Tag Archives: medicine

by

cancer pen

A patient told me about the “cancer pen” yesterday. I promptly picturedย  Star Trek’s Bones holding his device over patients, but no, this has to touch tissue…aka a piece of you…and do a chemical evaluation. It is to be used during surgery.

Here: http://www.bbc.com/news/health-41162994

This is neat new technology… but. I can hear my sister saying, “Uh, so what about PREVENTION?”

This is technology to remove cancer after it’s already grown. And presumably metastasized. So this is stage II, stage III, stage IV cancer.

Cancer deaths are the second biggest cause of death in the US. Around 23% of yearly deaths and that does not count the people who survive cancer. At present we do not have many screening tests for cancer: pap smears continue to evolve, and now the recommendation is an HPV test or pap smear every five years AND we have a vaccine for the high risk HPV.
We can screen for colon cancer.
Mammograms for breast cancer.
The screen for prostate cancer sucks.
We can do skin checks.
The screen for lung cancer is now a low dose CT in a certain population that is high risk, that is, smokers. The recommendations have not addressed smoking marijuana.
Recommendations in the US are here: https://www.uspreventiveservicestaskforce.org/.

There are lots of cancers that we don’t have screens for…. yet.

Proteomics is on the horizon. Genomics is looking at the genes, but it turns out that lots of cancers and infections and other illnesses have particular protein patterns. There is TONS of research in this area. Someday we may have protein tests: put a drop of blood or urine on it and say, “Hmmm. Looks like you have a positive test, probable lung cancer.”

That in turn creates problems. Initially we may be able to diagnose a cancer but not FIND it. Also not know how to treat it. The first big study trying to set up lung cancer screening had over 600 worrisome CT scans out of 1000. How many lung cancers did they find? Nine. And half of the nine had symptoms and could be found on chest xray by the time they did repeat CTs. Think of the anxiety of the 600 people who might have cancer and “We will repeat the CT scan in four months. Don’t worry too much.” Also there were complications from biopsying the lungs, like bleeding and pneumonia….

The best bet to avoid cancer is still living in a healthy way: don’t smoke anything, avoid addictive substances, eat good food, exercise, have friends and loved ones, work for yourself and your community, do some things you love…..

 

I took the photograph of my sister in 2011. She died of breast cancer in 2012. Her blog is here: butterfly soup.

For the Daily Prompt: strut. Struts support things: airplane wings, cars, things that move. How do we as a culture support people to live healthy lives?

by

My clinic and the state of medicine

January has been the busiest month in clinic since I returned to work in April of 2015 after the ten month systemic strep A hiatus. It took another ten months for my fast twitch muscles to start working again. I was working “half time” for the first ten months after I returned.

Right now, though, my receptionist and I are about maxed out. We saw 4-8 people a day in January, averaging 6.5, and with Martin Luther King’s birthday off. I see patients five days a week, try to stop by 2 pm and then do paperwork until 4 or 5. Lately I have been going in at 7 am, because I am feeling behind. Three very sick patients, one who has been sick and hospitalized nearly weekly since October, are each taking 1-2 hours a week and I can’t get to the routine paperwork. Labs, referral letters that need to go out, reading referral letters that come back and updating the med list, xrays, pathology reports….

Yes, we could hire someone to scan it all faster, but scanning it does not mean it has been read. And it is me that has to read it. One of the complex patients has five specialists and four different electronic medical records are involved. I had to call the rheumatologist, because the doc was not responding to the patient’s calls. I had sent the rheumatologist letters and updates: turned out the doc didn’t read any of them until the patient missed a visit because their car broke down. And another of the specialists said they “didn’t have the notes” from the other hospital. I wrote a letter to ALL of the specialists and said, the notes are in there because I faxed them to our hospital myself. Unfortunately scanned notes are difficult to find in the EPIC electronic medical record. Ironically both hospitals use EPIC but the two versions do not share their information. This is REALLY REALLY BAD. It is bad for patient care and bad for this specific patient. Not only that, but when one of the specialists orders something, the report doesn’t get sent to me as well as them. I tracked down labs and I tracked down an xray report and sent him back to the hospital at that visit. I do not know if the hospitalization could have been averted, but….I’ve told the patient and spouse that if ANYONE orders a test, call me. So I can track down the results.

So it looks like five clinic days a week, seeing up to eight patients a day, will take forty hours or more. This is a rural family practice clinic. I cannot see any way to see more and actually keep up with the information coming in with my patient population, half of whom are over 65. And an additional one is in hospice and another on palliative care.

A fellow doc has retired from medicine, in her 50s. She is “med-peds”: internal medicine-pediatrics, which is sort of like family practice except they don’t do obstetrics, less gynecology and less orthopedics. I hear that she is retiring because every 20 minute clinic visit generates an hour of paperwork. The hospital considers 4 days a week, 18 patients a day, full time. Ok, that is 72 patients a week, seen in four 8 hour shifts. 32 hours plus 72 hours of paperwork. One hundred and four hours. Can’t be done.

I dropped to 3.5 days in 2009 when the hospital said we had to see 18 a day. So 28 hours, 63 patients. 28 hours plus 63 hours. That is 91 hours a week. I still could not keep up with the information coming back from specialists, labs, xrays, pathology reports, medicine refill requests, requests for those evil ride on carts, spurious nonsense from insurance companies, and families calling about their loved ones. All ten fingers in holes in the dyke and 90 other holes spouting water.

Something has to give and something IS giving. Care is falling through the cracks and providers are quitting. I am not quitting, I just am not making anything anywhere near to the “average family practice salary” in the US. And we hear that burnout is now at 54% of primary care doctors. Hello, US. If we don’t go to single payer, you might have to ask your naturopath to take out your appendix. And good luck with that.

If I see 7 per day, five days a week: that is 35 patients. I do longer visits and more paperwork in the room, so call it 45 minutes of paperwork per patient. I see patients from 8:30 to 12 and 1 to 2. 4.5 hours five days = 22.5 hours plus (35 patients x 45 minutes)= 26 hours and now I am at 48.5 hours a week. And then if I have three really sick ones: more.

If we hire help, they have to be paid. Then I need to see more patients in order to generate that pay. Then there is more paperwork that I can’t keep up with. An infinite loop.

Let’s look at my clinic population verses county and state.
Clinic: 2.4% under age 18
20.7% age 19-50
28% age 50 to 64
48.9% over 65
Jefferson county (2014): 16.7% under age 19
51.5 age 19-65
31.8% over age 65
Washington state (2014): 29% under age 19
56.9% age 19-65
14.1% over age 65

We have an older county and nearly half my patients are over 65, and 77.9% of my clinic patients are over age 50.

And I should be reading all the new guidelines as they come out. The newest hypertension guidelines say that the blood pressure should be taken standing in all patients over age 60. Those guidelines are now a couple of years old. My patients tell me that I am the ONLY doctor that they have taking their blood pressure standing. The cardiologists aren’t doing it either. Just this week there are articles in the AAFP journal explaining the blood pressure guidelines. But the doctors need time to READ the articles. The guidelines themselves tend to be 400 pages of recommendations and explanations and a list of hundreds of studies reviewed since the last guidelines. And ok, there are also hundreds of guidelines. On blood pressure, who should be on aspirin, what to do for heart pump failure, urinary incontinence, osteoporosis, toenail fungus.

https://www.uspreventiveservicestaskforce.org/
guidelines: https://www.uspreventiveservicestaskforce.org/BrowseRec/Index
Ok, that is a list of 96 guidelines, which doesn’t even include the hypertension ones. The hypertension guidelines are called JNC 8, for the eighth version:
http://jamanetwork.com/journals/jama/fullarticle/1791497
Here is the two page hypertension JNC 8 algorithm: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf. Memorize it and the other guidelines, ok?
And here is the Guideline Clearing House: https://www.guideline.gov/

This week another clinic suddenly closed and we have gotten walk in patients and calls. About eight so far. We are booked for new patients out to April…..

I took this photograph from the beach as the sun set, camera zoomed. Different mountains were lit up while others were in shadow as the sun went down. This is Mount Baker and friends….

by

Prior authorization: call for comments

The Washington State Medical Association has called for comments on prior authorization rule making for insurance companies. https://wafp.net/prior-authorization-rulemaking-oic-call-for-comment/

Here is my reply:

I have a small solo family practice clinic. My business plan was arranged to spend more time with patients. I have an office manager and no nurse, no back office.

Thus all prior authorizations are done by me, with the patient in the room. Often patients have talked to their insurance company the day before and have been told “your doctor’s office needs to call us”. More than half the time, when I call, we are told that the patient’s insurance company does not cover that service. The patient says, “But I talked to your company yesterday.” The insurance representative responds: “I only talk to physician’s offices, that is another part of the company that speaks to patients.”

This is triangulation, where in the “standard” office, the patient has called their insurance. They call the doctor’s office as instructed by the insurance. The doctor’s office requests prior authorization. The insurance says it is not covered. The doctor’s office notifies the patient, who then assumes that the doctor’s office did something wrong, not that it’s not covered.

This is unacceptable.

I have stopped telling insurance companies that I am face to face with the patient, because some representatives say “I am not allowed to talk to patients, take me off speaker phone.” I document the name of the insurance person in the chart, the length of time for the phone call and I bill for time: counseling and coordination of care. Review by coders say that this is legal.

I suggest that every WSMA physician pick one day to call a prior authorization themselves with the patient present. This would reduce the insurance company triangulation.

I think that insurance companies should be required to tell a patient if a service is not covered, and not be allowed to say, “have your doctor’s office call us” for a service that is not covered.

Feel free to send YOUR comments to the WSMA! https://www.insurance.wa.gov/secure-forms/rules-coordinator/

I like slugs better than health insurance companies.

by

Dear Mr. Donald Trump

Two weeks ago I sent this letter to Mr. Trump and all of the presidential candidates. To date I have gotten a form letter from Mrs. Hilary Clinton.

Dear Mr. Donald Trump and all Presidential candidates:

Mr. Trump, I am a rural family practice physician, a woman, who owns and runs my own medical clinic. I take care of patients from age zero to 104. Currently my oldest is 98. I take medicare and most insurances, but not medicaid.

I am running into legal immorality across the board from health insurance corporations that are maximizing profits at the expense of my health care dollar, our taxes and my patients. I would like your advice.

For example, the Veterans Hospital contacted me in May of 2015 and asked me to accept Veterans Choice patients, veterans who live more than 40 miles from the nearest VA Hospital. I accepted. I have 6 veteran patients, who are very complicated. To date I have not been paid for one visit. Now, before you say this is the fault of our government, it isn’t. It is the private for profit government contractor Triwest who is not paying me. They have my notes and we have followed their instructions on how to submit bills. Would you advise me to drop these patients?

For example, my father died in 2014. I called the oxygen company to pick up 6 tanks of oxygen. Then I found 8 more. I gently inquired why he had 14 tanks. The company said that his medical orders said that he should wear it continuously, so they delivered it. “Medicare paid for it.” they said. Ah. Well, I kept the other 8 tanks, because it is my and my father’s oxygen in those tanks: the company can have the tanks back when they are empty.

For example, the head of the sleep apnea supply company came to see me. He said, “You are getting in the way of your patients getting needed equipment.” I said, “Really? How?” “You only allowed a refill of one of the 8 necessary pieces of CPAP tubing instead of signing off on the whole group so we can fill as needed.” “Ah.” I said, “Actually my patients are tired of you mailing them 8 pieces of plastic that are filling up their closets and they don’t want extra plastic crap.” He mails it at the interval allowed by medicare, never mind whether the patient wants or needs it.

For example, I called a patient’s insurance to get a prior authorization last week for a limited sinus CT. They no longer do prior authorizations. They will decide whether to cover the CT scan once they read my notes. I asked if there was ANY way to see if it would be approved. They offered to let me send a letter to a PO Box in Wisconsin. My patient was sick, Mr. Trump. What do you suggest the patient and I do?

This is all legal. But it is not moral. So, Mr. Trump, where do you stand? Is our country’s highest value free enterprise and profit at any cost, no matter how many of our seniors are legally ripped off? Or do we have morals that health care and our elderly are important and need to be protected from legal but predatory businesses.

Please let me know, Mr. Trump. I would rather stick with my small clinic in the United States. At this point I would be financially and emotionally better off working as a temporary doctor internationally. I am sure that there is immorality internationally, but I will be less ashamed when it is not MY country.

Thank you.

 

by

Fraud in medicine: prior authorization III

I see a patient who has had prolonged sinus symptoms AND her right upper molar has been irritated for weeks, but then Saturday it started hurting. She saw her dentist. The dentist did x-rays and said it’s her sinus. “But my tooth hurts too.”

On exam, her gum is bright red above the tooth, but not swollen as it can be with an abscess. No fever. No bright red spot over the maxillary sinus.

I call our independent radiology service and ask for a limited sinus CAT scan. She is off on Mondays only, it is Monday, she is out of town next Monday. Can they do it today? Yes, but she needs a prior authorization.

I call her insurance, after looking up the CPT code for sinus CT on google. As usual I have to enter numbers before I talk to a human:
patient insurance id number
my tax id number
my national provider index number
and others until I get a human.
Then I have to give the numbers AGAIN because the insurance company deliberately makes it inefficient, even though I have entered them into the phone it doesn’t transfer to the representative and you know that it COULD.
I give my name
patient’s name
patient’s date of birth
clinic address
clinic phone
clinic fax number
tax id
national provider index number
and finally explain: we need a prior authorization for a limited sinus CT and she has five ICD 10 symptom codes.
“She doesn’t need a prior authorization.” says the rep.
“What?” I say, “So it’s covered.”
“We don’t guarantee coverage, but we don’t give prior authorization.”
“What do you mean, you don’t guarantee coverage. I am calling to check.”
“We review the chart afterwards and THEN decide if it’s covered.”
“No. That isn’t good enough. I want to speak to someone who will check the codes and tell us if it will be covered.”
“I will have to transfer you to the (patient something).”
“Fine. Transfer our information please too.”
We go on hold. Time passes.
We are back to a recording:

TALKING TO A REPRESENTATIVE DOES NOT GUARANTEE COVERAGE OF A TEST. PRESS ONE IF YOU ACCEPT THIS.

No two. No other options are offered. I press one.
I talk to the new representative. “I have five diagnosis codes and want to know if the sinus CT will be covered. She is off and they can do it today. She is only off on Mondays.”
“We don’t do prior authorizations.”
“Isn’t there ANY WAY we can find out?”
“You can mail a letter to a PO box and we will review it and let you know.”
I am ….. hard to describe…. my head hurts.
“Would you like the PO box address?”
“How long does that take? Yes we want it. Don’t they have a fax?”
We get the fax number too. I hang up and look helplessly at my patient. “I think it will be covered. I would recommend we do it.”
“Ok.” She says. Her face and tooth hurt.

I call the independent radiology center and set it up for 2 pm.

They call back in the afternoon. She has a sinus infection and the tooth is bad too, they don’t quite look connected. I call the Ear Nose and Throat specialist who wants her on three weeks of augmentin if she tolerates it and then to see her. I thank him and get it rolling.

But….. ok, so the insurance companies contract with me and the patient say that they can change the benefits any time they want. They “notify” me with postcards with online links. Like I have time to read and remember the changes for …. 50 different plans? There are over 500 in the US.

When are we going to stop letting insurance companies take our money and refuse care and refuse to pay the physician and the radiologist? Medicare for all, one set of rules, I COULD LEARN THEM. I can memorize huge amounts of data: I am already busily memorizing the ICD10 diagnosis codes. There are only 48,000.

And I don’t know yet if her insurance will pay for the sinus CT…..

The picture is from Lake Matinenda in Ontario: no computers at our cabin, no outlets, phones mostly don’t work…. heaven.

by

Cost comparison of brain MRI

I called Advanced Medical Imaging (AMI) in May 2014ย to get a prior authorizationย for a brain MRIย with and without contrast.

This is for a woman under 65 who is having short term memory problems. We are looking for treatable causes of short term memory loss. The blood work is negative. Next is the MRI.

Her MRI is already scheduled at the local hospital where I worked for nine years. It is the only hospital because we are a small county.

The AMI representative suggested that the patient get the MRI in Everett.

“The cost there is $917.00. It would be cheaper. It is only 29 miles away.”

“Yes, but Everett is across the sound. She’d have to drive around or take a ferry. What is the cost in Bremerton?” I asked. “At the radiology providers there?”

“The cost there is $967.00.”

“And where she is scheduled?” My local hospital has a “Rural Hospital” designation. Medicare will pay them more than other hospitals.

“$4585.00.”

I squeaked. “For the same MRI?”

“Yes.”

“Um. You should tell the patient.” Except that, is the patient willing to drive to Bremerton? And is the cost to the patientย the same? And do they care?

“Do you want the prior authorization for that site.”

“Can it be changed if I talk to the patient?”

“Yes, she can call us.”

The prior authorizations are now site specific. That is, I’m getting approval for the MRI at a specific place. I have no idea why.* Seems stupid. Seems like just another hoop to remember to jump through and if we get it wrong the insurance can say, “Oh, ha, ha, ha, we don’t have to pay for that. You do.” Chalk up some more profit for the investors. Mission accomplished, money made.

I called the woman and explained. She was willing to go to Bremerton and said that she would call AMI. I asked her to call us back if she had any trouble.

The cost really matters to my medicare patients and any patient that has to pay a percentage of the cost. If they only have medicare part B, with no secondary, they pay 20% of the bill. 20% of 4500.00 is a lot more than 20% of $900. But some of my frailest most elderly most confused don’t really have a choice. Going 29 miles might as well be going to the moon.

And this is a woman with memory loss, remember? She wrote down the instructions and repeated them back to me three times.

Every phone call to insurance is like this, and makes me wonder about our culture.

* Actually, the authorizations are site specific because some places are “out of network” and the insurance won’t cover anything done there. Though I think the whole point of health insurance in the US is to try to remove money from people and avoid paying for care.

This was first posted at everything2 on Friday May 9, 2014. The womanย died last month.

by

Comparison of cost of abdominal CT with and without contrast

I keep reading that the US Health System should be a “free market” with competition.

To have an free market, one needs to be able to check the prices. I want to compare price tags. I have a patient who needs a CT scanย of the abdomen and pelvis with and without contrast. So can I, as a doctor, find out the price?

I start making phone calls:

I call AIM Specialty Health, a procedure clearing house hired by many insurers here, to get prior authorization for the CT of the abdomen and pelvis with and without contrast. They ask for the usual identifying information: my name, tax id, NPI number, patient name, insurance number, check my address, phone number, fax number. They ask for theICD-9 codesย — codes for the diagnosis. I know those. They ask for the CPT code, which is the procedure code for the test. I have to scramble to find the book and look it up: 74178. With the brain MRIย the other day they volunteered site specific charges. Not this time. The representative said they didn’t know. I asked for prior authorizationย in Poulsbo, since that was most reasonable for the brain MRI. I asked what the patient’s copay is: AIM does not know.

Call to Premara Blue Cross, which is the patient’s insurance company. They can tell me that the patient has a $10,500 deductible each year. She will have to pay that much before the insurance pays anything. I ask them what it will cost at different sites. They say they can’t give me that information.

Next I call 5 different sites to get the price for that CPT code/proceedure.
Call to my local hospital: Charged amount is $4200.00
Call to a free standing radiology clinic in Poulsbo: Charged amount $1416.00
Call to the hospital in Bremerton, south of us: $8958.00.
Call to a free standing radiology clinic further south in Silverdale:$1526.00 + $20.00 for contrast.
Call to the hospital in Port Angeles, north of us: $ 3101.70 for the facility fee. Gave me Radia’s number for the physician fee.
Call to Radia and left message.
Left message with patient.

Radia called back and the fee is $346.80, so that would be added to the $3101.70 at Olympic Medical Center.

Now I know the amount BILLED at five sites. However, that is not the amount my patient will PAY.

If the site is “in network” then the site has a contract with Premara Blue Cross, which states the amount that Premara is going to pay. The patient will get an EOB, an explanation of benefits, from the insurance. “Benefits” is an interesting choice of words. The patient has paid for the insurance so that they will cover the bills. Is that a “benefit”?

On the EOB, it will state the amount that was billed for the service. Next it will state the amount “allowed”. “Allowed” is misleading. To me it implies that the insurance has held the cost down. But the insurance “allowed” the site to be “in network” because the doctor/site signed a contract. So this is a contracted price or agreed upon price.

I want to know the allowed/contracted/agreed upon price.

Call to the WA State Office of the Insurance Commissioner. The office says that the patient should be able to request the allowed cost for a specific site. Each site has a separate contract with the health insurance, so the allowed cost could be different at each site.

Call to Premara Blue Cross. This time they say that it’s not that they refused the information, it’s that it was not available. Now the representative says that they need the “units or minutes billed.” I don’t know what that is, but I will find out. I ask if that is the only other thing that I need. They say yes, but I cannot contact the same rep directly. I have to go through the rigamarole each time: my name, my tax id, patient’s name, patient’s insurance identification number, my clinic address, fax number, phone number, sometimes the patient phone number. Usually I have to punch 4 or five of these into the automated system and then have to repeat it all when I reach a human being.

Call to Poulsbo. The units refer to 100 units of contrast. Some patients will need more, up to 200 units.

Call to Premara Blue Cross again. I go over everything with representative Hailey, who then wants to know the amount that Poulsbo is billing. Explained that I was told only the units were needed. She put me on hold and checked with Poulsbo. She is quoted the same price.

Continuing with call to Premara Blue Cross. Hailey has entered everything and doesn’t get a result. She says she doesn’t know. I explain that they have a contract with Poulsbo that names an actual amount. She transfers me to another department after 25 minutes. The representative there says that she can give the allowed amount information to the provider doing the test, that is, to Poulsbo. I explained that the WA State Office of the Insurance Commissioner says that a patient can indeed request that information. I asked if they are refusing it to the patient. Rep repeats that she can give it to that provider but not me. I offer to have the patient in for a visit and get them on speaker phone and again request the information. Without the information, I will strongly consider filing a complaint with the state insurance commission. She decides to transfer me. That’s at 30 min and I am again put on hold.

The call to Premara Blue Cross ended after 45 min and 37 seconds and the third representative in the provider relations department states that if they get a call from Poulsbo that they could tell THEM the contracted allowable amount. Again stated that the insurance commissioner’s office says that the patient can request the amount. Are they and will they refuse it to the patient? Representative Whitney says that she has access only to provider accounts and that the contract with Poulsbo is proprietary information*. I say that I think health insuranceย is also a contract between the patient and the insurance and surely the patient can ask what it will cost in advance. I stated that I would be calling the patient and the state insurance commissioner’s office again.

I talk to the patient. She will now call the insurance and ask the “allowed” amount for this site. I give her the diagnosis code, CPT code and units billed.

She calls back. Premara says “around $600.00”.

I call Poulsbo and ask if they will check the contracted amount. They call Premara. They call me back.

If she only has 100 units of contrast, the CT of the abdomen and pelvis with and without contrast will cost her $641.00, as the “allowed” amount by contract between her insurance and the radiology site.

I still do not know the “allowed”/contracted amount for the other four sites, so I have failed in my attempt at comparing price tags. I only know the amount the sites would bill. The “allowed”/contracted amount for each site could be different. The hospitals bill more because they have a “facility” fee. I think this means that they are allowed to factor in various hospital costs. Even so, it seems outrageous that one hospital bills twice as much as the other two and more than six times as much as the least expensive site, but the allowed amount might be lower then the billed amount.

I don’t think this is a free market. I think it is an obscured market. And this is just one procedure and one single charge. Think of a hospital stay.
AIM Specialty Health http://aimspecialtyhealth.com/about-aim/guidelines
Washington State Office of the Insurance Commissioner is at http://www.insurance.wa.gov/
Premara Blue Cross https://www.premera.com/wa/visitor/
* When I called about the head MRI, why wasn’t the information about what is billed at different sites proprietary then?

This was initially posted on everything2 on Friday, May 16, 2014.

by

sometimes the hummingbird

sometimes the hummingbird

Boa cat
meows
the meow that means she’s caught something
and wants to show me

and I go to look
it is a hummingbird
probably immature
dead

I pat her and praise her
Good Boa
I see what you caught

She taps the hummingbird
around the room a few times
but it is dead

so she eats it

and I’m crying

sometimes the hummingbird
gets eaten

and that is ok

by

Mad as Hell Doctors in California: October 5, 2010

October 5, 2010

Today I rejoined the Mad as Hell Doctors (http://madashelldoctors.com/) on the road trip, this time in California. This day was a mix of planes, trains, cars, single payer health care, social justice and neoprene.

The Mad as Hell Doctors have been two weeks on the road in California, doing town halls for single payer. Some doctors are there for the entire trip, some have come for a week at a time, many local chapters of Physicians for a National Health Program (PNHP http://www.pnhp.org/) have local speakers and local providers join us at the events. Each event is different, with a mix of our team and the local team. One more week to go, ending in Chico, California on October 12th. I am leaving my practice and my children for one week, the last week of the trip.

The previous trip was from Portland, OR to Washington DC, 26 cities and more than 30 town halls, a road trip across the United States. I joined the Mad as Hell Doctors in Seattle and participated for a week. I flew home from Colorado and then rejoined them for the last 5 days, ending in a rally across the street from the White House.

Up at 3 am and quick finishing my packing, left at 3:40 after kissing the kids. Drove from home to Sea Tac, about two hours, down through Bremerton and across the Tacoma Narrows Bridge as the sky is starting to lighten and then north on I5. I5 luckily not busy and not backed up. Left the car with some company on International Boulevard and rode the van to the airport. At the scanner after I checked one bag, security found a jackknife in my carry on. Rats. I did not have time to go back around and mail it home. I wonder what really happens to all the confiscated knives. On to the gate and the flight was boarding. Nice flight down to San Diego. We left at 6:50 am and arrived at around 9 am. I felt disoriented as soon as I stepped outside: the sun was too high in the sky and those palm trees are just wrong. The air is so dry after the Pacific Northwest.

I checked on a van to go meet my Mad as Hell Doctor compatriots, but it would cost $170. โ€œNo? How about $150? How much can you afford?โ€ The 3 pm train was $17.00 so I waited for that. I checked my bag at the train station and wandered around San Diego for a while, had breakfast.

At 3:00, the train moved out. San Clemente Pier was the third stop. The disembodied train speaker said โ€œYou should be going down the stairs and be ready at the doors: this is a very short stop.โ€ I was ready and the only one to get off. I rolled my bag along as the train pulled away. No one was there. Then I heard my name and from the ocean side a man was running, sort of, in a black shortie wetsuit with one yellow flipper in his hand and the other on his right foot. I must be insane, I thought, and got a very wet oceany neoprene hug from Dr. Mike Huntington.

I changed into my swimsuit and joined Drs. Huntington and Sapir (http://madashelldoctors.com/2010/10/05/california-road-trip-day-14-san-clemente/) in the ocean, my suitcase tucked up on the lifeguard tower. No lifeguard. The water was at a crisp 68, which is better than the usual Pacific Northwest 56 degrees. I bodysurfed for half an hour until I couldn’t feel my toes and my hands were turning bloodless and white. Changed back into clothes and we played frisbee on the beach, me with enthusiasm but little skill. Mark Sapir said, โ€œFirst chance to exercise in two weeks. I went running today and now everything hurts, so now we’re letting waves pound us in to the sand.โ€

We trooped back to the houses where they were staying and I met our hosts. Dinner with 14 people, kind and gracious hosts. Much discussion of medicine and politics. This was a day off for most of the [What I learned from my first Mad as Hell Doctors week|Mad as Hell Doctors], though Dr. Paul Hochfeld was at a talk given by a Physicians for A National Health Program California Chapter Fellow to medical students. He was back for dinner, reporting on the event.

This trip is streamlined. Currently there are eight of us. The trip is still 3 weeks, but with a little recovery time built in. Instead of staying in motels, we have stays arranged with PNHP members along the way. Phillip Kauffman is with us, saying that this trip is both easier and harder than the one last year. We have less paid support crew so more duties have fallen on him, but it is also a smaller group of people to coordinate. Dr. Hochfeld called him a โ€œbutterfly herderโ€ in his blog yesterday, but I still think we’re more like cats. I don’t think of butterflies as having the same sort of egos or defense weapons as cats. And I am delighted to return to the group. They are incredibly dedicated and stubborn and willing to go on fighting for single payer. They, or we, are ignoring the people that say, โ€œWhy work on this? The health care bill passed. You won’t get another for years and years.โ€ They might be right: but social change and social justice is not attained by sitting back, being apathetic or giving up. It takes dedicated people continuing stubborn work. I feel closer to these people after less than two weeks last year then some physicians that I have worked with for ten years: to be back on the road with the Mad as Hell Doctors is like coming home.

by

Old men never die, they just spout poetry

When I was in residency we rotated through the Veterans Hospital in Portland. Most of our patients were either very elderly or they were alcoholics or addicts in their 50s, starting to really go downhill medically.

One elderly patient is particularly vivid in my memory. He was in his 80s and black. He was weak and had various problems. I was not doing a very good job of sorting him out.

He wouldn’t answer questions. Or rather, he would give a reply, but it was not yes or no and I couldn’t figure out how the answer related to the question.

On the third day he gave a long reply to a question and I recognized it.

“That’s Longfellow,” I said. He nearly smiled. “We did a bike trip around Nova Scotia and read Evangeline aloud in the tents at night. The mosquitos tried to eat us alive. That’s Longfellow, isn’t it?”

He wouldn’t answer but the twinkle in his eye indicated yes.

So our visits were cryptic but fun. I would try to guess the author. He knew acres of poetry, all stored in his brain, no effort. I tried to relate the poems to my questions to see if he was answering indirectly. I wondered if he had schizophrenia and these were answers, but I didn’t think so. I thought he was just stubborn and refusing to answer.

I challenged him. “Ok, you are the right age. Come up with a song with my first name that is from early in the century. My father used to sing it to me when I was little. Can you?”

The next day he sang to me: “K-k-k-katy, beautiful Katy, you’re the only beautiful girl that I adore. When the m-moon shines, over the cow shed, I’ll be waiting by the k-k-k-kitchen door.”

We sat and grinned at each other. Soon afterward I moved on to the next rotation. I don’t remember his medical problems. But I remember him and remember wondering what he had done in his life to have a memory and a store of poetry in his head. A teacher? A professor? A man who loved poetry? I started matching him with my own store of poems, the Walrus and the Carpenter, songs, bits and pieces.ย  I felt blessed and approved of when his eyes twinkled at me, when I recognized an author or even recognized the poem itself. I looked forward to seeing him on rounds, daily. And he seemed to look forward to my visits. I was sad when I had to say goodbye and the next rotation was out of town. And since he had never told us his name, no way to stay in touch. Farewell, poetry man, fare thee well.