to the teeth

Friday, July 20, 2007

As we take this blog's energy to a new project, build with us...

It's time. It's time to take the energy from this blog, which has served as the intial experimental space and the foundation for a larger project, to a bigger space. The same notorious team who put this blog together (Andru Ziwasimon and myself) and an amazing team of others (including my brother Nalin) have created the first health justice focused online community space -- titled Cure This. Here's what it's about:

For two and a half years, "Cure This" was a pipe dream shared by just a handful of us. We envisioned a grand goal: to create an online space to discuss health in its broadest sense, share personal stories, creatively make positive change, and build an online community along the way — connecting us locally, nationally, and perhaps internationally. We envisioned a humble beginning: here and now.
Cure This has now transformed into a reality, and we’re excited beyond words. We welcome it into this world with a loving, gentle nudge and an encouraging whisper in its ear. Let the beautiful journey begin.

But first, thank you to everyone who read To the Teeth -- written by Andru, myself, and guest bloggers Sri and Rahat over the past few years. This blog saw its start back in January 2003, when there weren't many health justice-oriented blogs on the internet. We poured a great amount of love and passion into the creation and maintenance of the blog. It was exciting receiving comments and emails from folks who really believed in what we were sharing. For those of you who have not perused the archives or the rest of this front page, I especially encourage you to read Andru's posts -- whether on building his innovative clinic or on pushing the edges of health justice work. They are truly inspiring pieces of writing. Come back to read them if you don't have time now -- this site will be archived indefinitely (for as long as blogger allows it to be!)

The last few months have been met with very sparse posting here on To the Teeth, as Andru and I have been involved in quite a few other projects. Andru has been building an amazing innovative clinic (which he shares stories from in this blog) and railing against the injustices of the New Mexico public health and hospitals system, in a quiet but hugely successful coalition-based people-based way. He's also been leading the Racial Disparities initiative of the National Physicians Alliance, a young organization of progressive physicians. I've been writing at my personal blog -- Los Anjalis. I've also been involved in intense training in my family medicine residency program at Harbor-UCLA (check out our resident blog), doing some international medicine, and serving on the Board of Directors of the National Physicians Alliance (check out the NPA's blog, full of energetic physicians' posts!) During this time, we were also holding secret meetings with team members on the creation of the not-so-secret-anymore Cure This project.

Now, what a way to end a blog project! The last post on this blog, entitled "Support the Bhopalis right to live", was written in March 2007, about the hunger strike that 6 community leaders undertook in Bhopal, India (read the post for more info). Satinath Sarangi, one of the bhopalis fasting, wrote a comment on the blog WHILE fasting, on the 12th day of the fast as his body was breaking down its own stores into ketones. He thanked us for spreading the message. Talk about the power of the internet to bring the day to day activities, direct actions, and strategy of health justice work to the rest of the world -- so beautiful and so humbling at the same time.

With this spirit and energy and awe, we hope you will join us at Cure This, create an account, share your own thoughts, and promote greater collaboration among various groups and individuals separated by geography, on various issues of health and health justice. because we love the internet and its ability to bolster movements. because our health (personally and collectively) is ours and nobody can take it away from us. because it's time we dreamed instead of only reacted.

posted by Anjali Taneja | 7/20/2007 12:43:00 AM | (1) comments |

Wednesday, March 14, 2007

Support the Bhopalis right to live.

6 strong Bhopalis are on a hunger strike right now, demanding action on 6 important areas (health care, economic rehabilitation, cleanup of toxic wastes are 3 of them) that have been neglected by Union Carbide and Dow for the last 22 years since the deadly disaster in Bhopal in 1984. Today, the world community is rallying behind the courageous community in Bhopal and the 6 hunger strikers. I sent a fax in a minute to politicians in India through the Students for Bhopal "Right to Live" campaign website, you can too. Let's call also!

From the International Campaign for Justice in Bhopal blog, a reportback on Day 9 of the hunger strike:

As the six fasters plan out the future of the 'Right to Live' campaign, the Tinshed is overflowing with supporters from all walks of life. Students from Muskan, women from Mahila Manch, teachers from Eklavya, and the passion-ridden youth from Yuva Samwad offered their support through numerous acts; some fasted in solidarity for the day, while others participated in singing which has become inevitable in the twenty-two days the survivors have occupied the tent. The headline maker of the day was the visit of Narmada Bachao Andolan activist Medha Patkar. As soon as word got out that Medha Patkar was at the Tinshed in support of the Bhopalis' dharna, the press promptly arrived and flooded her with questions and flashing cameras as phone microphones were thrust in front of her. "The gas peedit symbolise the affected... This struggle, indauntable, gives inspiration and strength to all who are fighting imperialist forces." She also said that through Sangarsh 2007, she will raise the issue with hundreds of organisations.
Along with national support, international support is starting to pressure the government from another front. The phone lines are being flooded by callers from America and the United Kingdom. More than a hundred calls a day flood the phone lines of the secretaries and personal assistants of the Chief Minister, the Collector, and the Prime Minister, to the point that they know by now that a call from America or the UK is regarding the fast. Some of the secretaries say they will convey the message to their boss, while others simply hang up. I suppose getting a hundred and fifty calls late in the night could possibly lead to immense frustration. The receptionist at the fax machine does not have it any easier. About 1500 faxes have been sent to the state government. That is fifteen hundred more people all over the world who will not stop until the government ceases its insensitive idiocy and for once, does what it is supposed to do. Because twenty-two years of negligence is much too long.

cross-posted at Los Anjalis

posted by Anjali Taneja | 3/14/2007 10:00:00 PM | (1) comments |

Monday, February 19, 2007

There's always the option of self-diagnosing...

From yesterday's Dilbert (click on the cartoon for an enlarged, easier-to-read view):

more Dilbert cartoons here.

posted by Anjali Taneja | 2/19/2007 09:03:00 PM | (0) comments |

Thursday, February 15, 2007

"Medicine is a noble profession. You render it shameful."

...or "the tale of an unlucky appendix, at the hands of the daughters of charity, in the city of angels."

Robert Issai
President and CEO
Daughters of Charity Health System
26000 Altamont Rd.
Los Altos Hills, CA 94022-4317
Dear Mr. Issai:

I recently suffered from appendicitis, and was admitted to the emergency room at Saint Vincent Medical Center in Los Angeles on November 10 of last year. I underwent an appendectomy and was released from the hospital on the morning of November 12. I have no complaints about the quality of my care. My surgeon, Dr. Charles Hunter, was excellent, and with very few exceptions all of my encounters with hospital staff were as pleasant as they could be under the circumstances. But I received a profound and unpleasant shock shortly after returning home. The bill arrive, account number XXXX, if you're curious.

I was charged -- am being charged, I should say, as I have not yet paid -- $15,833 for the care I received during the 40-odd hours I spent at Saint Vincent. I then received additional bills from the surgeon, the anesthesiologist, and the emergency room physician for their respective services. (The latter is asking for more than $800 for the approximately three minutes he spent at my side.) I am a freelance journalist, and I am fortunate enough to have health insurance at the moment. Blue Cross covered $12463 of your bill. But $3370 is still a considerable sum of money, so I telephoned the billing office and asked for an itemized account of the charges.

I hardly know where to begin. Perhaps with the $21 I was charged for each of ten 10 ml saline IV flushes. I do not know the going rate for a 500 ml bottle of saline solution at CVS, but considerably less than $105, I am sure. I was charged $80 for each of three 50 cc doses of .9% sodium chloride, a few spoonfuls of table salt, and $154 for each of twelve one-liter bags of sugar water. For my pajama pants -- of such flimsiness that I would be hard-pressed to find their equivalent at a 99-cent store -- I was charged $35. Given such absurdities, it seems hardly worth mentioning that I was charged $982 for an hour and three quarters spent unconscious on a gurney in the Recovery Room and $1768 for each night of room and board. Rents are high in Los Angeles I know, but that is nothing less than an outrage.

A few weeks later, I was doing a little research to find out where to send a friend who had broken her ankle in New Mexico and needed surgery in Los Angeles. One of your own orthopedic surgeons advised me to use another hospital. "Saint Vincent is notorious for overcharging its patients," he said. This was not news to me. Another example: my friend was charged $1.05 for a 2 ml dosage of fentanyl at the ER in Albuquerque. At Saint Vincent I was charged $71 for a 250 mcg injection of the same. Assuming a standard 50 mcg/ml concentration, you overcharged me by a factor of approximately 28. I can only congratulate you for your chutzpah.

Mr. Issei, if you were in any other line of work, no one would hesitate to call you a thief. I understand the complexities of our healthcare system better than most do, but this is inexcusable, and all the more so in an institution that masks itself with the gospel of charity. Medicine is a noble profession. You render it shameful. I am sure you have better insurance than I do. I wish you good health, and poor sleep.

Yours sincerely,

Ben Ehrenreich

Source: "Medical Larceny" by Barbara Ehrenreich, in the Huffington Post

Mr. Ehrenreich is author Barbara Ehrenreich's son. She says this about the issue:

The odd thing is that many politicians and pundits believe that the only way to control health costs is to get consumers to limit their consumption of health care - as if an appendectomy, for example, was a kind of self-indulgence. In my son's case, we have someone who is vividly aware of his health care costs, if only because he bears so much of them. His letter is not only an individual complaint but an act of good citizenship. We all need to be prepared to blow the whistle on medical larceny.

There are some interesting comments and perspectives written by readers of the post, at the link above. Imagine what kind of discourse and building and action could grow from folks around the country sharing these stories? What's your story?

(cross-posted at Los Anjalis)

-anjali

posted by Anjali Taneja | 2/15/2007 09:57:00 PM | (0) comments |

Saturday, February 10, 2007

An unfinished poem... I don't know if I will ever finish it, so here it is. Not sure if it works or flows.

Sri

On AIDS in Tanzania

Something as simple as a pill in the palm of her hand

This Tanzanian woman

Sings as she breast feeds

They say it was the rain

But it was always my tears and sweat

Which brought up the maize

They said the railroads

Will bring a new day

But it was always diamonds going

with the sunset

The other way

----------------

And now she dies and is dying

-------------------

Something as simple as a pill in the palm of her hand

This Tanzanian woman

Brilliant orange head wrap

Red African mud between her toes

Any pill

Anything close to healing

She does not hold in the palm of her hand.

-----------------------

her left breast sags in

the sun.

ribs exposed

continuum with the spine of her too large wooden chair

she resembles the chair

both of them frail

twigs

ready to snap

-------------------------

a pill

something as simple as a pill in the palm of her hand

her hands scathed

rough as maize husk

she dies and is dying

her 5 month old

baby boy born at dawn

suckles at her dry left breast

he suckles ashes from her left breast

--------------------------------------------

something as simple as a pill in the palm of her hand

Who owns this pill?

What plant or human genome extract gave birth to it?

Who cut the compound, packaged

into compact cure?

In which boardroom, what lawyers patented it?

Blue suits and leather suitcases

tucking death into the space between fine print

---------

Who keeps the cash?

Which markets rose while she fell?

Which corporate graph will track her demise?

Who will clench their fists one over the other as she opens her hand?

--------------------------

This Tanzanian woman

Her baby boy born at dawn

Who will began to ask for a moratorium on their death penalty?

Something as simple

as a pill in the palm of her hand

--------------------------

Who will join this standing up?

A reach to claim the pill

demand the pill

And place it in her hand

Something as simple

And good

As healing

A pill in the palm of her hand

Sri

2/9/07

posted by srijeeva | 2/10/2007 12:42:00 PM | (1) comments |

Thursday, January 04, 2007

We did it! Our clinic has a new home.

I've been silent the past two months. Activity at the clinic has boomed and during the month of December we began moving the clinic to our new building. I probably put in 16 hour days for the past month working with 30-40 other volunteers doing tiling, bamboo flooring, wall painting, moving massively heavy x-ray machines and hydraulic exam tables, and setting up a clinic. There were so many wonderful moments I could never find a way to express them all but i'll share a few because it was such an inspiring and unbelievable process.

I have to give thanks to the building owners and occupants who let us "push them out" early so that we could get our remodeling work done!

And thanks to the core volunteers, members of the Topahkal Health Collaborative who put in weeks of backbreaking work. We know every grout line, every groove of the bamboo flooring, every layer of paint on the walls, every wrong cut on the 800 pound doors. If i never had to cut another 36inch heavy wood door again, i'd be a happy man.

Thanks to the christmas eve crew of tile volunteers who took a bunch of beautiful donated tile, 5 different kinds, that together barely covered the last room needing tiling, and made a gorgeous design to welcome out patients into the clinic. it converted the place from a beautiful clinic, to the "beverly hillbillies" clinic. we were all so exahusted by that time that we would never have been able to finish the remodel work before opening without their generous help.

thanks to the children who screwed down backerboard, but the fridge doors on and cut tile on the wetsaw.

thanks to the detention kids who came by and helped us move thousands of pounds of heavy equipment from the casita clinic to our new space.

thanks to the hardy souls who showed up after a foot of snow fell and we still had two solid days of work left.

thanks to the lock and key guy who came and changed our locks and then told us that he wanted to do it for free to honor the work we are doing in the community.

thanks to our patients for putting up with our dirty, calloused hands, our dusty clothes, our muddy parking lot, our scattered brains. even though we were closed, patients kept showing up with urgent issues and we would just find a quiet spot, sort thru boxes to find the gauze and take care of business.

thanks to the carpenter who worked thru snow and ice to put in our new windows. because of the snow the windows were delayed and arrived the day before we were to open. He got two of the windows in before we opened and the third went in as patients began to show up yesterday.

thanks to the health worker who is now answering our phone for us in the mornings.

thanks to our work study students and pre-medical volunteers who put in tons of hours, learning skills they never thought would be a part of taking care of patients. it was great seeing students learn to drill, cut backerboard, tile, paint, put in wood flooring. :>

thanks to my family and friends and the supporters of the Kalpulli Izkalli for all the financial and material donations that helped us pay for the cost of the move.

We opened yesterday and saw 20 patients on our first day. our patients all like the new space even though it's still a bit rough around the edges and two cars got stuck in the snow/ice.

Personally, i LOVE the new clinic building. it is 2200 square feet of "homey hassle-free medicine." i no longer have to move my desk out of the way to open the closet to get the ultrasound machine out to do an exam for a pregnant patient! we also no longer have to store our medical supplies on shelving in the shower! :> yehaw! we now have a triage area, a gynecology room, three exam rooms, an x-ray/ultrasound room, two traditional medicine rooms, a kitchen and three bathrooms! and we have a huge parking lot and tons of space for gardening outside, once the snow melts.

so many blessings, so much love and kindness and good work done. i am pleasantly exhausted and beginning to physically recover from the work.

i wish joy and peace to each person on your journey for a better world.

sincerely,

andru

posted by andru | 1/04/2007 09:38:00 AM | (0) comments |

Tuesday, December 26, 2006

Goin' to Tanzania, Kenya feel me now?

January will be a good month. Partly because it's a new year and everyone likes to be optimistic about a new year. But in addition, I'll be visiting a continent I've never before stepped foot on, and that's damn exciting. I'm heading to Tanzania and Kenya (for a whole month) in just a few days!

Even better, i'm heading there with 10 friends -- all resident physicians (and one faculty member) from the Harbor-UCLA Family Medicine residency program. We're going to be doing two weeks of mobile medical clinic work in the rural town of Shirati, Tanzania -- a town that borders Lake Victoria in the northwest part of the country. After the two weeks of work, a few of us will be staying on to do some travelling -- Zanzibar, the Serengeti, Dar es Salaam, decide as we go, etc. And in the last few days of our trip, we head to Nairobi for the activist orgy otherwise known as the World Social Forum!

One of the residents in our program spearheaded this trip to Tanzania, as is becoming a nice tradition in our residency program. This past year, a few residents and faculty members worked in a rural hospital in Chiapas, Mexico for two weeks. And last year, residents organized a trip to Sri Lanka and a trip to Pakistan to assist with relief efforts post-tsunami and post-earthquake.

I'm stoked about this trip, although i'm frantically trying to get things organized for it. i'm hoping to post about it in the next few days before I leave, and then in the infrequent times that I'll have internet access in Tanzania and Kenya I'll try to post here. But the place to check out the posts from several of the residents is our unique Harbor-UCLA Family Medicine Residency blog!

Kenya feel me now?

(cross-posted at Los Anjalis)

Labels: kenya, residency, tanzania

posted by Anjali Taneja | 12/26/2006 01:09:00 AM | (2) comments |

Saturday, December 16, 2006

Did you put something in your ear?

Yesterday I worked a long 12 hour shift (yes, there are short 12 hour shifts and long 12 hour shifts) in the pediatrics emergency room at a county hospital as part of my pediatrics experience during my family medicine residency training. I didn't end up leaving the hospital until a while after my shift ended because I wanted to tie up loose ends and make sure two patients who were being admitted to the hospital wards had their studies (imaging, blood studies) all tucked away. I was exhausted.

But all is still OK. Why? Because my ER shift was fun. FUN. The kids are the cutest. There are traumas and emergencies that bring us joy (in stabilizing/curing) and sadness (gun shot wounds and freak accidents in kids are the worst). But some of the funniest interactions occur with the less acutely sick patients.

For example, a 10 year old girl with headaches for a week straight gives me more information on these pains -- how long they last, what they're exacerbated by, how they affect her at school, and i rule out the most dangerous causes of headaches with a number of questions. But the first thing she says to me when I walk into the room, introduce myself, and ask her what's bothering her is -- "I've been having headaches for a week and I just cannot afford it." I had to stop myself from busting out laughing during the rest of my interaction with her.

And a 3 year old boy who we think has whooping cough (pertussis) because of his extended coughing pattern (and related symptoms) also had some trauma to his left ear, and there's a little bit of dried blood in the ear canal, but no damage to the eardrum. Definitely looks like he tried to put something in his ear. But he vehemently denies it, when I ask nicely, and when mom asks nicely. Then the attending doctor (the senior doctor running the ER) comes to see the patient again with me, kneels down in front of him and says in a really sweet voice, "Hi I'm [insert male first name here]. How are you? Did you put something in your ear?"

The child nods his head side to side, motioning "No."

The doctor whispers, "I won't tell anyone if you put something in your ear, you won't get hurt." And then the doctor repeats, in a cute voice, "Did you put something in your ear?"

and the child nods his head up and down and smiles the cutest smile EVER.

posted by Anjali Taneja | 12/16/2006 04:26:00 AM | (0) comments |

Sunday, November 26, 2006

Why do we clamp or cut the cord at birth?

If you are a medical student, resident, doctor or L and D nurse, have you ever wondered why we are so quick to cut the cord? Is there evidence or proof or a serious reason or any thinking at all behind this nationwide medical tradition?

I was told during medical school that we cut the cord to prevent the baby from getting too much blood and being iron overloaded... Made perfect sense at the time and I never questioned it again until about two years ago when it dawned on me that there might actually be benefits to NOT CUTTING the cord immediately at birth. I'm not particularly thoughtful or insightful, I just hang out with midwives and doulas and one is bound to get some common sense knocked into your head if you are quiet long enough to hear a thought outside of your own narrow training.

Is there any evidence that not cutting is harmful? Not that i've ever seen and i've asked alot of experts as well. There is a new research article out that demonstrates delayed clamping of the cord (3 minutes instead of 15 seconds) can prevent neonatal anemia and only raises the hematocrit within normal range. No dangers at 3 minutes. According to the article, this is a highly controversial topic. What amazed me is not that it is controversial, but that no doctors seem to even talk about it. It's not controversial, it's another medical taboo. These guys probably did a lit search and they also say there is no research stating that it is dangerous to delay cord clamping. (http://www.pediatrics.org/cgi/content/full/117/4/e779)

I challenge medical students and residents to push the envelope on this one and question your teachers. You will learn alot about how medical opinion is formed and protected. First elicit your teachers expert opinions. "Why do we cut the cord right away? Is it harmful if we don't? What benefit is there? Is there a situation when it might not be necessary?" Then ask them to share with you the research evidence that supports this practice. And then report back here what you find.

Now take a moment, trust nature, and think about the physiology of birth. Isn't the cord how the baby "breathes" in the womb? If the baby is blue and not breathing right away (assuming the mom was relatively healthy and the cord isn't falling apart in your hands from infection or IUGR or mec staining) and there is a strong pulse in the cord, wouldn't the baby be better served being placed on mom's belly with the cord attached, receiving warmth and oxygen for a few minutes while it acclimates to the physics of it's new surroundings?

And for normal healthy babies that come out screaming, what harm is there in letting the kid transition for a few minutes while the physiology of the placenta and cord figure out it's own end moment? Why do we need to put a human touch tainted by an aggressive relationship with time into the birthing matrix?

I'm so curious why we intervene in a normal process and more curious what a comparison trial would show for blue babies who are whisked away in the first 10 seconds to intubation or blowby O2 compared to blue babies with a healthy cord pulse given a few minutes to acclimate while still attached to it's natural O2 source.

Fear will probably never let that trial happen, with the assumption that we would be placing the baby in harm's way... I'm not sure. I think it's worth a serious conversation between MD's, midwives and birth assistants. We might even have to invite the opinions of doctors, midwives and birth assistants from countries that aren't completely dependent on technology to get a more grounded and physiological perspective.

andru

posted by andru | 11/26/2006 09:09:00 PM | (6) comments |

Thursday, November 23, 2006

Topahkal Clinic growing and moving

November 2006

We are approaching the beginning of our third year of business as a fair priced, hassle-free, primary care clinic offering holistic same-day medical services to low-income people in New Mexico. Our patients have come from as far away as Juarez, Mexico and Denver, Colorado, people referred to us by family or friends. We are seeing 20-25 patients daily, totaling about 5,000 visits each year with 1-3 hour wait times. We've collected over 95% of our fees and made the up other 5% by small and large donations from patients and friends. We started working with medical students and residents at the local public hospital and we are developing a staff of work-study students who are mostly pre-med and pre-nursing students helping us as health workers and medical assistants.

All in all, it's been an amazing two years for me. My patients have been kind, considerate, appreciative, and gentle with me when i've made mistakes. We have a diverse patient population with problems ranging from substance abuse to miscarriage to complex gynecologic issues to dermatology, wound care, chronic pain and chest pain. We've sent 5-6 patients to the Emergency Room for serious illnesses including stroke from brain cancer, subtle myocardial infarction, new diagnosis of acute leukemia, profound cholecystitis requiring a 9 hour surgery, and wolf parkinson white syndrome.

We have outgrown our little casita and have a daily whirlwind of too many cars trying to fit into too few spots.

It's definitely time to move! We searched for over 8 months to find an appropriate location and will be moving the clinic right around the corner to a building that was originally built as an urgent care in the 1980's. It was built small (but is three times larger than our little house) and abandoned by the hospital that built it for a much larger building futher down the road. Parking is GREAT. Location is GREAT. The building is kinda dumpy and constructed with no windows. i'm still wondering if that was for security or privacy or to save money.

We have a plan in place to remodel. Tile the floor, cut in windows, paint the walls, landscape, decorate, tea and footbaths. Transform the building from a windowless office to a homey, welcoming, warm, holistic clinic. That work outlines the entire month of december and probably well into the future.

We have to leave our house clinic. Our neighbors have had enough, and rightly so. The traffic is overbearing, the parking is spilling out to neighbors yards, the trash is piling up from all the sodas and bags of chips that patients eat before they come into the clinic and are told they have diabetes. Our last day in our little casita clinic is Decmber 22. We open in the new building January 3rd, 2007.

Wish us luck, this is gonna be quite a journey to get that building ready in so short a time.

andru

posted by andru | 11/23/2006 12:23:00 PM | (1) comments |

Monday, November 20, 2006

Shock and Awe: thoughts on the UCLA taser incident

My friend Vivek is a law student at UCLA and writes at a wonderful blog called Your Good Name. He participated in a protest organized by UCLA students, on the issue of a Persian-American student who was tasered (stunned by a stun gun with 50,000 volts) several times by community police in the university library. And he had this to say about the framing of the protest:

But after attending the protest today at UCLA, where the messaging was around public safety rather than police brutality and race, I realize that we do not have much time. We don’t have time to obfuscate, to skate over the issues that dig deep into us and threaten to rip us all apart.

If we don’t call things as they are - that Mostafa was targeted because he was a Persian male, that he was cuffed and then tazed more than four times because he was a person of color, that the UCPD’s actions have created a climate of fear for people of color all over campus, that ’safety’ as a message only means more cops and no change in accountability - then we all suffer.

We don’t have time to call things otherwise because eventually we all are going to be hit by this. And it will hurt like hell when it happens to us or to someone we love.

Amen. I agree with that. Here's to calling it like it is, for our kids' sake. Good analysis, Vivek.

Now, for some other thoughts on the tasering incident:

[1] I'm so impressed by the actions of the student who was tasered in this incident. I mean, he fell to the ground, limp (in true civil nonviolent disobedience style) when the police wouldn't let go of him. He called the police out on the Patriot Act while they had their tasers pointed at him. He repeatedly explained to the police that he wasn't attacking them. Do you know what a taser does to you? It's 50,000 volts of stun gun. Makes you lose bowel and bladder control in many cases and literally stuns you into paralysis for a few minutes. And all that time, between the taser shots, Mostafa Tabatabainejad was telling the policemen like it was. I don't think I could have been so courageous.

[2] Don't know what i'm talking about? Haven't checked out the YouTube video yet that was shot on a cell phone videocamera? Indymedia has a link to the video here (disturbing) -- [link]. Upon seeing this video, I was shocked (no pun intended) by how brazen the police were, KNOWING very well they had an good sized audience of undergraduate student witnesses (and maybe they even saw the cell phones pointing at them, shooting video). I mean, how do you do this with an audience? How do you not think twice about the brutality of it? I wonder how brutal they would have been if there was NO audience. Can you even imagine? And in the last minute of the video, a police officer tells students to leave and then threatens "or we'll taser you too" after they ask for his badge number. Wait, i thought we at least ACTED like we live in a democracy... (and by the way, how brilliant that that was caught on video)

[3] It made my day to see, on the front page of the LA Times, impassioned students marching with signs taped to their chests saying "I'm Studying, Don't Taser Me". More often than not, the mainstream media picks up an outlier at a rally doing something really weird, to place as their photo representing an event. And if the event even gets a photo or article, it's usually nowhere near page 1. So thanks LA Times for placing the photo and article front and center. Did I just "thank" a newspaper for representing the peoples' voice?

[4] Back in 2004 (so long ago!) there was talk of tasers becoming available to the public for consumer purchase (yes, we're talking negotiations between taser manufacturers and the retail shop The Sharper Image. I wrote a post on this blog, and compared our society to that in Minority Report (Department of PreCrime).

[5] If it was a white boy who was asked to leave the library? He wouldn't be tasered, first of all. And second, if he was tasered, there would be no talk of well...maybe...why didn't he just leave...why cause trouble...maybe he deserved it...well not deserved it...but he was kinda asking for it... maybe he wanted publicity... and all the other twisted arguments I've heard.

[6] I love you cellphone videocameras. And I love you YouTube. There's nothing like you two. You've done so much for documenting and sharing in this world, and you are yet so very, very young.

(cross-posted at Los Anjalis)

posted by Anjali Taneja | 11/20/2006 11:22:00 PM | (0) comments |

Sunday, November 05, 2006

Angels and Children

Hanging from the light in my exam room is a "flying angel" made of wood. Most people don't look up much, and if adults have noticed it, they haven't said anything. It's there as a message to spiritual and religious people to let them know they and their beliefs are welcome in the clinic, that we honor angels and mystery, of all kinds.

Twice now children have noticed the angel and have had really funny reactions.

One was a 2 year old who was playing with his mom's keys. He looked up, saw the angel, dropped the keys while his mouth opened wide in joy, and he just smiled the biggest smile i've ever seen on a two year old. He started jumping up and down pointing to the angel. The visit was about to end but he didn't want to leave so his mom picked him up and let him touch the angel, which seemed to calm him down.

Last week a four year old girl was hanging out during the visit with her mom. She was sitting on the floor and when she looked up she saw the angel and jumped to her feet and put her arms out like she was flying. She kept repeating, "un angel, un angel," while smiling and laughing.

:>

It's not a usual part of a clinic, most docs shy away from expressing spiritual beliefs. I've felt it to be an essential part of creating my practice. I don't claim any particular religion although I have a fancy for the Quakers approach to god and life. If only I could sit still for an hour i'd probably go to more of their circles. In the clinic, we all stay neutral, to be sure. There are alot of Mexican symbols, the Virgin Mary adorns the wall. With 80% Mexican patients, that seems relatively appropriate. But even so, we welcome Catholic, Evangelical, Traditional, Atheist, etc patients. I'm not sure what all the fuss is all about, I haven't had a conversation with other docs in quite a while about this but it seems that people are simply afraid to express their beliefs.

I'd love to hear other people's opinions on spirituality and religion in medicine.

andru

posted by andru | 11/05/2006 08:41:00 PM | (1) comments |

Friday, November 03, 2006

Family Practice Office UPDATE - Successes and Moving

Our little boutique medicine clinic for poor people has taken a few interesting and big growth steps over the past few months. I'm personally shocked and pleased that things are working out so well. I almost feel like we are defying gravity, breaking some physical laws of the universe but as I watch the patient volume grow by word of mouth, the complexity of medical disease increase, the flow of money continue to grow, and the interest in what we are doing in our community soar, it seems we aren't breaking any physical laws of the Universe, just alot of social and economic myths.

A look back at the last two years of patient volume shows the first six months with an average of 3-4 patients a day, the second six months with an average of 10 patients a day, the third six months with an average of 15 patients a day and the final 6 months up to now with an average of 20 patients a day. We had an all time high last week of 36 patients in a single day. don't ask me how we saw that many people in a tiny little house at the end of a dirt road with parking enough for about 5 cars, all in 6 hours. We are routinely now seeing 25 patients at least 1-2 days a week.

This has given us our first major problem - the wait time. Some patients are now waiting over 2-3 hours to be seen. So far everyone is very respectiful and thankful but you can feel the frustration mounting. The only solution is to bring on more practitioners or limit the number of patients we can see to 15 a day, which isn't going to happen. Out of everything that is going really well, the one thing that isn't is trying to find another practitioner to work with us.

On the financial level, the clinic is doing great. We have had an increase in expenses as our patient volume soared, paying for some office help, but we've been able to pay for it just from patient revenues to date. Both the nurse practitioner and I are making enough at the clinic, part-time, that we don't need other jobs anymore. I'm working my last two shifts at the Hospital this month and then I'm going to be able to focus all of my efforts on the clinic because the income is becoming more than I even wanted to earn in a year. I haven't done the full analysis yet but my hunch right now is that the money earned is roughly equal to what i'd make working for a big clinic system as a primary care doc.

With all this growth we have decided to move the clinic to a new location. We spent a year looking around for the perfect building and found a wonderful site just down the road. It's on a main intersection, a building that was initially built by a large hospital system in Albuquerque year ago. They outgrew it and moved down the street to a bigger buliding. So it used to be a clinic, it has a lead-lined room for an x-ray machine and is set up for most of our needs. Of course when they built it in the early 1980's they weren't thinking outside the box. They were so in the box that they built it with NO WINDOWS. Some notion of patient privacy, building security, something like that. We have some serious work to do to renovate/remodel the building but we are all really excited about the move. We will do all the work of renovation over the next two months and then open our doors at the new location in early January. The current owners of the building are a non-profit group called the Rio Grande Community Development Corporation (RGCDC). They are a great group of visionaries who have come together over the years to do economic develop projects but in their wisdom they recognize that without health, economic development doesn't go very far. And in our wisdom, we recognize that without economic development in this society, health doesn't go very far. It's a great beginning to a hopefully long partnership in bringing our efforts together for deep social transformation.

The really exciting part of the move is that the Kalpulli Izkalli traditional medicine practitioners are moving in with us and setting up an Altar. We are going to attempt to truly integrate the health services at our clinic by bringing togeher practitioners of very different kinds of medicines to see what we can do together for our patients. And on this note, we just found out that we were awarded a grant from a local foundation called "Con Alma" which means "with soul" in Spanish. The grant was written to help our groups come together over the next year, to provide some foundational support to the complex process we are engaging in.

So iive got lots more to say but i'll wait to post in another message. i'm trying to get back to sharing some of the good/bad/ugly of the clinic and the political work going on here.

andru

posted by andru | 11/03/2006 06:01:00 AM | (0) comments |

Thursday, October 12, 2006

Geek and non-Geek activists throw down together!

I wish I had known about the Web of Change conference earlier — I’d be there in a second. I’m not a techy much myself (although in my circle of like-minded doctor folk, I come off as one, because I know what a “blog” is, but more so because I’m psychotically fascinated by how the internet and the "web 2.0" can help facilitate community building and power building. And I do enjoy discussing the similarities among peanut butter and jelly and the web 2.0 and health justice).

My friend Adrienne Marie Brown, an absolutely wonderful woman and the current Executive Director of the Ruckus Society, gave a session at this conference. I’m reposting Kate Milberry’s reportback from that session (and a link to it, on the web of change website is here). It’s beautiful (and where things are bolded, emphasis is mine):

Titilating Technology
Submitted by Kate Milberry on Thu, 2006-09-21 14:09.

Maybe you know Ruckus Society, maybe you don’t. But for those of us who didn’t know Adrienne Maree Brown before today’s session, we won’t be forgetting her any time soon. For starters, she made us sing. I was fine with that but, not being a singer (in fact, being almost tone deaf) I didn’t know this meant standing up. One gets lazy once one has parked one’s ass on the floor.

So, we all sang a note (which one, I couldn’t say) and it reminded me of church. I’ve not been in a long time, but still, the music (when not in Catholic mass - unless midnite mass on xmas eve) is typically uplifting. And in fact, it set the tone for Adrienne’s talk, which ended with her calling our geek work divne, and the geeks among us holy! Holy @%!*; that’s a nice compliment.

Adrienne started her talk as she ended it - on a tributory note. She said that geeks are key to the survival of folks like her - activists involved in the non-profit sector working for progressive social change. The work of geeks - their various tools, programs, apps, whatever - acts as a conduit for the things social justice activists are dreaming of, imagining and planning for.

One of her central points, and an underlying theme of her talk was this: technology only works if there’s a huge loving idea behind it. The problem, or sticking point, is that geeks don’t think of it this when actually developing the stuff. Adrienne’s message: don’t sell yourself short - you are the Justice League!

I thought it charming and refreshing that this self-described “wannabe geek” was throwing down w/some who are arguably hard core techs. Her presentation was lo-tech - no power point (or mac alt) but notes in a “cool” book that she referred to on occasion to ensure she wasn’t rambling. But even if (or when) she did ramble - it was highly entertaining. That girl is fun-ny! Even her invocation of Jesus was a yuk, surprisingly.

Another main idea of Adrienne’s talk was the need for integration (or interoperability?)- of social change software in the non-profit sector, in order for the sustainability of progressive organizing. So, techs, stop function in “silos” and start talking to each other.

One of the most resonant points of Adrienne’s talk, however, was the need for a theory of how change actually happens. We need to have one. And in thinking about this, organizers need to consider some crucial points:

1. Impacted communities are the ones who create change. Often social change activists are “do gooders” - we put ourselves in the position where we try to do good for impacted communities. BUT revolution is a personal thing that happens in your heart; people come together when something big happens, and people are deeply affected.

2. Invest in people not necessarily resources. It’s about moving people from a state of lack to a state of abundance, from needing to doing, from aloofness to leadership .

Despite the term “open source”, things aren’t always so open. Free software philosophy is not always practiced - we need to practice the change we want to see in the world. Share.

A closing point Adrienne made was this: We can’t expect to use the tools of the oppressor and expect a different outcome; that’s just dumb (her words)!! So what does this mean for techs? Build a new world through building a new technology. Developers are creating the systems by which we interact w/each other - this is powerful - let’s make something new! Not just a single killer app, but an integrated, holistic system that changes power dynamics, social relations - the whole thang.

Check out the rest of the posts on the Web of Change site — there are numerous interesting reportbacks on the site currently.

I’m excited about all this in so many ways, and this is personal, too, as I’m involved in two current projects (minus the pipe dreams in my head) related to health/medicine and health justice. I’m currently working with others on a subcommittee on web/technology for the wonderful National Physicians Alliance (I'll write more about this exciting organization in a future post on this space), and we’re trying to revamp the current site to become more interactive, more democratic/two-way, and more fun for those passionate about the issues that the NPA works on. That’s going to take up a bulk of my time in the coming months. The other project has moved officially from the “pipe dream” category to the “this is going to happen damnit, real soon, real soon…” category and involves a huge community of health justice folks. Both projects involve loving ideas and loving people behind them (see? project number two can’t still be a pipe dream if there are others working on it too!)

(this post cross-posted on Los Anjalis)

posted by Anjali Taneja | 10/12/2006 11:25:00 PM | (0) comments |

Monday, September 11, 2006

the "Green-House" of Healthcare:

For the past 7 years i've wanted to build a greenhouse on the south side of my house. it would reduce my $400-500 monthly winter heating bill, as well as add some beauty and capacity for winter veggies. three years ago i drew up some plans and got started and three years later i'm almost done with the foundation and frame... i call it turtle construction, slow and stead, making sure every nail, screw and piece of cement stands the test of time before another nail, screw or piece of cement is added. that's, of course, the bright side. From another perspective, i'm just a damn slow builder.

The greenhouse is being added on to a Victorian style house built in 1903 that was either constructed crooked or tilted over the years. there is not a single 90 degree angle in that house and the studs are never the same distance apart. as well, the wood used was truly 2 inch by 4 inch, not the smaller versions used today that are still called 2x4's but have shrunk HMO style to something that no longer has any fat or meat left over. pure bone, the new wood.

For the past 7 years i've been doing home construction to "relax" from doctor stuff, learning electrical, plumbing, demolition and framing skills on this tilted, awkward, frustrating, lovely old house. There was something simply elegant about putting in a new foundation, framing up a fresh new structure for the greenhouse, designing "from scratch." But when the greenhouse started butting up against the old house, all the old crooked demons of warped angles, erratic distances, different sized pieces of wood surfaced again and i realized something that felt quite profound.

The House of Medicine is like this 100 year old Victorian house. Crooked, intense, beautiful, frustrating, layers and layers and layers of things built on things built on ideas built on air. Like my house, it sometimes feels like the house of medicine was put right on the ground, with no foundation, no plumbing system, out of date wires. It works. For some people, in the master bedrooms, it works really well. But for many of us, practitioners and patients alike, it's a mess. Learning in it, working in it, receiving "Care" in it.

Out of this mess, I decided to build my own clinic, to start fresh, from "scratch," working with others who shared similar values. Set down the foundation, the frame, fill out the walls with beautiful windows, put on a solid roof and leave the door open for anyone to come in. But like my small greenhouse, it has to butt up against the house of medicine and therein lies all the intricate mess of history. Fortunately we built our "greenhouse of medicine" in such a way that the insurance system is out of range/sight/smell. They could be on another planet for all we care in our clinic. No CPT codes, no coding of visit lengths, no billing office, no checkboxes, no phone arguments over pre-existing conditions or prior authorizations. halleluyah. We only have to deal with labs, x-ray, MRI/CT and the occassional hospitalization. And with most of these external systems, we've had pretty good luck. Lab is fairly standard, x-rays are covered by an independent doc who charges $50-100 per shot, hospitalization has worked out amazingly well with a local non-profit hospital. MRI/CT is a mess, costs $500-3000, but we are working on it and have a potential solution coming down the road.

I know not everyone will agree with the grandiosity and negativity of this perspective of medicine. I don't mean to come off sounding black and white. the house of medicine does have some foundation somewhere. But please hear this criticism from a recent graduate of the system, from someone who has survived it's training programs and successfully built an alternative model that is working, that is making money charging 50-90% less than other operations. Whatever foundation we might have had in the past, similar to my victorian house (that was lifted from it's foundation on the other side of town and moved to it's present location over 50 years ago), large parts of our health system no longer seem to touch the ground.

The ground in medicine is science, research and common sense, connected to a trusting and powerful therapeutic relationship with our patients. Legal fears, Insurance relationships, personal/individual greed, and race/class factors all contribute to our instability as a coherent "house" of medicine.

andru

posted by andru | 9/11/2006 05:35:00 PM | (2) comments |

Sunday, August 20, 2006

Move on out, sharks...

From "The High Cost of Being Poor" by Barbara Ehrenrich, author of the book Nickled and Dimed:

There are other tolls along the road well-traveled by the working poor. If your credit is lousy, which it is likely to be, you'll pay a higher deposit for a phone.If you don't have health insurance, you may end taking that feverish child to an emergency room, and please don't think of ER's as socialized medicine for the poor. The average cost of a visit is over $1,000, which is over ten times more than what a clinic pediatrician would charge. Or you neglect that hypertension, diabetes or mystery lump until you end up with a $100,000 problem on your hands.

So let's have a little less talk about how the poor should learn to manage their money, and a little more attention to all the ways that money is being systematically siphoned off. Yes, certain kinds of advice would be helpful: skip the pay-day loans and rent-to-pay furniture, for example. But we need laws in more states to stop predatory practices like $50 charges for check cashing. Also, think what some microcredit could do to move families from motels and shelters to apartments. And did I mention a living wage?

I love the idea of microcredit/microlending in the United States. LOVE it. For some reason i've been narrow minded in my understanding of the concept - I've always heard of microcredit working in other countries and hadn't thought of it as an option here, although i'm sure it's utilized in various ways in this country. (Microcredit is essentially lending to low-income unemployed folks or folks with no credit, with the idea that a bit of assistance for a small business or a family can allow the people involved to slowly generate income and not spiral further into poverty. Microcredit organizations around the world have been extremely successful, with most or all loans paid back in full, no sharks necessary).

So, anyone down with starting a sustainable microcredit lending organization with me? The gap between hard-working low-income families in Los Angeles and the wealthy folk is ever-widening (as is happening in many communities across the country). And the homeless population in the Skid Row area of Los Angeles increased almost 200 percent in the last year. Maybe this could be a move to turn the tide a bit (and kick out some sharks).

posted by Anjali Taneja | 8/20/2006 10:55:00 PM | (2) comments |

Tuesday, August 01, 2006

Reception Racism - Scandalous

over the past six months my clinic has tried to find an answering service to take calls for us when we are closed or super busy. it's a common service for doctor's offices and other businesses and i had the impression that it would be a simple thing to find a company to answer the phones. how hard can it be? for my clinic, we have simple needs on that level - tell people the hours, basic info about the clinic, and help them with directions. we don't even do appointments.

let me share with you my disappointment and insights.

my main criteria when finding a company was that i needed bilingual services and a fair price. 60% of my patients are monolingual Spanish speakers. another 20% are bilingual but most of them are more comfortable in Spanish.

the first company, the owner told me she spoke spanish but after a few weeks it was clear that her level of Spanish was barely adequate to get a name and a phone number. she had assured me that she spoke the language. when i called to cancel the service she tried to negotiate with me to stay and told me that her house cleaner spoke fluent Spanish and would be able to help out. no thanks.

the seoncd company was more professional. my English speakers loved it for the most part but i was getting reports that my Spanish speakers were getting hung up on and facing angry voices on the other side of the line. i had some bilingual friends call to test the system and they corroborated the stories.

i have called every answering service in New Mexico, from Albuquerque to Las Cruces, and not a single one is bilingual. This is in a state that has Spanish language written into the constitution, that has a heritage of Spanish colonialism and has a very proud Hispanic population...

so what is going on? i see two forces at play.

1. from the many Hispanic owners/receptionists that i talked with, trying to find a company, most of them expressed a certain pride in their Spanish and believed that because it is part of their ethnic heritage, they had a right to claim they were fluent when their abilities were truly inadequate. when i would press the point and ask if each of them were able to SPEAK SPANISH, they would reply, "I'm Hispanic." this confused the difference between Spanish language skills and ethnic background, two distinct things.

2. from a long conversation with the manager of the second company it became clear that there was an element of active hostility that was generated against my patients because of Racism. she was very honest with me about the internal process that was happening and told me that she had a parent from Mexico so she was sympathetic to my cause. here's what happened.

when i contracted with the second company, it was clear to them that they didn't have enough bilingual receptionists, so this manager promised to find and hire them. i did a major advertising campaign amongst friends and patients to get people jobs with the company and they did hire some. the company structured a small raise for bilingual receptionists, above what English-only receptionists would get. the focus on Spanish and the raise caused a ripple of resentment to flow thru the receptionists and they took it out on my patients because they couldn't say anything to their manager... underneathe it all was a sense that Spanish speakers don't belong here, a sort of nationalism/racism, bigotry and anger...

the really sad part of all this is the abuse of power displayed by these receptionists. they stand in a position of power, able to help or harm vulnerable people who are seeking medical care for illnesses. it's unethical and inhumane. i used to have more tolerance but i'm at the point now where if people want to act like little napoleans or bigoted jerks, they can do so without my monetary contribution to their salaries.

even if our electoral democracy is a sham, our economic democracy is still vibrant. money talks and mine is gonna keep walking until i find the company that cares about their work on a professional level from the owners to the managers to the receptionists.

my next step is to look in Southern California...

andru

posted by andru | 8/01/2006 07:34:00 AM | (1) comments |

Sunday, July 30, 2006

Sustainable Economic Development

about a year ago we fundraised $35,000 from private donations and two small grants to purchase an ultrasound machine for the clinic. we bought a small, portable, sonosite Titan machine, brand new, and started using it during urgent care hours, mostly for early pregnancy dating and miscarriage.

we also started a new business, called Access Ultrasound, run by two wonderful women who coordinate with licensed ultrasound techs and a radiologist to offer high quality abdomenal and pelvic ultrasounds for an affordable price. they charge $100 per study, noone is turned away. the Radiologist is semi-retired and gave us a great deal, $25 per read. the techs earn about as much as they do elsewhere but their gift to the process is extreme flexibility in the face of a slow building process.

currently the ultrasound business takes referrals from about 4-5 clinic, a few midwives and some nurse practitioners, in albuquerque and some very distant towns. word is spreading.

and just this past week the ultrasound business gave out it's first dividend checks to my clinic and to the Kalpulli Izkalli, our partners who run the Traditional Medicine clinic. $350. it was a proud moment for all of us. A first visible step towards sustainable economic independence in a way that supports and promotes people's health instead of preying on their wallets at their moments of vulnerability.

with a health system so out of control, so profit driven, and with some really good, relatively affordable technology available, it's hard work but doable for small groups to set up competitive businesses and make human scale profits that price fairly for the average working-poor person.

andale pues.

andru

posted by andru | 7/30/2006 09:04:00 AM | (0) comments |

Monday, July 24, 2006

FIBROMYALGIA - what the heck is this thing?

last night i worked a shift in the hospital, admitting patients from the ER to the floor. a 55 yo woman came in with concerning symptoms of stroke. right sided facial, arm and leg numbness. her motor exam was normal and a CT of her head was normal, it didn't show any stroke, but CT's can be normal with a stroke so the standard of care is to admit these patients, watch them overnight, get an MRI, an ultrasound of the heart and an ultrasound of the legs to make sure everything is working okay. that's about a $10,000 work up.

i've dealt alot with chronic pain. upon taking a history of the patient, she revealed that she had fibromyaligia, chronic fatigue syndrome, anxiety/panic disorder, depression, hypothyroidism and had a hysterectomy for fibroids, and most recently, her gall bladder removed for gall stones and pancreatities. she had tried a vast number of alternative medicines including acupuncture, herbs and remarkably, was not yet on chronic pain medications. she felt hopeless.

she had had a panic attack, one of her worst, the night her symptoms started and got scared because the numbness on her right side didn't go away.

what the heck is going on? what kind of illness is this? i don't believe she had a stroke. it was more like a peripheral nerve palsy. we got to talking, spent a good hour together. she had great family support, with about five really caring people in the room during the whole time. no easily identifiable stressors but then we got to NUTRITION. BINGO!. the woman is a coke fiend, not cocaine, soda. she eats mostly fried foods, still cooks in lard (manteca) an eats tons of sweets.

you don't learn nutrition in medical school. we are basically taught that food is calories, fairly interchangeable (carbs, fats, protein) and vitamins. we learn that study after study shows minimal benefit or harm with all kinds of combinations and permutations of these different entities. it's a mess from a physicians perspective. hard to advise on anything. even with diabetes, once the person has it we can safely say to avoid carbs but noone really counsels their patients at high risk that sugar might CAUSE diabetes.

i take a stronger stance. from my experience and lots of reading, this woman's chronic pain and fatigue make sense. and the failure of alternative therapies makes sense as well. teh most basic element in life, to sustain it and to promote health, is FOOD and WATER, followed closely by exercise. if someone is malnourished, you can give them all the drugs you want, it won't make them healthy, even if it makes their numbers look better.

this woman is profoundly malnourished. she has fed her cells on a diet of sugar and heavy, saturated fats for 45 years. it's simply the wrong fuel. i owe my education on nutrition not to medical school or residency training but to the many naturopaths, midwives and acupuncturinsts who have taught me how to see past the puree of processed research that compared plastic oranges to vinyl apples and sees no difference in outcomes.

by the end of our time together this woman was prepared to try changing her diet with the energetic and sustained support of her family. break the sugar addiction, remove the heavy fats, add in fiber and vegetables, clean out the liver and intestines (detox) and slowly begin to heal. perhaps i'm wrong, but for sure, that woman had hope, she had a pathway that she could follow, and one that didn't prey on her wallet or force her into a dependency role taking medications for the rest of her painful life.

Fibromyaligia, to me, is a combination of dietary disaster, sedentary life and complex stressors (emotional, financial, familial, work) that are unique to the United States of America at this point in history with our wealth, processed, non-nutritive foods, and car/TV/computer culture. speaking of which, i'm outa here. i need to go stretch and walk. before my chronic back pain gets any worse.

andru

posted by andru | 7/24/2006 11:35:00 AM | (5) comments |

Saturday, July 22, 2006

Clinic Vignettes July 2006

yesterday we saw 23 patients, today (saturday) 15... we are too busy. patients are now waiting up to 2 hours to be seen, some are leaving before being seen. part of me feels bad, i hate for someone to have to wait so long, but at least here the prices are fair and we stay as long as we need to in each visit, ensuring the person is heard and cared for as best we can, once they get to their visit. i would love to see five more clinics like this in Albuquerque, at least. we need a resurgence of independent, local, fair-trade, neighborhood health clinics.

------------------------

chronic pain - i have about 14 patients on chronic pain medications from narcotics to benzodiazepines for anxiety/panic. Many doctors won't do this because they feel like they are promoting addictive beavior. I have similar concerns and I pay attention to the issue but i'm finding that my patients on chronic meds, with loving encouragement and some alternative medicine tools, are finding their way off of the meds within 3-9 months. i have had to send away two patients over the last year who were manipulating to the point where it felt unhealthy to me to even try to help them, but otherwise, i am really comfortable with the progress my chronic pain patients are making. It is a process of empowerment, phsychology, learning self-care and new behaviors in an environment of non-judgement that seems to be stimulating these transformations. people seem genuinely happy to have someone take their pain seriously at first and then work to help them find simpler, natural ways of dealing with it.

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Obesity - overweight and obesity are some of the fasting growing problems in the U.S. population. Why are people overweight? why isn't there a simple cure? one case this week highlighted the reality for me quite clearly. a 35yo woman, obese, with multiple physical complaints. she has been fully studied and all results are normal yet she continues to feel like something is wrong. upon further exam and questioning we determine she has alot of anxiety about her physical health. she has fairly good information about foods. she works in a bakery and loves her job, but only has one day off every two weeks and two small kids at home. she states that when she tries to quit eating sugars and fats, two things happen. 1. she is okay for 1-2 weeks and then she hits a major craving and satisfies it by binging. she is definitely dependent/addicted to sugar. 2. she works in an environment where everyone drinks coffee and eats sweets for breakfast and when she changes her diet she is castigated and punished by her peers who pick on her because of their discomfort.

it's a mess. we did some education work around healthy foods, flax seeds and aloe to help with her constipation and a full exam of her diet to remove all of her milk products. she knows she gets bloating and constipation with milk but thinks that if she isn't "drinking" milk directly it doesn't count, like in ranch dressing, milk in cereal, chocolate milkd and oatmeal, etc...

what i think is really going to help her is addressing her sugar addiction and the peer pressure, along with gentle encouragement to "follow her gut" around dairy use. we spent alot of time together and helped her find some behavior tools and flower therapy to strengthen her resolve against these two forces. sometimes just being conscious of the forces working against you is enough to empower you to overcome them. we'll see. obesity is not a simple problem, there is no simple cure.

------------------
had a patient come in towards the end of thursday night. she had continuous vaginal bleeding for 3 months. she did a good job at home waiting to see if the symptoms would resolve but the bleeding was actually getting worse. she is 45yo and of course concerned that it might mean she has cancer. we were able to do a uterine biopsy during the same visit and arrange for a pelvic ultrasound within 1 week to evaluation for fibroids or cancer. I am proud of that. no hassle, fast, affordable service even for fairly complex medical problems. It's happening. We don't need big systems, or misManaged Care to attain quality and efficiency in healthcare. We need networking, collaboration, fair distribution of resources, affordable tools and medications, accessible hours for patients, safe places for people to come with their worries and fears, a focus on reducing pain with medical procedures... patient-centered care. not system-centered care. not lawyer-centered care. not research-centered care.

----------------------
AMAZING CASE:
35 yo man came in six weeks ago and was diagnosed with diabetes. this was new information for him. at the time, he seemed interested, so we did a complete dietary counseling session, started him on one medicine (metformin), and got some labs to see how bad his diabetes was. his hemoglobin A1C came back at 18. for those who don't know, below 6 is normal. 18 is the highest i've ever seen in my life. the patient came back to the clinic two days ago. he had truly changed his diet, cut out all sodas, started on flax seeds, nopal (cactus) and regular oatmeal (without milk). he was doing a great job recording his sugars and his average was already down to 130 which is just about the most remarkable improvement i've ever seen in six weeks. we ordered another A1C test for a week and i'm very excited to see what it comes back as. this is as close to a cure of diabetes as i've ever seen so far. and you could feel the man's pride during the visit, he was so happy with his success. it certainly helped that i was seriously so floored that i kept saying "WOW." he's hispanic, very into futbol, so at one point i looked right at him and said, "GOOOOOOAAAAAAAL." he loved that. :>

andru
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posted by andru | 7/22/2006 01:36:00 PM | (0) comments |

Friday, July 21, 2006

Medication Prescribing Errors

Institute of Medicine Issues Report on Medication Errors

The other day in the clinic a patient came in and told me he was recently in the ER with severe hypotension. He had a rough time, they poked him relentlessly to try to find a vein, wound up putting in a central line first in the artery by accident and then finally in the vein and after all that they wound up not needing to use the venous access since his blood pressure was resolving nicely with IV fluids from the initial IV started by the ambulance crew.

He is a patient i was seeing for chronic pain and chronic high level opiate use (pills). I was trying to help him detox off the narcotic medications and I had used a routine medication, Clonidine, (a blood pressure medicine). It is usually started at a fairly high level for people detoxing off opiates and then weaned down as their symptoms of withdrawal ease. He had started it two days prior to his emergency.

Turns out that he had high blood pressure, was already on three blood pressure medications, but i didn't review his medications before starting the new drug. It was in the chart right in front of me. A dumb and potentially dangerous oversight on my part.

I recognized my mistake while he was telling me the story of his ER visit and started to apologize. It is part of my practice philosophy to own my mistakes and apologize, and even to refund money if the person feels harmed by an error. While i was attempting to apologize, he was very kind, and refused to accept my apology. He acknowledged that the error was mine but didn't feel angry. Somehow in the matrix of life, he actually felt even more strongly about getting off the narcotics and was prepared for another round (without the Clonidine) after resting for a month.

While he refused to accept my apology, out of kindness to me, I know he heard it, I could see him relaxing a bit as I acknowledge my error. he felt validated for his fairly rough experience in the ER and the bill he will now have to deal with. Contrary to the fear promoted by insurance companies and professional physician organizations, honest apology works as a powerful form of malpractice protection. most people are reasonable until they feel betrayed or abandoned by their physicians and then they get upset and use whatever tools are available to them to "get even."

This seemed a fairly timely incident to discuss given the most recent report by the Institute of Medicine citing medication errors as a huge cause of morbidity and mortality. You can bet that I read it carefully and will now be more vigilent with my prescriptions. I find their recommendations to be fair and accurate and even useful. see below.

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Institute of Medicine Issues Report on Medication Errors

More than 1.5 million patients are estimated to be injured each year
by medication errors, a committee of the Institute of Medicine
reported Thursday.

The committee's report, "Preventing Medication Errors," was written
at the behest of the Centers for Medicare and Medicaid Services,
which intended to estimate the incidence of drug errors and identify
the best preventive strategies against them.

Among the report's recommendations that directly affect physicians:

-- All prescriptions should be written electronically by 2010.

-- Providers should improve communication with patients about how to
take drugs safely and about potential risks.

-- All medication mistakes should be disclosed to patients.

-- Doctors should use electronic decision-support tools to write
prescriptions.

-- Physicians should regularly review all medications with patients
and other providers involved in a patient's care, particularly when a
handoff occurs.

-----

posted by andru | 7/21/2006 12:43:00 PM | (0) comments |

Yes, I'd like a 7-layer burrito, oh wait hold up lemme check my PDA

Yesterday evening i spent some time trying to update the programs on my Sony Clie NX80 PDA to better assist me in the hospital. I was checking out some freeware and came across the taco bell calorie counter!

Now I can switch up my order at the drive thru window after reflecting on how many calories my 7 layer burrito contains. Or, I can show a patient how his 2600 calorie taco bell diet is hindering him from losing weight. Oh, the uses of this application!

posted by Anjali Taneja | 7/21/2006 07:05:00 AM | (0) comments |

Saturday, July 15, 2006

Delivering another message around OB...

We've been caring for pregnant women at the office who fall thru the chasms in the system and have no affordable place to go. Most recently I cared for a woman who got caught in a crossfire between Medicaid and the Public Hospital. She was uninsured, working, earning too much to qualify for Medicaid, too little to pay for private insurance. By the time she registered at the public hospital she was no longer working so they told her to apply for Medicaid again before they would put her on their payment plan. No resolution yet and she's already had her baby...

finances aside, i had the opportunity to follow this patients progress while in the hospital. I have a few thoughts to share. i had worked for 6 months helping this woman face her fears around pain, her underlying depression and fear around becoming a mom, the tensions of her relationship with her husband, her stress and anxiety around the hospital bills. Towards the end of the pregnancy she was particularly ancy about having the baby as soon as possible, ready to get the whole experience over with. we did some counseling and some therapies to help her relax, accept the pace her baby and her body were setting and find some joy and peace in her pregnant condition. and she was shifting, relaxing, enjoying.

when her contractions started, 5 minutes apart, she went in. she was 4cm so they admitted her. She entered the hospital with a smile, ready to birth as naturally as possible. her progress was slow so after a few hours they augmented her labor with pitocin which made it more painful for her. at 7cm they ruptured her membranes in an effort to speed things up. up till that point she was laboring without pain meds but once the membranes were ruptured her pain increased significantly (a well known reality is that the intact bag makes laboring more comfortable, a cusion effect for the mom). after an hour she needed an epidural for the pain, it slowed her progress down, she almost needed a c-section and in the end, the epidural wore off before the baby birthed so she wound up feeling most of the final labor.

her first words to me back in the clinic with a 3 day old baby were - "it was so painful." not, "it was so beautiful, look at my baby, what joy i'm feeling." this is a problem. more easily visible from outside the hospital than inside. the focus on rushing, on controlling every variable, and the ignorance of the subtle and deep personal issues of each case are a bad combination of factors that lead to excess intervention, dehumanized experiences, a focus on pain and suffering instead of enjoyment to achieve what we euphamistically call a "good outcome." the baby didn't die, the the mom had no physical complications, and she didn't sue.

there's no reason why a few different pathways couldn't have been activated successfully. she could have been sent home until her contractions were closer together but we use 4cm as the magic number for admission for everyone. there is no reason why she couldn't have walked and walked and walked inside the hospital until she was in true active labor. there is no reason why they had to rupture her membranes. babies can be born with the membranes intact and removed after birth. in some Native American cultures that is considered a very special, powerful omen for the person's life.

no doubt this patient was anxious, scared and eager to make the process happen faster. in a "karmic" sense, she got exactly what she wanted so this isn't so much a complaint against the system as an expression of frustration. the patient could have chosen to stay home longer, until her contractions were closer together. (i know many women who stay home until they can no longer tolerate it. they show up to deliver their babies fully dilated. it frustrates the heck out of nurses and doctors because they aren't then in control of every aspect of the labor but it means less interventions for the woman, which some prefer.) at the same time, docs and nurses in these big institutions could make sure that the patient is fully informed before each intervention. they never told her they were going to rupture her membranes. it was an ASSUMED decision by the doctor, not chosen by the patient. i remember when i was a resident that i would have been frustrated if someone told me that rupturing the membranes required informed consent, it seems like such a small detail in the BIGGER picture of hospital care, but when the bigger picture is patient comfort, patient-centered care, quality of care, it is front and center.

andru

posted by andru | 7/15/2006 01:06:00 PM | (4) comments |

Monday, July 10, 2006

In Labor

I'm finally a second year resident in family medicine (yikes!). 2nd year started off with a bang -- I'm on week two of working at a hospital in downtown Los Angeles, doing obstetrics/gynecology. That means I'm triaging women who are possibly in labor early or in labor on time, admitting women to the Labor & Delivery section of the hospital, delivering babies (YAY!), assisting in cesarean-sections, and caring for women for the 1-3 days they're in the hospital after deliveiring their babies. I'm working with both physicians and midwives, which is a great experience. I've got lots of stories from my past week, but yesterday I worked overnight, and my last patient in the early AM hours was a 17 year old girl who came into the hospital to be evaluated because she was having contractions regularly. She was 39 weeks pregnant, so contractions would make sense, she was in active labor and ready to deliver her baby. The only issue? Well, she hadn't told her parents until that morning that she was even pregnant. They were livid, but calmed down appropriately in time. But what? She lives with them, and they didn't notice that she had gained weight or looked different. And in the process of not telling anybody, she never got any prenatal care. A social work consult was in the works, and I hope everything ended up going well in her delivery, which happened after my 28 hour shift.

During this month, i'm improving my baby delivering skills but also observing how the senior residents and attending physicians and midwives "coach" laboring women and gain great rapport with them as they're going through some of the most intense pains any of us may ever feel. Humor during this process really helps, and as we're crouched in front of a woman's vagina, coaching her to push as if she's having a bowel movement (to push the baby out of the vagina), the first bit of the baby we obviously see is his/her hair. So some of the more recent hair comments by the physicians:

"Oh my goodness, your baby has hair! We're off to a good start"
"Hmm...mommy your baby has black hair, no highlights"
"No way, your baby has a mohawk!"
or "No way, your baby has dreds!"

Day Labor

So moving on from the hospital to the folks who make it run -- nurses. Right now a battle is being waged against them by Bush's National Labor Relations Board:

In a series of pending cases known as Kentucky River, the Bush board could strip what remains of federal labor law protections from hundreds of thousands-perhaps millions-of workers whose jobs include even minor, incidental or occasional supervisory duties. The pending cases involve charge nurses in a hospital and a nursing home and lead workers in a manufacturing plant, but these workers could be just the tip of the iceberg.

The Bush National Labor Relations Board is easily the most anti-worker labor board in history, but even against this sorry backdrop, the scope of what they now are contemplating is breathtaking....

The stakes are high for the public, too. In health care, for example, scholarly research has documented that heart attack survival rates are higher for patients in hospitals where nurses have a union than in hospitals where nurses do not.

Already in 2000, months before George W. Bush was declared president, Human Rights Watch issued a powerful report that found U.S. labor laws were grossly out of compliance with international human rights norms. That organization's bill of particulars was lengthy, but the first item on their list was the failure of U.S. labor law to cover millions of workers, including among others, managers and supervisors in the private sector...

It is therefore imperative to push back against the Bush board's assault on workers' rights. We must, moreover, go beyond good defense; we must win serious protections for workers' rights. The Employee Free Choice Act (EFCA) is the most significant federal legislative proposal in nearly 30 years to protect the freedom of America's workers to form unions and bargain collectively. Since its introduction in the 109th Congress by Ted Kennedy, D-Mass., and Arlen Specter, R-Pa., in the Senate (S. 842), and by George Miller, D-Calif., and Peter King, R- N.Y., in the House (H.R. 1696), EFCA has garnered 215 House cosponsors, just three shy of a majority, and 43 in the Senate...

(from Lawless Workplaces by Stewart Acuff and Sheldon Friedman of AFL-CIO

And more from AFL-CIO:

Have you ever shown a co-worker how to perform a task, or been asked to look over someone else's work? If so, your freedom to form a union and bargain collectively is in danger. The Bush-packed National Labor Relations Board (NLRB) is considering three cases that could alter the definition of supervisor—and that could mean hundreds of thousands of nurses, building trades workers, newspaper and television employees and others could be prohibited from forming unions...

During the week of July 10, hundreds of thousands of union members will take to the streets in a week of action to fight for their right to union membership. Already, some 7,000 nurses and other health care workers at eight New Jersey hospitals threatened to strike to protect nurses' right to speak out for their patients through their union.

You can send a quick letter to your congresspeople here.

And from the California Nurses Association:

The National Labor Relations Board will soon issue a major ruling that could jeopardize the ability of RNs to receive the protections afforded by CNA/NNOC representation. At the request of healthcare employers and anti-union consultants, the Board is expected to make the absurd ruling that many thousands of RNs are "supervisors" under the law because they make clinical patient care assignments to other staff. Under federal labor law, supervisors have no protection. THEY HAVE NO RIGHT TO UNION REPRESENTATION.

This coming Tuesday, CNA is organizing rallies in Los Angeles and Oakland. More info here.

Art and Labor

On a very related note, I'm hoping to check out the "At Work: the Art of California Labor" exhibit at Pico Gallery, Downtown Los Angeles, sometime in the coming month. Details below and more information here, comment below or email me if you're interested in joining me or if you've already checked it out! Looks good...

The story of labor - which comprises passionate struggles and triumphs as well as dehumanizing forces - has figured largely in the art of our time. At Work: The Art of California Labor exhibition opened at the Pico House Gallery at El Pueblo de Los Angeles Historical Monument on June 13, 2006. It is the first exhibition to explore this important topic through the eyes of artists who witnessed or were inspired by some of the most significant trends and events in the history of the 20th Century...

Many Californians are aware of San Francisco's 1934 General Strike, but probably few realize to what degree labor movements shaped the state's political and social climate. Even fewer know of the copious art which both inspired and reflected California's labor struggles throughout the 20th century. "At one time, the strongest and most important artists in California made art about labor," explains Mark D. Johnson, Professor of Art at San Francisco State University. A mid-century backlash, however, including the persecution of labor sympathizers in the McCarthy era, has all but erased from public memory the very "vast and compelling" art surrounding the labor movements, he says.

And lastly -- Manual Labor

Ending on an upbeat note (pun intended), join me for some manual labor, aka dancing, each of the next 3 thursdays, at the Root Down party at the Little Temple in the silverlake area of Los Angeles. I've got each of the next 3 fridays off and I'm working each of the next weekends, so it's party time each thursday night, and this party/movement is where it's at.

(cross-posted at Los Anjalis)

posted by Anjali Taneja | 7/10/2006 01:22:00 AM | (0) comments |

Saturday, July 08, 2006

Gall Bladder Emergency;

about a month ago a woman entered the clinic jaundiced and feverish. no abdominal pain, no vomiting. her vital signs were normal so we felt safe to order some lab tests and figure out what was going on. we did the usual liver and hepatitis tests. the results were very concerning for gall bladder disease. the patient was still relatively asymptomatic so we continued with an outpatient workup, ordered an ultrasound and results showed a markedly diseased gall bladder with a dilated common bile duct (indicating a stone stuck in the duct system). Even though she was still relatively asymptomatic, the reality of her labs and ultrasound demanded an immediate surgical consult.

at this point my stomach always lurches a bit because the usual reality is anything but pretty for uninsured patients, especially undocumented immigrants.

i called the publid hospital, and for those who have read my posts before, guess what the response was.

WE'd LOVE TO HELP, SOUNDS LIKE SHE NEEDS SURGERY BUT WE HAVE NO BEDS.

Okay. Texas is a big rich state, perhaps i will start sending my patients there... Another idea that crossed my mind was to buy her a ticket to Canada. Years ago i had a roommate who was doing a musical tour in Canada. He was in a car wreck, not too bad, but was brought to an ER and evaluated with x-ray and CT scans. On the way out the door he tried to pay and the doctor said, "don't sweat it, we have national health insurance here, it's basically paid for, there is no bill for you."

check out this irony. another roommate at the time was Canadian. she was here in the USA as a student. she got sick, abdominal pain, and wound up in the ER at our local public hospital. everyone assured her there would be no cost to her, she was savvy enough to ask before being seen. after a few weeks the bills started arriving and she had to pay $800 for the visit. guess how mucha round trip ticket to Canada is. under $800. she could have flown home, gotten free healthcare in Canada and taken two weeks of vacation and come out about even.

okay, so it might be difficult to put a very sick undocumented immigrant on a plane to Canada. i assume it breaks alot of governmental laws, even though it honors human rights and the laws of ecnomics and free trade, but that's another story.

so lately i've been offering the option to my patients to go to other hospitals in albuquerque, names Presbyterian, which is the only other non-profit hospital in town. they have been known to disocunt bills significantly for working poor uninsured patients.

i called the surgeon at Pres and was treated a rare medical miracle. The surgeon was amazing on the phone. respectful, thoughtful, supportive and eager to see the patient. Most times docs ask the insurance status of the patient. She didn't. when i offered to her the social and financial issues, she shrugged her shoulders and said to send the patient right over.

the hospitalization turned out to be fairly complex with a 9 hour surgery. while the patient didn't look sick by her symptoms, she was actually on death's doorstep. this surgeon saved the patients life. i have already written a letter of gratitude to the surgeon because i was so touched by her compassion and perspective and desire to help someone who needed help.

while the patient is also super appreciative, and has already started to pay her bill, the total came to about $50,000. gulp. out of the frying pan, into debtors prison. perhaps Canada wouldn't be such a bad place after all for this patient and her entire family... Pres is a non profit and offers some discounts so my volunteers are helping her fill out the paper work. we'll keep you posted.

andru

posted by andru | 7/08/2006 04:24:00 PM | (0) comments |

Wednesday, July 05, 2006

Exercising Compassion

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first off - welcome SRI! thank you for that deep and insightful sharing of wounds, history, medicine, internship and healing. i am humbled and touched by your words and i look forward to more of your writings.

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the other day in my clinic there were four people waiting to be seen. we see people first come - first served, but there are occasions when medical necessity dictates a change in order.

a young woman was in the clinic waiting to be seen. she was missing a leg from an accident years prior. i had talked with her on the phone earlier in the day and let her know that when she arrived i would skip her ahead of the rest of the patients because of her particular problem.

when i called this young woman back out of order, an older hispanic woman scowled at me. she wasn't fuming mad but she was clearly irked that i was skipping over her daughter who was waiting with her to be seen. they had been there for almost an hour already.

it took about 15 minutes for the visit. afterwards the older woman came in with her daughter, they were next, and the first thing shedid was offer an apology. she thanked me for seeing the other woman first, recognizing that it was a clinic, not a bank or a restaurant, and sometimes others have deeper needs. i let her know that the reason i saw the patient first was that she had arrived by bus and it had taken her 2 hours to get to the clinic, plus she had the ride back, all with a handicap that made it just that much more complicated.

it was an interesting exchange and i was glad for it. i had broken the order out of compassion for a patient with a disability and a long bus ride and my other patient came around after a few moments to share that compassion with me.

andru

posted by andru | 7/05/2006 03:40:00 PM | (0) comments |

Thursday, June 22, 2006

because i have been getting a little flack from a certain miss anjali regarding my non-activity on this blog, here is something i wrote in March. I remember Langston Hughes said something like when you are busy living life, it is sometimes hard to sit and write. Or maybe that is my own lackluster interpretation to justify my lack of writing. -sri

from march... on the wards.

people walk around with so much. heavy-ness. carry it and tuck it away.

it is one in the morning. My last patient for the night. A tough black woman. 60 yrs old. sweet but tough. short gray hair and a quick smile but a smile like she's been working so long without a break. her lungs are kinda shot. she has smoked for so long and is wheezing now. wheezing so much you can hear it when you enter the crowded, noisy ER room. she had a Lakers hat on and a Lakers blanket and I started chatting with her about how the Lakers suck right now and you could tell she had been watching the Lakers for a long long time.

It is always great to talk about Cooper and Byron Scott and Magic and showtime. That itself makes the day. So after examining her, i tell her she will have to be admitted upstairs.

She got all freaked out and said "I don't do elevators I am closterphobic and I can't ride an elevator" Her sister is with her and says "She don't get on no elevators-She scared of them closed space. Her sister leaves and I say we can sedate her but she will have to take the elevator.

All of a sudden she starts to shake like a leaf. Her right hand shaking and she starts to cry. Not a sad cry, a scared spontaneous cry.

I squat down to look her in the face since her Laker hat is blocking my view as I stand over her. I tell her I can walk her slow up the stairs if she wants but "what's up- Why are you so scared"?

She says she doesn's tell anybody this but when she was seven, her uncle locked her in a closet and raped her. and she hasn't taken the elevators since. not once. she is 60 now. She said her aunt died a few years back and she went to the funeral and she brought a gun to kill that man. That uncle who had raped her. and sadder than seeing the aunt dead in a casket was finding out that that uncle had been dead for two years. She said she wanted revenge -- for that man who broke her to the point that she couldn't have kids. she can't pee without keeping the bathroom door open. She was never married.

There are certain things that are a Fuck You in the moment but don't make you feel any better. I told her that her life, her leading her life healthy and standing still without fear, without a running away is the biggest Fuck You to that man. That dead man who had raped her fifty some odd years ago. I felt like telling her that without forgiveness for that man her own heart would be affected. but it felt contrived and what do I know of rape and a trespass of something so sacred that you can never feel safe in your skin.

so i was getting paged and paged and a man was dying upstairs and i had to go... but i told her I would be back to figure this out with her and make it upstairs with her.

the man dying upstairs is another story- i shocked him with paddles. it took till 4:30 am to stabalize him. my DNR/DNI patient died at 2:30 in the morning and the family was bedside and I didn't make it there until 5 in the morning. to sign the papers and talk to the family. and the daughters in spanish said doc, you abandoned us. you took care of our father for so many days and his body has been cold for two hours and where were you? and my spanish is okay with a capital OKAY and i mustered something not very convincing.

i kept getting paged by the ER and I called back and they said you have a patient here who will not be taken upstairs until she talks to the doctor. it is now 6 in the morning and i have not slept and I run downstairs and my patient says doc what happened to you. You abandoned me. and I tell her what went down. and ask her if i can walk her slow up the stairs.

she says No. She will take the elevator. And I ask if she is sure. and she says she is.

And I go to round on her in the morning and she is on the third floor and she tells me like a kid who has just hit the winning shot in march madness. she made it up the elevators.

sri

posted by srijeeva | 6/22/2006 10:32:00 AM | (2) comments |

Friday, June 16, 2006

needles, flower essence, placebo and other health tools

clinic has gotten busy lately. we are now seeing on average 15 people per half day with jumps up to 25 at times. sicker people. the word has spread that we can do D&Cs for early pregnancy loss at least 1-2 women a week show up with miscarriage and we've had a rash of women with cholecystitis who have wound up hospitalized and surgerized with very complex medical/surgical cases. one woman required an eight hour surgery. interestingly enough, i haven't been able to send a single patient to the public hospital (University) because they are so full, there are no beds. and when given a choice, these very poor patients would rather get respectful care, receive a much higher bill and hope for some mercy from the non-profit hospital (Presbyterian). dignity and respect definitely rank higher than inexpensive, hostile care.

so last night, in the middle of a busy clinic, an older gentleman came in complaining of severe pain that he could no longer tolerate. he had a recent diagnosis of Rheumatoid Arthritis and Heart Failure, and he was sad and upset with the deterioration of his body. he was well insured and under the care of a primary care doctor, an arthritis specialist and a cardiologist, all of whom were very responsive to his needs. he was already on percocet for pain, a fairly sizable dose, but it wasn't taking care of his pain.

i was confused at first, i wasn't sure what i could do for this man. he made it clear that he wanted to try alternative medicine for his pain, try anything actually, that worked, and he had heard that we did integrated medicine at the clinic. i must admit, i felt a moments hesitation and insecurity, what could alternative medicine do that steroids and opiates couldn't for pain?

we dug a little deeper - he was clearly interested in acupuncture as a potential treatment. both the nurse practitioner and myself were trained in ear acupuncture for helping drug addicts detox more comfortably. neither of us claim to practice acupunture. that requires years and years of education and study. but i was on the spot last night. he was in pain, asking for help, strong drugs weren't cutting it and compassion moved me to "PRACTICE" medicine. I informed him that my skills were limited but that i could insert some needles in his ears and we would see what happens. this was after giving him a referral to a real acupunturist, but it was late in the day and there was no way to know when he would get the appointment in the future.

fortunately, i had also actually studied reflexology which uses the same map of the body on the ear so i was familiar with other points aside from the detox points. i put five needles in each ear, on the major joints and some "master" points that assist the body overall in healing. i left the man in the waiting room on a comfortable couch and started seeing other patients. about 45 minutes later i checked in with him and he had a HUGE grin on his face; he felt better. he was thankful to me and left eager to get a full acupuncture treatment.

don't ask me to explain how it works, i can't give you a mechanistic description. but clinical evidence is clinical evidence and this man benefited. at a cost of $30 for the consultation and the needles.

in the world of primary care, whether we are MDs, DOs, DOMs, NDs, NPs, PAs, Chiropracters, Massage Therapists, Traditional Medicine practitioners, Herbalists, Energy healers, etc, we all have the same task - diagnose the problem with some degree of accuracy, help people find their health when they are out of balance, and identify people who are so out of balance that they need hospitalization or specialist care to address their dis-ease. this requires humility and courage. the humility to know your limits and the courage to truly "practice" medicine, to try things with attention to minimizing cost, harm, grief (yours and the patients) and suffering.

there is NO ROOM to do any of this in the managed care world. the incentives, the environment, the "standard of care" all define the parameters of what's okay and what's not okay to do. there is no place for intuition, for reasonable, cautious experiement, for learning completely new and potentially amazing tools. every change in the system is a battle, a power game, a decades-long struggle by "alternative medicine" practitioners to earn the right to have insurance companies pay for their services.

boring. lame. gag me with a spoon.

i'm appreciating working in an environment where we can play, where we can try things out that seem utterly ridiculous on the surface, that have no scientific explanation (yet) but put smiles on our patients faces when "standard of practice" medicine can't do the job.

primary care calls for some creativity but there should be a method to the madness.

here's my theory of everything -

1. diagnose the problem. do this with as little invasive technology as you can, stay humble and re-evaluation your diagnosis if there is poor therapeutic response to treatment.

2. figure out the cheapest, simplest, least side-effect, most human dignifying solution, even if the success rate is not guaranteed to be 100%. placebo is a great example. in study after study of high tech drugs, placebo always comes in a close second on cure. CURE. not feeling better or some soft endpoint. CURE. it averages around 30-40% CURE. sit with that for a while if you are a practitioner. it's amazing. imagine the personal and social cost savings if everyone were to try placebo first and the 60% of treatment failures were then to move on to more expensive modalities. with this as a known scientific fact, you can't go too far wrong trying almost anything that is non-toxic, inexpensive and potentially useful. it gets weird (and criminal even) when you start pushing a particular "remedy" that cures everything, that costs alot and that you make tons of money off of. this is a form of abuse of placebo that charlatans can use to play off people's suffering.

3. the first line therapy may be antibiotics, flower therapy, flax seeds and aloe juice, ear acupuncture, a short course of benzodiazepines, prozac, hospitalization, surgery. it all depends on the diagnosis, severity of illness and your breadth of knowledge.

4. if first line therapy fails, move on up the ladder of cost, invasiveness and dependency.

5. remember that every step of the way it is the patient who decides (this is primary care, not a major trauma in th ER where the rules are different) and you who offer suggestions, insights, ideas and recommendations.

in our clinic we are learning to use inexpensive, interesting home remedies, nutritional remedies and energetic remedies (like flower essence and homeopathy). with the patients consent, these become first line BEFORE major antidepressants or anti-anxiety drugs, before laxative treatments or antacids and proton-pump inhibitors. those who fail the less expensive options can be quickly switched over to cholesterol lowering drugs and the purple pill (nexium) and xanax and prozac and all the mish mash of pharmacological glory our generation of scientists has produced.

as with any scientific endeavor, we are tracking patients who are beginning on these therapies and doing case studies to document success and failure. anecdotally, first response is very positive. within two years i'd like to have a whole series of independent interviews analyzed that can help to understand the usefullness of this approach amongst our patients.

andru

posted by andru | 6/16/2006 06:07:00 AM | (4) comments |

Sunday, June 11, 2006

Report-back from HMO "row"

Last week, I mentioned here that folks were gathering in Woodland Hills, CA (san fernando valley) to go on a "walking tour" of the headquarters of several HMOs -- putting together an innovative education and creative direct action event.

Here's a link to a podcast by the California Nurses Association around the event, and Deborah Burger (president of the california nurses association) wrote a report-back from the event, at the Huffington Post:

Everything you need to know about can be found in just one block of America, a quiet business-park block in a San Fernando Valley town named Woodland Hills. Here we find such the headquarters of such titans of the healthcare world as Blue Cross/Blue Shield, Wellpoint, Health Net, and Meridian Healthcare Management.

In just this handful of companies, we find the three values that mark today's system of big-business healthcare: denial of care, cash register politics, and huge profits amidst a growing crisis.

Our tour guide Sue Cannon, RN, starts at Blue Cross, to talk about the corporate need to save money by denying care--hardly the way a health CARE system is supposed to work. We're at Blue Cross because they've just been sued by numerous patients who've for"retroactive denial of coverage." Here's how that works: you get sick and Blue Cross approves a certain medical procedure. Then they go over your original application to see if they can find any inconsistencies; if so, they boot you out of the system, and leave you with the bills they just approved...

Our final stop is WellPoint, to discuss the disparity between huge healthcare industry profits and the growing crisis of the uninsured. WellPoint used to be a for-profit division of non-profit Blue Cross. Subsequently, it bought Blue Cross of California, turning the whole organization for-profit. Why? In the words of one stock analyst, to "liberate them from their social responsibilities." This liberation led to $2.5 billion in profits in 2005, and $157 million in direct compensation to their top five executives over the past three years. Yet HMOs have led the fight against a universal healthcare system based on a single standard of care for all, despite the fact that some 50 million Americans and over 6 million Californians have no health insurance.

Denial of care, cash register politics, and record profits from a health care crisis. That's the health care system we enjoy in America today. Thousands of people die unnecessarily each year because of this, and every year we fall further behind countries like Canada and England that haven't handed their health care off to big corporations like these in Woodland Hills.

And, I just received an update from CNA organizer Joseph Newlin on an upcoming CNA day of action:

July 11 is going to be a major day of action around the country to protest an anticipated ruling from the National Labor Relations Board that would re-classify thousands of nurses as supervisors and make them ineligible for union membership.

Reclassify nurses as supervisors because they make clinical patient care assignments to other staff? (rendering them incapable of having union representation) What? More information here. Can we think of other creative ways to exacerbate the critical shortage of nurses in our country?

I'm sure the national Committee of Interns and Residents (CIR) union, of which our hospital's resident physicians are well organized around and which is part of the Service Employees International Union (SEIU), will be working with the CNA on this action. I'll keep ya'll updated. If we don't support our nurses, who are the backbone of our healthcare system, the system will will go to hell in a bigass diaper and no amount of policywonking or healthcare reform will matter.

posted by Anjali Taneja | 6/11/2006 12:57:00 PM | (0) comments |

Thursday, June 08, 2006

Always and never

A pediatric cardiologist I worked with today reminded me of this piece of wisdom (from psychologist wendell berry) as we discussed a kid's physical exam findings and possible diagnoses:

"Always and never are two words you should always remember never to use."

Seems to make so much sense in the field of medicine, where the strongest truisms are always refuted and the mysteries of the mind and body are never wholly understood. Oops.

posted by Anjali Taneja | 6/08/2006 09:03:00 PM | (0) comments |

May Garriage

Boo: Senator Bill Frist is pathetic for pushing the gay marriage amendment to the floor of the Senate but blocking numerous other important bills from reaching the floor. The power he has as Senate Majority Leader is obscene. I think we need an amendment to broaden who makes decisions on what bills are allowed to be discussed (in committee or on the floor of the house or senate).

Ooh: Lou Dobbs is incensed. Dobbs, a not exactly center of the road kinda guy, gives congress the smackdown. He delves into our education system, poverty, lack of health care access, and our Congress' unrepresentative priorities in his CNN piece:

Dobbs: Gay marriage amendment sheer nonsense

...The president and the Senate's Republican leadership are now claiming that an amendment to our Constitution is necessary to save the American family. No matter how you feel about the issue, and many of us feel deeply, a constitutional amendment to ban gay marriage is utter and complete nonsense. It's an insult to the intelligence of every voter, Republican or Democrat, liberal or conservative....

The president and the Senate are focusing on one of the few reasons that has not been proven to cause divorce. They instead should look to financial hardships, and the lack of communication about family finances. The median family income is stagnating while gasoline costs and higher interest rates are eating up the family budget...

Both political parties love to excite and enliven their so-called "bases" by focusing on wedge issues like gay marriage, abortion, gun control, school prayer and flag burning. Both the Republicans and Democrats raise these issues to distract and divert public attention from the pressing issues that affect our way of life and our nation's future.

Are these wedge issues really how Congress should be spending its time, especially given how little time politicians spend in Washington, D.C., these days? I'd rather see our 535 elected representatives and this president use their time to combat poverty, fix our crumbling schools, secure our broken borders and ports and hold employers accountable for hiring illegal aliens. And like millions of Americans, I am desperate for a resolution to our wars in Iraq and Afghanistan.

How can we tolerate elected officials who press wedge issues when 37 million people in the United States live in poverty, one in every eight Americans? Almost 18 percent of children under the age of 18 live in poverty -- 13 million children.

Nearly 46 million people live without health insurance, about 16 percent of the population, a number that has risen by 6 million since 2000. More than one in 10 children are uninsured, and one-quarter of people with incomes below $25,000 also lack any health insurance.

College costs are skyrocketing. There's been a 40 percent jump (inflation-adjusted) in tuition and fees at public four-year colleges and universities over the past five years, according to the College Board. The costs for brand-name prescription drugs have also increased twice as fast as the rate of inflation. In fact, over the past six years, the average rise in the price of brand-name drugs is 40 percent, according to the AARP.

But while these increases in the price of the basics make it harder for hard-working men and women to make ends meet, the president and Congress would rather drive wedge issues than work toward real solutions.

I wonder if the president's political advisers know just how ill-advised and smarmy this wedge issue looks to the millions of us who want solutions to the critical, urgent problems facing this nation. Worse, I wonder if they even care.

posted by Anjali Taneja | 6/08/2006 12:10:00 AM | (0) comments |

Monday, June 05, 2006

Taking a walk down "HMO Row"...

I'm posting the following because it's a great example of a creatively planned event (not because I expect totheteeth readers to trek over to the san fernando valley, ca -- but if you can, go go go!). It's really exciting to see a health care reform event utilizing education, direct action, and creative filming:

On Wednesday, June 7, nurses, patients and healthcare activists will host a Walking Tour of 'HMO Row' in Woodland Hills. Join us for a short, guided tour of several insurance company office buildings, with descriptions of the harm these corporations are doing to patients as we advocate for Medicare for All-a national bill (HR 676) authored by Rep. John Conyers (MI), and a California state bill (SB 840) authored by Sen. Sheila Kuehl.

Please come and support this San Fernando Valley event for Universal Health Care.

Wednesday, June 7
11:00 AM
Blue Cross Headquarters
Corner of Owensmouth and Oxnard
Woodland Hills, California
Parking available at the mall by AMC Theaters.

Come shortly before 11:00 AM, since the event will begin promptly.
Don Schroeder will be filming this event and Doris Nelson will be speaking for SB 840 representing HCA.

Hope to see you,

John Glass
Outreach Coordinator
Health Care for All-San Fernando Valley Chapter
(818)766-6381
If you can come, please let me know at jglasshouse@earthlink.net

Or call the California nurses association -- 818.637.7115 or 510.273.2202

posted by Anjali Taneja | 6/05/2006 07:14:00 PM | (1) comments |

Sunday, June 04, 2006

Big Ideas

This is big. I received an email from MoveOn.org, about the results of the house parties they had all over the country (over 100,000 attendees) and subsequent voting to choose their top three Big Ideas to work on for the next phase of their (our) actions. Parts of the email are below, it's pretty impressive how front-and-center health care reform is among the moveon members (obviously a little more left-leaning than your average joe, and possibly more middle-upper class -- not even sure of this actually). Someone told me back in the day, movements really push forward in this country when (1) self-interest is at stake and (2) the issues start seriously affecting the middle-class, not only the low-income folk. So, ya wanna join in?

Dear MoveOn member,
The results are in. We're proud to announce the MoveOn member choice for our new, positive agenda:

Health care for all
Energy independence through clean, renewable sources

Democracy restored

These three goals were nominated, debated, and overwhelmingly selected by more than 100,000 people in local house parties and then online. Most groups would say this is a far too risky way to make such a big decision. But it's this grassroots consensus that makes this agenda different—and powerful...
Our strength lies where it always has: the voice, energy, and creativity of 3 million MoveOn members. If we're going to make health care a right, power America with clean energy, and restore our democracy, we're going to need as many likeminded folks on board as we can get. So today, we're turning to you to help build the team.
When the polls closed Wednesday night at 11:59, "Health care for all" and "Energy Independence: clean, renewable sources" were the clear winners for the first and second plank, with 82.8% of voters choosing one or both. We're proud to put these bold, inspiring goals front and center in our work to come...
It's exciting to know how united we are—a full 96.8% of voters chose at least one of these top issues.
We've set our eyes on a pretty big prize here, and there's a lot of hard work to do. But our history is full of stories of millions of people uniting behind a vision and fighting together 'til they've achieved the unthinkable. And heck, most of them didn't even have email.
Let's make it happen.

–Ben, Matt, Adam Green, Marika, Justin, Jennifer, Carrie, Rosalyn, Eli, Adam, Tom, Noah, Wes, Joan, Tanya, Natalie, Roy and Nita, the whole MoveOn.org Political Action team

Friday, June 2nd, 2006

P.S. The online vote was between the 10 most popular goals that MoveOn members generated and sent in from over 600 house parties last week. Here are all of the "MoveOn top 10" and the final vote count for each:

Health care for all 65091

Sustainable energy independence 61030

Restored constitutional rights 35675

Guaranteed accurate elections 35133

Global leadership through diplomacy 28912

High quality education for all 27874

Solutions to global warming 26306

A guaranteed living wage 25527

Publicly funded elections 21096

A balanced federal budget 20945

P.P.S During the voting, members were asked to add their own words about why these goals are so important. Here's what just a few had to say:

Health Care for all:

We need a system that is equitable and affordable for all...Health care should not be treated like a commodity. We have 46 million uninsured and many million more who are underinsured and don't have adequate health care. It is estimated that 18,000 people die each year because they don't have adequate health care that works out to 50 people every day. We cannot continue to tolerate a fragmented health care system which worries more about profits and stock holders than it does the well-being of Americans. It is time for a systemic change which will bring down the cost of health care.
–Rebecca E. from Ithaca, NY.

I think that people with health care sometimes think that this is just a problem for the uninsured, but that is absolutely not true. Even if you have health care and develop a serious illness (cancer, MS, etc.) while covered by your employer, you better be sure you love your current job. Because if you decide you want to change direction in your life, you will become all too familiar with the words "preexisting condition". You will find you most likely cannot get coverage from a new provider. This system traps us all, insured and uninsured. We need comprehensive, affordable health care so that all of us can have the freedom to live our lives the way we want to, doing what we love, not being trapped by the health care system.
– Rebecca p. from Moose, Wyoming

posted by Anjali Taneja | 6/04/2006 11:16:00 AM | (0) comments |

Saturday, May 27, 2006

Grand Opening and other updates

Great news and updates from the Topahkal clinic.

Most importantly, we used up another soap dispenser in the bathroom. This one was used up in less than 6 months, a sure sign we are growing. We could just count the number of visits but as scientists, it's always good to make sure we have corroborating evidence... :> Our patient numbers are vastly outgrowing our capacity. We are consistantly at 10-15 visits per day average with more days per month seeing over 20 patients. We had a new record of 26 patients the other day, which i'll write about in another post.

Almost as importantly, we started a Mercado ("store" in Spanish).

We are selling orgaqnic flax seeds for $2, Auralgan (ear drops for pain) for $4, urine pregnancy tests for $3 and local bee pollen for $2. As you can see, it's an integrated health convenience store. :>

I'd like eventually to be selling organic bulk foods, local organic produce and yogurt, wheelchairs and crutches and canes (organic if possible...), rice socks, tennis and golf balls (for acupressure treatments, although if my patients want to take up the sport, i'd encourage it), and various other sundries, like non-toxic deodorants and soaps.

Other than that, we are still on the hunt for another practitioner, PA, NP or MD. We have a few leads but nothing sure yet. And we are still looking to move our location to another house, larger and easier to find, that has the correct permits to have a business.

Oh yeah, and we are on the verge of signing our first contract with a local non-profit business that will use us for primary and urgent care for their workers coupled with a catastrophic medical plan for hospitalizations and emergencies. I'm a bit nervous, with contracts come the "devil in the details." But realistically, our non-profits are struggling under horrible payment plans right now with managed care companies, high to begin with, raising prices at lesat 15% each year. You can't budget for that in the grant world, it's impossible. So within a few months we'll see what kind of cooperative associations can be formed to help the non-profits and us do our jobs better.

andru

posted by andru | 5/27/2006 11:51:00 AM | (0) comments |

Saturday, May 13, 2006

Ambulance Call

after almost two years operational, we made our first ambulance call yesterday. a woman entered the clinic barely able to walk, breathing fast, disorganized in her thought, with a heart rate of 140. i didn't know her previously.

i called 911 and spoke with a very annoying, by the book receptionist who kept scolding me for giving her more information than she wanted, out of sequence with her set of questions. we spent more time with her scolding than anything else, but aside from that, i was really impressed with the emergency response. the ambulance crew arrived within 3 minutes. turns out they were local guys from right around the corner.

the team did a great job assessing her while i finished up seeing a patient with gastritis. they were cool. they felt she was stable and thought she could transport herself to the ER. this would save her over $300. after speaking with the patient, i wound up finishing her care in my clinic so she avoided an ER visit altogether. turns out she was hyperventilating and panicking. she was also on herbal weight loss medicines which probably provoked the attack. she got some IV fluids, reasurance and recovered very nicely from the episode. final cost was $50 for the visit, IV fluids and blood sugar test.

i learned recntly that the paramedic school here in albuquerque is starting to train their paramedics in primary health care because so many of their visits are like this one where the person has a basic problem that could resolve with some simple steps in the field, but the person doesn't have insurance, a doctor or clinic to go to. i'm not sure if this is happening in other states. i support it. if the doctors in the health system don't meet the need, then let another trained group of professionals take over the work.

people need the care.

andru

posted by andru | 5/13/2006 01:28:00 PM | (0) comments |

Tuesday, May 09, 2006

shake it, shake it like a Polaroid picture

In my next 2 weeks of my family medicine residency program, I'll be working at and learning from various community health projects in LA. These are two weeks that other residents tell me are grounding -- they awaken us sleepy/agitated/tired/hospital-based first year residents to the community health work around us and inspire us again -- THIS is why i went into family medicine, or THIS is community health!

I'll be going to prison clinics, job corps, a clinic at a high school for pregnant teens (started by one of the faculty members when she was a resident!), and a tattoo-removal clinic -- started by one of the former Harbor-UCLA family med residents, in collaboration with Father Greg Boyle and his organization Homeboy Industries, who have been working with former gang-members (with tattoos on their faces and other exposed areas) to help them back into society and into the workforce.

I'm not sure if it's because i'm rested after a vacation, or because i'm ready for something other than the hospital right now, but i'm pumped about this rotation. On one of the afternoons, I'm going to have to talk to high school kids at one of the local schools about a health-related topic, and I've already been thinking about incorporating music into my session, for so many reasons (music is great at breaking the ice, connecting with youth, and helping to convey messages). And really, I just wanna be down with the kids :>

So I was elated when I read about 'musical cues'. Andy Hilbert is a teacher in Los Angeles who runs a blog where he discusses education, the Los Angeles Unified School District, and teaching, from his perspective -- as an 8th grade teacher and chair of the Carson area United Teachers of LA. He's experimenting with musical cues in the classroom:

On my first attempt I opened the class with a question, "What is a musical cue?"
Usually there was little response.

So, I continued. "What if I could play a sound or a tone or a piece of music and everyone in the class would instantly know what to do? Well that would be a musical cue."

The class seemed perplexed yet curious.

"I think musical cues work. I’ll play a note or sound or song and everyone will know what to do and start doing it. It works. You’ll see. Let’s try it."

I walked slowly to the CD player and pushed play on track nine for the song "Hey ya" from which I had lifted the "shake it, shake it, like a Polaroid picture" lyrics. Once my students heard the song, they burst into exclamations of recognition, started singing, smiling, and taking out 8½ by 11 pieces of paper and folding them into word charts. I illuminated the definitions on the screen and everyone started copying the definitions as the song continued to play. When the song finished, the class was in a trance. They could not be bothered. They wanted to complete the word charts quietly by themselves without my instruction. I didn’t have to issue a single instruction, let alone repeat one twenty times. It even took me a little while to bring them back from absolute silence, but I slowly managed to engage the class in discussion about the words.

Now I just have to think of appropriate tunes to cue transitions into group work, silent reading, and clean up time. Hey maybe I can turn my students on to Neil Young, Bob Dylan, Ben Harper, and Victoria Williams. I better not push it; this is supposed to be a job.

Check out the rest of his blog, Horsesense and Nonsense. He's pretty passionate about his classes *and* about Los Angeles politics and education. Rock on.

(cross posted at Los Anjalis)

posted by Anjali Taneja | 5/09/2006 12:41:00 AM | (0) comments |

Monday, May 08, 2006

Insider Igorance

this is a message to all healthcare staff, nurses, doctors, administrators and students.

a patient's mom fell and broke her arm about six weeks ago. after spending nearly 16 hours in the ER, she got good care, was splinted and sent home to heal. after a month, she had a follow-up appointment where it was determined that she was healing poorly, technically called a "mal-union." she was scheduled for a pre-op surgical appointment last week. her adult son accompanied her because she doesn't speak English and has trouble advocating for herself in big systems. he reports that he was told that he was not aloud to accompany her into the visit and had to wait outside. he is a humble man and accepted that at face value without challenging his right to participate. the surgery was discussed, a date was chosen, the patient was sent home and the patient didn't understand a thing.

if possible, i'd like for her to have local instead of general anesthesia to reduce surgical complications and recovery time. she has no idea what kind of anesthesia they are going to use. her son had been prepped by me to ask that question but he wasn't aloud in.

we are getting closer to the message for healthcare workers.

i called this week to try to track down the surgeon. i made it to the right clinic and spoke with a receptionist. i shared my concerns and told her about how the patient's son wasn't aloud to participate in the visit. she became defensive and then flatly denied that the patient's son wasn't aloud to participate, stating that it wasn't policy to exclude family members from visits, and finally, that it didn't really matter because they have interpretation services available so the patient should have been fine on her own.

we will never improve our systems, our quality of care, our ability to care for people who are more vulnerable, if we maintain a defensive, ignorant posture when patients and families share their stories of poor treatment or mis-treatment.

noone is perfect, systems are far from perfect. this isn't a tirade to try to make everything perfect. it's a call to those reading to please stay humble, listen and believe your patients, take what they say with a grain of salt of course, but don't discard the concerns raised because they don't fit nicely into what is supposed to be happening per stated policy.

andru

posted by andru | 5/08/2006 01:32:00 PM | (0) comments |

Sunday, May 07, 2006

Disruptive Physician - Are you one?

ever heard of a disruptive physician? i've gotten quite an education on the topic in the last month. there are two surgeons, both in the ENT dept at our publc hospital, who are being forced out of their jobs. Every conflict has two sides so this may sound a bit biased, but after my experience of being forced to resign from UNMH, and having met personally with these two physicians, I am convinced that they are honest, skilled, caring doctors being targeted and pushed out for their advocacy for patients, their concern about certain unethical behaviors within their department and for standing up to the intimidation being thrown at them by their administrators. Our hospital administrators love to play tough with people who express moral or ethical concerns. there is alot to the story of these two physicians that will have to wait for public disclosure but i am proud to say that my community has taken the step of publicly asking the hospital to ensure that these two gentleman have due process and a fair trial. we'll see where it goes from here.

so what is a disruptive phsycian? if you do a google search, you will find plenty of info. in summary, a disruptive physician is a doctor who jeapardizes or compromises patient care by their attitude, behavior, actions, prejudices, etc. a perfect example is a doctor who has caused so much fear in the nursing staff that they are afraid to call that doctor to report a health concern with a patient and the patient has a bad outcome. one could blame the nurse or one could see the deeper toxic dynamic the doctor set up over time by punishing the nurse inappropriately.

it's important for any clinic or institution to be able to identify a disruptive doctor and take corrective or terminative action. when patient care is at the center of the mission, this is a critical necessity. i know plenty of disruptive doctors (we all do). they are all over the place in medical education. they are typically mean, obstructionist, angry, incompetant, and insecure in their abilities. and i wish there were ways to get rid of them because they made my life miserable and they were fundamentally bad docs for the patients. i'm still traumatized to call a surgical or specialist consult years out of my training.

so what's the hubbub about?

well, it's a fine line between a disruptive physician and a doctor who is advocating strongly for his or her patient, especially in a corrupt system where in truth, the administration, not the doctor, is disruptive and obstructionist to patient care. this is what we find in our public hospital system. when you get into the nitty gritty details, adminsitrators play out their little power games by sabotaging the OR schedule, by hiding critical surg ical instruments so that cases for poor people have to be postponed, by cancelling at the last minute a surgey because the person wasn't pre-qualified by the indigent care committee... etc, etc, etc.

in my own time, i witnesses alot of disruptive behavior by administrators but i didn't have a vocabulary word for it, i just got pissed and whined alot. in one of our FP clinics, the docs worked for a year with front desk staff to train them to be nice, to welcome patients before asking for money, to greet people and smile, all the basics. right after things started flowing more smoothly, more patients were getting in (who had no insurance) and patients were happier, the front desk staff were moved to a new location and new staff put in their place. and the cycle started all over again. DISRUPTION.

just as there are being developed mechanisms to identify and remove disruptive physicians, we need a process to identify and remove disruptive administrators, staff, insurance companies, politicians, etc. and we need to be sure that when the charge of disruption is made, that it reflects the truth around patient care. i am proud of the disruption i have caused to the buracracy. buracracy needs disruption, it needs a good kick in the ass.

andru

posted by andru | 5/07/2006 08:35:00 PM | (0) comments |

Thursday, May 04, 2006

Blogging others' stories on HIV/AIDS, and "NGO 2.0"

Brian Shartz and Curt Hopkins at Blogswana (creative name) are doing some innovative blogwork. I'm always excited about innovation in web technology, and as this one related to health and storytelling, it piqued my interest. Check out this project:

Our proposed project would involve training about 20 students in Gabarone who would commit to a year of blogging for someone whose life has been effected by HIV/AIDS. They would post blogs for those on the far side of the digital divide, those without access to computers and connectivity. While the scope of this project may be unique, the concept is not. Patrick Makokoro provides a great example of ‘blogging for others’ in AIDS in Zimbabwe: One Orphan’s Story. He allows Chipo Baloyi to tell his own story about the devestating effect AIDS has had on his family:

My day begins very early in the morning when I light the fire and heat the water for my two small brothers and three younger sisters to bathe in before they go to school. If we have access to maize meal, I cook a pot of porridge for them to eat. After seeing them off to school, I start my daily household chores: sweeping the yard, cleaning the dishes and washing the linen soiled by my young siblings. Since it will still be cool, I then go out to the garden and water.

My father was the first one to pass away, in October 2002. He had been sick for quite some time, and we had to sell off some cattle and goats to pay his hospital bills. We also visited traditional healers to get local medicine for his ailments, but all this was in vain. After he succumbed to this strange, unnamed disease, we had to sell two more heads of cattle to pay for the funeral expenses and to pay some people who had done different services for us. This left my family with nothing...

* * * * * * *

As I mentioned in a previous post, I like to talk about the Web 2.0. A few friends and I are putting together a project in the near future (no talking about pipe dreams before they come to fruition, i was advised by a wise sage), and we can't stop talking about the potential of the web 2.0 -- which is why the defined concept of NGO 2.0 grabbed me:

If the transition from Web 1.0 to Web 2.0 can be said to be the transition from static, authorial, unitary, proprietary, non-transferable content to distributed, networked, user-generated, shared and easily transferable content, and if traditional NGOs may be said to function as cash-intensive, centralized, hierarchical, bureaucratic, specialist-driven operations, then Blogswana is, in a sense, NGO 2.0.

Blogswana bypasses the hierarchy of both the traditional charitable organization and of the recipient government. Its organization is largely horizontal. It distributes funds to a network, populated by the actual individual recipients of that aid, to do its work. It aggregates the work product of those individuals. It enlists those recipients to create and distribute the next generation of aid themselves. It’s a user-generated, entrepreneurial, person-to-person network of aid.

It’s NGO 2.0.

Sweet. Thanks for that clarity, Blogswana team. :>

posted by Anjali Taneja | 5/04/2006 11:17:00 PM | (1) comments |

Thursday, April 13, 2006

A Shocking Moment - Public Healthcare System WORKS!

it may sound from the title that i don't believe in public healthcare. let me reassure you that it's about the only healthcare i believe in. but for many reasons, our publichealthcare systems are underfunded, underperform, attract slackers, support incompetant administrators, promote yes-men and yes-women and generally focus on trying to look good instead of trying to perform good. everyone, from janitor to doctor becomes powerless to improve aspects of the system. my criticism is made with the intention of someone trying to fix the system, not destroy it.

so here's the "good" news.

i saw a young woman in my clinic two weeks ago. she is poor, spanish speaking, three kids, no papers, no husband, helped by a social worker to get to the clinic. you may have presumptions or preconceived notions about this woman and her right to even receive healthcare from that brief desciption. let me say one thing to put you in the right space: this is a lovely young woman in a difficult situation beyond her control. think of her as your sister if you have trouble recognizing that people of other cultures and nationalities are human.

she had a rapidly growing lump on her forehead but was fearful of high bills and hostile doctors so she avoided medical care. after a month, her social worker convinced her to come in and we did a fairly difficult biopsy of the lump. i was trying to maintain a minimal scar which forced me to make a very small incision along the scalp line which led to a difficult but ultimately productive procedure. the biopsy came back with CANCER. type still unknown. rare enough that it was sent to a super specialist who can help figure out if it's terribly malignant or mildly so.

we have a volunteer pathologist who helps us with these cases and he was able to get the assistance for free from this super-specialist pathologist who is one of the leading experts on this type of cancer.

while the pathology is being processed, i met with the woman and her social worker. we took about 45 minutes to break the news, process her grief and fear, answer her questions, let her know she isn't alone on this terrible journey, and start to make a plan to get her situated asap.

usually a person in her position would have avoided healthcare for many more months, but she had the social worker caring about her. usually a woman in her position would have had to wait 2-4 months for the appointment to get the biopsy done, if not longer. but we had my clinic open which does walk-in appointments on the same day a person wants to come in. usually a person in her position would have had to pay $500-$1000 for the biopsy procedure and pathology results. she got it for $60. usually a woman in her position would have had to wait another few months to get in to see a surgical specialist because the public hospital system is so overcrowded.

here's where the final piece of magic came in. i'm getting to know a surgeon at the university who is a technically excellent ENT (facial) surgeon with extra training in plastic surgery. he is a strong patient advocate, believes in the economic model of doing private practice to bring in extra money to use for uninsured poor patients. this is the officially stated economic model of our public hospital. turns out that they really like the money he is bringing in but are very resistant to his advocacy for also bringing in poor uninsured patients who need medically necessary surgeries. they are now threatening to not renew his contract, even though he is one of the only facial plastic surgeons at a level three trauma hospital in a poor state.

what is somewhat personally and historically interesting to me is that it was in an ENT clinic where i first learned about the profound discrimination going on against poor and uninsured patients at the public hospital 5 years ago, when i was a lowly resident. it was in that ENT clinic that i decided to help form an external health justice coalition that has successfully challenged the hospitals erroneous, hostile and unethical exclusionary policies and theoretically had those policies changed (on paper). fast forward five years and here the situation reveals itself how little functional progress we have made that this surgeon, as a patient advocate willing to work for free, bringing in good private money to the system, is being pushed out for his work, and cannot get patients the surgeries they need. so much for changed policies. this is a lesson in social justice. the policy on paper is 10% of the battle. the implementation of that policy is where the heart of the work is.

well, he hasn't been pushed out yet. many hospital employees and the health coalition are backing him up to ensure that he gets a fair trial and hopefully a new contract.

so it turns out that he is the exact surgeon that this woman needs to resect her cancer and give her a good cosmetic result. i called him on his cell phone. he answered, was great to talk to, accepted the patient without question of her insurance status and she now has an appointment with him in 1 week to figure out what needs to be done. which is perfect timing because we are still waiting for the final pathology results.

this woman, while she is struggling with a potentially terrible medical situation, has had the blessings from good hearted people who have created a simple pathway for her to definitive medical care with minimal cost, humiliation, friction, invasiveness. basically, she has been treated like a human being, with care and concern.

i am proud to have been a part of her journey thru the public healthcare system, which is something i cannot often say these days when i have to reach outside of my own little clinic.

andru

posted by andru | 4/13/2006 10:54:00 PM | (2) comments |

Saturday, April 08, 2006

Country Boy...

yesterday i had a great time. i rented a large trailer, hitched it up to my veggie oil burning diesel pickup truck, drove over to another town and picked up a donation of 5 antique (used) medical exam tables. had to load them with the help of the medical assistant. he just kept saying, "see, if you have a Mexican you can do anything." i kept trying to respond, "hey, what am i, chopped liver, it helps to have a Jewish doctor also!" i was grunting those 500 pound tables right next to this dude. :>

but the really fun part was learning how to drive in reverse with a trailer. finally, all those years of organic chemistry helped! trying to imagine what direction that trailer was going to try to go in based on the direction i turned the wheel, it felt like inverted logic and fischer projections.

unfortunately, the only thing doctors really want to get rid of are older exam tables and the oldschool scales so i'm full up on those items and am starting to outfit other free clinics and independent doctors.

now, a new opportunity is presenting itself. a local hospital, owned by a multinational dork corporation, is threatening to close. too many poor people, not enough profit. i'm wondering what they are going to do with all their older medical supplies and i'm sending in agents to see if we can't capture some of their stuff before they throw it away. companies like that almsot never take the time to recycle or donate their equipment. it's more efficient to haul it all to a landfill.

andru

posted by andru | 4/08/2006 09:28:00 AM | (1) comments |

Friday, March 31, 2006

Clinic Vignette March 30th, 2006

driving in my car, i got a phone call from a distraught mom.

the question of doing "car medicine" with cell phones will be saved for another post, but the issues are seriuos - i wonder what the cost-benefit ratio is of "care given" vs auto accidents with cell phone use... would my car insurance count as liability insurance in that case? is there a special medicare billing modifyer that covers cell phone use but discounts for multi-tasking since likely you are talking on your own personal time? so many questions...

but back to the distraught mom. her son is a 40yo heroin user. still lives at home. he's been my patient trying to detox off heroin for a few months. over the past few days she reports that he is acting strange, hallucinating, disorganized, leaving the stove on and almost burning down the house with cigarettes. she had already tried unsuccessfully to convince him to get mental help, to enter a rehab facility, she had called the police to pick him up for his own safety (and hers), had called the mental health center twice seeking help. she was told repeatedly that since he is an adult, if he doesn't want to come in on his own, he doesn't have to, regardless of the fact that he is clearly incompetant to make that initial decision.

now i am all for personal autonomy, patient autonomy. but there is a line in our society between competancy and incompetancy. when someone is ill enough that they cannot care for themselves, that they are a danger to themselves or others, we respect the fact that they can be picked and evaluated by mental health experts. it's not jail. it's supposed to be done with good intentions, i.e. the express welfare of that person. and if the evaluation shows they are competant and perhaps the person calling is crazy or misguided, or trying to lock away someone they dislike, the system figures that out and lets the person go.

but why didn't our system, police or mental health, assist this woman with at least an evaluation? so there i am driving up 4th street on my way to pick up some pvc parts for a grey water system at 4pm and this mom is asking me to help her. my first step was to give her the special code words we use in healthcare - call the mental health center and say, "he is incompetant, he is hallucinating and is a danger to himself and others," don't focus on the drug use, heroin doesn't make you hallucinate. didn't work. she called me back and said they refused her concerns. next step was for me to fax the police dept with a "pick-up" order. that apparently is the right buracratic (side note - i am sick and tired of trying to remember how to spell bureacreaucy so from now on i'm going fenetic) form. i didn't have the form and it was 4 :30 and i'm now in the hardware store.

luckily, those guys are kinda cool and they let me fax off a prescription with the order. got a call back that the script wasn't adequate, couldn't i get the right form. NO! but thru some negotiations and begging, i convinced the police to at least send a cruiser by the house and look in on the situation. that way they could decide if he was a danger or not, at least. they went, thankfully, and actually took him in to the mental health center where he was evaluated.

the mom called me the next day to say thankyou. and then reported that they sent him home because he was an adult and didn't want to stay.

she heard my suggestion to call her county commissioners or the press, because what the heck else could she do? she hung up crying.

andru

posted by andru | 3/31/2006 11:18:00 AM | (1) comments |

Tuesday, March 28, 2006

Peanut Butter and Jelly sandwiches, the Web 2.o, and Blogging Health Justice

That's the title of a talk i'm giving at the National Physicians' Alliance conference this weekend in Chicago, which is happening back to back with the American Medical Student Association conference -- so yes, i get to go to both. sweet. I've never done a panel presentation before on this topic, and boy I'm no expert either, so we'll see how it goes. But i'm pumped about talking with graduating medical students and doctors about the potential of the web for expression/writing and also for organizing around health justice issues.

The PB&J in the title has to do with the progression of blogs from mundane personal expression (I had an amazing PB&J sandwich today) to reflective personal expression (Yummy PB&J sandwich today, and by the way it made me think about the incentives of the drug company that gives us these sandwiches free with our lectures) to community minded, organizing expression and discussion (I love me my PB&J sandwich, what if everyone had a right to PB&J sandwiches, how can we make that happen?). That's the general theme. I'll save this for another post, but I think, with the medical related blogs, we do the first two really well (especially the 2nd), which makes me really happy. But we're not yet at the third, and i'm pumped about being a part of developing the third in the coming months and years.

Lots of other talks. My co-intern and fellow past AMSA Jack Rutledge Fellow Casey's going to talk about sustaining activism during residency, and Andru (co-writer on this blog) is going to be talking at both the AMSA and NPA conference. He's popular, was asked to talk about public hospital and activism issues, as well as this fabulous topic and description:

"Brewing an Affordable Integrative Clinic for Poor and Uninsured Patients - Putting Care and Wonder Back into the Mystery of Health" will include a brief presentation on the creation process involved in birthing a new integrative clinic for uninsured patients in Albuquerque, NM, followed by group discussion of the various elements involved. Audience participation expected. Discussion to include all aspects of "practicing" medicine: team building, racism, pros and cons of insurance, business structure options, malpractice, labs/x-ray/specialist referral, patient advocacy, pharmacy, homeopathy, volunteers, donations, grants, politics, etc. We will discuss some of the laws that stand in the way of connecting good patient care to affordability and some ideas on how to overcome these limitations.

And that's just a snippet of the tons of other great interactive sessions, discussion groups, breakout sessions, and a rally, in the windy city. We'll report more when we're back. More about blogging health justice, the new and much needed National Physicians Alliance and updates from the NPA pow-wow, and other thangs in a few days... though i may need quite a few days to process the intravenous infusion of energy and discussion and building with dreamers, otherwise known as AMSA and NPA.

Over and out.

posted by Anjali Taneja | 3/28/2006 10:24:00 PM | (0) comments |

Tuesday, March 21, 2006

Clinic Stories - March 21st

today was a fascinating day in the clinic. we broke alot of social/medical rules but hopefully no true physiological laws in our practice of medicine.

we received a call from a local DOH office with an urgent referral of a hypertensive woman with chest pain, 180/110 blood pressure. she had the pain for over a month but it was getting worse. the woman is undocumented, uninsured and refused to go to the hospital for fear of a crushing bill. we agreed to do an initial assessment of her with our handy EKG and sensitive palpatory skills so they sent her on her way to see us. about 20 minutes later we get a call telling us she doesn't have a car so she's walking over!!!! at this point our awesome receptionist volunteered to go pick her up and transport her the 2 miles to our clinic. when she arrived, she looked sad, tired and was toting two young children. a quick EKG revealed Q-waves in two inferior leads (not reassuring) with no ST changes and a regular rhythm (reassuring). blood pressure of about 160/100 (not reassuring). and on top of it all, she's allergic to aspirin! (not good). what a day. she got metoprolol PO and some clinidine to control her BP, a GI cocktail which actually helped her chest pain alot (reassuring), and a physical exam which revealed reproducible mucsle pain along her sternum (reassuring). at this point we recommended her to the ER but she refused to go so we agreed to draw her blood and send off a STAT Troponin-I while she waited. Once again our receptionist volunteered to take the blood to the lab and amazingly enough, it came back FAST - completely normal value (very reassuring). we are bringing this woman back tomorrow to ensure her blood pressure is controlled and will do strong risk reduction counseling to ensure she minimizes her future potential for more heart attacks. the EKG findings could have been her baseline but i suspect that at some point in the past she lost a bit of heart function. she's had high blood pressure since she was a child.

what are you going to do? what would a court of law say? looking back with hindsight, if she was having an acute MI or if something happens to her tonight, it ain't going to look good for us. but from my perspective, we are honoring her wishes, and doing a good job within her means. it's a risk i'm willing to take.

we also saw a woman with bad cellulitis of her right hand secondary to injecting Crank (speed). she missed her vein and caused a serious bacterial infection to happen. we treated with a shot of ceftriaxone in the butt and a return visit tomorrow but she is right on the edge of needing hospitalization and possible surgery on her hand. she's another one who was mortified by the idea of entering the hospital, but for different reasons - she doesn't want anyone to know she is using drugs or else she'll lose her job.

another gentlman came in, alcoholic but recently quit, with a sebacious cyst right on his adams apple. i had cut it open a few days ago and drained out the cyst but it was in too delicate a place to remove it completely, so he was just back for followup wound care. he is going to have to try to get himself an appointment with a surgeon at the public hospital to have it removed. i'll let y'all know what that journey is like in a few months because that is likely how long it will take him to resolve this fairly simple problem.

andru

posted by andru | 3/21/2006 06:25:00 PM | (0) comments |

Sunday, March 19, 2006

Clinic Vignettes - March 18th, 2006

The man with severe hypertension survived the night, is still alive, has reduced his tobacco intake, and is now at a level of Blood Pressure that is relatively controlled. i used a technique with him that i've been experimenting with for folks with high blood pressure. most folks cannot "feel" high blood pressure, it is a silent disease in many ways, until arteries start popping and people lose sight, kidney, heart or brain function. interestingly, many people claim their headaces are from high blood pressure related to stress but i am told by my medical colleagues in research that this isn't the case at all, that people cannot really feel high blood pressure.

so how can we help patients understand what is happening to them? what high blood pressure means and why it needs to be reduced?

this is my technique - while the cuff is inflated i hold the pressure at their systolic for a moment and ask them to feel that pressure on their arm, then i drop it to a normal systolic (120), let them feel that, then their diastolic for a moment, then a normal diastolic (70). then we have a conversation about fluid mechanics, pressure, and micro-arterial damage. once they feel the different pressures it is no longer an academic or intellectual exercise, nor is it faith or belief or trust in your doctor - it is REAL. it seems to be helping folks get a handle on why hypertension matters.

----------------------------

a musclebound weightlifter, Spanish speaking young guy came in the clinic the other day. he has had some issues with fungal skin infections that have responded well to diflucan. in the middle of our visit, something kinda cool happened. he asked me if i knew where he could find contemporary flute music. he had a shy look on his face and stated that he isn't like most other Mexican wieghtlifters who like ranchero or rock music. he's into the soft music of flutes. i found this to be so endearing and also insightful into the relaxed nature of the clinic, that a man could feel comfortable to ask his doctor to help him find flute music. i love that! i think part of the prompting came from the music we play in the reception area. it's an ipod loaded with lots of jazz, blues, some Mexican Indigenous flute music, Nora Jones, all the good stuff. turns out that Rasa, the naturopath, knows a couple yonung Mexican men producing their own flute music so we sent him in that direction. perhaps they will all click and the world will be a better place. :> here's to lots of broken stereotypes!

------------------------------------

a tile worker and her partner came in to the clinic with bad bronchitis bordering on pneumonia. fairly straightforward visit. towards the end of it, the patient asked me if she could help us finish our tiling in the bathroom. we are missing a transition piece that would act as a mini-ramp for a wheelchair, from the saltillo hallway to the slightly lower bathroom ceramic tile. i tried to barter her visit for the work but she and her partner refused, they paid the visit and once she is better, they will come back for the small volunteer job. they said were so happy to have found affordable, kind healthcare. and for them, it's only a few blocks away from where they live.

this past two weeks saw about four random and beautiful offers by patients to help us with various aspects of the clinic from finding new reception area chairs to the tiling to printing up more intake forms to helping us with our move to a new location, which will happen in about 3-6 months.

more than anything, these offers, and the continual small donations we get from our patients are the surest signs to me that we are on the right track, that we are offering something that really touches people, that inspires them to share a small part of their wealth, their skills, their time in helping us get even better.

andru

posted by andru | 3/19/2006 05:40:00 PM | (0) comments |

Sunday, March 12, 2006

I am learning Spanish yesterday, es verdad!

I'm still quite embarassed at my spanish language skills these days. I'm finding myself confused by the tenses and using the present tense way too often. Working at an LA county hospital affords me the opportunity to work with many spanish-only speaking patients -- in the clinic, in the hospital -- and I've improved my Spanish immensely in the past few months. There's really nothing like immersion. But i'm just not nearly where I need to be. I used to be a pro -- I took 4 years of Spanish in high school and I was a conjugation and vocabulary rockstar, and a pronunciation queen. Then... I forgot everything. And now... it's coming back to me, but muy despacio.

Yesterday, I met a friend at a bookstore before we grabbed some dinner. I hunted down the Spanish language section, on a mission to find THE BOOK that would help me. Spanish for travelers? No. Spanish for lovers? Hmm, perhaps in the future, but not right now. Latino Slang for Gringos? what's this? here's a description:

“ Learn Spanish Slang Now - You Can Use Our
Exclusive Latino Slang 4 Gringos to Understand
What Others Are Saying About You. . .
And Stop Feeling Powerless At The Office,
The Mall Or While On Vacations! ”

I'll hold off on that item for now. Still lookin'....various spanish-english dictionaries of various mid-range pocket-fitting sizes. Do I want a dictionary? maybe. Do i want a 42,000 word one or a 100,000 word one that would take up my whole pocket? 42,000 words seems like it would be enough for me, really. Oh forget it, maybe i'll get a dictionary for my PDA instead of stuffing my pockets so much I can't close my white coat. What i'm looking for right now is a mastery of conjugation, not how to say "pencil sharpener" in spanish (try fitting "sacapuntas" in a conversation with a patient. Let me tell you, I've tried. You've gotta show you know some spanish, even if it's "your leg looks like it was eaten by a pencil sharpener. le duele?")

The various Spanish tenses are way back in the depths of my brain, and sometimes I recall them from my high school days. But the fact of the matter is, I only really have present-tense confidence right now: I'm still past tense shy, present progressive tense anxious and preterit tense scared-out-of-my-mind. I'm tired of using the present tense for everything:

Like: How much does that hurt you yesterday?
Or: I am going to will be in the future drew your blood in 5 minutes.

(ok really i'm not THAT bad). Well, my broken spanish gets me by, but would I want a doctor who talks like that? So anyway...still looking... looking for the right book for me. Thoughts go through my head as I pan my eyes over the rows and rows of Spanish learning tools. Wow, what a great industry, I think to myself. Books, dictionaries, audio CDs to distract you while driving, slang dictionaries, nicely dressed up and durable multi-colored plastic binding travel guides, etc. I even saw a Panjabi audio CD selling here -- I can't even imagine trying to learn Panjabi while driving in my car.

Oh wait, what's this?!? Complete Medical Spanish! Sweet! WITH tense explanations, vocabulary, AND only 280 small pages. Now I can add to my wealth of medical terminology...

'Doctora, tengo una enterrada' = 'I have an ingrown nail, Doc'

...while learning conjugations again :> Rodillas, pulmones, corazon, picazon, comezon, bring it on!

So here I go, my friends. I bought the book. And it's so cute, the authors have thrown in cultural references to go with the grammar and vocabulary. I'm hoping they don't stereotype and make me cringe, but so far so good (as of page 2):

"One should shake hands with everyone to avoid being seen as extremely rude, cold, and uncaring. An even more kind, caring, and warm gesture is to cup your left hand over the hand you are shaking which conveys the feeling of trust (confianza). It is a quite comforting action seen from the Latin American point of view, and it tends to communicate the feeling that "You are in good hands now." It does not transmit the trite or paternalistic attitude that may be interpreted by U.S. Americans."

Sounds like a great way to shake hands with everyone, latino or not, paternalistic or not :> Mucho gusto, 'Complete Medical Spanish'. We're off to a good start.

(cross-posted at Los Anjalis)

posted by Anjali Taneja | 3/12/2006 11:53:00 PM | (0) comments |

Wednesday, March 08, 2006

Refreshing talk back in Kenya

Ignore the World Bank on health, says minister
By Elizabeth Mwai
The Standard

Kenya should ignore donor restrictions and employ health workers needed urgently countrywide, an assistant minister has said.

The country needs 10,000 health workers to offer improved services, Health assistant minister Enock Kibunguchy said.

"We have to put our foot down and employ. We can tell the International Monetary Fund and the World Bank to go to hell," Kibunguchy said.

Speaking at an Aids workshop in Nairobi on Monday, Kibunguchy said the Government should ignore the freeze imposed by the World Bank and IMF.

He said 7,000 nurses, 600 doctors and 2,000 clinicians and laboratory experts were urgently needed in various health centres.

Kibunguchy said over 1,000 nurses leave the country every year yet the Government cannot hire more.

He said about 130,000 infants born yearly to HIV-positive mothers were not being cared for effectively for lack of medical staff. He said the scaling up of the prevention of mother-to-child transmission of HIV could only be achieved if there was adequate personnel and infrastructure.

Right on -- refreshing that the assistant health minister's standin' up for the people in Kenya. So...why exactly are the World Bank and the IMF lending money to Kenya with the tradeoff of a freeze in numbers of health workers? And where are the healthcare workers worldwide talking about and organizing against such conditions in loans? Something to think about. Healthgap an PHR have done some great work in these arenas, check out Healthgap's resources on "health systems capacity" -- big words for let's put our feet down and employ, empower.
-anjali

posted by Anjali Taneja | 3/08/2006 06:58:00 PM | (0) comments |

Saturday, March 04, 2006

Hypertension Crisis?

a 55yo gentleman came to the clinic yesterday. a smoker, he had known hypertension, untreated for 2 years from lack of funds and health insurance. he recently lost some vision in his right eye, a few weeks ago, which motivated him to find a doctor. he had the highest blood pressure i've yet seen in my career. 250/140. he was clear that he wouldn't go to the hospital, too expensive.

this raised ethical and legal questions for me. what is the right thing to do? he needs treatment, that is obvious, but where? in the clinic, in an ER, in a hospital setting? what does the research show? this is clearly a hypertensive urgency, perhaps even a hypertensive emergency (i would only know if i had more lab tools at my disposal). yet research is showing that if you drop the BP too fast, you place the patient at high risk of lots of complications, so outpatient treatment isn't necessarily wrong, it's just far from ideal. the benefit of the hospital is that you can monitor the patient, intervene immediately if he starts stroking or having a heart attack, you can monitor the blood for kidney function, etc. and all that costs thousands that this man doesn't have.

but what would a jury say if he stroked out overnight or had a heart attack? would they understand patient choice, system limitations, the role of a consulting doctor giving good information even if a bad outcome happened, the limitations of the patients resources? so many questions. would they understand that his high blood pressure is caused significantly by his own actions, smoking tobacco, taking in alot of caffeine? does any of that count? i believe it must so i will stand my ground, practicing medicine without mal-practice, even if it feels a little foolish now and then.

after counseling him on the importance of being in a hospital, i put him on norvasc 10mg daily and clonidine 0.1 mg three times a day, with a baby aspirin. i worried about this guy all night long. he was late to his clinic appointment today, making me more nervous. fortunately, he made it to the clinic, his BP was down to 200/135, he was feeling better, slept well, and is more committed to taking care of himself, now that he has an affordable option. he was still smoking though... i'll see him back on tuesday.

andru

posted by andru | 3/04/2006 11:33:00 AM | (1) comments |

Thursday, February 23, 2006

Volunteers Rock!

The last year has been an amazing journey building this new clinic.we've managed to sustain ourselves thru fair prices, support three part-time practitioners and do a lot of high quality, integrated health care. none of it would have been possible without the help o our volunteers. we have volunteers working with us on two different levels - massage therapists and receptionists.

Massage Therapists:
Jennifer and Matthew have both volunteered their time with us to care for very poor, stressed out people, most of whom have never had body work in their lives. we send them whole families! they have both made time each week for 3 hours and we are so appreciative, as are our patients. the best story i've heard so far is a woman who came in thinking she had gall bladdder disease, months of terrible abdomenal pain, and after a single massage session, she had lost 20 years of age, her pain had dissolved, and she was ready to dance. :>

Receptionists:
Bianca, Glenda, Camila, Laura and Lorenzo are our volunteer receptionists. They each give 2-4 hours per week hanging out in the clinic with us, answering phones, greeting the patients, and learning how to take vital signs, give shots, recognize sick people, and understand the funky pricing/injustice in the health care world. Many of our volunteers are pre-med or pre-nursing and very eager to learn all aspects of clinical medicine. And each brings their own flavor and knowledge that helps our patients - from herbs to WIC to preventive health.

Work-Study
While i'm at it, i need to say something about our two work-study students. They aren' volunteers, but their diverse services are indispensible - from reception to health literacy projects to coordination of donations. Ocelotl has been with us for about 5 months, has brought a level of professionalism and compassion to the job, and has helped us develoandrup an understanding of how to navigate the local lab to get our patients the best prices. Rose just started last week. She has a strong interest in nutrition and natural medicine.

The Family Practice Office is blessed to be part of a growing team of creative, dedicated people at all phases and stages of education.

andru

posted by andru | 2/23/2006 11:12:00 AM | (0) comments |

Tuesday, February 21, 2006

HSA's: a great way to burden individuals & govt; I mean, consumer driven health care, yeah!

"To summarize, I estimate that the President’s budget proposals will cost almost $12 billion dollars per year if fully phased in. I estimate that these proposals will on net raise the number of uninsured (by 600,000 persons), as those left uninsured through firm dropping of insurance exceed those who gain insurance through taking up tax-subsidized high-deductible plans attached to HSAs." (source: Jonathan Gruber's CBPP/MIT study)

And from the press release of the study:

The analysis, conducted by Jonathan Gruber of M.I.T., projects that while 3.8 million previously uninsured people would gain health coverage through HSAs as a result of the President's proposals, 4.4 million people would become uninsured because their employers would respond to the new tax breaks by dropping coverage and they would not secure coverage on their own. The net effect would be to increase the number of uninsured Americans by 600,000.
"The Administration estimates that its HSA-related tax proposals would cost $156 billion over the next ten years, which would worsen the nation's fiscal problems," Robert Greenstein, the Center on Budget and Policy Priorities' executive director, noted. "Professor Gruber's study raises very serious questions about the wisdom of these proposals."...
These proposals would eliminate all tax advantages for employer-sponsored coverage (as compared to coverage purchased in the individual health insurance market). Those tax advantages were designed to encourage employers to provide insurance to their workers. As a result, some employers -- typically, small business owners -- would respond to the new HSA tax breaks by dropping coverage for their workers or (in the case of new businesses) electing not to offer coverage in the first place...
To estimate the impact of these proposals on health coverage, Professor Gruber employed a micro-simulation model that is very similar to models used by the Congressional Budget Office, the Congressional Joint Committee on Taxation, and the Treasury Department. His findings include:

-- Under the proposed tax breaks, the number of people with individual health coverage would increase by 8.3 million when the proposals were fully in effect. Some 3.8 million of these people would previously have been uninsured; about 4 million of them would have switched from employer-sponsored coverage to individual coverage coupled with an HSA; and 500,000 would previously have received coverage through Medicaid.

-- Some 8.9 million people would lose employer-sponsored coverage as a result of the tax breaks. About half of them -- 4.4 million people -- would become uninsured, while another 4 million would switch to individual coverage coupled with an HSA, and 500,000 would enroll in Medicaid...
Adding to the concerns that Professor Gruber's paper raises, Greenstein said, is the strong probability that the currently uninsured people who would be most likely to gain coverage as a result of the Administration's proposals would be relatively healthy, since they would best be able (with the help of the new tax subsidies) to obtain affordable coverage in the individual market. In contrast, the people most likely to become uninsured would be less-healthy employees in small businesses that dropped coverage, since less-healthy people have the most difficult time obtaining affordable coverage in the individual market.

posted by Anjali Taneja | 2/21/2006 09:42:00 PM | (0) comments |

Thursday, February 09, 2006

Hi my name is Sri - I am new to this experiment in blogging medicine. I am in residency with Anjali and homies with Andru from a Patch Adams gathering last year. I spent last April in a refugee camp for Tibetans in India. Here is an essay I wrote about the experience. Hopefully, it isn't too long to hold your attention.
- Sri

The largest Tibetan refugee colony in the world lies five hours from where I spent the summers of my childhood at my grandmother’s house in Bangalore,India. Neither my mother nor my father nor most of my Indian relatives who grew up in Bangalore knew of its existence despite the fact that it houses over 10,000 refugees. Half of the residents are Buddhist monks and nuns. I first heard about the colony when I decided to spend a part of my final year in medical school abroad inIndia. I wanted to experience rural medicine inIndia and understand the barriers that prevented the poor from receiving adequate health care. I also liked the idea of returning to my ancestral home stateof Karnataka, and improving my Kannada. The hospital was attempting to serve the Tibetan refugee population and desperately needed medical volunteers. I was unsure how much Kannada I would use but the location was rural, in Karnataka, and would allow me the chance to work with a refugee population that had been in India for generations.

---

I spent the first night in Bangalore at my cousin’s house and the next day left early for Bylakuppee. After passing through the smoggy, congested streets ofBangalore, we entered village after village where crowds poured out into the streets and hot dust mixed with the hum of the simultaneous Kannada spoken soft and loud and almost sung in every corner store shop. After about the four hundredth tea stall and street food daba, we reached a stretch of the greenest forests and farmlands. Somewhere in that stretch of farmland and open green road the climate changed from the sulky suffocating heat of April in South India toa cool about to rain comfortable. And somewhere along that stretch of road the color of the faces changed from a rich, beautiful brown of my familiar knowing toa lighter yellowish East Asian undertone. The eyes changed. Just as the faces changed, there rose out ofthe green earth four or five massive Buddhists temples and universities in a row spread out and separated by about ½ mile each.

----

I found out quickly that I had entered a place with entirely different notions about life purpose and productivity. Soon after I arrived I pointed out to a monk that a mosquito was sucking his blood. He nodded in acknowledgement and said something brief about the accumulation of merit and allowing another being to nourish itself off your own. (Luckily, we were in a region where the prevalence of malaria is low). The second day I was there, a monk took me to the local Indian restaurant. A fly fell into my daal. The monk’s reaction took me by surprise. I wrote this poem about it.

-----

For my friend who says the way the world works has broke her heart: good news from the subcontinent. Living with the monks study #1

----

There are those who

When a fly drops Plop! into yellow daal

it is not their bowl of food they worry about.

It is the fly and her wings

The ability of fire and spice

To sear wings

And with so much kindness

They place the fly in their palm

Unfold a white creased napkin

Clean the wings and the space

Between the wings

with water rinse away

Any hot yellowness

Place the fly gentle

On the edge of the table

Until

by the end
Of our meal

The fly has flown

made her way

Back into the world

----

I worked in fourth camp where there were over 3000 monks and 600 nuns, mostly between the ages of 5 and25. They attended the large Buddhist school in the colony which did not teach math and science, onlyBuddhist philosophy. Children were separated by their proficiency in Tibetan. As a result 15 year olds are placed side by side with seven year olds. Most of the monks and nuns came from Nepal, Bhutan, Darjeeling,Sikhim, and Tibet. They came for a variety of reasons. Some of the older teenagers came out ofconviction and interest. The younger children were sent by traditional Buddhist families who believed it was auspicious to have at least one family member become a monk. Still other families were very poor and knew that sending their child to a monastery or nunnery would at least guarantee that they would receive three meals a day.

To go along with my many new experiences, the hospital was like none I had ever seen. There was no doctor. None at all. The doctor who had been there for a few months was a retired ENT doctor who wanted to make some extra money at the camp. He was from the city and did not stay past two months. Without a steady physician, the hospital had not been useful for the monastery or nunnery trying to take care of their population.

---------

As the hospital struggled to get off the ground, Sherap Lama, a 30 year old monk from Sikhim decided some form of health care was necessary for the young monks. He was a schoolteacher at the Buddhist school and saw so many oozing pus filled ears, belly aches, bald spots and six children die from unknown causes that he attempted to start a clinic. About a year and a half before I came to the colony, he obtained a copy of the book Where There Is No Doctor and studied it. He raised money to buy some medical equipment and medications to treat the young monk school children. His clinic consisted of keeping semi-hygienic conditions in the monastery. Boys were clumped together 14-15 in a small room to sleep. Monks or not, groups of young boys with parents nowhere insight do not willingly wash. Before Sherap set up a spare room as a clinic, the community would say the stray dogs looked better than the children.

Sherap made enough progress in his project that the nuns soon grew interested. Sherap taught Ani Dichen, a young nun from Nepal about what he learned and she soon started a similar clinic for the 600 nuns.

--------

I spent my mornings at the monk makeshift clinic and my afternoons at the nunnery clinic. At seven in the morning the young monks would line up to see me. In my first week there at the clinic I met a young 14 year old boy, coughing up blood. I soon realized that crowded sleeping conditions caused the quick spread of serious ailments like tuberculosis. More and more boys with chronic coughs and blood tinged spit started to present themselves. This meant that I had to come up to speed on the protocol for treating TB patients in India. I learned of the WHO recommended plan called the RevisedNational Tuberculosis Control Programme which was orchestrated throughout the country by the Indian government and financed with a loan from the World Bank.

-----------

The closest government distribution of medications was about 10 minutes away by auto, in first camp. I immediately went to speak with theIndian government doctor in charge of the local program about the high rates of tuberculosis I hadnoticed. He knew the reality of fourth camp well. He was aware of a 22 year old monk who had been left partially paralyzed and that TB had spread to his spine. He was well aware six other monks had started treatment after they began coughing up blood and another three were dead of an “unidentified sickness”. These outbreaks took place within a year in a population of 3000. He knew that treatment in fourth camp was sometimes sporadic and continued isolation of the infected monks was not maintained with regularity.

--------

With highly effective treatment so close by it seemed unacceptable to me that so many cases of tuberculosis should go undiagnosed and not treated properly. He stated that the Tibetans were non-compliant by nature and difficult to keep track of since they regularly travel through India and between different Tibetan colonies all over the country.The reality, however, was that although the government had provided state of the art treatment there was no doctor or health care worker on site in camp four to diagnose TB. Sherap and Ani Dichen had been extremely proactive in starting their own makeshift clinics. No government program was in place to train them to recognize the symptoms of TB. The result was that many monks would continue to go undiagnosed until they coughed up blood and came forward on their own accord. Meanwhile, before getting treatment they were likely to spread TB to those sleeping less than two feet away from them.

--------

If a monk can show so much concern for the fate of a fly surely we can muster up enough courage to stop the death of those dying needlessly in front of our eyes. As my short month came to an end it became obvious that in this historical moment the requirements of being a real deal effective doctor goes up hundredfold.

--------

Doctors must understand structural inequalityand their underpinnings. We must understand the politics of funding projects, where the money comes from and where it is being funneled towards, and to what end? We must start one on one, patient by patient and expand out to include so many things we never thought were medicine. Poverty, race, class. WorldBank funding practices. If only out of necessity, because our patients’ lives depend on it. We must tell the stories again and again of who died and what commitment financial or otherwise could have prevented it. We must understand who is vulnerable and why? Who becomes sick and why? We must strive to be doctors and advocates. Doctors and organizers. Doctors and policy makers. Doctors and journalists.

---------

Of so much good news from the subcontinent, the status of TB in the Tibetan colony is not one of them. But the key, I think is to make it news. If it becomes news, maybe it will turn good. As the poet June Jordan says “We are the ones we are waiting for.” There are so many Sherap Lama’s and Ani Dichen’s who are ready and willing. I hope to be among them.

posted by srijeeva | 2/09/2006 10:54:00 AM | (4) comments |

Monday, February 06, 2006

Clinic Vignettes February 11, 2006

a 37yo man presented with signs and syptoms of stroke, right arm weakness, right leg heaviness and a slight change in speech. this is very unusual in young people. the first day he presented last week, i was totally confused and didn't put the story together until after he left. he had a few other complaints and i didn't pick up on the leg and speech changes until his second visit. the first night after he left, i was thinking alot about him and started getting more and more concerned. we spoke by phone the next day and my suspicions were confirmed with deeper questioning. he had symptoms for almost two weeks so he was well outside the 3 hour time period to try to do anything about a stroke urgently but it never makes you happy as a doctor when you miss something important. back in my clinic at his second visit, we did a thorough review of systems and picked up a bleeding tendency and a smoking history as the only two risk factors i could find.

so here ends clinical medicine and now starts this mans journey into the perpetually painful world of trying to get healthcare when uninsured for a complicated illness. turns out this man is undocumented. he was trying to be responsible and was a few weeks ago from his work insurance kicking in... with the urgency of the situation, we can't wait a few weeks to i had no choice but to send him to the public hospital ER for an immediate workup which will no doubt nail this man with a pre-existing condition prohibiting his imminent insurance from taking effect. this man has bigger worries, but this financial piece is going to be a painful thorn in his side. he has lost significant function of his left hand and will no longer be able to do the construction work that was supporting him and his family. and he will not be eligible for disability as a non-citizen. now for all you people reading this who immediately think - "well, so what, why doesn't he just go back to his own country," let me run a few ideas by you.

immigrants make up the majority of this country, every one of us, except for the "First People's," also known as Native Americans, are immigrants. so who is calling who illegal. secondly, many Mexicans in particular have made the southwest their home for thousands of years, crossing what is now a border as naturally as any of us would cross a state line. many Mexicans are Indigenous and have historical roots long predating the formation of the United States of America. That's just a little reminder of whose land we stand on, and a brief history lesson. Now fast forward to the present moment where we live in the comfortable illusion that this country is Ours. Even in that case, it cannot be denied that "illegal" immigration is a huge part of what makes this nation so great. our fields, restaurants, contruction sites, music, culture, house cleaning, etc are fueled by the continual influx of illegal immigrants, people drawn to this land by the hunger in their bellies and the very real promise of businesses and people who demand their cheap labor. if you are sitting there on your couch having some stiff opinion about people you don't know, about economics you don't understand, then please, turn off teh computer, do some traveling, learn a second language, study macro-economics and history, and then, let's talk.

(By the way, i got a call from the family after two days in the hospital, this man didn't have a stroke, he had cancer of the brain. they found four separate lesions in his head. the family is awaiting the biopsy results at this moment.)

--------------------------------
a 28yo man comes to the clinic with right sided eye pain and redness for three days. he does landscaping and was out in the wind when a bunch of dirt got in his eye. on flourosceine/woods lamp exam he had a large corneal scratch and a piece of dirt, small, sticking into his cornea. the dirt wouldn't come out with irrigation. luckily i had purchased a Nikon slit lamp which is a microscope for examining the surface of the eye. it's a really cool tool. i picked it up for $150 used from a local eye doctor who had a newer electronic one. they usually run for about $5000 or more. with the slit lamp and some courage, i was able to remove the speck of dirt saving this guy a visit to the ER for a cost of $500-2000. a note for other docs starting up clinics - you can make your own woods lamp for about $10 instead of $300. just buy a regular bulb lamp, portable is best, and use a "black light" bulb. works great. we wound up charging the man $50 for the visit and procedure. he left very happy and promised to use his safety glasses next time.

andru

posted by andru | 2/06/2006 04:50:00 PM | (0) comments |

Thursday, February 02, 2006

Clinic Vignettes - February 1, 2006

Yesterday a patient called from an ER. He had been there a few hours already with a cut on his hand and was looking at a long wait and a huge bill. We were open so he abandoned ship, left the ER, and with his hospital bracelet still on, came over to the clinic for stitches. 20 minutes, $40 and 4 stitches later, he was on his way home... it doesn't have to be that complicated.

A pregnant woman showed up at the clinic around 6 weeks gestational age. she was complaining of passing a clot vaginally. no cramping. she was concerned that she was having a miscarriage. she had already scheduled her first prenatal appointment, but it wasn't for 6 more weeks at the local hospital clinic for poor women. noone educated her that she could go there sooner if she had a problem. she was already concerned that the public hospital ER would not treat her well thru bad experiences of friends, neighbors and her husband, so she refused to even consider going there. With an exam and the ultrasound i was able to verify that she still had a viable pregnancy but was at risk of miscarriage. we are watching and waiting this week to see what nature will do.

i've mentioned this previously - Spontaneous miscarriage is one of the most frustrating health policy situations for me as a doctor. pregnant women hope beyond hope for a normal pregnancy and a healthy child. the medical system is geared for maximal cost and reimbursement. uninsured woman have no easy access to urgent care. most private urgent cares charge $150 up front so the ER looks alot more inviting since the bill comes later. Miscarriage early in pregnancy is a natural, often sad, but fairly uncomplicated medical problem that doesn't necessarily need much intervention, and there is NO WAY to medically prevent an early miscarriage. put it all together and you get financial injury compounding emotional distress. it's just not right. can some politician PLEASE take some leadership on this?

ths same woman's husband had already had an ER experience for a badly infected big toe. They removed his toe nail for him. guess how much he was charged. $800.00. blows my mind.

at what point does it become unethical and/or even illegal to charge someone exhorbitant prices for basic medical services? there is a law called the New Mexico Fair Practices Act that supposedly is there to prevent used car salesmen from ripping off unsuspecting customers. It;s about time to see if this law applies to healthcare as well...

these stories just keep on coming. i'm determined to share stories every week now, if nothing else to document the incessant toxicities of our health care system.

today a young women came to my clinic with one year of abdominal pain. she had previously had her appendix cut out at the public hospital for the same pain. turned out that the appendix was normal. (as a medical side note, that doesn't particularly bother me. for a surgeon to be sure that they aren't missing any life threatening surgical conditions, they have to have the flexibility to make some mistakes in the direction of unnecessary surgeries to some small degree. in a statistical and complex world, i'd rather have a surgeon make some mistakes like that than be too stringent and make mistakes that cost people their lives.) given all that, the problem in this case is once again, FINANCIAL. this young woman was given a bill of $50,000. did you catch that? $50,000. for removing an appendix. she is a citizen, but for some loophole she didn't qualify for the public hospital financial assistance so she is now paying this bill for the rest of her life. ain't right. perhaps $5,000. it just ain't right.

andru

posted by andru | 2/02/2006 04:12:00 PM | (3) comments |

Sunday, January 29, 2006

Pregnant and Uninsured:

i had a follow-up visit from a pregnant patient. she had seen me two months ago for initial medical care while awaiting Medicaid approval. turns out her husband, who works three jobs, makes a little bit too much for Medicaid so they didn't qualify. of course with three jobs, he's uninsured since none are full time.

i put this out on the blog to make a clear point that one of the most basic and beautiful human functions - pregnancy and birth - can turn into a financial nightmare for parents. i know some people who call themselves conservative (what exactly are they conserving?) might say "so what." " if people cannot afford to have a baby, they shouldn't have a baby."

i'd like to point out an uncomfortable truth. it is not expensive to be pregnant, or to have a baby. it's actually free, unless you happen to crave really expensive food, something like caviar braised lobster in a bed of godiva chocolate.

what is expensive about pregnancy and birth is the systems put in place to "manage" and "care for" pregnant women. a hospital birth has a price tag around $2000-4000, if it's normal. $5-10,000 if it's a C-Section. Prenatal care, including labs, can cost around $500-2000 as well. high risk pregnancies can be alot more expensive, up to $30,000 or more.

now consider receiving your care from a midwife. midwives are a diverse group, some emphasize labs and technology more than others so there will be a wide range of costs. i've seen charges, including necessary labs and a few home visits for the newborn baby, ranging from $800-$1500 and up.

in New Mexico, there is a vibrant and healthy midwife community. birthing centers exist and more are opening. midwives are organized politically to help shape Medicaid policy. yet many patients choose expensive hospital births instead of midwives and the overwhelming reason is FEAR. groundless fears.

For example, this patient was told she has a high risk pregnancy because she experienced 2 months of hyperemesis gravidarum (severe morning sickness). she needed IV fluids a few times and some anti-nausea medications. the "high risk" statement was probably a random comment from the doctor, but it escalated her fear over the pregnancy. the truth is that women who have morning sickness usually have stronger pregnancies. the nausea is caused by higher levels of hormones put out by the placenta, which is doing it's job vigorously. of course the vomiting can cause dehydration and pregnancy complications but the solution is very simple. access to affordable health care with IV fluids and nausea medications. this is not a "high risk" pregnancy.

a preaching moment: as doctors, we need to stop perpetuating the myth that pregnancy is an illness, that it is dangerous, that hospital birth is safer than home birth. we need to learn how to differentiate high risk from low risk women and counsel women and families appropriately. and at the least, support women and families that want a more natural approach to a very natural biological "process" - BIRTH.

andru

posted by andru | 1/29/2006 10:37:00 AM | (7) comments |

cure this!

We've MOVED! and grown!

Join us at Cure This!...

...where we invite you to create a user account, read, comment, write your own posts. Let's discuss health in its broadest sense, share personal stories, creatively make positive change, and build an online community along the way...

what's "to the teeth"?

To the Teeth is a weblog discussing issues of health justice, medicine, race in America, public health in its broadest sense, healthcare at a local clinic level, and honest discussions around strategies in advocacy. Ok, so it's not so focused, but it's all connected. The regulars who post to this site are:

Anjali Taneja, a resident physician in Family Medicine at Harbor-UCLA in Los Angeles, California (a recent transplant from the east coast). She also blogs at Los Anjalis and the Harbor-UCLA Family Medicine Residency blog. She's on the national leadership of the National Physicians Alliance and previously worked as the Jack Rutledge Fellow for Universal Health Care & Eliminating Health Disparities at AMSA. She dj'ed for several years with the M U T I N Y dj crew and currently DJs and produces electronic music. (email: movement-at-gmail-dot-com)

and Andru Ziwasimon, a family medicine physician in Albuquerque, New Mexico, and a lead member of the Community Coalition for Healthcare Access, a diverse group of providers/patients/advocates addressing access issues with the state hospital system, translation and interpretation issues, billing for under and uninsured patients, and other disparities locally. He created and runs a sustainable and innovative clinic that serves uninsured patients with quality care and fair prices. He also serves on the leadership of the National Physicians Alliance. (email: aziwa-at-null-dot-net)

and Sri Shamasunder, a resident physician in Internal Medicine at Harbor-UCLA in Los Angeles, CA. He's passionate about health justice, good music, and spoken word/poetry. (email: elsrizee-at-yahoo-dot-com)

"to the teeth" (idiom):
-> in opposition; directly to one's face
-> completely, fully
-> title of a song by Ani Difranco
-> alotta alliteration

For them RSS lovers (more about rss here), here's the atom site feed for To the Teeth.

hot links

Inspiring spoken word from Poetic License
Conversation: Growing up in the Shadow of Chemical Pollution - Michigan and Bhopal
Missing: Minorities in the Health Professions
Angell: The Truth about Drug Companies
Wonderful animation on procrastination!

dope orgs/sites

National Physicians Alliance
American Medical Student Association
The Peoples' Institute
Alternet
The Policy Action Network
The Principles Project
Common Dreams
No Free Lunch campaign
Kaiser Family Foundation
Families USA
Consumer Project on Technology
Campaign for a National Health Progam NOW

weblogs droppin' science

We've MOVED! and grown! Join us at Cure This!...

We've MOVED! and grown!

Join us at Cure This!...