The Eyes Have It

I tugged on the handle of the heavy root cellar cover to lift it to one side in order to descend the steps to the underground room that serves as a year round natural refrigerator on our farm.  At the bottom of the stairs, I opened the thick sealed door to permit a shaft of sunlight to illuminate the inner darkness–there is always a moment of wondering what I might find on the other side in such a mysterious place.  A rush of cool earthen air blew back at me as if displaced by the light that had rushed in.  Until I snapped on the lights, it was as secret as a womb harboring its precious cargo.  This place smells of dirt and moisture–the lifeblood of the fruits and roots that tarry here until it is finally their turn to be brought up into the light.  Potatoes, onions, apples, pears, nuts all resting and waiting, as if suspended in time.

It had been awhile since my last visit.  As the lights blinked on, I blinked too in unbelief.  There had been a startling transformation, as time no longer was standing still as it had through the winter.  Long white arms, almost waving with enthusiasm, were reaching out from the potato bin in a desperate searching plunge through the blackness.   In this dark place, their blind eyes must sense a better place and set out on a mission to get there.  The naked shoots were so entangled one with the other, it felt voyeuristic, as if I was witnessing something private and personal.

I gathered them up,  apologetic for causing them a moment’s doubt about their destiny.  A trench was dug,  they were placed gently at the base with shoots pointed toward the sky, and the dirt swept over them in a burial that was more commencement than coda.

The eyes have it, having reached for a light not seen but sensed.

Was blind, but now can see.

Reasons I’m Running Late

The Doctor's Waiting Room Vladimir Makovsky 1870

It may not be rabbit season or duck season but it definitely seems to be doctor season.  Physicians are lined up squarely in the gun sights of the media,  government agencies and legislators, our health care industry employers and coworkers, not to mention our own dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim.   It’s not enough any more to wear a bullet proof white coat.  It’s driving doctors to hang up their stethoscope just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too overcommitted, uncaring, egotistical, close minded,  inflexible, and especially– perpetually late.

One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule.  Doctors do run late and patients wait.  And wait.  And wait some more.  Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character.

I admit I’m one of those late doctors.   I don’t share the reasons why I’m late with my patients as I enter the exam room apologizing for my tardiness.  Taking time to explain takes time away from the task at hand: taking care of the person sitting or lying in front of me.   At that moment, that is the most important person in the world to me.  More important than the six waiting to see me, more important than the several dozen emails and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message from my daughter from school or the worry I carry about my dying mother.

I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources.  I don’t earn more by seeing more patients.  There is a work load that I’m expected to carry and my day doesn’t end until that work is done.  Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch.  I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.

The patient who is angry about waiting for me to arrive in the exam room can’t know that three patients before them I saw a woman who found out that her upset stomach was caused by an unplanned and unwanted pregnancy.   Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair.   Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection, but is showing signs of a pulmonary embolism caused by oral contraceptives.  Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men,  or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to suspected undiagnosed chronic hepatitis.

Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs.  Quite the opposite.  We strive to make our patients feel respected, listened to and cared for.  Most days it is a challenge to do that well and stay on time.  For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time.  The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”  Patients need to bring a book, bring knitting, schedule for the first appointment of the day.  They also need to bring along a dose of charitable grace when they see how crowded the waiting room is.  It might help to know you are not alone in your worry and misery.

But your doctor is very alone, scrambling to do the very best healing he or she can in the time allowed.

I’m not hanging my stethoscope up though some days I’m so weary by the end, I’m not sure my brain between the ear tips is still functioning.  I don’t wear a bullet proof white coat since I refuse to be defensive.  If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed to the needs of the “most important person in the whole world.”

And that human being deserves every minute I can give them.

Physicians As Environmental Activists

Railway in Whatcom County photo by Josh Scholten

My response to a letter sent by 80+ Whatcom County physicians opposed to a proposed new deep water port in our county to ship, among other things, coal to China, with coal trains to run frequently through our local communities.

Dear Colleagues,

as a twenty six year Whatcom County resident, I have mulled whether to add to this discussion.   I must admit that I’m no expert in predicting the potential health hazards of this particular proposal in this particular community at this particular time in its history. What is most needed here is a collective deep breath.   We need to exercise the experience, wisdom and caution demanded of our profession.   I don’t make a decision about a treatment’s effectiveness (or lack thereof) until it is fully investigated and studied.   Similarly, I will not speculate about environmental health hazards without solid data and evidence to back up that opinion.  As the only physician member of the Whatcom County Public Health Advisory Board, I can assure you a formal evaluation of the potential health effects of more frequent coal-bearing trains delivering diesel particulate matter into the environment will be tasked to Whatcom County Health Department Environmental Health staff once (and if) the application for permits ever takes place some time in the future.

I can share my perspective as a 21 year employee of the largest employer in Whatcom County (WWU) and a former 20 year employee of the second largest employer in Whatcom County (PeaceHealth St. Joseph Medical Center).  Both institutions have been forced to make significant budget and staffing cuts due to the lack of tax base from diminishing private industry in our county and state.   Without the presence of thriving businesses supported by citizens like you and me, our public funded institutions will continue to falter, with fewer employees working more hours,  inevitably resulting in diminishing quality of service.

I am a fourth generation northwest Washingtonian, born of fisherman, loggers, and farmers who stewarded land and shorelines in this area since the mid-1800s.  Some would say they adversely impacted the environment by the work they did in order to support their families — catching fish, cutting down trees, and spreading manure for fertilizer.  Some would say any environmental impact by humans is too much.  Coming from my perspective, and living on a farm myself,  I see things differently.  Whatcom County’s bounty is not just its beauty and recreational opportunities.  Its bounty is in the  harvest yielded from the hard work of our hands in its soil and its waterways.

Surely as physicians who care deeply about our patients, our fellow citizens, our environment and our families’ futures, we can work together as discerning community leaders.  Our goal should be to find a balance to attract and support businesses that someday will provide employment opportunities for our children and grandchildren yet still respect and preserve the natural beauty of our county for generations to come.  Whether this is one of those opportunities has yet to be seen.

With Our Own Hands

Our spring in the northwest has been chilly, extraordinarily wet, and gray.  Yesterday was our first day so far this year when our thermometers actually climbed over 70 degrees F.  The farmers in our part of the county were working practically around the clock chopping grass in fields that have been too muddy for machinery to safely navigate, trying to get silage in the silos before the next round of field work is demanded by the calendar.  Huge tractors pulling all manner of equipment were rolling up and down our rural road all day, and heavy trucks carrying loads of grass silage roared by late into the night.  And so the maxim: make hay when the sun shines (or silage when the ground dries enough).

This has not been good gardening weather for anyone.  Truly avid gardeners have been struggling with seed rotting in the ground before it can germinate and seedlings actually coming out of the ground being flooded by heavy rains.  Here on our farm, we’re late getting started, as usual, with too many other things happening in our work and home life to even think about getting the garden in–until yesterday.  Starting a garden the first week in June is not something I recommend to anyone.  It is like bushwhacking to make a bed suitable for the seeds.

Many weeds are not discouraged by cool rainy weather.  Quack grass and dandelions are positively encouraged.  They have been growing very well and going to seed themselves, thank you very much. That meant a garden plot that was a veritable forest to contend with before the soil could be prepared for seeding.  My husband and strong middle son set to work on the jungle on hands and knees, digging into the turf of weeds, loosening the grip the weeds had, pulling them out, shaking off the clinging clumps of dirt from the roots and turning over fresh soil to dry in the sun.  Even so, it was cold and wet to touch, hardly hospitable for seeds, but more delay is no longer an option.   I followed behind him, trenching out a row for the seeds and dropping them one by one into the too cold dirt with a little wish and a prayer that there was still enough time left in the growing season to actually bear a harvest.

I admit there are times my life feels like that neglected garden plot.  If not kept tended, if not exposed to enough warmth and light, if not fertilized with the steaming loam from the compost pile, if not kept clear of the unwanted weeds that take hold and grow no matter what the weather conditions, there can be no harvest of value whatsoever.  I will accomplish nothing than sow more weeds that eventually must be contended with by the next generation.  I leave behind a life unrecognizable as a source of nurture and overrun by weed creep.

Each year I’m determined to do better but I know I’m running out of time and gardening seasons. It isn’t just the resultant sore back and dirty fingernails that serve as reminders of the hard work of tending one’s life like one’s soil.  It is that burst of sweetness that comes from eating the first fresh peas, the sharp tang of a radish straight from the ground, the bowl of greens unsullied by chemicals.  It is the satisfaction of knowing that this we accomplished with our own hands.

This I can do.  And I must.

Slow Down and Reduce Speed

‘Twas the week before finals and all through the dorm, few students were sleeping, since Adderall is the norm…

What is the state of academic performance and achievement in the age of adult ADHD?   Recent media publications feature “neuro-enhancement” sought by college students and stressed professionals through the use of prescribed and non-prescribed medications, particularly stimulants, to guarantee focus, concentration and alertness when needed for studying and work demands.    It’s as easy as bargaining with a roommate for one of their prescribed stimulant pills for $5.  Some campus studies suggest as many as 40% of college students self medicate with non-prescribed stimulants during their college years–in certain settings like fraternities and sororities, it can be much higher.  Graduate students certainly partake as well, and that includes medical students.

Approximately 15% of students entering university now have been diagnosed (some very cursorily) with Attention Deficit Disorder and the majority of those students are medicated for their illness.   This is a significant increase from twenty years ago when I first started working in a university health center.  At that time a diagnosis of adult ADHD was extremely controversial and the incidence of ADHD diagnosis for entering freshmen was less than 1%.   In 1991 I attended a college health conference where a Harvard Medical School professor flat out called treating adults with stimulants for ADHD a “clear case of malpractice.”    Since then, the diagnosis has gone mainstream in the DSM IV and the criteria are likely to be even more liberalized in the upcoming DSM V revision.  Some estimates suggest one in seven adults meet criteria for ADHD.  That is a lot of inattention and impulsivity out there.  That results in a lot of stimulant out there.

Amphetamines are hardly the new drug on the block.  In the 50’s and 60’s they were routinely prescribed for “tired housewives” and became the go-to diet pills to suppress appetite and aid weight loss.  My paternal grandmother was one of those tired overweight housewives.  She kept a large jar on her kitchen table full of multi-colored capsules that she would pop prior to meals.  The appealing looking pills appeared very much like a candy jar to her grandchildren.  I remember being warned many times that “those are Grandma’s diet pills and you kids can’t take them because they would stunt your growth”.   They didn’t seem to do much for Grandma’s weight problem, but they certainly contributed to her moodiness, anxiety and chronic insomnia, a problem that resulted in prescriptions of sedatives to counteract the stimulant effects.   She wasn’t alone in her doctor-prescribed addiction to then uncontrolled substances–thousands of patients were treated with similar drugs that worked at cross-purposes,  handed over by well meaning physicians who truly believed they were doing their best to prevent suffering in their patients.

Does that sound anything like the well meaning physicians of today who prescribe stimulants based on “evidence based standards” and “best clinical practices”?   Currently the diagnosis of ADHD is difficult to standardize and easy to fake for an adult desperate for that extra edge in a competitive world.  No imaging studies have become the gold standard and would bankrupt an already overstretched health care system if they did.  Indeed, there are many patients who have legitimate need for the benefit that stimulants offer them–I’ve seen the difference it makes in their chaotic lives.  But I know there is no way 40% of college students have legitimate need for stimulants–they are self medicating solely for the extra boost they get from speed.  This is no different than the pill popping dieters from the 60’s.  And I don’t accept 15% of adults warrant prescribed controlled substances for the rest of their lives.   When I see these young adults struggling with insomnia, poor appetite, hypertension, and rapid pulse all thanks to the side effects of their stimulants, it is time to look at other solutions for their learning issues besides amphetamines.  Sadly the response from too many doctors is to add on the antianxiety drug, the sleeper, the medical marijuana, the anti-hypertensive.   Once again these are well meaning physicians who truly believe they are doing their best to prevent suffering in their patients.  It seems we haven’t come far in sixty years.  Same overprescribed dependency producing drugs, different diagnostic indications.

It’s time to really take a look at what we physicians are doing in the name of “best clinical practices.”  The physical and psychological toll of life long stimulant dependency is clearly understood in street amphetamine addicted patients, what few years they have left because of their snorting and shooting. But we know very little about the ADHD treated individual on routine prescribed amphetamines for thirty, forty, or fifty years or more.   In another generation, the health care providers of the future may well shake their heads looking back at our collective ignorance, just as we now shake our heads over the dexedrine- and valium-pushing doctors of fifty years ago.

First, as always, do no harm.  It is time to slow down and reduce speed.