psychiatry
Into Each Life...
Mon, August 13, 2007 at 08:14PM 
Not a bad day today. No substance abusers. Mostly saw real people with real problems and several no shows for appointment.
The subject of grief and loss is unavoidable in my line of work, mostly because such a process is at the root of much of the unhappiness we experience during our lifetime. I'm thankful for the last couple of months even though there has been more than the usual amount of grief in my own personal life. I visited my father in the nursing home last night and talked with him during a fit of sundowning, better known as acute delirium. He's down to about 85 pounds and confined to the bed in a diaper. His hallucinations seemed a bit frightening for him but there was a child-like quality to his voice as he urged me to pull and push him through whatever place he was trying to escape.
He asked me to not let him die. I asked if he were afraid to die? He replied he wasn't afraid but he didn't want to die. Here I was, the mighty physician, reduced to utter helplessness. I could try soothing him and telling him that he was okay and everything was going to be alright. That actually seemed to help. Just last week I had told a grieving and guilt ridden patient that at a certain point of illness it doesn't matter what we humans do because it is out of our hands. Still I felt useless. I was able to hold his hand and tell him he was loved. For me that is a major accomplishment for such words usually come with great effort.
Hospice teaches us that a time comes when we can give our loved one permission to go. I couldn't quite find the appropriate words for that. I wondered what motivated him to fight so hard to hang on at this stage. His 90th birthday is in a week. Maybe that's the reason. I gave him a sip of water and he would not release the straw from his lips. I felt numb as I looked at the empty bed his roommate left as he departed this life as I exited the room. I felt guilty for leaving but the imagery was more than I could emotionally continue to deal with. Death in the theatre and story books does not happen this way. I began my grief in June and I don't think I'll cry again until I learn of my father's passing. I'm thankful and glad that God allowed these extra weeks for me to try and prepare, as much as one can prepare for the passing of a loved one. I realize that some things are even worse than death. Suffering with no quality of life is one such thing.
Medical School introduces the physician to the art of healing. Soon we learn the limits of this art and realize that without the cooperation of our patient and the will of God we can easily be rendered useless. My last patient today was a 20 year old young man amidst his first psychotic break. I started him on medication a couple of months ago to which he responded but struggles with compliance issues. He is uninsured, unemployable at this time, and his mother works 2 jobs. She has payed out of her pocket for his visits. He opened up more to me today about his impaired thought process and thoughts of suicide. I've worked in the Mental Health Center and I don't feel it in his best interest that I send him there just because he cannot pay. I believe he is worth saving and as long as he and his mother remain committed I will try and work with him and help him pursue disability. I suppose the reality of not being able to help my father has helped me see more value in helping someone not beyond the benefit of human intervention and compassion.
Weekly Entry 
Sicko: Emergency Vent
I just spent an hour trying to order Real Rhapsody from the internet when it should have taken five minutes at most.
Am I really that retarded? It's just like I've always said. The world is crazy, not the individual. I set out to research why this elementary task of using a Visa could become so difficult for a reasonably intelligent person. Okay, I did mess the numbers up during the first attempt. I proof read and made the necessary corrections then re-entered them. I then received a message my address was wrong so the order couldn't be processed. I put in my address every way imaginable but still no luck. I put in my old address, still no cigar. Alas! I remembered that the bank had made an error with the street number when I applied for the card 3 years ago. I had instructed them to fix it at least 10 times over the past but the thought that they probably never had done so dawned upon me and I decided to try entering an address where I don't live and never have lived. This was crazy. It worked beautifully. What the heck, at least I won't receive any junk mail and I'm enjoying my favorite music today at last.
I haven't seen Sicko yet but I felt it several times during the past week. I saw at least a dozen Pharmaceutical Reps during the week who updated me on how wonderful their drugs were for my patients. I must say the detailing is usually pretty good and I like having a break from just talking to patients every now and then. It's nice that the drug companies care so much about my patients.
At this point the number of prescriptions rejected by the managed care people are about at 30 to 40%. This means I have to fill out a form to explain why I want my patient to have this particular medication. I thought that was settled with the Pharmaceutical Rep earlier. It's suppose to be the state of the art treatment for what I have diagnosed the patient with. Now some unknown entity in some unknown location is giving me hoops to jump through before I can see the Wizard and get my wish granted. After the 7th or 8th time of going through this for the week, I am so frustrated and pissed that I feel like letting somebody have it. The last time I talked to a real person on the phone I spent 30 minutes on hold to finally be told that half the dose prescribed would be approved but that they might reconsider if I could produce 2 epidemiological clinical studies supporting the treatment dose I was prescribing for the patient. I thought I was the expert, but certainly not in medical economics. Since that day I abstain from talking to idiots because it's a big waste of time and it makes me homicidal.
I think it's better to fill out the forms most of the time than to give in and prescribe the generic product I'm pressured into prescribing. Sure it takes a bit of time and if the wrong box is checked the med is still not approved. The process has greatly damaged the clinical science in treating a patient. It is reduced to the Dr. taking an exam for the managed care organization. Can we give them the answers they want? I'll play their little game for now to get the medication I want to use in my patient but I know that the rules will continue to change as soon as I catch on to the answers they want me not to give.
Is this not just sicko? The Pharmaceutical Industry is not regulated and can charge a thousand dollars for a bottle of pills it cost them five dollars to manufacture while the Managed Care companies have the incentive of saving their funds to satisfy their shareholders. The product intended to help the patient may never reach them because it's priced higher than what their third party payer wants to pay. So whose getting screwed the hardest here? If I choose to be passive and not play the game or fight back it will indeed be the patient. If managed care wants to be the clinical decision makers I think they should be forced to do their research scientifically and should carry the liability malpractice insurance.
Let's face it. This system is total bullshit (for the consumer) and we can and must do better than this as a country. When I think of the billions spent in Iraq unnecessarily and the lives lost it enrages me. We've been told there isn't money for health care and education. Don't be fooled, there is not an endless supply of fossil fuels but it is guaranteed the rich in America will never run out of money. If they do they will just print some more and make the middle class and poor pay for it.
Thank you for supporting this emergency vent, it may have saved my sanity and my life.