out

For the Daily Prompt: talisman.

What an interesting word. Talisman. What makes me feel safe? Where do I feel most safe, most loved, most joy?

Outdoors. Outside. With the birds, the deer, the trees. I am safest in the forest, away from people.

The latest news regarding Facebook and apps certainly reinforces that. I don’t trust technology, I don’t trust corporations, Big Data puts profit and money first, I do not trust people. Not in groups. Individually in clinic, yes. On Facebook, no.

And I realized the secret reason that I don’t twitter this week: I am a terrible speller. Yes, I am thinking of our twitter in chief and the spelling of counsel.

I would rather be outdoors trading songs with a bird than be indoors with a screen. Our television was turned off four years ago. I check varied news sources for a few minutes in the early morning. And then I turn them off.

Health to you and everyone.

Substandard

What comes to mind for today’s Daily Prompt: substandard?

As a rural Family Practice Physician, what comes to mind is the United States current health care system.

There is nothing substandard about our health insurance system: it does what it is supposed to, which is earn money for owners and investors. But it is frankly terrible at delivering health care, health care is not the goal, and we spend twice as much per US citizen as the next most expensive health care system in the world. And we do not have universal health care for our citizens and we rank below 30th in health care measures.

Wake up, US citizens. Let’s buy health care with our dollars, not health insurance. Single payer, one system, low overhead, clear rules and coverage and everyone in, no one out.

 

 

 

But I don’t want to pay for the obese smoking couch potato

I wrote this in 2010 and I am posting it again. It’s TIME, Congress, time for single payer, medicare for all! Lots of Senators are all talk about repealing Obamacare. One part of that law is that your health insurance company can ONLY keep 20% of each dollar for profit. The other 80% must be spent on health care. Before that, health insurance companies kept 30% of every health dollar. So tell me, US citizens, WHY do you want to repeal that? So health insurance corporation owners can go back to keeping 30% of every premium? Call you Senator and say NO.

And by the way, Senators who want to repeal Obamacare. You could have been writing a new bill with transparency and honesty for the last seven years, but all you’ve done is say “We will repeal Obamacare.” Saying “We can do better,” is boasting: you haven’t done the work. Stop hiding behind closed doors. I am submitting this to the Daily Prompt: hidden.

From 2010:

I went on the Mad as Hell Doctor’s tour for a week. I went from Seattle to Denver with stops for town halls one to three times a day. We are talking about single payer, HR676.

One question or objection to a single payer system was: Why should my money go to pay for some obese person who drinks and smokes, doesn’t exercise and doesn’t eat right?

Three answers to start with:

1. You already pay for them.

2. Put out the fire.

3. People want to change.

First: You already pay for them. As a society, we have agreed that people who show up in an emergency room get care. Suppose we have a 53 year old man, laid off, lost his insurance, not exercising, not eating right, smokes, drinks some and he starts having chest pain. Suppose that he lives in my small town.

He calls an ambulance. They take him to our rural emergency room. Oh, yes, he is having a heart attack, so they call a helicopter to life flight him from small town hospital to a big one in Seattle. This alone costs somewhere between $7000 and $12000. Now, do you know how many clinic visits he could have had for $7000? To see me, a lowly rural specialist in Family Practice where I would have looked at his blood pressure and nagged, that is, encouraged him to stop smoking. We would have talked about alcohol and depression. And who is paying for the helicopter meanwhile? All of us. The hospital has to pass on the costs of the uninsured to the rest of the community, the government is paying us extra, with a rural hospital designation. 60% of health care dollars already flow through the government. One estimate of the money freed from administrative costs by changing to a single payer system is $500 million.

Taking care of people only when they have their big heart attack is ridiculously expensive. It is a bit like driving a car and never ever doing maintenance until suddenly it dies on the highway. No oil, tires flat, transmission shot and ran into a tree in the rain because the windshield wiper fluid had been gone for a while. I get to take care of Uncle Alfred. He is 80 and has not seen a doctor for 30 years and is now in the hospital. “But he’s been fine,” says the family. Nope. He has had high blood pressure for years, that has led to heart failure, he has moderate kidney failure, his lungs are shot from smoking, turns out he developed diabetes sometime in the last 30 years and he’s going blind. Can’t hear much either. We have a minor celebration in the ICU because he doesn’t drink, so his liver actually works. He goes home on 8 new medicines.

Secondly: Put out the fire. When someone’s house is burning down, as a society we do not say, well, she didn’t store her paint thinner right or trim her topiary enough and she has too many newspapers stacked up. We go put out the fire. Putting out the fire helps us as a society: it keeps the fire from spreading to other houses. It saves lives and is compassionate. We think firemen and women are heros and heroines. And they are.

In the past, a homeowner would have to pay for fire service and would have a sign on their home. If the house was on fire and a different company was going by, that company wouldn’t put out the fire. We have the equivalent with health insurance right now. It would be much more efficient and less costly to have a single payer. Medicare has a 3-4% overhead: it is a public fund paying private doctors and hospitals. For private insurers the administrative costs are 30% or greater. That is, 1/3 of every dollar of your premium goes to administration, not health care. The VA is a socialized system, with the hospitals owned by the government and the medical personnel paid by them.

When someone asks why they should help someone else, I also know that they haven’t been hit yet. They have not gotten rheumatoid arthritis at age 32 or had another driver run in to them and broken bones or had another unexpected surprise illness or injury that happened in spite of the fact that they don’t smoke, don’t drink, eat right and exercise. Everyone has a health challenge at sometime in their life.

Third: people want to get better. Really. In clinic I do not see anyone who doesn’t hope a little that their life could change, that they could lose weight, stop smoking. True, there are some drinkers who are in denial, but I will never forget taking the time to tell a patient why he would die of liver failure if he didn’t stop drinking. He came back 6 weeks later sober. I said, “You are sober!” (We don’t see that response very frequently.) He looked at me in surprise: “You said I’d die if I didn’t stop.” He never drank again. It made it really hard to be totally cynical about alcohol and I can’t do it. People change and there is hope for change. I feel completely blessed to support change in clinic and watch people do it. They are amazing. But they need support and they need someone to listen and they need a place to take their fears and their confusion. Primary care is, in a sense, a job of nagging. But it is also a job of celebration because people do get better.

We are already paying, in an expensive, inefficient and dysfunctional way. It saves money to put out the fire. People want to get better. Winston Churchill said, “Americans always do the right thing after they have exhausted all other possibilities.” It is time to do the right thing. Single payer. The current bill is HR676. We can and we will.

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.

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.

Coming soon: The Unaffordable Health Care Act!

Coming soon in the United States!

Aren’t you sick of the Affordable Care Act? aka Obamacare? Time for a new administration and time to get rid of Affordable Care. We don’t want that! Competition, Corporations and Profit First!

Call Mr. Future President Trump, call you congress persons, call your senator, call your representative, call your state ones. Stand up and be heard, US Citizens! Tell them you are all for the Unaffordable Health Care Act! We can kill more small businesses faster! We can make doctors and nurses quit by age 50! We can have more people turn to addictive drugs for numbing and comfort!

Come on, US Citizens! You voted! Now call! The Unaffordable Health Care Act! brought to you by an all conservative all corporate all discriminatory group of unbelievably rich congresspeople and your stinking rich and suing everyone future president.

Or you could say you want Medicare For All! Hey, one system, one set of rules, all US citizens have care, we could start small businesses, business might return to the US since they don’t have to pay more and MORE and MORE for health insurance, wages would go up instead of yearly decreases in health care coverage….nah, US Citizens, you wouldn’t want that, would you?

W is for wrath

W is for wrath, the seventh sin.

From Webster 1913:

Wrath

1. Violent anger; vehement exasperation; indignation; rage; fury; ire.
Wrath is a fire, and jealousy a weed. Spenser.
When the wrath of king Ahasuerus was appeased. Esther ii. 1.
Now smoking and frothing Its tumult and wrath in. Southey.

2. The effects of anger or indignation; the just punishment of an offense or a crime.
“A revenger to execute wrath upon him that doeth evil.” Rom. xiii. 4.
Syn. — Anger; fury; rage; ire; vengeance; indignation; resentment; passion. See Anger.

 

Wrath is a sin, yet is it ever justified?

I am wrathful about this: http://www.npr.org/sections/health-shots/2016/03/23/471595323/drug-company-jacks-up-cost-of-aid-in-dying-medication

In my state a terminally ill patient may choose Death with Dignity: http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct

The person must be terminally ill, must not be suicidal and must go through a process. But one of the tablets prescribed, which only the person may administer to themselves, has had a price increase from $200.00 to over $3000.00.

I heard this from another physician, who has a patient who is going through the process.

I feel wrath and anger and hurt and rage that a corporation is choosing to make an enormous profit from terminally ill patients.

And so wrath may be a sin, but it is also an appropriate feeling at times.

In a sermon about forgiveness, hate is also discussed:

“Let me also say a word here about hatred, since I am speaking of forgiveness as being the release of hatred. Many  of us,  I suppose, like myself, have been taught not to hate.  We have been taught that hatred is always a bad thing and there is no place for it.  Thus, we feel uncomfortable in the face of this intense emotion and attitude.  Many times I have stumbled on the line from the biblical book of Ecclesiastes which reads, “There’s a time to love and a time to hate.”

Can there be  a time to hate?  Ironically, when  reflecting on the subject of forgiveness, I see that there is a place for hatred.
 
First,  your  hatred  lets  you  know  that  you  are  feeling  diminished  and  perhaps  being stepped on and treated as no human being ought to be treated.

Secondly,  your  hatred  lets  you  know  that  you’re  fighting  back  and  that  you  have something  to  fight  back  with.    It  lets  you  know  that  the  situation  is  intolerable  and  you will not put up with it.

And  so  hatred  can  be  a  natural  and  even  necessary  response  to  situations  that  threaten human dignity.  Says one author, “Not to feel resentment when resentment is called for is a sign of servility,… a lack of self-respect.”  (Forgiveness, Haber)”

From: November 15, 2009, here: http://www.quuf.org/index.php?page=2009—2010-sermons

p7
http://www.quuf.org/uploads/Sermons/Is%20Forgiveness%20Always%20Called%20For%20Part%20II%20Nov%2015%2009%20print.pdf

I took the picture in 2007. No wrath here, but three different expressions, and all complex….