is my current favorite about psychophysiological disorders. I heard a lecture from the physician who runs the site. He is at OHSU in Portland and gets the gastrointestinal patients where “they can’t find anything wrong” from all over the state. He is really good at this. He and I are in agreement: the symptoms are real. However, the symptoms may come from emotional suffering and from emotional trauma in the past and present.

It is clear that fibromyalgia is a “real” disorder: functional MRI of the brain shows the pain centers lighting up more with a standardized pain stimulus than “normal” patients. PTSD is “real”. It is interesting that there is more stigma surrounding fibromyalgia and chronic fatigue than PTSD: is that because the former two are more often diagnosed in women, and the latter is legitimate (finally) for male (and a smaller number of female) veterans?

And what do I, your humble country doctor, think? I think that chronic fatigue and PTSD and fibromyalgia and illness anxiety disorder and the others all may be variations of the same thing. Our body will handle and “store” or “stuff” emotions that we cannot handle or are not in a safe situation to handle it. Eventually our body decides that we are now safe enough and will notify us that we have to handle the emotions. Currently our culture is terribly unsupportive of this and there is huge stigma attached to dealing with it. We are all supposed to just be nice.

In the end, we can’t judge how a friend feels or whether they are well or not. We have to treat them with respect and kindness.

The photograph is me on my grandfather’s lap. He became a psychiatrist and I am a family physician. Taken in 1962 or 3. We are at cabins in Ontario, Canada. What a pair of grubs, but happy…..

primary care medicine: schedule

I see patients from 8:30 or 8:00 am until 2:00 pm.

We have people say, “You are off after 2:00.”

Well, no. Most days I work for 2-3 hours beyond the patient contact time. Sometimes I come in early and sometimes it is from 2pm to 5pm and sometimes it is the weekend or into the evening.

So what am I doing?

  1. returning phone calls
  2. doing refills. To do a refill I check when the patient was last seen and whether they are due for laboratory.
  3. reading specialist notes and updating medicine lists, diagnoses and contacting patients to get tests or follow up that the specialist has recommended
  4. reviewing lab results and sending a letter or signing to be scanned and to be available at the follow up visit or calling the patient
  5. reading emergency room notes and hospital discharge summaries and setting those patients up for follow up, updating medicine lists and adding to diagnosis lists.
  6. dealing with multiple stupid letters from insurance companies questioning the medication that I have prescribed. Mostly I mail these to patients.
  7. running my small business: long term planning, short term planning, advertising, commercial insurance
  8. 50 hours of continuing medical education yearly
  9.  Updating my medical license, medical specialty board eligibility, business license, CAQH, DEA number, Clia lab waiver, medicare’s shifting rules, medicaid’s shifting rules, tricare’s rules, and 1300 insurance company’s shifting rules and medicine rejections and prior authorizations even for a medicine a person has been on for 20 years.
  10. Worrying about small business costs as reimbursement costs drop: health insurance. Retirement. L&I. Employees. Malpractice insurance, small business insurance, the lease, staff costs.
  11.  Discussing and updating medical supplies and equipment, office supplies and equipment
  12. Updating clinic policies and paperwork per the change in laws. Have you read the Obamacare Law? Over 3000 pages. HIPAA. The DEA. Recommendations from the CDC, federal laws, state laws, internet security, patient financial and social security security.
  13. Trying to track what we collect. That is, say I bill $200.00. Since I accept insurance, the insurer will tell me what is the “allowed” amount per me contracting as a “preferred” provider. The “allowed” amount is really the contracted amount. Then the insurance company either pays it or says that the patient has a deductible. This could be $150 per year or $5000.00 per year. With medicare I then have to bill a secondary if the person has it and then anything left is billed to the patient. Oh, don’t forget copays, if they don’t pay that we have to bill it. So to get paid the complete contracted amount, aka “allowed” we may have to submit bills to two or even three insurances and the patient. We might be done two months after the patient is seen.
  14. Trying to convince recalcitrant computers and printers and equipment that indeed, it doesn’t have a virus, oh, or maybe it does, and fixing them.

My goals are to give excellent care AND to work 40 hours a week. Half of my patients are over 65 and many are complicated, with multiple chronic illnesses.  When I saw patients 4 days a week for 8 hours, with an hour hospital clinic meeting every day, I also spent at least an additional 8 hours and more trying to keep up with most of those things above. The average family practice physician makes more money than I do. But they also report working 60-70 hours a week on average. I do not think this is good for patients or doctors or doctors’ families or their spouses or children. The primary care burn out report rose from 40% to 50% of the doctors surveyed.

We need change, we need it now, and we need to be realistic about how much work is healthy.

When I was still delivering babies, women would ask if I could guarantee doing the delivery. I would explain: “We do call for up to 72 hours. If you go into labor at the end of that, you would rather have a physician who is awake and rested and has good judgement. Besides, I’m a bit grumpy after 72 hours. ” And they agreed that they really don’t want an exhausted burned out physician.

I took the photograph of Mordechai, our skeleton, today. She is genuine plastic. I wish she would do some of the paperwork, but at least she lightens things by making us laugh. She gets various wigs and outfits and sometimes comes out to show a patient a hip joint.

I am NOT attracted to paperwork. I think I am repelled. For the Daily Prompt: magnetic.

 

S is for sloth

S is for sloth, the sixth of our seventh sins.

I took the photograph of my daughter a few weeks ago. She can’t be accused of sloth, though, because that was the day after a 12 mile mountain bike race. She came in first in the women’s 18-26 division. She also came in last, because she was the only one….

Dictionary.com at present:
1. habitual disinclination to exertion; indolence; laziness.
2. any of several slow-moving, arboreal, tropical American edentates of the family Bradypodidae, having a long, coarse, grayish-brown coat often of a greenish cast caused by algae, and long, hooklike claws used in gripping tree branches while hanging or moving along in a habitual upside-down position.
3. a pack or group of bears.

Webster 1913:
1. Slowness; tardiness.
These cardinals trifle with me; I abhor This dilatory sloth and tricks of Rome. Shak.
2. Disinclination to action or labor; sluggishness; laziness; idleness.
[They] change their course to pleasure, ease, and sloth. Milton.
Sloth, like rust, consumes faster than labor wears. Franklin.
3. Zool. Any one of several species of arboreal edentates constituting the family Bradypodidae, and the suborder Tardigrada. They have long exserted limbs and long prehensile claws. Both jaws are furnished with teeth (see Illust. of Edentata), and the ears and tail are rudimentary. They inhabit South and Central America and Mexico.

Just think of meeting a sloth of bears, eating blueberries, in the summer… I would not feel slothful then. And looking at the examples from Webster 1913, are we more slothful and sloppy with language than Franklin and Milton?

S

Sloth is a sin… but my daughter earned her rest…. and we all need to relax and rest sometimes and change our course to pleasure, ease and sloth…..

Recovering from influenza exhaustion

Influenza can cause swelling in the lung tissue. This is different from pneumonia, in that it is not fluid in the lung air spaces and different from bronchitis, where there is swelling and inflammation along the tissues lining the lungs.

In really severe influenzal lung swelling, the air spaces swell shut, the lungs are bleeding and bruised, and the person dies. Young healthy recruits in the 1917-1918 influenza would literally turn blue as they were no longer able to breathe and they would die.

If a person is still feeling exhausted after the initial week of influenza, they need testing to find out if they have lung swelling. This can be done at home or in your doctor’s office.

To test at home, the patient should sit relaxed for 10-15 minutes. Take a one minute pulse count: normal is 60-100 beats in one minute. Then the patient should get up and walk until short of breath. Sit back down and repeat the pulse. If the pulse is jumping up 30 points or if it is over 100 after walking, there is still lung swelling. The treatment is rest.

To test in my office, I add a pulse oximeter. I get a resting oxygen and pulse level, walk the person and then watch the recovery. The oxygen level will often drop and then rise to the sitting baseline as the heart rate recovers. Most people do not need oxygen if they have a healthy heart and healthy lungs to start with.

You can see why influenza would be so dangerous to someone with an unhealthy heart or lungs, because the heart can’t make up the difference.

I had influenza in 2003 and had lung swelling to where I could not walk across the room without my heart rate going to 132. Sitting, my heart rate was 100. My normal heart rate is 65-75. It took two months for the swelling to subside and mostly I lay on the couch. Be reassured that if you rest when you need to, you will recover.

The photograph has my father sitting and Andy Makie standing with the harmonica, at a music party at my house in 2009. Both my father and Andy are gone in their 70s, primarily from lung damage from cigarettes. Miss them both. Thanks to Jack Reid too.