Structure

How to structure life in retirement is a question I will spend hopefully years answering. This blog will be a part. I intend to return to it and resurrect some old posts, add new ones detailing both my experiences through my career and answering this “what’s next?” question. It has been said that one picture is worth a thousand words. I hope to tell much of the rest of my life in the art I produce but here are morning photos from my studio previously our eldest son’s bedroom.

Back to work  retirement.

Transitions

There have been many transitions in my life and in my career but none so definitive as leaving the practice of medicine. I reflect on this daily having begun to make the decision two years ago and now in the final weeks I am sure. I am glad that I am walking away and not being forced out. I am honored that there are people who are sad I am leaving rather than relieved to see me go.

Where am I going? Home mostly - a place that I made but never enjoyed as much as now. Ask my dog - I sketched his picture for you in pastels here

His name is “Jimmy” and he has become my muse as I purse drawing and painting. Another title I have given him is studio assistant. He is currently sound asleep by my side. 

My goal is to have more to say about the past, the present and the future in the days to come as I remain “the local MD.”

Wouldn't it be nice...

...if there were as much of an uproar in this country over say, gun violence, as there has been over Ebola?  I could pick several other topics for Congress, our state and local governments to get as serious as those institutions have been in the last two weeks about the threat of this disease in the past two weeks.

Edgy

The third definition of edgy on dictionary.com is: "daringly innovative; on the cutting edge" I have been a little on edge recently and I hope I am about to be daringly innovative.

Some of this edginess is just my age, I will be fifty nine and a half in a little over a month. For those of you too young to realize this, that is the age when you may, penalty free, drawn money from your retirement account.

Another aspect of my edginess is the time of year. June is when the current resident class will graduate, take their written boards, and enter the world as practicing obstetrician-gynecologists. Yes, this is a time of pride for these physicians and for all of us who hopefully contribute in ways great and small to this accomplishment. The patients contributed in great ways and we professors relatively small ones. I hope these young physician realize that to be successful they will have to keep on learning from patients. That is why we call it practicing medicine and not knowing medicine.

But the reason residents graduating makes me edgy, besides all that they don't know yet, is the fact that everyone moves up a level on about June 15 and some newly minted MDs arrive on July 1st.  That along with the fact that graduate nurses, respiratory therapists, surgical technicians, new social workers, and just about every other type of provider you can imagine will be in a brand new position on July 1st. Some seasoned nurses and administrators take the month of July off.  The problem is illness will not.

Luckily, September, the ninth month after the winter holidays will still be two months away. For those that do not realize it, human gestation is 9 months, and in celebrating the winter holidays most couples hold the belief that their god of creation will not allow them to make another human being despite the lack of effective contraception during this time.  I digress.

Other than my age, and the coming season of healthcare madness, my edginess is most likely due to the blatant bitterness I see exhibited on a daily basis toward the patient that I treat.  I deal with it in myself.  Delivering a set of twins to an eighteen year old mother of a toddler and wondering how she will take care of herself and these three children without a high school diploma is overwhelming.

Rick Santorum and I agree on one thing: A girl having a child before she is educated enough to be able to support herself and that child is a ticket to poverty.

I have watched this played out hundreds of times in the past five years. My city is the national leader of teens having more children before they reach majority.  My edginess is from the fact that I am not seeing much hope for change here.

Shell game

A family member just had a recent medical procedure and I reviewed the bills this morning.  Since this has become a rather routine procedure for two members of my family, and because we have a high deductible insurance policy, I have become astute at looking at the claims.  For this procedure, there are always four statements: One from the endoscopy center, one from the anesthesia provider, and two from the physician for both the procedure and the medical assessment justifying the need for the procedure.

In round numbers we paid $200 for the medical assessment.  For this my husband sat in the doctor's office for 45 minutes, answered a questionnaire, got weighed and blood pressured before his 5 minutes with the doctor.  The procedure itself cost $1200 and took 15 minutes of the doctor's time.   He did spend another 5 minutes explaining what he had done but multiply that by the 15 procedures he preformed that afternoon and I believe you will see why every medical student wants to subspecialize.

Now, least you think that is all the income this physician had from his afternoon (1:30 to 5:00 PM) worth of work, let me explain about the anesthesia and endoscopy center.  This endoscopy center is owned by the doctor and 9 other doctor's who do similar procedures.  They built it because of the money they saw the "not for profit" hospital system making in a similar fashion.  The final piece is anesthesia.

When I inquired, I was told there was no anestheologist on the premises.  This is a free standing center, 5 miles from the nearest hospital.  Five miles in city traffic.  The "anesthesia" is IV sedation.  You can sometimes get this in a dentist office (but I would not recommend it).  It is two drugs, fentanyl and versaid.  The first is a pain killer that makes you go to sleep and the second is a short acting valium type drug.  It makes you forget.

The person pushing these drugs is a certified nurse anesthetist.  I use them all the time in the hospital, where there is an anesthesiologist (read that one doctor who has been to medical school and done a residency in anesthesiology).  I have no problem with nurse anesthetists.  This is not the reason I am writing this.

My problem is that the doctor supervising this anesthetist is the same one doing the endoscopy.  He may (or may not) have had any anesthesia training.  He may or may not know how to take care of the patient should his heart or breathing cease.  For this we will pay the same $1500 that we would have if we had been in the hospital.

I ask where the money goes.  While I am asking, I am multiplying the $1500 by all the people I saw leave the waiting room while I waited on my husband.  This is probably somewhere in the neighborhood of 30.  We were only there for 2 hours.  Well, it's complicated, I was told.  Discuss it with the doctor.  Actually, he was quite happy to brag to me that this was the most lucrative operation he had been apart of in his 20 plus year career.

Before, the hospital got the money.  Now he gets a lot more of it.  Which demonstrates what medicine is all about:  Getting the most money possible from each patient.

Thoughts for the day

Sitting in my dirty scrubs, too tired to get a cup of fresh brewed coffee, I wonder why I have not done more with this blog.

Reading the facebook news, I see an Eleanor Roosevelt quote, "When will our consciences grow so tender that we work to prevent human misery rather than to avenge it."

Four years ago I felt I could change a lot.

This morning, I feel the only thing that has changed is me.

An extra hour

Well, I have managed to stretch the extra hour from falling back into three.  I have been assisted by the fact that this is the first morning in eight that I wasn't at work or going to work.  Seven days of twenty four hour every other day shifts cannot be healthy but that is not what I have been contemplating this morning.

I began by updating my facebook time line.  I know, everyone else did that three years ago but it is the reason I found the next activity, which was watching Jonathan Haidt (http://www.ted.com/talks/jonathan_haidt_on_the_moral_mind.html).  Also, I am not very good at writing on my iPad via facebook.

Anyway, I am now going to enjoy some of this glorious weather with a walk.  This is the day I will be thankful for not only this hour but all the hours in it.

'Modern' Medicine

I haven't written here in awhile.  It is not that I haven't written.  The reason for my absence is job related and I really cannot get into that story at this time.  Yet, I need a place to keep all my thoughts about medicine, the practice of it, and what it is like to be a physician in this time we call postmodernism. 

Take my father's stay in the rehabilitation facility for instance.  (I will write about his admission to the hospital in another post.)  He has been here now for a little over a week.  I must say, I have seen real progress.  But last night they restarted his the intraveneous fluids that he needed two weeks ago.

I was shocked when I came in this morning.  He ate and drank yesterday better than he has in over two weeks.  When I ask, I was told his creatinine is elevated.  Yes, it is.  It has been for TEN YEARS.  We have gone to the same hospital system for the past two years.  I have discussed this elevation with nine different physicians.  I have discussed it twice with his current admitting physician. But the tenth doctor was on call last night when someone notice the blood work which was drawn 12 hours before.  So the pearl for the day?  The electronic medical record is only valuable when someone reads it. 

"the difference"

You have heard it before.
Termed "The Serenity Prayer," the saying goes something like "God grant me the courage to change the things that I can change, the patience to accept the things I cannot change, and the wisdom to know the difference." 

Wisdom is key. 

Yes, you need courage to tackle the tough issues especially those of injustice and inequality in a land flowing with, well, if not milk and honey, then certainly flowing with information and money.  Patience is also required.  Real change comes slowly usually with Herculian effort, especially where hearts and minds are concerned. 

Knowning the difference in what can be changed and what must be accepted, even termporarily, to bring about a since of community and peace, is real wisdom. 

I will ...

not complain.

If I have in the past I am sorry. Please accept my apology and remind me, should I voice my discontent in the future that each day is a gift. While I am not perfect, it is my sincere hope that I can be grateful for each breath and live the moments, hours, and days given to me with grace.

Tough love

I will always be grateful for the depth and breathe of experience life has given me.  It is from this well of experience that I now draw in hopes of helping.  I am sure you have heard someone say, "An ounce of prevention is worth a pound of cure."  Prevention is where I hope this is headed.  For C, cure is now impossible.

As you may have guessed, C is dead, felled by the number one killer of Americans under the age of thirty-five.  He took his own life.  C had been involved with drugs, violence, and had threatened suicide in the past.  His parents were employing "tough love" to deal with his problems.  From what I have read, "tough love" is a way of dealing with troubled youth, especially those addicted to drugs.  Since he had threatened suicide in the past C's parents were told this was manipulative behavior and to ignore such a threat. 

I believe all love is tough at some point in time.  All parents experience this when our children push against our rules. It is tough to say no, mean it, and meed out the consequences.  Almost any parent will tell you, kids on their way to adulthood will push you to your limit and often past it.  That is when love is tough. 

I understand not enabling someone with substance abuse problems.  I do not understand not taking a suicide threat seriously.  I write this as I grieve for C, for his parents, for his friends.  I want everyone to take a suicide threat seriously.  While I maybe a professional, trained to assess the risk of such a threat, I can tell you that in the face of such as situation with one of my own family members, I would not stop until a thorough assessment could be carried out by an unbiased professional.  The threat of suicide is a serious cry for help.  Giving or getting help may be tough, but that is love.

On 9/11/2011

One of the attributes which makes us human is the ability to analyze the past and plan for the future. While it is easy to hold the picture of the twin towers of the World Trade Center burning and falling to rubble in my mind's eye, it is much more difficult to find pictures of peace and reconciliation. That first image of the towers is followed by those of the night raid bombings on Afghanistan, the ground war there and the invasion of Iraq. Ten years of fight is what I think of when I think of my sons who have grown from 10 and 12 year old boys to young men of 20 and 22 years.

An image I have tried this week to pair with that of the burning towers, is that of women dressed in white bonnets, holding hands, heads bowed in prayer. These are the women of the Amish community in Nickel Mines, Pennsylvania. Yes, I had to look up the name and I submit to you that their way of life is as foreign to most of us as the people we blame for those attacks ten years ago. If yo follow my facebook status, I left an interesting article there yesterday. My warning was to read all six pages. I guess no one did. Or if you did you did not "like" it.

There was a great deal of news surrounding the murder of the ten young girls in an Amish school house in Nickel Mines, Pennsylvania on October 2, 2006. A wealth of information is available on the Internet. Yet, the main image my mind goes back to on that day, now almost 5 years ago is the one of the women praying. News of the community has died out. Pacifist behavior does not sell many newspapers. It seems that the gunman's children are growing up without retaliation from the families of the victims.

One this day, when we remember the 2,996 individuals who died in those attacks, as we listen to their families, whose lives have forever been changed, could we please also weave some modicum of forgiveness into our beings. Violence begets violence. This is the truth of 9/11 for me. I have watch as a generation of young Americans has grown up with the idea that to make our world safe, wars must be fought. 1,680 Americans have lost their lives in Afghanistan in the past ten years. 4,792 Americans have been killed in Iraq since the current war began there.

There must be a better way forward on this planet. Please, I beg you, speak peace. Teach peace. Most importantly, live peace. Everything has to begin somewhere. What are the words to that old Christian camp song? "Let it begin with me."

A new address

All my thoughts about the work I do are being posted "In the belly of the big house." I have not found a way to move them here without destroying "the local MD." I can leave that blog totally since the physician in the big house is the local MD. To continue reading you will have to look here: http://inthebellyofthebighouse.blogspot.com/ at least for now.

The next moment

Looking in amazement at scores of New Year's resolutions, I realize that each moment of life is a chance to resolve to do better. Why do we wait until the calender rolls over to a new year? Why not constantly resolve to be kinder, fitter, smarter on a moment by moment basis?

With that in mind, I am going to be blogging from a new place in 2011. I am no longer "the local MD." I am a hospitalist. For the most part, I take care of those patients who have no physician. These patients have fallen through the cracks, usually of society first and the health care system second. Many are homeless, several are addicted to one substance or another, some are in this country illegally.

So, a new blog, possibly a new address, and yes, it is about to be a new year but where medicine, and life really, are concerned, I believe the goal is always the same: To do better. I tell my residents it is why we call it "practicing medicine." We may be perfect for a moment but in the next there is a new problem and a new challenge.

To the challenge of 01/01/11 00:01.

Sports and politics

I dressed in black this morning. At first I thought this was in mourning for my favorite baseball team, beaten in the World Series last night by a superior team. Then I realized it is election day. Oh, don't get me wrong. I have waited for this day for months. I cast my ballot weeks ago when early voting opened. I can't wait for all the yard signs to disappear and the negative ads to be gone from television and radio. Yet, in a moment of reality this morning, I realize that, just like the baseball game last night, this election cycle is another lost opportunity.

Going back to baseball, I liked the San Francisco Giants. I rooted for them against Atlanta and the Philles. They were the National League team I wanted to see in the World Series. I was surprised at myself when I began to feel something akin to hate in game 1. However, I think I can like them again, those young, quirky pitchers, that awesome catcher, who I don't think shaves every day, and a bunch of ol' guys who already have World Series rings from by gone eras on other teams. As I pulled on my black shirt, I realized they are just like my team in that they had hope and heart and they wanted to win. Really it was just the bounce of a ball back in San Francisco that gave them the momentum to do just that.

The change, the anger, rage really, that is sweeping this country is much different from fan excitement in sports. I have listened carefully to Mr. Boehner, who in all likelihood will be the next speaker of the House, for the past two years. He has been on a mission to discredit everything the current administration has tried to do. It is clear that Mr. Boehner cares about one thing - winning. If gridlocking Congress will accomplish that goal, then by all means, he and his colleagues were happy to do it.

Just as my Rangers made some errors, the other side carries some responsibility for their plight at the end of this day. From where I sit as the local MD, government has done little to help any of us through this quagmire that is the healthcare system. Yet, I am hear to tell you that our emergency rooms cannot continue to be the front line for care for what are ever increasing scores of uninsured people. It is an impossible task and it is also bad business and bad medicine.

Change

I am pretty sure what ever you choose to call my generation, officially known as the "baby boomers," the "me generation" would be a better fit. I see this everywhere. Many of us drive big, gas guzzling cars, live in homes with enough square footage to graze cattle, and believe that the current government is trying to take all of this away from us by taxing us to death. So, this election cycle, I have chosen to sit it out so to speak.

Oh, I voted. Yes, I was at the polls the first week of early voting with my choices for the least worst candidates in many cases and in some, those candidates who I think will preform rather well. I have "Had Enough" and in my state that pretty much means I have had enough of the Me generation politicians who have been in power since I was in college. In my opinion our current governor has used his near decade in office to ruin our public schools, get almost everyone their own personal handgun, and make billions for his friends. Again, mostly this has happened because my generation was too busy making money to worry about where the state, country, or world was headed.

Back to my participation in this election. I put my yard signs out months ago, which only served to alienate me further from my neighbors. Oh yes, and I have a sticker on my car. I know this is risky, since many of the supporters of my candidate's opponent carry concealed weapons. I am just careful not to cut anyone off on my drive to work. I have been lucky so far. If my candidate does happen to win, I will pull that sticker off the day after the election.

As I said before I voted, but I did not remind my friends to vote. They are all voting for the other guy. I know this because we have rather in depth conversations about what might change the current course of our state, this country and especially our profession.

I still believe the health care plan is a start. I am well aware of the fact that medical insurance has increased by 10% this year. Remember, I am self employed and I buy my own. I will continue to drive my old car, which gets better than thirty miles to a gallon. I could have a new hybrid for what I paid in medical insurance and health care costs this year for myself and my family. The truth is medical care costs money and no one took one the biggest cost which are the insurance companies themselves into consideration in constructing the latest legislation. Why, the politicians needed the financial support of the insurance companies to get re-elected. Their CEOs and the CEO of the hospital where I work will still make at least 7 figures. They are part of the "me generation" too.

Where is this going? To solve these very real problems, someone will have to give up something. Honestly, I don't think it will be the "me generation" and I am afraid we have not raised our children and grandchildren to do this either. I think those who have immigrated here will likely be the ones willing to work hard for less and find ways to make change happen.

As you shop for health insurance

In honor of the new health care policy beginning to take effect, I thought I would write a few lines to help those who may now find themselves in the market to purchase health insurance.

One of the first things you will learn is they charge by the pound. After your age, the next questions ask will be height and weight. The skinner you are, up to a point, the cheaper your insurance will be if all other items are equal. It pays to get and stay in shape, not only for your health but also for your pocket book.

If you use tobacco in any form, that is going to cost you too. You will be paying for this pleasure not just in the form of taxes on nicotine containing products, but your health insurance premiums will take a definite jump. Most companies require that you be tobacco free for two years to get a savings.

If you are under the age of nineteen, insurance companies can no longer deny you coverage if you have a pre-existing condition. What the insurance company can do is charge you a higher premium for coverage. That seems to be a recurrening theme: Increasing insurance premiums.

Under the new law, in case you haven't figured it out, by the year 2014 you will be compelled to purchase insurance if you cannot get it through your job or a social service agency (Medicare or Medicaid). However, when you purchase an individual policy it is going to cost you a lot more money than it would have previously. The average premiums will take a 20 to 40 percent jump. This is to cover the cost of manditory preventative care.

Who are the big winners in the new health care policy? I believe it is obvious. The industry with the biggest lobby in Washington and also probably your state capitol: Insurance companies.

Take the money and run

I called my health insurance carrier because I received a letter stating I was eligible to continue my health care coverage on an individual policy when my COBRA terminates in 2 months. It was mailed to my home address in Great Big State. With hope I called to initiate this conversion. After giving my name, social security number, and home address, I was told "you are not eligible."

"Well, then why does the letter say that I am eligible?" I replied.

"I don't know but you live in Big State. Any one who lives there is not eligible." said the voice on the other end of the line.

"Well your company mailed me this letter, to my home address in Big State. Did someone at your company think I did not live in Big State, I mean, I have been receiving bills and making payments from this address for the last 16 months?" I asked.

"I don't know about that but you are not eligible, I don't care what the letter you have says."

Who do I believe? The person who mailed the letter or the one on the telephone. I can tell you this, after searching for health insurance for over a year, there is not an honest person out there associated with an insurance company. The insurance industry holds are the cards and the Affortable Health Care Act dealt them a sweet hand. While health care is now becoming a requirement, I am not sure it is something the middle class will be able to afford.

Until this country is ready to do something about the insurance industry who has the largest lobby in both Washington DC and your local state house, they will continue to take our money and work hard not to pay for care.

Changing the world

Since it is Monday and the beginning of a new school year for many, I am thinking about the impact each of us has on the world. When I was younger, middle school and high school, my greatest desire was to make some world changing discovery. A cure for a deadly disease or an invention to ease human suffering was my goal.

With time and age, by about my second year of college, I realized these types of discoveries where a combination of brilliance and luck. Since I possessed neither in large quantities, I settled down to the slow, grinding task of preparing myself for medical school. In another couple of years, I realized that some combination of brilliance and luck were required for medical school admission also. Since I was short on the first, I would have to say it was the second of those two commodities which landed me in that now Well-Known Medical College of the south.

Getting back to change, it seems it comes in one of two forms. Change is either slow and insidious, something we are not able to appreciate in our life time. A physical example of this is the Grand Canyon. Or change is cataclysmic, the death of the dinosaurs (and many other forms of life) in a short span of time.

In the last 18 months, I have learned I am not going to have any type of meteoric change on the health care system, even in Major Metropolitan City. Hopefully, however, I am making some type of difference in the landscape, at least where the lives of my patients and colleagues are concerned.

American medical care

Two months ago I saw a woman who was employed and has insurance, both medical and disability through her employer. I am not implying I never see patients like this any more but this woman was not really ill enough to be in the hospital. She and her husband moved to a community south of the Metropolis 6 months ago from another state. For reasons I will not go into her that community does not have women's services at their hospital.

She woke up on a Saturday morning with some mild pain which increased over the day. Having no physician to call, she went to the local emergency room. With no gynecologist to refer to, the ER physician got out his protocol book and began ordering tests. Pregnancy test was negative, white blood count was normal, ag. ain she really was not sick, but the next step was a sonogram.

When the sonogram was done by the technician, who was called in from home, she informed the ER physician that the radiologist would read it on Monday. The sonogram did, however, show something abnormal in the region of the right ovary. Hearing this the ER physician called the ER physician at my hospital. The result was the transfer of this woman, by ambulance, 45 miles to the hospital where I was on-call. No one told me about the patient until she arrived in the emergency room at my hospital 5 hours later. By this time it is 1 AM on Sunday morning.

Seeing the patient, reviewing her laboratory values and her sonogram, I explained to her that she had a hemorrhagic corpus luteum cyst or a blood clot on her ovary from ovulation, which had grown slightly larger than normal, probably causing the pain she had the day before but had now resolved. Her blood counts had been repeated by the ER doctor at my hospital. He needed to have something to do and bill for, right. These tests were all stable and now she was pain free.

Her husband was there. He had followed the ambulance to be with her. Following my exam and review of all that had been done, both were relieved to find out it was nothing serious. They packed up and went home. I gave her a follow up appointment in my post op clinic the next week to make sure she was feeling OK along with the names of several gynecologist who have practices in the area.

When I saw this woman 4 days later, she was doing great. She had an appointment in a couple of weeks with her new gynecologist AND she had four or five pages of paper work for me to fill out to get the ER visits and the ambulance ride paid for. I did my best.

And why am I bringing this story up now. Well, at the time I thought about how pointless all this was. Her pain resolved with a little bit of time and not much else but she got several thousand dollars worth of tests. I am now really irritated because I am still filling out paper work for the expensive items: sonogram and ambulance ride while I have little hope of being paid for my part in her care.