Room at the Inn

I have long thought from my early years as a young child that physicians are the most giving of all creatures, mothers aside.  Historically doctors are more selfless, 24/7, than any other profession I have encountered.

When I was sick my mother would rush in to the doctor’s office with me in tow, having a fever, a rash, looking moribund or some other common, boring ailment. The doctor, it was expected, had to be available.  Often the doctor came to our house at evening hours, something no other professional did in those days. He brought his characteristic black bag, stethoscope and prescription glasses, miscellaneous drugs and would listen to my parents describe my symptoms. He was expected to be attentive, dutiful and faithful. First do no harm. I never thought much about how well our doctor did financially since I was only a kid.  I never saw monies exchanged.  Yet, we had a relationship and he had a shiny big car, wore fancy clothes, large, glossy, leather shoes and seemed very happy with his station in life. You notice polished leather shoes when you don’t have much as a kid.  I was content with my Converse Hi-Top Sneakers and never complained.

The doctor gave of his talents.  He was compensated well. Now that I am enslaved to obscene hours of studies, averaging last year about 3 hours of sleep nightly, and adjusting my schedule since then, so as to have a more equitable life for my body, I realize that the family doctor wasn’t born magically with an innate sense of healing.  He was a slave to service and that meant he had to forgo. He sacrificed, gave up the immediate, in order to reap something in the long term.

I recently researched the story of the ant.  It is found in the Old Testament of the Hebrew Scriptures, Book of Proverbs 6: 6-11:

Go to the ant, O sluggard, study her ways and learn wisdom; For though she has no chief, no commander or ruler, She procures her food in the summer, stores up her provisions in the harvest. How long, O sluggard, will you lie there? When will you rise from your sleep?  A little sleep, a little slumber, a little folding of the arms to rest— Then poverty will come upon you like a robber, and want like a brigand.

I printed the passage and placed it on my kitchen wall.  When ever I wash dishes or prepare food at the counter, I stare at it. The Ant works, and the medical student sacrifices.  The doctor gives but is also afforded beautiful, classy, well-made masculine shoes! There is nothing new about this formula. The inherent principles here are that these drives must come from within – a desire to work and a desire to give.

My mother always admonished us as kids, “the life of a physician is sacrifice”.  She was particularly sensitive to such imagery because she came from a country where people worked like slaves in the fields with Machetes, in brutal heat, and wearing white, linen shirts that deflected heat and with many pockets for field tools.  Those shirts today are en vogue, practically couture, in some fashion houses – Guayaveras.  What is missing in these shirts is the sweat the field workers accumulated by working the grasslands with their razor, sharp Machetes.

Pope Francis has some thoughts on the subject of sacrificing for others.

He wrote:

In this context, some people continue to defend trickle-down theories which assume that economic growth, encouraged by a free market, will inevitably succeed in bringing about great­er justice and inclusiveness in the world. This opinion, which has never been confirmed by the facts, expresses a crude and naïve trust in the goodness of those wielding economic power and in the sacralized workings of the prevailing economic system. Almost without being aware of it, we end up being incapable of feeling compassion at the outcry of the poor, weeping for other people’s pain, and feeling a need to help them, as though all this were someone else’s responsibility and not our own.

Source: Evangelii  Gaudium, Apostolic Exhortation of Pope Francis

What I found particularly telling about this quote was the insight the Pope has on the human condition.  His statement of “crude and naïve trust in the goodness of those wielding economic power…..” stuck out like a sore thumb to me.  In many of the Pope’s sermons he intentionally calls out Catholics, Vatican operatives, even Bishops and Priests for being less than holy.  Pope Francis is not afraid to admit the failings of Church workers, whether one is wearing a Roman Collar or is a simple missionary teacher. So it follows that the Pope discusses openly what we all share privately – greed exists.  In fact, Greed is one of the Seven Deadly Sins.

So is Sloth. As are Covetousness, Envy, Gluttony.

The Pope is not telling anyone to give away their riches in order that they can be poor. He has equally exacting words in the same Apostolic Exhortation on acedia and sloth. Acedia is apathy. His words are clearest for Catholic priests and teachers who want an easy journey without sacrifice. He wrote:

“Today’s obsession with immediate results makes it hard for pastoral workers to tolerate anything that smacks of disagreement, possible failure, criticism, the cross.”

“….many lay people fear that they may be asked to undertake some work and they seek to avoid any responsibility that may take away from their free time.”

I almost feel sorry for these individuals.  He is obviously calling out slothful slugs.  Know any?

He continues:

“Some resist giving themselves over completely to mission and thus end up in a state of paralysis and acedia.”

Conservative radio personalities take exception to Pope Francis for supposedly espousing “Marxist” views. They have never tasted Communism so I take offense to their retort. However, if I were a Catholic priest, I might feel black-and-blue right now.  Pope Francis is dressing down slothfulness in his own ranks. His document wasn’t just about Capitalists but rather about the world in general. The above comments come from the section of the document entitled Some Challenges of Today’s World. That’s what good leaders do – provide leadership in a world gone astray.

If I am going to be a successful Physician, I have to put in the work. I can’t allow an Ant to shame me with his own efforts as compared to me having computers, educational videos, digital online exams, and household comforts.  I don’t have it nearly as bad as the insect in the dirt hole shoring up food for the season.  I am also assured that after I put forth my effort, I will definitely be remunerated. I am already paid by people offering to do me favors because I made an unofficial diagnosis, they consulted with me about their malady, or I simply listened to their pain. It’s expected 24/7. People tell me about their personal illnesses and struggles in the darnedest places with no specific time schedule. They see. They approach. I’m flattered.

Pragmatically, there is the nuisance of giving. We want to hoard. We want to not give away our heart because it is somehow, in a myopic way, a betrayal of our freedom.  Well, those fall under the sins of Pride and Greed.  So we are covered on both ends of the spectrum. You can’t be a sluggard expecting everyone to give to you because you somehow feel entitled to it.  Saint Paul the Apostle had his own barbs about these type of people:

“For even when we were with you, we commanded you this: If anyone will not work, neither shall he eat. For we hear that there are some who walk among you in a disorderly manner, not working at all, but are busybodies. Now those who are such we command and exhort through our Lord Jesus Christ in that they work in quietness and eat their own bread. But as for you, brethren, do not grow weary in doing good.”              2 Thessalonians 3:10-13

There should also be in all of us, not the government, an inherent sense of being compassionate towards others because they lack, they are hungry, are without clothing, are in prison, or are sick.  We should, as individuals, be taking up the mantle to accept them in our lives, and not pass the responsibility to someone else, and much less a bureaucratic government initiative.  Some individuals are in need not because of slothfulness or acedia, but because life happens. It happens to all of us. Woe to them who are in need in the future and have no one to help them because they were a Scrooge to their neighbor.  It is not cool to be a Bah Humbug.

Making room at the Inn for the Holy Family in Bethlehem was done in a stable for animals.  It was no Ritz Carlton.  But it did the job.  Surely we can do as well with others.

Merry Christmas 2013. Happy New Year 2014. 

NB: This will be my last post for this blog. I am creating a website with my original writings in order to be a published physician author. I have had a calling since college to follow in the footsteps of Tom Clancy and Michael Crichton. May God bless me to this end. Thank you for joining me On the Road Less Traveled to MD these past 2 years.
Posted in affordable care act, bread, catholic, government, homeless, medical school, medical student, obamacare | 4 Comments

Taking Back Medicine – ObamaCare Part III

One of the better known stories of a sick person seeking medical healing is of that of a Leper who happened to be a Samaritan.  To understand this timeless story in the Gospel of Saint Luke, one first has to understand what Leprosy is and why being a Samaritan compounded the problem.  The story has relevance to medical students and doctors today.

Leprosy is a medical condition that comes in various forms. The one in the ancient story was the type that is highly infectious. It led to death if untreated.  Caused by a bacteria called Mycobacterium leprae it is known today as Lepromatous Leprosy.

Modern day Lepromatous Leprosy

Modern day Lepromatous Leprosy

In ancient days anybody with this type of leprosy was feared and taken to the edge of the village to be cast out of everyone’s midst.  Nobody wanted to be caught dead near a leper.  Adding insult to injury, a person with leprosy was disfigured, looked like a monstrous alien and instilled terror the moment someone’s eyes fell on them.  The figure to the right depicts a modern day case.

A Samaritan was a Jew in the region of Samaria. Samaritans espoused a form of Judaism that embraced the Torah in a way rejected by most Jews during that time. Samaritans were scorned by Jews much like a Leper. The larger Jewish group hurled out the other, to the point where Samaritan Jews today number less than 1000 on the Earth. To be a Samaritan was to be an object of derision, disdain and fear.

Not much has changed in several thousands of years.

From this one story we have in the USA the popular legal standard called the Good Samaritan Doctrine. The doctrine has been adopted by most of the States in the USA.  It allows a person to medically treat another person who is in serious peril without fear of liability if they commit negligence. The negligence can not worsen the person’s condition but if it does then liability may apply.

In the encounter of the Samaritan Leper, the depiction is one of a personal relationship between the Healer and the patient. There is scant literature that depicts medicine as a quid-pro-quo type of business prior to the mid-20th Century.  Whenever I tell people I am a medical student, their eyes rolls, they throw envious barbs at me and inform me that I will be rich beyond compare.  From their mouths to God’s Celestial Tablet.  Part of the problem of physicians today is that they do not communicate. Theirs is like the old Western Cowboy who suffers in silence with an angst that dare not be named. Prior to medical school I did not appreciate the truly Herculean task of obtaining the MD Degree. Now that I am in medical school I write. I share with people what it is really like.  Prior to medical school I was cognizant of the business side, the ugly side, the legal side and the existence of many butchers whom some call Doctor.  I also knew all to well the measureless number of men and women who truly want to help other human beings, become physicians but eventually get devoured.  They get lost in the maze of the business side, the medical industry.  This is the case because physicians are lousy entrepreneurs. They once married wives, hired nurses and receptionists to keep track of their appointments and finances. They were preoccupied with medicine not finances. Today most are lamenting their profession.

Medicine today is a business. That is the root of the problem. Medicine is no longer an intimate encounter between a doctor and a patient. If anything the patient gets a few minutes with their “medical provider” which may not always be an MD.

Prior to the mid-20th Century, Medicine was almost solely dedicated to the patient getting better. Payment of services was provided in one way or another.  There is little evidence in the historical record of medical care being denied by a sole physician if the person had no means to pay.  Hospitals and other medical business entities do this all the time.  Yet doctors do not fit the bill for the most part.  Though the human condition is shared equally amongst all professions, greed does play a role in some physicians minds.

The economic model of bartering was paramount in early America, where goods and services were provided in exchange for the same.  My grandfather was a medical doctor in a rural area of our family homeland.  He maintained a practice solo. Patients paid him with widgets – hens, pigs, gifts, cows, milk, services and cash based on their ability.  He was somehow able to maintain a palatial mansion, an army of maids, cooks and nannies to raise his nine children, one of them being my father. My father lacked for nothing as a child. The pictures and stories of my father’s home was something out of Tara in Gone With the Wind – marble staircase, multiple rooms and spacious hallways, an amazing kitchen, multiple floors, a beautiful, wrap around ornate porch with neighbors always visiting.  It’s amazing what a few eggs, pigs and containers of widgets will build.

Physicians started to veer into the Shadows in the 1970s.  As children we had no health insurance.  We got the medical treatment we needed in America, and my parents were dirt poor.  I recall in the 1970s when my father presented the family with a New York Life Health Insurance Card.  I saw it as a Disney World Ticket to a privileged ride.  Since then the ride has been pure hell with physicians succumbing. Physician greed gave us Health Managed Organizations or HMOs. President Lyndon B. Johnson signed into law on July 30, 1965 in Independence, Missouri the Social Security Act. Medicare was a provision as part of his Great Society Program.  The reasons for creating Medicare  were due to the following:

The 1950 census showed that the aged population in the United States had grown from 3 million in 1900 to 12 million in 1950. Two-thirds of older Americans had incomes of less than $1,000 annually, and only one in eight had health insurance. (Source) 

Medicare was meant for an individual over age 65 who had little income. Since then Medicare has become a fiat.  Like acne, grey hair and wrinkled skin, as one crosses a chronological milestone, Medicare is presumed. Vice President Dick Cheney, age 71, was interviewed recently by MSNBC Financial Analyst Larry Kudlow.  Mr. Cheney was asked about his heart transplant. He informed the audience that Medicare paid for it.

Hence this post.

Everyone deserves medical care.  No one should be deprived of healing.  When a multi-millionaire receives medical care at the hands of taxpayers, from a program that was intended for the poor, there is no need for accountants, lawyers, Members of Congress or other government “experts” to explain to us what is wrong with medicine today.  Medicare could be made solvent by limiting its services to those who were the intended target recipients. The US Government can refund financial contributions to those individuals who paid into Medicare who fall outside of the poverty level.  Dick Cheney should have paid for his Heart Transplant out of his pocket not Medicare’s.  Considering the most recent data by Pew Research regarding wealth in America, if LBJ’s original formula were applied to the intended demographic group, Medicare would be in a very different fiscal position.

When Princess Diana (Lady Diane Spencer) of the United Kingdom gave an interview in 1995 to BBC’s journalist, Martin Bashir, she provided a quote that is apropos to this discussion: “There were three of us in this marriage, so it was a bit crowded”.

The relationship a patient has with their physician is crowded.  The patient first has to find a physician, then make the dreaded phone calls to medical offices to hopefully talk to someone live, answer the telling question in the first 15 seconds that all physician groups want to know, “what insurance do you have?”, and join the circus.  A battalion of players are all waiting to see the patient and they are not even MDs.  All of them need to get paid, some more than others, and the physician is usually harried, unhappy, has little time for the patient, and flies out of the room in a frenzy to “see” the next patient. Registered Nurses are a thing of the past in private medical offices. Physicians largely can not afford them. Yet the physician has a payroll the size of a full kitchen staff to monitor billing and reimbursement. Behavior is everything, Psychologist Carl Jung taught.  Physicians have chosen their “priorities”. “Patients are lucky to see me”, I have heard it said.

Of all of the Physician Speakers who have visited my medical school and addressed my class, one stands above the rest.  He was the esteemed guest speaker for our White Coat Ceremony. We all stood with our right hands in the air, wearing freshly pressed white coats on our backs, and we recited a watered down version of the Hippocratic Oath. Few medical schools recite the original oath. The speaker physician is in his 80s, is a respected epidemiologist and loves his profession.  His pride was infectious.  He told us that 25% of all of his patients did not pay cash.  He had an agreement with the doctors in his geographical region where they shared the work load of 25% of the patients who could not afford medical treatment.  They paid what they could, when they could, if ever.  He referred to them as his friends.  The other 75% of his patients paid. He did not give us a breakdown of his schedule of fees for services, but we got the point.  He was in medicine for the noble reasons.  His finances were in order.  He was well dressed, had shiny shoes, snappy haircut, gold rimmed prescription glasses, and brilliant white teeth all aligned. He was loaded and his integrity was in order!

Like Jesus Christ grabbing a few cords of rope to whip the money-changers conducting business at the temple, ironically where people gathered for a different type of healing, the money-changers in modern medicine might be analogous.   These need to be taken to the edge of our villages and cast outside the boundaries of the physician-patient relationship.  They need to find new careers.  It is said that the USA medical industry accounts for roughly 20% of the US Economy. Small wonder the money changers hate ObamaCare.

Let the physician practice medicine and let the patient have direct access. The two can come to terms with methods of payment as the physician requires for their own monetary needs.  A physician is a trained diagnostician who can detect whether someone is trying to use them for ill gain, or whether they are treating a friend. They can come to a fair agreement where neither has to suffer. A physician can get by with a receptionist and a nurse.  Surely a doctor can do well financially with this simple model as it was done for millennia prior to the 1970s.

If Congress were to legislate a Bill entitled Integrity, and President Obama were to sign it into Law, most of our ills would be DOA.  Until that happens, physicians should talk to their patients about their future relationship without the voyeurs.  Bring on the goats and chickens.  They are worth more than what Medicare pays a physician anyways, and the wizards in Washington as well.

Posted in affordable care act, catholic, elderly, government, medical school, medical student, obamacare | Leave a comment

ObamaCare Part II

The Obama Administration released an 8 page report on December 1st, Sunday, 2013, claiming that the Affordable Care Act / Obamacare website is up and running with

the error rating below 1%

The Obama Administration is also claiming in their 8 page report:

  • Hundreds of software fixes, hardware upgrades and continuous monitoring have measurably improved the consumer experience
  • Site capacity is stable at its intended level
  • Operating metrics are greatly improved, and activity levels demonstrate the site is working for consumers
  • …the team is operating with private sector velocity and effectiveness….

It doesn’t provide any record from users regarding their consumer experience. It doesn’t elaborate on what they mean by the word “stable” considering it has been anything but stable. The report fails to provide facts to back up the claim that the website is working for consumers. It is as if the White House promulgated a document for reasons not based on reality.

As to the claim of private sector velocity and effectiveness, the comment makes the Obama White House seem very surreal, as if that were possible given its past year’s performance.

President Obama had more than three years and $1 billion in taxpayer monies to launch his signature achievement. Since it was launched two months ago it has been a catastrophe of epic proportions and thoroughly embarrassing to Americans. In one month the Obama White House has somehow fixed everything to a performance level of “private sector velocity and effectiveness”.

A better baseline at what Obamacare will look like can be ascertained by inspecting a more established government sponsored health care program.  The United Kingdom has the National Health Service (NHS), which was created in 1948. After decades of operation enough data exists for USA citizens to glean from the UK experience.

In as such, what can we deduce? How is the NHS doing after 65 years of providing government sponsored health care?  The NHS website is a reliable source of information.

At the time of this writing, the NHS Choices Customer Insight Reports page had only one entry by a UK Citizen about their medical care. It is posted en total here:

Vickaroo said on 03 November 2013

I first rang 111 on Saturday 02/11 around 12pm. I was describing my pain to a man on the other end, he gave me two addresses and numbers of two ‘Emergency’ Dentists in Bristol, one of which closed at 1pm and the other which didn’t answer me calls. So I called back around 2.30pm 111 to find myself speaking to a woman, repeating the same answers to the same questions that they asked about my pain. That’s fine, as I want the best treatment for me. This time they refer me to Smile Company, which is a company that deals with last resort Dental Car on Weekends. They said there was one available appointment for me at 3.10pm, I had no way of getting there in time so I had no other choice but to say no. They tell me to call back 111 between 6am – 9am on Sunday 03/11, so I did.

After a restless night of pain and answers. They then put me through to the Dental Assessment line, (Out-of Hours Dental Care). They asked further question only to come up with the conclusion that I need to see a Dentist… Well done, that’s why I called. They tell me to call 111 at 8am as I will only be able to get an appointment after that time, so I did.

Called again, same q’s, same a’s. I say “The Dental Assessment line told me to call you back.” Man is confused. He says “It’s a 24 hour wait, you were supposed to have been given an appointment for today when you called yesterday. Oh great. He says he has no idea what has happened. He told me he could only book me an appointment for Monday 04/11. I moaned at him and said I needed help, only then was it that he thought of calling Smile Company for me again. So I waited…

I got the call! I had the appointment, all booked and ready to go! Got to the Emergency Dentist half our early, to find out “Oh no, you can’t pay by card here, we don’t even have a machine for that. They should have told you cash only on the phone.”

Oh great…Thanks

The post is a reliable window of the NHS efficiency and consumer experience. Other user reports are not much different, posted below in this post and elsewhere on the NHS website.

The NHS System uses General Practitioners as the first point of entry for UK citizens (not visitors) to obtain health care. This is somewhat amusing considering General Practitioners are less than desired by USA medical students as their future career choice. The use of GPs in America is well understood, solid and justifiable. There is a long reliable history in using GPs in the USA in the past.  However, not all Americans today rely on GP physicians. Some prefer to see an Internal Medicine physician for their first point of entry.  GPs are not Internal Medicine doctors.  So already the UK and the USA paradigms clash.

To begin the process of gaining access to a physician in the UK, a UK citizen must be registered with a NHS designated General Practitioner. GPs are their ticket into the system. If you are visiting the UK, you are left out of the system. Cash is your only friend.

As to choices of GPs, the NHS website states:

You can register with a GP practice of your choice, as long as you live within its catchment area and it is accepting new patients. 

Thus if you live outside of the GP’s area, you do not get access to medical care. Your GP must be in your designated area or else.

Additionally, can you be refused treatment by a GP in the UK? This question is important in that a USA Insurance Company can refuse to cover an American citizen or resident due to a pre-existing condition.

Yes, a UK General Practitioner can refuse to accept an individual into their practice.

You have the right to choose a GP practice, although for most people this choice is currently limited to a practice near where they live. The GP surgery you choose must accept you unless there are reasonable grounds to refuse you, such as that you live outside the practice boundary.

When the NHS website indicates “such as that”, it is being generous. It is also providing only one example.  This is to say that a GP can refuse treatment on grounds other than living outside their practice boundary. Those other examples are not provided on the NHS website  Comments by NHS users provide much insight.

Hence the NHS system can reject patients. The NHS system disregards patient choices.

The NHS system relies on maps, boundaries and being seen by one type of physician – a GP. Many people in the USA use specialists for all of their illnesses.  An HIV/AIDS patient sees their HIV physician for their depression, insomnia, high cholesterol and high blood pressure.  Many USA women prefer using their OB/GYN physician for their every day maladies. Cardiologists are often seen by their chronic cardiac patients for routine illnesses as well.

When President Obama made the promise that Americans can keep their physicians, he was making a statement that not even the NHS system attempts to claim.  We have come to learn that President Obama was lying.

From there the NHS experience cascades. Complaints abound.

Factually speaking, political wistfulness aside, we should expect the same under Obamacare if we are lucky. Obamacare does not have 60 years of experience under its belt.  The UK health care experience has benefited from such hiccups. The USA has only begun its own treatment.

What will happen under Obamacare?  Can we expect it to be slightly better than the NHS?

First impressions are everything. Thus far, the USA has no reason to believe Obamacare will be encouraging nor any less flawed than the current USA capitalist based system. If we are lucky the USA healthcare system will be like the NHS system without the 60 years of history and experience the UK enjoys.

What is the answer?

To be continued

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http://www.nhs.uk/choiceintheNHS/Yourchoices/GPchoice/Pages/ChoosingaGP.aspx

The 25 comments about ‘Choosing a GP’ posted are personal views. Any information they give has not been checked and may not be accurate. 

pebbl said on 12 November 2013

There’s no need to remove the catchment areas entirely, they just need to be extended to logical sizes. Here in Tooting, we’re not in our nearest surgery’s catchment.. If the catchments are all based on ease of getting to patients for call outs, why aren’t they calculated using a radius, rather than street name lists? And why do they not extend beyond a few miles — a doctor isn’t able to drive further than 10 minutes?

As it stands my partner and I have the option of three small surgeries, which might seem like a boon in terms of choice, however the first messed up the booking of appointments, were rude and refused to admit a problem — not to mention that they are always booked up for at least two weeks; which means you’d have to have an emergency to see someone quickly. The second seems impossible to call, and they are never open when their times state they should be; We have yet to try the third but reading the reviews of all three you wouldn’t want to go to any of them. I have at least called the third to ask if they are accepting new patients from my street, all I got was a “Yes” and the phone hung up.

Recently — to avoid the above — my partner opted to go to a walk-in centre. After a couple of hours she got a very rushed evaluation which has left her none the wiser, with an allergic skin reaction to a prescribed cream, and no idea where to go next.

Basically the surgeries we have been “allocated” all seem to be sorely lacking in funds, buildings and professional etiquette. Whereas, one tube-stop over, there are three surgeries that have far better reviews, nicer facilities and — at least as far as I have experienced — polite and helpful staff who are quick to answer the phone.

If the catchment areas were opened up a sensible amount, you’d end up with more choice and actual competition. Which would mean the failing, poorly managed surgeries would become immediately apparent, and we’d escape at least one postcode lottery.

comment id 44491 

Rmonster said on 06 November 2013

I completely agree with miss_wilson.

There are no choices.

There is no point in NHS choices showing GP surgeries that are anything more than a mile away from where you live purely because of catchment areas. Staff in surgeries just simply don’t care.

I’m in the same situation as miss_wilson and as I no longer trust my family GP, I have no desire to go to him or to where my parents are to see a GP.

The surgery I want to go to is 1 mile from where I live. The surgery I want to go to has good patient reviews compared to the ones slightly closer to me all which have bad reviews.

I don’t know what to do as I’m now at a point I really need to go and see a GP as I need an appointment and possible referral very very soon.

Gow- Not all patients don’t take responsibility for themselves, some people do. I’m sure nearly everyone commenting on here wants and does take responsibility but also in changing GP’s want the best for themselves.

comment id 44272 

Keith Straw said on 07 October 2013

Gow, with one expection, you are correct in everything you say. The error you make is in differentiating between patient and customer. We pay for this service and so we are customers. That does not preclude a lack of choice. In most of Devon, most services that are on offer lack choice, ie the only landline telephone provider is BT. That makes it incumbent on the providers to give best value for money. The NHS, as a public service, is better placed than most to do this, ie no profit-driven shareholders to pander to etc. The first step they could make towards this aim is to stop spending money on advertising “choice” when no such option is available. If I do not go to the only Health Centre in my town, I do not get a doctor. Do I have the option of not paying my National Insurance – No. That is not choice. In short, stop spending my tax money paying for web sites and glossy pamphlets that spout lies.

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Gow said on 13 September 2013

For all the people saying get rid of catchment areas please lets us know then how you would deal with someone that wanted a home visit? You never know when someone will require a home visit and saying keep someone on till they require one won’t work. You would then have to register with another practice when you require a visit and are now potentially housebound which is beyond ridiculous. Not only that but you are now seeing someone you don’t recognise or have trust in and has no background knowledge about you when you are at your most vulnerable.

The spurious comments are really annoying – Chris you aren’t a customer you are a patient, the reason you are being asked to move on is as stated above. You have already requested one visit the fact that it was refused is irrelevant as it would have been triaged. There is no mention of negligence and you want to stay with this GP so it sounds like the refusal was correct.

aUkGP – “So for a practice you get paid better if you avoid patients that come often. You also get paid better if you make it so unpleasant that patients do not come so often. And you get paid better if you do consultations as quickly as possible.” – I hope everybody knows how ridiculous this comment is……………GP’s get paid via various methods one of which is QOF, guidelines based on good practice to ensure those on disease registers are seen appropriately i.e. see these people, treat them appropriately or don’t get paid.

The no catchment area idea was piloted and scrapped because of the lack of interest and uptake from patients. This is not the answer. Choice is part of several deep routed issues within the NHS based on lack of GP’s, difficulty of setting up practice, overwhelming patient entitlement, lack of patient responsibility for their own health, poorly advertised services amongst other things.

comment id 41990 

Chris Spencer said on 10 September 2013

I have just tried to stay with the surgery we have used for the past 23 years, having now moved a few miles away.
Based on the ease with which one can always get an appointment, I would suggest that their list is far from full.
However, the doctor was not interested in retaining us because we were outside his catchment area. He cited the possible need for home visits and yet the one and only time we requested one, it was refused.
In the business world this would be called a cartel and would not be permitted. (I won’t steal your customers and you won’t steal mine.)
We are now left with the “choice” of registering with a practise that we know is unable to provide prompt appointments.
It saddens me to have to report this as I sit on the Board of an NHS hospital, but we should not insult people by telling them they have a choice when they clearly don’t.
Get rid of catchment areas and give people real choice. It would not be impossible to say that the price of selecting a doctor outside your catchment area was to agree no home visits. Then people can decide if the trade-off is worthwhile.

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miss_wilson said on 21 August 2013

what a load of rubbish..
there are no choices at all!!
im not happy at my current GP which im registered to at my parents address as the GPs in my area have bad reviews. 
i wanted to go to a GP within a 2 mile radius and they tell me i am out the catchment area – so this leaves me with 2 GP’s with bad reviews.. great start! 
also the information about the walk in centres.. not true. i went to a walk in centre once as i came out in a rash all over and i was told i shouldnt be there unless i would go to a&e about it. as it was a service out of hours rather than going to a&e – im glad the NHS service i pay for is so helpful!!
they need to hurry up and bring the law in that i can choose with GP i go to, as in that case if GP werent busy due to poor service, then they may step up their game!!

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User792128 said on 31 July 2013

I agree that there is no NHS choice for GPs – especially in my case – I and my family of 5 are being removed from the surgery we have been using for over 20 years as they are struggling to satisfy appointment requests and we are 200 meters outside their boundary! 
Having trawled around the 7 nearest to us (of which they are the 3rd closest) we are only inside the boundary of 1 practice which we do not want to move to as it has a very poor reputation.
This is a postcode lottery and madness, especially as we are closer to our current practice than over 70% of the rest of their patients!!

Exasperating to say the least 😦

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limeCut said on 30 July 2013

Catchment areas = Joke!

There is no choice whatsoever.

”find the surgery you feel most happy with”

Its such a waste of time.. If you are so unlucky as to live in a catchment area of only bad surgeries with bad feedback. There is no option but to use it. 

Is there any wonder why people get private healthcare??? 

There is no choice until the NHS gets rid of the Catchment area issue.

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Chris1946 said on 11 March 2013

We have just tried to change our doctor and because we are outside the catchment area of all available doctors, the nearest of which is only .98 miles from us, we cannot move.

This catchment area limitation makes nonsense of NHS choices.

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HelgaCabbage said on 21 February 2013

I have a similar problem to many on here.

I have had many GPs that I have not felt comfortable with, or have struggled to understand their accents when they ask me questions, or who I felt did not listen to me… then 8 years ago I found a GP I have been very happy with, and recommend to everyone. 
But now I’ve moved house and am considered out of catchment area, even though I am very willing to drive to the surgery, which is only a few miles away, so that I can keep the doctor I have had for the last 8 years, who I trust and respect and feel comfortable with.
Instead of registering with a new GP at the surgery they tell me I now have to use, I am no longer registered with anyone. I was awaiting test results, but when they I tried to change my address for them to be posted to me, they instead sent me a letter saying I would now have to lose my doctor.

I am so depressed by this. If I was telephoning for my GP to come out to me, I could understand the catchment area thing, but since I am driving to the surgery not the other way around, why can’t I choose who I wish to be registered with and who performs intimate examinations on me?

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nataliegreen2 said on 15 April 2012

True or faulse catchment areas do not exist
I have phoned Barnet PCT GP registration department on Friday and the management confirmed that catchment areas do not exist. Can someone confirm that this is true, as when I phoned the clinics which they gave me as possible places, they told me as you would expect since you are not in the vacinity you are out of the catchment area and we have never taken anyone which is out of the catchment area. So just wondering?

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Amsterdam said on 16 March 2012

NHS GPs have no reason to provide decent service: contrary to the misleading info on this website – Primary Care Trusts do NOT investigate complaints – they just spend our money on sub par services without ensuring we get value for money. If you complain to them they just refer your complaint back to the GP- what a farce!

My GP did not know that a ferritin level of 70 was required to stimulate hair growth and i’ve suffered from hair loss for years: i had to tell him this info and ask to be prescribed ferrous sulphate!

The simplest things are hard work in this country, which about 100 years behind Africa in medical terms. You cannot get VIT B12 shots on the NHS: i need these due to an absorption problem identified by a private GP (NHS just couldn’t figure it out), but i can’t afford to go private.

In South Africa, you get get a Vit B12 shot at any pharmacy without prescription. The ampules (£1.50 each!) and syringes are available over the counter, so I’m travelling out there to buy a year’s stock-otherwise i have to pay a private consult fee of £120 + £20 for the shot every month in UK. I need these injections as, combined with other health conditions, not getting them causes me serious health issues. 

This country is a joke! I resent being taxed to the hilt and not even getting the most basic of care in return. Wonder whether anyone from the NHS actually reads these comments…….

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AlaricAdair said on 24 November 2011

The information on NHS Walk-In Centres needs some amendment as many of the original Walk-In Centres have been closed and/or nurses transferred to GP Practices with the accordingly revised hours.

The are no published statistics on whether people, who have actually used a WIC, would prefer a visit to a GP or to a WIC. It should be noted there are some unsupported and biased suppositions propagated by GPs that GPs attendance is preferred.

People should make their own mind up while they still have the opportunity.

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Noemie said on 10 November 2011

I live in Edgeley and wanted to change GP practice as I’m not happy with mine. this webpage tells us that we can check for most practice 1. if they accept new patients and 2. what their catchment area is.
Most of them do accept patients, but the info about catchment area is not online which means that you have to contact each practice by phone! and guess what the answer is?! No of course!!!
I am a French national and so was looking to go to Heaton Mersey practice but I’m not SK4. I found this very unfair. And I am very disappointed. It seems like discrimination to me. I have a car and driving for a mile or two does not bother me. if it means I can get the service I need.

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Ipsa said on 18 October 2011

NHS No-Choice!

My GP has decided to only see patients in the mornings (with no notice given to the tax-payer customers), as I work 2hrs from where I live this is about as useful as a chocolate teapot. I will not see one of the other GPs at the practice as they are male and I insist on seeing a female doctor … as is my right.

I wanted to move to another surgery, which has better facilities and more appropriate opening times (for me), and two female GPs, however, although they are only 3mile away, I am out of their catchment area. Even an appeal to the practice manager did no good.

I have gone through the complaints system, which again, was next to useless – all completely missed the point about my wishing to see a female doctor!

When are the reforms being passed which will eliminate the catchment area fiasco?

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Pepperman said on 12 October 2011

Sorry NHS Choices, but your site is seriously misleading on choice. When I searched for a GP your site listed 50 Gp practices within 5 miles of my home. In practice 95% of them were a waste of space because I am only within the catchment area of 3 of them. I only found this out after I had wasted my time comparing practices and choosing the one that I thought would be best for me – only to find that they wouldn’t take me because I was outside of their catchment area.

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aUKGP said on 31 August 2011

“Choose carefully, because a good family doctor will direct you to the best specialist care when you need it “

Codswallop: a bad GP has just as much access to specialist care as a good one.

Why does the NHS have contracts with bad GPs? Like the “one that seldom answers the phone” and then tell you on this page to avoid them somehow? it does not make sense if they are so bad stop using them.

Now supposing this site can really help you find the best GP, who would want to be registered with anyone else? so the best GP should have 60 million patients? And if this site can really help you find the best GP why not list GPs in the order of quality instead of “the nearest shown first”?

”Some people may be happy to see a different doctor each time ” 

Double codswallop – most people would like to see the same (the best) doctor all the time and not a different nurse in a walk in centre. The local walk in centre is only interested in seeing patients that are eligible to register, all others are referred back to their own (substandard if we believe this site) GP with the absolute minimum they can get away with.

Catchment areas are there because a GP is obliged to do home visits (something you do not get from walk in centres) in the catchment area. However some practices have used this to exclude undesirable areas. Unlike walk in centres that get paid for each consultation GPs get a fixed fee per year (about £65 on average) no matter how often you come and nothing extra for home visits. 

So for a practice you get paid better if you avoid patients that come often. You also get paid better if you make it so unpleasant that patients do not come so often. And you get paid better if you do consultations as quickly as possible. Why woud the NHS have such a payment system if the NHS really wanted to get patients the best care?

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nhshellraiser said on 09 July 2011

Why do I have to ask around when choosing a GP practice? Also, patients choose a doctor for a good service they are not looking for a friend.

Every NHS GP practice should be required by law now to be open and give full details on their website, of all the services they provide and details on all of their employed staff, including full qualifications with photos.

I have seen one such excellent online website but it is a Scottish GP practice only. All UK patients should be able to read about all the staff who would be treating them before making a choice. It would also help to reassure patients and to build trust/confidence in a healthcare system where standards have fallen.

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FSade27 said on 26 August 2010

If I an not satisfied with my GP’s diagnosis how do I get a second opinion?

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Jeee said on 12 August 2010

Re: Catchment areas.

When I went to “NHS Your health, your choices” page, I find that the GPs I want to register with, won`t take me?. Out off the closest to me I find I am out off their “catchment area”. How can this be???. 

”Choices”, you don`t really get a choice. It will all change when the NHS goes private. You will have planty of “Choices” then and NO “catchment areas”, well you wouldn`t would you with doctors getting £200.00 (off you) just to come to your house, it will all change then.

I am disabled and have a life-threatening condition, I need to take medicines prescribed by a GP and I don`t have a doctor?. I can`t get registered with one to suit my needs?. How can this be???. I run out of my medicine yesterday. 

Such is life, good job I have given up on it or I would feel depressed.

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danielbb said on 08 July 2010

I cant see any official performance figures or inspections. So how are we supposed to make an informed decision. I hate the way the NHS is run. I was told by my GP that you cant be refered to a specialest unless the doctor knows what the condition is you likely have, so you have to rely on a GP knowing EVER condition. 

Why not have a system where you are first refered to an intermedary doctor that specialises in the area. Instead my doctors say ‘ I dont know, have some prozac’

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Sabbry said on 28 May 2010

My GP is not in my catchment area anymore (it was in my old address), but I do want to stay registered there (it’s still fairly close and on my way to work). Do I have to change it? How can I keep it? I feel I should stay with a Doctor I trust and I don’t think it’s fair for them to force me to leave that practise.

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disappointed with the service said on 29 March 2010

It seems billybump had a similar problem to mine. That is my exact response. You are given all this sweet talk about ‘choices’ but you either stay with a GP surgery that you are unhappy with or just don’t go to a doctor even if you are dying. So what kind of ‘choice’ is that? When I first went to the surgery where I live I was perfectly well. But now I feel they are making me ill and then wanting to cure me. What a great choice!

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Manu_london said on 09 January 2010

ahh, but you still have the choice – you can take the existing GP surgery service or leave it !

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billybump said on 22 November 2009

This site states that if you are not happy with the service at your existing GP surgery you can change to another practice in the area. What if there is no other practice in the area and all other practices in areas in close proximity refuse to take on someone out of area? Thats when there is no help, not even PALS so a person is left alone without medical support. This site could perhaps be a bit more honest in its information. The NHS is supposed to be changing but its too little too slowly. 

Posted in affordable care act, government, medical student, obamacare | 2 Comments

ObamaCare Part I

The Affordable Care Act (ACA) or Obamacare has arrived and to hear the voices of the elected representatives of the USA citizenry, you would think the land is rife with Civil War. Members of Congress are indeed apoplectic.

Medical students are frenetic about their medical student loans. Few medical students talk about starting a medical practice. Medical students are young kids. They are gullible, wide eyed and bushy tailed. They should be. Someone has got to believe in a system where few adherents exist. When you are 20 something, you are not equipped nor have the raw experiences of entrepreneurship to think far ahead of your business future. A SWAT Analysis and/or Business Plan do not register for medical students. Sadly no one is there for them to teach them how to run their economic affairs. Learning about the business side of medicine is not part of the medical school curriculum. It is strictly autodidactic. The lack of preparation of medical students in learning how to navigate the economics of a medical practice shows in the 99.99% of physicians today. In my professional life I met few doctors who were savvy financial wizards. Most were victims to the whims of the economic marketplace. For being a population that is vaunted as members of the Illuminati, most physicians are clueless about what they are doing as to their business.

Physicians at one time were leaders of our communities. They were the Oracles of our society when it came to healthy living. A doctor spoke and everyone paused silently to listen reverentially. The Doctor knew best. Since the 1980s, Physicians have been largely AWOL in the Public Square. Victims of self-inflicted wounds of unhealthy lifestyles, reckless eating habits, addiction disorders and the highest rate of mental illness among all professionals in the USA, doctors have given people few reasons to be inspired. They became one of us. The vast majority of my physician clients in my former career told me not to enter medicine as a profession given, as these individuals told me, that they are miserable.

Physicians miserable?

Physicians, as a general rule, are miserable.

President Barack Obama has done the USA a favor by forcing the subject at our kitchen table discussions, assuming we are not tweeting on our “smart” phones while seated in front of our family and friends during dinner. Obama has pressured us into a national dialogue. Yet we are no longer listening nor engaging each other. Members of Congress are a reflection of Anytown, USA. They are us. They come from us. We elect them to office from our communities. We keep them in office. They are an extension of our persona. Unlike We the People, Pygmies in Central Africa communicate with each other more than we do. Houston we have a problem.

In the 1990s Hillary Clinton, as wife of President Bill Clinton, tried to ramrod the subject through Congress but it was shut down. She did it in less than honest ways which may or may not account for the reason her vision of universal health care was catapulted out of the Congressional Halls. I will never forget the humorous piece authored by political satirist P.J. O’Rourke where the last line in his famous article on “Hillary-scare” ended with, “The price of health care will be fixed below market value. And we’re all going to die.” I had that newspaper clip taped on the inside of my locker in the Operating Room Men’s Locker Room where I would change into scrubs. It used to make me laugh. Today no one is laughing.

Twenty years later the medical business landscape is extensively worse. There is a tie to the 7 Deadly Sins, but that is for another discussion. The rationale for justifying sky high medical costs is sloughed off on compensating the developers for their investment into Research & Development. R & D has never taken it on the chin so poorly thanks to Public Relations personnel in Medical Corporations. There is a valid point in the R & D argument. It’s just that, like with most other good points, the devil is in the details and they are manipulated for the sake of justifying unscrupulous actions. Again, the 7 Deadly Sins are at play. You can not separate one from the other. Behaviors are an indicator of who we are. As B.F. Skinner and Sigmund Freud taught us, behavior is everything.

I often laugh to myself when I think what a man must pay to acquire a pill to be able to perform sexually with his lover. The cost for a tablet of Viagra, Cialis or Levitra is anywhere between $20-$25. One pill, one sex act. We are now paying for sex. That would make us members of the oldest profession. Some intravenous chemotherapeutic medications costs are in the ballpark range of $10,000 – $20,000 for one month alone, (e.g. Zaltrap by Sanofi andAvastin by Genentech). A total hip replacement procedure costs about $4,000 in the USA, $2,000 in Australia, and roughly $700 in Canada.

Physicians, nay their lawyers and accountants, have crafted a business schema that is truly impressive from a 30,000 feet level. They charge Third Party Payers (insurance companies) astronomical prices for their professional services, in hopes Payers will reimburse them for a dismal fraction. For example, a physician medical group might charge Blue Cross Insurance $1000 for providing medical services to a patient carrying that insurance policy. The Medical Group knows they will get $100. If they charge $100 they might get paid $1. That’s the logic. Doctors know this. Payers know this. It’s just part of the dance of doing business in medicine. Likewise Third Party Payers reimburse physicians under net terms of 30-60-90 days, at least that was the timeline when I worked in the field. Doctors today tell me, as a medical student, that they literally have had their phones turned off due to lack of payment for their phone bills because they did not have enough money to pay their phone service carrier. An Infectious Disease Specialist Physician told me her story. She did not have phone service for 2 days for her patients to call her. I know Physicians who are not getting paid in a 6-12 months window time frame by insurance companies, and that is with doctors calling the insurance companies to beg for reimbursement of services. Physicians are begging third parties. We read in monthly news articles that government sponsored Payers (e.g. Medicaid and Medicare) are worse as to percentage of payment and timeliness of payment. Patients are oblivious. No one talks about this but everyone wants their medical doctor to go on glibly while attorneys, car mechanics and plumbers bill for their professional services unthwarted.

However, given that Congressional leaders would have a hard time passing a dog ordinance on which they can all agree, the feasibility of their passing harmonious legislation that accounts for almost 20% of the Gross Domestic Product of the USA is naïve. We can not rely on Congress for this issue. Clearly the current practice of medicine is a failure. With more than three decades of people calling attention to the problem nothing has been done.

Any good medical student knows that before you can prescribe a treatment to a sick patient, first you have to know the history of the problem, understand how it evolved and how it impacts the quality of life of the patient.

What is our answer to America’s health care crisis?

To Be Continued…

Posted in medical preceptorship, medical school, medical student, nontraditional student, older student | Leave a comment

Mental Illness

This Post is Dedicated in Memory to Kaitlyn N. Elkins. Permission granted.

Marie has one of the highest Grade Point Averages in my class. She has told me for over a year that everyone in our class hates her. In recently recounting a class disagreement about a test where she earned the highest score, Marie described our classmates as “haters”, “jealous” and “losers”. She has no friends. Marie said last year she experienced a darkness like she had never seen, did not understand why it happened to her, and vowed to not let it happen again this second year of medical school. Whenever we get together she conveys anger, detachment from her surroundings, and an inability to get along with people. She has a cockiness that is unbecoming of a medical student. I hope she doesn’t turn into a disruptive physician. Possible Diagnosis: Personality Disorder.

Daniel describes driving onto campus as going to “prison”. He hates the school, lives alone and socializes with no one on weekends. Daniel rarely speaks in public, has never raised his hand in class, and slithers into class in the same fashion as he exits it: like a stealth spy. When we recently spoke he told me he had just awoken from a 14 hour sleep cycle. I told him I was stunned he had slept that long, and that I have yet to sleep more than 6 hours in one 24 hour period in the last year. He told me he takes sleeping pills because he can not sleep. Possible Diagnosis: Sleep Disorder.

Patrick is in my class as well and is gripped with anxiety. Whenever he sits for an exam, he is overcome with apprehension, is the last to leave the exam and slinks around campus as if a black cloud were over his head. His is a general feeling of failure coupled with anxiety. I recommended to Patrick that he seek professional help outside of school. People who know him better than I say he is a mess. Possible Diagnosis: Anxiety Disorder.

The American Psychiatric Association (APA) is the largest psychiatric organization in the world. You will find no definition of the phrase “mental illness” on their website. The APA uses a handbook, the Diagnostic Statistical Manual, in order to diagnose disorders. The DSM-IV states that:

“… although this manual provides a classification of mental disorders, it must be admitted that no definition adequately specifies precise boundaries for the concept of ‘mental disorder.’ The concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations.”

As the news media broadcasts their nightly programs through our televisions, it takes minimal effort to mentally connect one of the reported violent events by an individual with the possibility of a mental illness. On October 3rd a woman attempted to drive her car over barricades in front of the White House. She was shot and killed while unarmed by Washington DC policemen. She had been diagnosed with postpartum psychosis. On November 1st , a 23 year old man in Los Angeles communicated with his family in Pennsylvania via text message that he was going to commit suicide. He had no friends in high school though he had two roommates. He was dropped off at the Los Angeles Airport and was on a mission to kill TSA Agents. He was successful. A popular 20 year old young man was loved and sought out at his place of employment, a pizzeria, because he was funny, endearing and engaging. On November 5th, he went to a major shopping mall in New Jersey, pulled out a shotgun, fired a few rounds in the air aiming at no one, and then ended his life in a dark room alone.

What was particularly glaring in each of these cases was that every one of them was followed with commentary by people who knew these individuals. Their comments expressed shock and bewilderment that their loved one had done such a thing. They said they had no clue, saw no signs nor symptoms.

We are learning that any one of us is capable of doing anything.

Television anchors, journalists, politicians and commentators utilize unhelpful, uncharitable terms like “crazy”, “nut case”, “lunatic”, “threat to society” and “psycho” to describe the individual at the crux of the news. “Gunman” is one of the better terms but it too is laden with heavy connotation, none too flattering. Those on the Hard Left rush to conclude that guns are the problem, while those on the Hard Right focus attention on the Second Amendment of the Bill of Rights. Both are obfuscating. In medicine we know when someone is medically ill because they present with clear, measurable, observable symptoms. They are quantifiable and predictable because the source of their symptoms are often caused by physiological, anatomical or biochemical errors.

Not too long ago symptoms that we consider today as being strictly medical in origin were once viewed in similarly disapproving ways. A woman with a hemorrhage was described as being possessed by demons. A person with leprosy, a neurological, skin condition, was shunned as an outcast. A person with migraines would have holes drilled in their head to allow the malady to “escape”. Bloodletting with or without parasitic leeches was an acceptable treatment in order to let the “bad blood” gush. Just over 15 years ago people who sensed ringing in their ears were considered to have psychological problems. Today the syndrome is known in medicine as “tinnitus”. It is recognized as a bona fide medical malady. It can not be measured or observed by a physician.

Headaches, nausea and the physical sensations of numbness, pain and discomfort are strictly subjective.

There is a conundrum here. Apparently some medical illness are viewed by society as requiring support, understanding and treatment. Other reported symptoms have yet to persuade society as needing to be embraced. About 20 years ago obesity was considered as being caused by an overactive thyroid gland. Today many medical clinicians consider it an eating disorder, which falls under mental illnesses. Euphemisms & invectives abound: “full figured”, “whale”, “pleasantly plump”, “lard ass”. Another de rigueur mental illness example: Mr. Rob Ford, the Mayor of Toronto, has the misfortune of being caught on a video recording smoking crack and, in a separate video recording, in a wild, alcoholic drunken rage swinging his arms and screaming obscenities. He claims he is not an addict, which is to say someone with a mental illness. Followers of the Twelve Steps of Alcoholic Anonymous know it takes an addict to know an addict.

Society has used algorithms over the centuries to determine whether a cluster of symptoms should be anointed or ridiculed. These have evolved over time. Evolution needs to continue.

Meanwhile, medical students battle disclosing to school administrators that they might be struggling with a mental illness for fear of not having the “right stuff” to be a doctor. Miami Dolphins Football Player, Jonathan Martin, is facing such a chorus from the Dolphins players for not being a “real man”. His teammate, Richie Incognito, who is accused of aggressive physical and emotional hazing of Martin, was placed on indefinite suspension by the General Manager of the Miami Dolphins. Incognito’s response? He bought himself a $300,000.00 Ferrari and is tooling around Fort Lauderdale showing it off. At least Incognito is consistent: he knows how to be offensive. Who has the mental illness in this celebrated NFL case: Martin, Incognito or the entire team? It depends on who you ask.

# # #

The American Psychiatric Association

Signs and Symptoms of Mental Disorders

If several of the following are occurring, a serious condition may be developing.

  • Recent social withdrawal and loss of interest in others.
  • An unusual drop in functioning, especially at school or work, such as quitting sports, failing in school, or difficulty performing familiar tasks.
  • Problems with concentration, memory, or logical thought and speech that are hard to explain.
  • Heightened sensitivity to sights, sounds, smells or touch; avoidance of over-stimulating situations.
  • Loss of initiative or desire to participate in any activity; apathy.
  • A vague feeling of being disconnected from oneself or one’s surroundings; a sense of unreality.
  • Unusual or exaggerated beliefs about personal powers to understand meanings or influence events; illogical or “magical” thinking typical of childhood in an adult.
  • Fear or suspiciousness of others or a strong nervous feeling.
  • Uncharacteristic, peculiar behavior.
  • Dramatic sleep and appetite changes or deterioration in personal hygiene.
  • Rapid or dramatic shifts in feelings or “mood swings.”

One or two of these symptoms can’t predict a mental illness. But a person experiencing several together that are causing serious problems in his or her ability to study, work, or relate to others should be seen by a mental health professional.

At the very least, the affected person should:

  • have a diagnostic evaluation by a trained professional;
  • be educated about mental illness and signs and symptoms to watch for;
  • receive supportive counseling about daily life and strategies for stress management;
  • and be monitored closely for conditions requiring more intensive care.

The American Psychiatric Association

Posted in depression, medical school, medical student, mental disorder, mental illness | Leave a comment

First Do No Harm

Hollywood Actor Tom Hanks, age 57, recently disclosed he has been diagnosed with Type II Diabetes (Non-Insulin Dependent Diabetes Mellitus). The news was given to him by his doctor with the following: ‘You know those high blood sugar numbers you’ve been dealing with since you were 36? Well, you’ve graduated.’ ‘You’ve got Type 2 diabetes, young man.'”

I attended a Cancer Conference a week ago and a physician friend was one of the lead presenters. He delivered two expert presentations that were laden with evidenced based data. It was impossible to refute him. The other speakers referenced him during their presentations extemporaneously due to his impressive breadth of scientific data. One of the speakers, a leading New England Surgical Oncologist, touched on the topic of obesity and cancer. She related from the stage to the physicians in attendance that as much as 40% of Cancers are related to Obesity. Few people know this. My physician friend and I huddled around the conference tables during breaks and I observed obese physicians elbowing for cupcakes, Danishes and sodas. When my friend made a comment about it I asked him one rhetorical question: “are you surprised?”

Physicians, Psychologists and Attorneys are now commenting that mental illness may be driving a disproportionate amount of violence we are seeing in the news. Dr. Drew Pinsky, MD, an Internal Medicine Physician with a TV Show on CNN, regularly hosts a group of psychologists and behavior experts he calls the “Behavior Bureau”. For the past 2 weeks they have been discussing the road rage incident of a group of motorcyclists in New York City who chased after an SUV and exacted violence against the family in the vehicle. Dr. Drew’s panelists remarked “are you surprised”? Their explanation included mention of the mood of Americans, the uncertainty, fear and destabilization that the citizenry are undergoing. Invariably Dr. Pinsky’s guests assailed the politicians of Washington DC for not giving Americans any sense of hope in solving the country’s problems. People, the panelists said, are depressed globally and we are seeing it on the nightly news.

Enzymes are molecules that are designated as catalysts. Our bodies need enzymes to function on a second by second basis. Catalysts, by definition in chemistry, allow a chemical reaction to proceed in the forward direction. It would be comparable to boiling water in a pot with a lid on it on the stove. The water will boil eventually with the appropriate heat administered to the pot. Any good cook knows that adding some salt to the water will make it boil faster. The grains of salt in this situation are catalysts. Likewise, when some motorcyclists gather together for an annual event prohibited by the local authorities, they are riding together in order to self-medicate: they want to forget their problems and choose to ride with the wind. It’s a freeing sensation to have one’s hair fly in the wind while riding a high speed hog. The SUV driver was a catalyst. His vehicle was surrounded by a gang of motorcyclists who threatened the safety of his family. When some of the motorcyclists starting hitting his vehicle, the SUV driver feared for the well-being of his family and pushed the pedal to the metal, flooring the accelerator and running over one of the motorcyclists. It was a moment of panic. In a classic example of cause-effect, the reaction of the motorcyclists was predictable – they did not want the SUV driver to escape after running over one of their fellow bikers. The chase ensued. All of the ingredients were in place regardless of who was driving an SUV, a truck or a tricycle.

One of my favorite TV shows during my adolescent years was M*A*S*H with actor Alan Alda. I marveled at how Alda’s character, Dr. Hawkeye Pierce, took on the societal taboos of the time. He pushed the limit with his uncomfortable commentary on the effects of the Korean War and how the physicians had to clean up the hazards of combat. Hawkeye resigned himself to tending to the sick regardless of the reasons they were brought to the MASH Unit. He made it a point, however, to make known the cause and effect relationship.

Doctors and medical students see people daily in their midst who are engaging in behaviors that put them at risk for ill health. When my Oncologist friend and I gathered around the food table at the conference room, he grabbed some fried food and I poked him in his belly and asked him, “do you really need that?” He is a borderline Type II diabetic, just like Tom Hanks was 21 years ago. My friend put the offending food item back on the table. Given that Tom Hanks had his physician warn him 21 years ago about his borderline diabetes, it begs the question about an affluent actor, “why did he ignore it?” Similarly, when some motorcyclists are gathering in riding groups and tear off after a driver to exact justice, considering the dynamics at play in society, we should not be stunned at what we are watching nightly on TV. People are choosing to ignore the undercurrents around them just like Tom Hanks.

There exists a cause and effect in life and none of this is terribly new news. I remarked to someone at school recently that when you stand in the rain you get wet. When you don’t address a problem at hand, expect it to unravel. Mental illness is like that. So is excessive eating. Likewise with frustrated, anxious, worried people. When push comes to shove, something is going to give. We are all capable of doing anything, including running over a motorcyclist when we fear for our lives. Catalysts make sure reactions go forward. They work extremely well.

As a future physician I am continually assessing my surroundings and discerning what is complimentary to life and what is injurious. I will also argue for the right for people to make their own choices especially if those choices produce disastrous results. People have been given free will, and to remove that is to remove liberty. The great Christian Philosopher and Theologian, Saint Augustine of Hippo, reasoned accordingly in the 4th Century A.D. He argued that God’s love is so great that God will not take away our free will to reject Him. Saint Augustine influenced much of the legal system we have today in the Western World.

I will treat anyone and everyone who comes my way regardless of how they became ill. It is unfortunate that Tom Hanks was diagnosed with Diabetes Type II in spite of being warned 21 years ago. He can still reverse his course by following his physician’s treatment guidelines of losing weight. However, Mr. Hanks has already discounted that option. He commented on the Letterman Show that he can never drop to the weight he had in high school of 95 pounds, while cajoling others in his midst to laugh along with him. His doctor never asked him to drop down to 95 pounds. Hanks is still choosing to ignore the obvious cause-effect relationship.

Diabetes Type II is no laughing matter. Diabetes is a disease that causes a slow, agonizing death with multiple organ systems gradually shutting down. Likewise people with any type of illness, be they paranoid schizophrenic like the Washington DC Naval Shipyard gunman, or the Cleveland kidnapper Ariel Castro who held women hostage for his sexual addiction, need help. Their cries can not be ignored. Otherwise the catalysts of life will allow them to proceed forward.

It is not enough to be a physician and treat the ill, as Captain Hawkeye Pierce did in M*A*S*H. Illnesses need to be addressed beforehand and action must be decisive. Otherwise we should all expect the predictable.

“Let them eat cake.” Marie Antoinette

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Tweeting About You

The Physician is much like the Priest: they both must have the gift of attentive listening. The physician begins the patient interaction by receiving the patient into their office or hospital setting, and asks them the tell tale question, “how do you feel today?” From there a fluid, intimate dialogue is supposed to evolve, allowing the physician into the patient’s private world. This interaction is referred as the narrative, history of present illness or simply the S in SOAP – subjective, objective, assessment, plan – note for medical documentation. Without the patient’s subjective story telling of what ails them the physician is left to read the patient’s mind. Hence, the physician must create within the patient a sense of trust and protection so that the patient can feel safe to be honest in their reason for seeing them. Diagnostic, objective tools that measure and record clinical symptoms are important but the subjective report given to the physician by the patient is imperative. The patient’s story is also a shield for the physician. If a question is raised down the line as to whether the physician was treating the correct problem, the doctor can state with confidence that they relied on the patient’s narrative and treated accordingly. A more succinct way of putting it is having a physician greet a patient, forges a warm, welcoming environment and states with a smile, “talk to me”.

The Humanistic Psychologist Abraham Maslow wrote in 1943 a paper proposing a Hierarchy of Needs. The bottom of the pyramid served as the foundation of the psyche: Physical Needs – food, water, sleeping, breathing. The next level above is Safety with the next higher level being Love and Belonging. Nearing the top of the pyramid was Esteem (respect of self and respect of others) capped with the end all and be all of Self-actualization. Few people get to the very top, Maslow taught.

It is a running theme in life that human creation yearns to love, belong, and be respected. Maslow felt these are core components of living. The physician does well to keep these in mind whenever any sort of human being comes their way. It does not matter their size, shape, color, race, weirdness factor or unique presentation. The physician must receive all without flinching, yet they can facilitate matters by establishing that environment. Juxtapose this to the managed care model of physician reimbursement, and the now well known and disliked assembly line type of factories that physician offices have become, “get ’em in, get ’em out”, and the clash becomes apparent between the needs of the patient and the needs of the myriad parties within the business of medicine. Dr. Marcus Welby, MD, is now part of American folklore. Yet, medical students are taught to be exactly that type of physician. Not a few older physicians have pulled me aside and told me that it just doesn’t happen that way anymore. There are too many hands, they say, involved in the patient-physician interaction, and those forces are hungry for their part of the pie.

The Roman Catholic Church has a new leader, Pope Francis, and he is stunning the world by his person to person interaction. The Pope is not teaching anything new, there are no new proclamations nor decrees, nor any hint that new paradigm shifts are about to take place with regard to basic moral teachings. What is different about this Pope, and the entire world is noticing in just 6 months time, is that he takes a personal interest in the individual. Without borrowing a Madison Avenue marketing jingle for X, Y an Z corporation, this man from the other side of the world really cares. No, really. Wipe that smirk off your face.

Pope Francis has taken to calling individuals on the telephone without notice. He has caught a few individuals off guard, prompting the recipient of the call to not believe it is the Pope calling them. He is also penning personal letters to people who have written him. No form letter, no machine generated document with an electronic signature. This Pope is doing essentially what we all hope someone will do for us. He is showing respect for others. He is giving others a sense of belonging.

Why would these simple acts be so momentous? Why are so many “tweeting” and “following” Pope Francis on Twitter? Precisely because he is not trolling the internet calling attention to himself. He is showing up for people, and that really is rather stunning for a public figure.

I know many fallen away Catholics. I also am friends with atheists, Jews, Muslims, agnostics, people who call themselves “spiritual”, “Buddhists” and critics of organized religion. However, in a colossal chorus that no one would have thought possible, they all are intoning together – this guy is impressive. Some rabid anti-Catholic cradle Catholics have gushed that they might even return to the Catholic Church because the Pope is making them feel welcome.

On the opposite spectrum we have today’s usual suspects: President Barack Obama suffers from a world wide credibility factor, the popularity of Members of the US Congress continues to be in free fall, and now Judges of US Courts are taking a shellacking for being, as one jurist friend calls it, “stupid”. We have the horrific events of random gun shootings in varied settings, killing innocent victims. They were committed by people who were mentally ill, now dead or imprisoned, because they had reached out for help at one point, only to “fall through the cracks” as the media euphemistically puts it. In a matter of minutes after the gun shots, everyone ran to brand the gunmen as being “psycho, crazy, a maniac, threat to society”, and more. What gets lost in the analysis is that these people did what they did, as unfortunate at it is, because they had sought help but no one seemed to notice them. They took it up a notch and soon the entire nation and world were watching second by second. In one scenario a school secretary coaxed one gunman to put down his weapon because she conveyed to him that she too had her dark moments. She cared. She communicated that. He got it. He walked away assisted. The Washington DC Navy Yard incident was perpetrated by a man who had a long, well documented history of seeking help for hearing voices and believing aliens were following him. When he tried to share his story, he apparently felt no one was listening. His Hierarchy of Needs was unmet.

Much of this was predicted back in the 1960s in a Papal Encyclical authored by Pope Paul VI entitled Humanae Vitae. In it Pope Paul VI warned the world that people are seeing women as objects of pleasure, instead of as honorable pursuits. He wrote that the world was losing its sanctity for the individual, losing respect and concern for each other. Sage by no other name. Physicians have been left with the aftermath: abortions, unwanted pregnancies, unwed mothers, deadbeat dads, sexual transmitted diseases have mushroomed, and the internet is busy with meet up sites in hopes of meeting their Prince/Princess. I do not know anyone who has their Hierarchy of Needs met on the internet. We continue to tweet, though, rack up friends on social media sites and, like the Navy Yard gunman, call attention to ourselves. Students from my school tell me these venues are nothing less than “Look at me” repositories. I wouldn’t know. I’m too busy engaging people on the street to get eye contact.

Somehow, through all of this morass, the Physician has got to keep a staid gaze, pretend they are different than the rest, and instill in their patients that they can come to them for healing due to all of the blows of society. A classmate of mine considers me his closest friend in medical school. He reminds me regularly, via text message, that he has a 3.85 GPA. He crows about it. Since classes started in August I have received scores and scores of text messages from him. They are all about him. He never asks me how I am doing. He does not return my phone calls. And twice I have asked him to get together with me. Still, when he sends me text messages, he is letting it all hang out. He is angry, lonely, depressed, outraged at the “kids” in class (he is 30 years old) and misses his parents a lot. When he is home with his family, he sends me text messages and emails as well. I do not know him well. He definitely knows nothing about my heart.

One by one Pope Francis is reaching them. For good measure he also sends Tweets on Twitter, something I find endearing because his Tweets are not about him. They are other directed, as the Humanistic Psychologist Carl Rogers would have said. The Pope tweets about you and me, about having Faith, having Hope, having Love. I think it would be a worthy trend to follow.

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