Tag Archives: healing

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Long notes and unhappy patients.

A patient of mine saw a cardiologist recently.

His previous cardiologist has retired. The patient had a cardiac bypass in the past, he has a stent, he has known coronary heart disease and he’s in the young half of my practice. That is, under 60.

He had not seen a cardiologist for 2-3 years because he had a work injury, worked with Labor and Industries, the case was closed, he couldn’t go back to work, he found a lawyer. He lost his regular health insurance along with the job, so couldn’t see the cardiologist.

The L & I case is reopened. A physiatrist recommended specific treatment that was not done, and that allowed the case to reopen.

The specific treatment center then notes that he has heart disease and that he needs clearance from a cardiologist. I set him up with a new cardiologist.

“How was the visit?” I ask.

He shrugs. “The staff was nice.”

“I have the note.”

“The cardiologist spent under ten minutes with me. It was clear that she was rushed. She did not seem very interested. It was difficult to get my questions answered.”

“Her note is six pages.”

He snorts. “Great that she could get a six page note out of that visit.”

“Do you want a copy?”

“No.”

He is cleared for the specific treatment.

I have no doubt that the cardiologist spent more than 6-8 minutes on his visit and his note. But not in the room. Other people are entering the information filled out in the waiting room, medicines, allergies, past medical history, family history. Hopefully the cardiologist is reading my note and letter. But the problem is, doctors aren’t doing it in the room. So the impression left with the patient is that we spend 6-8 minutes on their visit, we are late, we are rushed. Doctors are looking at data. They are not listening to patients.

Medical Economics, a journal that arrives without me asking for it, says over and over that we need more physician “extenders”, that we need to have people doing the data entry, people doing the patient teaching, more people and machines….No. They are wrong. We need LESS barriers between us and the patients, not MORE. We need more time with patients. Every single extender we add burns physicians out more, because the salary has to be paid AND more patients seen faster to do that AND we are still ultimately responsible for knowing and reading and absorbing every single piece of information that is placed in that patient’s chart. An extender is NOT an extension of my brain and an extender is another person I have to communicate with and train.

Just. Say. No. to the managers who pile MORE barriers between the physician and the patient. NO.


It just makes me so mad that he lost his health insurance BECAUSE he got injured at work and so then his heart disease goes untreated as well… can’t afford medicines…if he then has a heart attack while uninsured we lifeflight him to Seattle, it costs a fortune, he loses his house and property and then is on medicaid and may end up on permanent disability, and what are the chances he returns to work? The US medical corporate money grubbing is insane. Single payer, medicare for all, make the US great again.

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Heart and brain and alcohol, 2018

For the Daily Prompt: infect. Maybe heart and brain health could be an infectious idea…..

Heart disease is the number one cause of death in the US, around 24% of deaths every year. Strokes are fifth most common cause of death at 5%, dementia sixth most common at 3.6%, data here from 2014. Accidents have beaten strokes out for fourth place because of “unintentional overdose” deaths.

I did a physical on a man recently, who said what was the best thing he could do for his health?

“Reduce or better yet quit alcohol.” is my reply. Even though he’s within “current guidelines”. I showed him the first of these studies.

Two recent studies get my attention for the relationship between the heart and the brain and alcohol.

In this study: http://www.onlinejacc.org/content/64/3/281, 79,019 Swedish men and women were followed after completing a questionnaire about alcohol consumption.

They were followed from 1998 to 2009 and 7,245 cases of atrial fibrillation were identified. The relative risk for atrial fibrillation was alcohol dose dependent: that is, the people who did not drink had a relative risk of atrial fibrillation set at 1.0. At 1-6 drinks per week the risk was 1.07, at 7-14 per week the risk was 1.07, at 14-21 drinks per week 1.14 and at >21 drinks per week 1.39. They also break it down by number of drinks per day. So why do we care about atrial fibrillation? “Atrial fibrillation (AF)/atrial flutter (AFL), the most common cardiac arrhythmia, is accompanied with a 4- to 5-fold increased risk for stroke, tripling of the risk for heart failure, doubling of the risk for dementia, and 40% to 90% increase in the risk for all-cause mortality.”

Atrial fibrillation, stroke, congestive heart failure, dementia and 40-90% increase in all-cause mortality. Want to protect your brain and live longer? Quit alcohol.

Well, that instantly decreased my enthusiasm for alcohol, now down to one drink per week if that.

Here is a second study: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30134-X/fulltext?code=lancet-site

“Findings:
In the 599 912 current drinkers included in the analysis, we recorded 40 310 deaths and 39 018 incident cardiovascular disease events during 5·4 million person-years of follow-up. For all-cause mortality, we recorded a positive and curvilinear association with the level of alcohol consumption, with the minimum mortality risk around or below 100 g per week. Alcohol consumption was roughly linearly associated with a higher risk of stroke (HR per 100 g per week higher consumption 1·14, 95% CI, 1·10–1·17), coronary disease excluding myocardial infarction (1·06, 1·00–1·11), heart failure (1·09, 1·03–1·15), fatal hypertensive disease (1·24, 1·15–1·33); and fatal aortic aneurysm (1·15, 1·03–1·28). By contrast, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction (HR 0·94, 0·91–0·97). In comparison to those who reported drinking >0–≤100 g per week, those who reported drinking >100–≤200 g per week, >200–≤350 g per week, or >350 g per week had lower life expectancy at age 40 years of approximately 6 months, 1–2 years, or 4–5 years, respectively.”

Ok, over half a million people followed, 40K+ deaths, 39K+ heart events (heart attack, atrial fibrillation, new congestive heart failure, etc), that’s a pretty impressive study.

A 5% 12 ounce beer is 14 grams of alcohol. Here: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink. Our local brewery and pourhouse usually serve pints, 16 oz, and the range is from 5% to over 9% alcohol. Two 9% pints is how many standard drinks? You do the math. Currently the recommendations in the US are no more than seven drinks per week for women (98 grams) and fourteen for men (196 grams) per week, no saving it up for the weekend, no bingeing. The UK stops at 98 grams for both men and women. The rest of Europe goes higher.

Heart and brain, how I love you! I like my brain and don’t want to pickle it. I think I’ll choose heart and brain over alcohol, long term over short term, health over escapism.

Have a great week!

More:
https://www.sciencedaily.com/releases/2018/02/180220183954.htm

https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30022-7/fulltext

http://www.acc.org/latest-in-cardiology/articles/2016/08/26/16/48/consumer-news-stroke-esc-2016

I took the photograph. It reminds me of neurons in the brain.

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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.

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door into spring

This is for Norm2.0’s Thursday doors: my front door this past Saturday. It was so gorgeous and the plum flowers opened and opened.

Prayers for a friend of mine, who called in the night, and was in the emergency room last night. All healing thoughts, prayers, denominations accepted…. with grateful thanks.

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red door 2

This is also for Norm2.0’s Thursday doors, and also today, taken at around noon. The snow is disappearing very fast, but there are still treacherous ice patches in any shadows and it will all freeze again tonight…

I am having an Interesting Week, with simultaneous dental/medical/eye stuff. I get to see my FOURTH doctor this week this afternoon. Emergency root canal two days ago and antibiotics and pain medicines, so I am on the wrong side of the stethoscope this week. I would rather work than see doctors, wouldn’t you?

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without a net

For photrablogger’s Mundane Monday #148: clothes hanging.

I was out from work very sick in 2012. I had strep A in lungs and muscles, including throat muscles. I could not talk. I put my hammock up in a tree, high up. There was no one to talk to there, just the leaves and wind and birds and sky.

And here are some socks and another view:

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I could watch the deer from the tree.

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It was a very good place to be quiet and heal.

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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.