First….fix the harm we have done.

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The opioid crisis.  It could have been predicted, after all.
Today you hear the smart young health advocates talk about setting up “pain clinics” as the “NEW” answer to the opioid crisis. You have already seen holistic wellness centers and alternative medicine practices cropping up on almost every corner.  But, let’s remember the ’70s.  When you had unlimited visits to chiropractors and physical therapists; when doctors could take their time to talk to you and treat you – when triple booking patients was not an industry best practice – but reserved for flu epidemics and such?  If you’re under 45 years old, you won’t have any idea about this – unless you are a medical history buff.  If you’re a physician you won’t even get this “old school” information taught to you in med school.  But this was before managed care – before big pharma, big health-insurance-business, big hospital-business, and big government regulation – when these things weren’t just tried here and there – they were a staple of medical care.
In the early ’80s a severe sciatica problem had me going dutifully to my chiropractor 3 times a week.  The most I did for pain outside of those visits was Tylenol and an ice blanket.  I was re-educated about how to not cross my legs at the knee, but instead at the ankle, when I sat for long periods of time; how I should get up and walk around about once an hour at work; and why carrying a heavy pocketbook and briefcase over one shoulder was no longer advisable.  I also learned about anti-inflammatory foods, and got advice on the proper exercise to do – and not to do.  It was a struggle, and it didn’t go away quickly, and there was one bout of a prescribed muscle relaxer for a few days – but, slowly, I learned the triggers and the treatments.
What would that treatment look like today?  What would the pill of choice be that I would be prescribed?  And how many would I get?  Would I get beyond 5 to 10 office visits to a chiropractor?  Would physical therapy be covered at all – and what would the wait time be to get in to see someone?  Would there be some counseling provided as to a good diet and proper exercise – and preventive techniques?
90% of pain clinics ceased to exist – yes, they were closing up shop, except for those serving the more well to do – out-of-pocket patient base. Other than that, compensation and reimbursements were drying up.  People were still in pain – and there was no miracle new drug that had been discovered.  Big-everything changed all that.  Managed-everything was faster, cheaper, and less holistic. And, today we find ourselves in an addiction and overdose epidemic of epic proportions.
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I agree with this article, by Cindy Perlen, LCSW, and posted on KevinMD.com.
Now that we are in this crisis – in 2016 – what are we talking about to deal with this opioid prescription crisis and a population increasingly in need of pain control? We’re talking about opening pain clinics, and encouraging (not paying for) people to seek alternative methods of dealing with pain – get a massage, go to an acupuncturist, utilize exercise.  Only if you really get hurt will it be paid for, and then, that treatment will also get restricted as to numbers of visits and/or costs.  We’re also talking about limiting pills doctors can give their patients.  We’re investigating doctors.  We’re criminalizing the medical system – and people who get hooked. Of course, there are real reasons to do some of that.  But in our rush to criminalize, to sanction, and to walk government right into the hallowed privacy of the doctor patient examining room, we have forgotten what got us there.  We have forgotten that we already know much about how to fix people in chronic pain.
For those who, because of their brain wiring, being prescribed opioids was the worst possible treatment. Now, they are on an addiction spiral, and we struggle to know what to do.  We have never seen a crisis like this.  Our drugs won’t take care of it.  Our prisons won’t.  Our mental hospitals won’t.  For now – it is our graveyards that are.
It is time we face this square on.  Pay for proper treatment of people in pain.  Open the pain clinics.  Pay for “alternative” care.  Re-educate the medical specialists who know so little about other ways to treat – other than pills and surgery. Stop the problem from continuing. And figure out how to clean up the mess that has been left behind.
Put the blame where it belongs.  We did this to ourselves.  I swear if you live long enough, you really do begin to see everything “old” become “new” again – functional exercise replacing use of complex equipment; simple, real foods replacing fast food grazing; custom-made anything replacing manufactured goods; “made in the USA” a better brand than the magic of manufacturing “made in China”, natural materials over plastics, organic over GMOs.  Eastern medicine looked at with new eyes, as Western medicine struggles to keep the healthy healthy, but has a pill for every ailment.
Don’t blame the doctors. Don’t blame the patients. Blame big pharma, big business, big medical-training, and big government…
Retraining and new curriculum for medical professionals. Healthcare for all might be the only answer – with a prevention and holistic focus – that’s two places to start.  Pay for proper treatment of people with pain.  Invest in prevention.  Help the addicted and the overdosing.  Sometimes it seems as though the plan is to wait until they all die away, and we can hit reset.  Sometimes it seems that we are on that road. We simply can’t do that. Nor can we fail to address that as we live longer, and are more active, people will have pain.  Intense pain.  Pain that we already know much about treating.  And we’re only offering half the treatments that are out there. Or will we only stoke the science machine to develop that next new pill?

“I am fearless now….”

th-2There are different kinds of memories. Events and happenings. Climactic moments. Hallmark days, such as a wedding, a funeral, a graduation. There are other memories that run deeper.  Memories of…scents…sounds…sight. Memories of emotion and feeling are perhaps the strongest.  The overwhelming moment when something happened inside of you; it changed the way you thought or felt about something. Like you could almost feel your brain morphing. The light bulb went on. The “aha” moment. The door shutting – for good this time – on a path of the past, a path that had been worn down and was going nowhere, and you struggled to get out of its rut, and now you can. These moments are, as they say, more ’emblazoned in our memories’ – because they go to our core – our heart and soul – they become more memorable because we were changed in that moment, that moment that we’ll always remember. We are different going forth.

This week the President gave an interview on radio which was somewhat controversial – but he stood rock solid, with a smile to his critics.  Something had changed in him.  A light bulb moment. An “aha” moment. A door shutting, or perhaps opening.  He put it simply when he said it: “I’m fearless now.” With that familiar jaunty full-faced smile we see more of these days.

This week I listened to a speech made by our new “fearless” President, this new Barack Obama.  And as he was expected to do, but no one could have truly anticipated, he gave a rousing one. But he went beyond rousing. He made a substantive one. He used high emotion, tragedy and deliverance to talk about issues that our country has yet to solve – poverty, poor educational systems, unfair housing, gun control, mass incarceration, jobs, racism, subtle prejudice – and he couched it all in the word “grace”.  Not “hope”, but “grace”.

And as natural as the gently waving program books in that church of 5,400 people – and in our homes and offices as we listened – our President began to sing. Low and deep he began. With the words, “Amazing grace. How sweet the sound…”.

Amazing-GraceI closed my eyes. I wanted to remember this day. Friday, June 26, 2015.  I wanted to emblazon its memory into my mind. I wanted it to change me. I wanted to call my children to gather and listen, but I was frozen watching this all transpire.  And as I thought of my children, grown and working now, I remembered Tuesday, January 20th, 2009.  My daughters were 20 and 22. Just coming of age in this adult world. We sat in the living room with snacks. Dip and chips, Guacamole, Nachos, and fruit. We wore our baseball caps of red, white and blue – one for each of us – with the word “HOPE” stitched right on them. And we watched our President take the oath of office. He delivered another speech that day – and it was a rousing great one, too.

getPartI remember thinking back to another day – September 11th, 2001.  The day when hope died. When ‘future’ seemed grim and hard to imagine. My daughters were 12 and 14. I knew on that day as I watched them come home from school, that their lives had changed. Forever. 2001 began a time of war and fear in our country – faded only somewhat into the hope and change promised to us in 2009.  Things seemed so bright. There was hope again.

Six years we have walked this path with the first black president in our country’s history.  We have seen polarization and stagnation – and yes, we have seen change, and progress. Healthcare. Immigration. Employment. Yesterday we watched as same-sex marriage become the law of the land – and in a moment of glory and grace it became – just – “Marriage”.

We have watched our President age and turn grey. The memory of that promised hope has tinged grey, too.  But he has moved beyond hope. As legacy looms in his mind and for history, he has moved the conversation along and called upon ‘grace’.  He says he’s fearless now. He carries this new state of being with him, as he carries forth with a song from deep inside. He’s making new memories. With new words. Grace. Fearless. Legacy. He says he would have been a better president – today – than he was. Self-awareness is not lacking here.

520976963_295x166But what can we learn? Have we learned that “hope and change” is not a plan? Do we need to conjure up some grace to lead ourselves along? And, if we can conjure up being fearless…think what we might do? Legacy looms closer at my age. The older-agers that 20 year olds grow weary of having around, are so important to moving hope and change along. The young-invincibles with a lifetime ahead of them, with things we need in this country – spark, energy, new ideas, and yes, hope.  But fear stalks the young. It limits them. It holds them back. Fear of speaking out. Of repercussions. Of loss of friends, colleagues, or opportunities. Of career short-circuiting. Of brass-ring missing.

But with the legacy years comes a sense of fearlessness. And that is power. Yes, it’s time to perfect the chocolate chip cookies – to be remembered forever for.  And to try for that hole in one.  But let’s not drift away too far. Together, wrapped in hope, wrapped by grace, together, think what memories we could make. Think what legacies there could be, not just for us as people, but for these United States.

Everything I needed to know about patient care I learned from my vet

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My “Bella” is a long-haired, black-and-white “Tuxedo” rescue cat. Her veterinarian, Dr. Cathy Lund, opened an all-cat practice in 1998 in Providence, RI.  As her website states, she thought being an all-cat vet was just “purr-fect for her”.

DrLundI work on the fringes of healthcare, now, usually in promotions or marketing for a particular advocacy initiative or to raise funds for the cause du jour.  However, I spent over 25 years engrossed in healthcare – most of it in the marketing end of a large, national nonprofit.  Some of it as a communications professional for a small local hospital in an urban setting.

I spend a great deal of observation time these days looking at healthcare and its changes, improvements, and fragmentation bringing those professional perspectives to bear.  A year or so back I looked at these issues from the inside, when my daughter had a short and sudden illness.  But, a few times a year I look at it from the perspective of a cat.  A black and white perspective, you might say.  And each time I wonder, what lessons can be learned from the world of vet care to the world of human health care about a more patient-centric system.

First, I imagine how her medical record “notes” section might read:
“Bella is now in her 13th year, and is relatively healthy, though has struggled with mild obesity for most of her life. Her weight-loss attempts appear to have been exacerbated by a psychological need to overeat, perhaps as a coping mechanism resulting from post traumatic stress disorder of unknown origin, occurring early in life. Genetic traits are unknown, as Bella was taken in as a homeless stray at a few months of age. Our family accepted Bella into a home that had experienced a recent loss of two adult cats to old age.  Bella’s earliest days included gender confusion, as she was first thought to be male and referred to as Mason. She was also aware of early desires to take her to a shelter and adopt her out to another home. However, these additional early traumas soon resolved themselves, and Bella acclimated well into her forever family. “

Bella, which translates to “The Beautiful One,” aptly describes the prominent place she has taken in the family.
While Bella has not had any extraordinary illness, other than a mini-surgical procedure for a five-foot long piece of string down her esophagus and the extraction of several teeth, she is not an easy patient. Her unknown past, and suspicion of being feral, has meant a delicate handling. All eyes are on prevention. Preventive care has meant regular check-ups, shots, nail clipping, and blood work. It has also meant dealing with a progressively standoffish attitude, which has deepened with age into full-blown rage at invasive examinations and the sight of any other feline. Her “mental health problem” has exacerbated the provision of her medical care. Bella does not take well to invasive procedures, yet requires regular examinations of nails, teeth, and ears. Inoculations. Blood work. Cautionary procedures include full-length protective gloves for all medical staff. Mild sedation is recommended. Experimental prescription of valium proved to be ineffective and was halted.

Throughout her years of care, reminder postcards and e-mails are received when it’s time for a check-up. Appointments are made on the phone or by request over the website. You can even request an appointment on Facebook; there’s an app for that. Waiting time is less than a week [same day if there is a crisis, and phone calls returned within an hour, if needed].  Appointments are confirmed by e-mail, and again, a few days before the appointment, there will be another e-mail and a phone call, along with any special instructions, such as nothing to eat and drink after midnight. The day of the appointment there is no waiting, and because Bella is a mild-sedation patient, a first-in appointment is always available, so the distress of not eating or drinking since midnight is not too discomforting. When she is brought in, given her mild state of a building mental health crisis, she is talked to calmly and gently by staff. They pet her paw through the gate of her carrier and she is quickly taken in.

In an attempt to take care of her quickly, due to her sedation, one can only envision the Mario Andretti racing team pit crew being called to her tableside. They swoop down and, in quick order, in less than half an hour, the care is done. Using sedation on an older cat is a concern that grows with age, so the quicker, the better. Their specialists have come together, each taken his/her turn – nails, teeth, ears, shots, blood work, a little shaving here and there, and good to go. Recovery is almost immediate as the sedation wears off. With a groggy “hisssss”, we know all is well.

There are follow-up instructions and education at the front desk. A quick checkout and then the next appointment is set. There is the constant reassurance, explanations, and calm demeanor. There is even a pat on the back for me, when I’ve needed it. We are good to go.  Within a few hours of being home, City Kitty will call to see how Bella is doing and if I, her caretaker, have any questions. They refer to her by name and speak in an unhurried manner. Later that afternoon I will get an email. It asks us to submit a review: how did we do, and are there any suggestions? A few days later, there is another call. How is Bella? We’re thinking of her. Here is the result of her tests. Guess what? She is at her ideal weight! May she live long and well, and just call us with anything.

I am often struck by the quality of the “kitty care” provided to Bella – and what we could learn from it that might be applied to “health care” provided to humans.

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Slow down might be a start. Look the family and the patient in the eye. Call the patient by name. Speak as if you genuinely care, because I assume you do. Don’t be afraid to touch the patient, or put your arm around a family member or caretaker. Repeat instructions. Ask if there are questions. Ask again. Provide information. And, educate and follow up, in several ways, by e-mail and again on the phone. Have a website that has a picture of the patient and their information, too, so they can see their records.

Keep good records. Have a resource link that is tailored for different types of patients and conditions. Tell us about who works there – not just their medical credentials, but a little bit of the personal, too – and perhaps show us their photo. Include a way on your website, or by e-mail or on social media, for us to ask you to call us, or to make an appointment.

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Bella’s birthday is in February. She will be 14. She will receive a birthday postcard from City Kitty – and an email greeting, too – just as she has every year.

As published in the June 8th issue of ConvergenceRI

http://newsletter.convergenceri.com/stories/Everything-I-needed-to-know-about-patient-care-I-learned-from-my-vet,158

On the eve of Obamacare…. “to our health!”

Many who know my family have followed the journey of my daughter’s sudden, inexplicable illness, and her road to recovery.  A ‘sore tummy’ turned into two emergency department visits in 10 hours, a five day hospital stay, in-patient and then out-patient testing.  More questions than answers.  More doors to open than close behind us.  Five days of constant, never-ending pain, five days of morphine drips and anti-nausea meds (to tolerate the morphine); food replaced by IV fluids.

Three days with sheets unchanged and no sponge baths or washcloths to ease her discomfort – three days with the same johnny.  No little pile of towels placed precariously on a chair or table.  I was so distracted by talking to one specialist after the other – they all started to look like each other with big question marks on their faces as they came into the room. There were the crisp white-coated fellows from Beth Israel or Brigham, I can’t remember now.  They were eager to show us they had washed ‘their’ hands – they held them up and rubbed them in front of us, like surgeons waiting to dive into their task.  Their white coats were tailored and went all the way down to their knees – designer, no doubt.  These young people were beautiful – so nicely dressed, so clean and crisp, pretty jewelry, precisely coiffed, nice shoes.

For four nights I slept on a geri chair – the newest thing, they said.  Designed for those family members who wished to spend the night at bedside.  Orange plastic with breaks in two places – one at your waist and one at your knees.  When you stretched out – trying desperately with your weight to make the chair click open like a rickety barcalounger, and stay flat so you could stretch out, it would only do so until you shifted, then the weight would push the parts together, and the chair would begin to catapult forward.  A torture chamber, better replaced by a big ol’ easy chair – they should demand their money back – I’d write testimony to help with that.

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On day 3, I looked up and said, “who changed your sheets?”  “What do you mean?” my daughter replied.  Mom went into action and sheets were changed, but still no new johnny or face cloth, or warm soapy water – no toothbrush and little toothpaste in the kidney shaped plastic dish. Was she that sick, I thought?

On day 3, we learned about an emergency code the patient could call on the phone – a kind nurse suggested it.  And yes, late at night, a team arrived – an administrative team.  My daughter, who is skilled in conflict resolution, ran the ‘code’ herself.  She explained what had happened and how we knew no answers, how her sheets hadn’t been changed, and for her first foray into solid food she was brought pasta with red sauce.  “What were you thinking?”  At five a.m. one morning, a phlebotomist came into the room, a dashing young man, flipped on the overhead light, went between the geri chair and the bed, flipped on the bed light, grabbed her arm and put the tourniquet on as he shouted, “good morning! I have to take your blood!” and she yelled, “go away, what are you doing – who does that to someone when they are dead asleep and sick?  What are you thinking?”  (That moment was my first ray of hope she was getting better.) And how the nurses – some of them – would lie – would tell her they were going to get the doctor, and not do that.  Would tell her that the big team was coming in from Beth Israel or Brigham, and they never did.  Five days.  And she was waiting.  Maybe the ‘experts’ would have answers.  But they never came. The emergency code team took their notes.  We wondered if some famous star had sued the hospital and this team was part of their settlement to the patients left behind.  To this day we don’t know what happened after that late night bedside meeting – because no one ever told us.

Eventually, the situation improved.  She took her first steps down the hall.  Straight from her bed, without having even sat in a chair yet.  “Oh, oh..”, I thought.  And, yes, lickity-split, she was being prepared to go home.  No answers.  Lots of medication.  IVs being pulled out.

Recovery took some time.  Just walking in the door and seeing her cat made a world of difference.  Couch all made up with sheets and pillows.  Mom by her side – where else would I have been?  And time did its miracle.

Tests followed – one by one – answers, we needed answers.  Almost none were to be found.  “Don’t look further (in literally a hushed whisper) we don’t do that today, in our ‘new’ medicine – we just treat symptoms and if they go away, wonderful. We don’t look for more.”  Really.  Almost by accident we find some fixable vitamin deficiency and it gives us something to work on, a crack in a door, and we go down that path.  And still do…  We have no diagnosis.  Just questions.  Just a somewhat uneasy feeling and a “what the heck was that all about?” nagging, nagging question.

As 2013 comes to a close, I have four days left to pay the bills that have accumulated – to get the medical tax deduction for this year.  I might as well.  I have been collecting bills, notes, forms, tests, hospital ID bracelets, etc. in this folder that is so thick it no longer closes.  Tonight I open everything, decide to sort it, which bill to pay, which one to dispute (two ED visits in 10 hours? – don’t charge me for both when she should never have been sent home…please…thank you…), and then – the big question – how much has been covered by insurance?  I take a photo.  Each pile is a different ‘vendor’, if you will.  We were in one place, but I’m counting 10 separate places to be paid.

ImageMy daughter is very smart.  She is a grad student at a Massachusetts university – one with a unionized faculty.  One that offered her a position assisting a professor (and by the way, that makes you a union employee, and by the way, you also get health insurance, and there is no charge to you for it).

Our bills will total $50,000 gross.  Or more.  The door is still open.  Massachusetts was the first state to have Romneycare.  I will be doing final calculations, but it looks like we will have less than $2,000 to absorb.  Maybe $1,000 if we can negotiate based on being an adult student with little income/assets.

I am grateful.  If this were part of the health insurance plan I paid $1,500 a month for previously, in RI, I would have been looking at a bill of $6,000, $10,000 or more.  For a five day stay.  Two CT scans?  $2,500 each.  Really.

Tonight, as I write this, the Christmas lights fill my living room.  The house is quiet.  I have poured myself a glass of wine.  Red wine.  It’s healthy, isn’t it?  My daughter is going out with friends to celebrate Christmas. And yes, I’ve asked her if she’s taking her prescription vitamin and when is her next injection….and blood work….and the path is open before us.  But finally, at this odd interlude between Christmas and New Year’s, I’ve had time to think – and ponder the thousands of stories far, far worse than ours – the stories of extended hospital stays, and cancer treatment, and open heart surgeries, and extensive rehab stays.  And I smile.  It seems like an odd reaction.  But Obamacare will save lives.  Indeed it will.  It will also do more than that.  It will open access sooner.  It will force payers to force payees to lower costs.  It will empower patients as never before.  It will not be perfect.  It will moan and groan and cry and quake as it births itself to a whole new future for us – “we, the people” of this great American nation.

“Yes…to our health!”

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(that’s Mom’s glass of wine)