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….

 

Patients or profit?

We can choose single payer, medicare for all, with overhead of 3-4 percent. That means 96-97 cents out of every dollar goes to HEALTH CARE, not PROFIT.

Or we can choose PROFIT:  the current law says that the private insurance companies have to spend 80 cents of every dollar on health care. 20 cents to PROFIT.

The insurance companies’ goal is to earn money, PROFIT, not give health care.  They are posting BILLIONS in profit.

The person on the phone who says your medicine or care is not covered? I think the insurance companies say that is health care. They are paying the person to refuse your care. They send us weekly updates on what has changed in the 1300 different insurance companies and I don’t know how many insurance plans because they all have more than one. You ask me, your doctor, if something is covered and I say, “I have no idea. It was covered last month. It should be covered. I don’t know.” The insurance companies pay people to write an individual website for every insurance company: 1300 websites. Can YOU keep track of 1300 log ons and 1300 passwords? And I think the insurance companies say that the money paid to set up the website is health care. I don’t think it’s health care, do you?

I want my health care dollar to go to HEALTH CARE not PROFIT.

Stop the bill. Stop the insanity. Stop putting INSURANCE COMPANY PROFITS in front of HEALTH CARE. We the people of the United States can decide and can tell Congress what we want.

Medicare for all, one set of rules, 3-4% overhead, we are one nation, under God, indivisible.

And we do not put profit first.

Physicians for a National Health Program: http://www.pnhp.org/

March for people

My daughter and I marched yesterday.

She decided to come home from college for the weekend, planning to leave Saturday night. I decided not to go to the Seattle Womxn’s march, but do the Port Townsend one and asked her to join me.

We went out to breakfast and then to our small downtown. I no longer have television and look at news sites daily though a bit erratically, so neither of us had a pink hat. I wore my Mad As Hell Doctors t-shirt, my lab coat from working at the National Institutes of Health with the National Cancer Institute Patch, my Rotary name badge and pins gathered from going across the country trying to get medicare for all, single payer health care, from 2009 until now.

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Four bus loads went from our county to the Seattle march. We heard that the Bainbridge ferry was FULL. That is, they couldn’t not take any more walk on people. Another thirty people or more flew to the Washington DC march. And in Port Townsend, my guess is that we still had 200-300 people, women, men and children, people in wheelchairs, babies, gay, lesbian, straight, bi, trans, that marched from a small park downtown to the Haller Fountain. Galetea, naked statue at the fountain, sported a pussy hat.

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Our local organizer spoke and our House Representative, Derek Kilmer.

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Older women spoke about demonstrating over and over in their lives. A friend of mine called me up to help her sing Holly Near’s Singing for Our Lives, making up new verses on the fly. They invited people to speak.

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I spoke: “I am one of your local doctors. I want to be able to treat anyone who comes to my clinic. We are one nation: health care for all. No discrimination: medicare for all.”

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Home then, and tired. My daughter has decided she wants to learn guitar, to play while people sing. I taught her basic chords and basic strumming. We sang Jamaica Farewell. She picks it up immediately, after all of those years of viola. And she will take one of my father’s guitars back to college.

And this is amazing: https://www.nytimes.com/interactive/2017/01/21/world/womens-march-pictures.html?smid=fb-share

Blessings all around.

Physicians for a National Health Care Program: http://www.pnhp.org/

https://dailypost.wordpress.com/prompts/successful/

Bruise, muscle and bone

I asked an older patient recently, “What is a bruise?”

She thought about it and said, “I don’t know.”

A bruise is blood, bleeding. Old blood changes color and is reabsorbed by the body as it heals. But where does that blood come from?

Any tissue in the body can bleed. Even a tooth, if broken into the center.

So what is bleeding for MOST bruises?

Muscle. Muscle, muscle, muscle, tendon, ligament, fascia, occasionally bone if broken and internal organs can bleed as well.

Somehow we entirely fail to teach this, at least in the US.

If you fall, or like my mountain biking daughter, hit something, your body will bleed. I tried to train the mountain bike team to carry an ace wrap and use it any time they hit something hard with an extremity. I pretty much failed. Why do I want an ace wrap and why use it immediately?

Trauma or hitting something hard causes bleeding. The more the muscle and tissue bleeds, the more swollen it gets. Usually the peak of bleeding and swelling is at about 48 hours after the injury. By then the body is sending immune system cells and repair cells to fix the trauma. It is swollen, red, hot, inflamed and painful! If we ace wrap our ankle or foot or elbow immediately, the bleeding stops faster. Wrap it, ice and elevate to keep the bleeding down. The torn muscles are held in their normal position, the bleeding stops more quickly, there is less swelling, less redness, inflammation and pain!

Our acronym is RICE:
Rest
Ice
Compression
Elevation

There are things that you can’t ace wrap: don’t ace wrap your neck or ribs and if it’s bad trauma to the head, neck, chest or abdomon, go to the emergency room! But even then, ice and compression help. First check airway, breathing and circulation, that the heart is beating if you happen on a trauma. But then try to use pressure on bleeding.

Do not put heat on a bruise for that first 48 hours. Why? It bleeds more and swells more. The exception may be if you do much more exercise than usual without a localized injury: hydrate, stay away from alcohol and a hot tub or hot bath may help. The hydration and hot water help the muscles relax and wash out the CK, creatine kinase, the protein from tiny muscle traumas that make us “stiff”.

The I in RICE used to mean ibuprofen as well. However, ibuprofen and aspirin and naprosyn are all blood thinners, so they may help with pain and inflammation, but may make the bruising worse. Acetominophen is not a blood thinner and also doesn’t do as much for inflammation, but it may be a better choice. It does help with pain.

In her third year of mountain bike racing, the Introverted Thinker had a quarter size bruise on her knee after a race.

“Are you going to do anything about that bruise?” I asked.

“No, it’s small.” she said.

“Ok.”

Two hours later: “Mom? Would you look at my knee?” Now the bruise is the size of an orange.

“Hmmm. What are you going to do about that?”

“I think I might ace wrap it and ice it and put it up for a while. Where is the ace wrap?”

Good plan. It didn’t get any bigger.

I see the handouts from the emergency room given for back pain and they are terribly misleading. It shows the spine and talks about the discs. 99% of the back pain I see is NOT a disc: it is the six layers of back muscles, and complex web of tendons, muscles and ligaments that hold the spine together and let us move in very complex ways. I pull my Netter Anatomy out daily in clinic and show people the six layers of back muscles.

What happens after a muscle is torn and bruised and bleeding? The muscle cramps up to stop the bleeding and attempt to keep from being torn more. No, I don’t like muscle relaxers much as medicines and they are useless long term. For sleep only right after injury. I am not talking about major trauma, but back pain and injuries.

If the muscle heals in the cramped position, it won’t work right any more. It can form scar tissue. It takes about six weeks for a muscle or ligament or tendon tear to heal and during that time we need to gently stretch the muscles without tearing them, so that they heal in the right position. Once they are healed in a scarred position, it’s more work to rehabilitate them, but it can be done. Physical therapy, massage therapy, chiropractor, acupuncture, but the most important work is done BY the patient, not TO them. I can’t fix it with pills. Yes, it is work.

You can bruise bone too. Ow. The surface of the bone is living cells and the bones are continually torn down by osteoclasts and rebuilt by osteoblasts. The bone can be bruised without breaking. Again, 6 weeks to heal, little kids faster and 90 year olds kind of slow.

Take care of your muscles, ligaments and tendons, and they will take care of you.

 

I took the photograph on the first Mad as Hell Doctors tour for health care for all in 2009. I will be marching again today:  WE ARE ONE NATION! HEALTH CARE FOR ALL! NO DISCRIMINATION!  MEDICARE FOR ALL!

 

Your health care dollar

I have been writing posts about fraud in medicine: but I think I am using the wrong title. Instead it should be your health care dollar: how the US medical corporate system wastes your health care dollar.

Think about it. What do you want to spend that dollar on?

Do you want it to go to 1300 different insurance companies and their web sites, their advertising, their competition and their profit? Do you want your healthcare dollar to go to complex coverage rules and contracts, to forms for prior authorization, for the weekly postcards and emails that they send me telling me that they have changed your coverage? Is it any surprise that I have no idea if your insurance company covers a test? They may have last week and not this week. The overhead for medicare is 2-3% administrative costs. Now why would we privatize that when the overhead for the health insurance companies is 20-30%?

How much of your health care dollar do you want to go to corporate competition?

I don’t want ANY of my health care dollar going to corporate competition and profit. I want my health care dollar going to my HEALTH. We spend the most per person in the world, almost twice as much per person per year as the next most expensive: and we don’t guarantee care. Hello, the next most expensive and all of the other nearly 40 countries, first and second world, have universal care for all their citizens. So is our care twice as good?

No, no, no, and no.

Hello, new administration. Let’s put the health care dollar where it is paying for health…. in medicare for all and in a single payer system. We have guideline after guideline on how we should treat illnesses, here:

US Preventative Task Force

The guidelines are regularly updated. If we have medicare for ALL then I will KNOW whether a test is covered or not. I have memorized the entire list of medicare covered screening tests and all the details: screen for abdominal aortic aneurysm is covered in male patients age 65-75 who have smoked more than 100 cigarettes in their life and any patient who has a family history. I have the whole list in my brain.

You CAN make a difference. Write to your congresspeople, state and national. Call them. Email them. They all have websites. Tell them YOUR health care story or the story of a friend or family member.

Join Health Care Now and Physicians for a National Health Program.

I want my health care dollar to go to HEALTH CARE.

For the Daily Post Prompts: gone and interior. Interior because I am so angry at the poor spotty costly health care for my fellow people in the US. And gone: your health care dollars is GONE: let’s use the next one wisely.

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.

http://www.aafp.org/about/policies/all/rural-practice-paper.html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071163/
http://healthleadersmedia.com/content/COM-208773/Physicians-Offer-Insights-on-Practicing-Rural-Medicine.html
http://www.siumed.edu/academy/jc_articles/Distlehorst_0410.pdf
http://doctordrain.journalism.cuny.edu/the-broken-system/family-practice-just-doesnt-pay/
https://www.aamc.org/newsroom/newsreleases/358410/20131024.html
https://www.washingtonpost.com/news/to-your-health/wp/2014/05/22/how-many-patients-should-your-doctor-see-each-day/
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.