D’oh! July 29, 2008

Yet another explanation for my patients’ mysterious symptoms of dizziness, nausea and malaise: Antidepressant Discontinuation Syndrome. A recent newsletter from the National Women’s Health Network reminded me of what I had forgotten about psych meds: many patients will experience some degree of withdrawl after discontinuing their antidepressants. This is especially problematic for patients who self-d/c their medication abruptly instead of tapering down. Effexor and Paxil are apparently the big offenders here, but almost any antidepressant can cause withdrawl symptoms. I shudder to think about all of the patients that I’ve seen who discontinue their psych meds on their own (in fact, it seems like none of the patients that I’ve seen have ever waited to be told by their provider when and how to stop their meds). Dammit! How do providers ever tell the difference between run-of-the-mill depression symptoms, fibromyalgia, antidepressant discontinuation syndrome and generalized malaise?

It’s easy to talk about how we should avoid antidepressant use in everyone who doesn’t have moderate-to-severe depression–especially since research doesn’t really bear out the efficacy of antidepressants in mild depression anyway. So what does work? Well, when I get depressed in the winter I start buying OTC Sam-e supplements (this year I tried 5-HTP, which seems to be working too). Last winter me and the gf purchased a light box for $150. I have a gym membership, and this week I’m treating myself to a massage at the local massage school. Who pays for all of this? Oh, that’s right…me. How did I know to do all this? Mostly because I know how to use the internet. I’m also pretty motivated to take care of myself. But how do I pass this stuff along to my patients? Few of them can pay $25 a month for alternative medicine supplements, not to mention the fancy-schmancy lightbox. And even with my advanced degree, I hate going to the gym when I feel like crap, so I know how hard it is to motivate oneself for exercise.

As I’ve probably mentioned in other posts, the wait for a therapist in my community is now almost 10 months for a Spanish-speaking patient, and 3-4 months for an English-speaking one. What to do for a patient who has no access to therapy, no extra money for supplements, no gym to go to, no hot tub, no money for a massage and no access to the internet? I guess I’ll just have to try harder with my “don’t stop this medication suddenly without calling us first” antidepressant education. sigh.

*Edit: If this post comes across sounding frustrated, it’s not at my patients. It’s because my patients have so few resources–financial, social and psychological–that I feel like my only option is to prescribe them pills for their depression, even if pills aren’t their best or only option. And that makes me frustrated.

More Healthcare Haiku July 29, 2008

Went to work today…

Surprise! Move to new work space!

??Communication??

Poor schizophrenic

Came for lab results–instead:

sent back to psych ward

Feeling kinda wierd.

I’m part of interview team

For new grad NP!

Worked all day Sunday

On twenty overdue charts

Not so glamorous.

 

Free market? Or just being a greedy, money-grubbing private practice provider? July 23, 2008

For those of you not familiar with Suboxone, it’s an outpatient treatment for opiate addiction. A main advantage of Suboxone is that patients can take the pills at home, instead of having to go to a methadone clinic every day. For a motivated person who has things to do (like, say, a full-time job), Suboxone is important. Unfortunately, providers have to be specially certified medical doctors–no NP’s allowed. There aren’t many providers in my community, although Suboxone is covered by our state’s insurance. I saw a patient last week who came in with a complaint of “going through withdrawl.” He had attempted to enroll in a Suboxone program through our clinic, but our only certified provider wasn’t taking new patients. So he found a private doctor who is willing to take new patients…for a fee. You see, this provider doesn’t take insurance. And the cost for an initial visit for Suboxone? $400. Plus $75 every two weeks for the new prescriptions. And that doesn’t cover the cost of the pills. My patient had been taking suboxone TID for a few weeks when he ran out of money–thus the withdrawl.

Now, I know that heroin is an expensive habit, so the patients have to be getting the money from somewhere, right? And addicts are a difficult and mostly undesirable bunch to work with. But it just doesn’t seem fair to me to take cash from a struggling father when insurance would reimburse for the same thing (I know…at a lower rate). I guess that’s why I never feel tempted to go into private practice.

Quotes of the week July 21, 2008

• From a man with low back pain: “Let me tell you, honey, I tried to get up this morning and I screamed like a hooker!”
• From a hard-of-hearing elderly woman, in response to the statement ‘We’re going to change the dose of your morphine.’: “WHAT?  YOU’RE SENDING A MONKEY?!  WHY?”
• From the same elderly woman, who called an left us a voicemail after finding that her insurance had not yet approved her new med: “Your clinic doesn’t help people at all!  May God rest your lousy souls!!”  (slams phone down)

Cheesy language, heal thyself! July 21, 2008

I am many things: an educator, a paper pusher, an underpaid community health worker.  Do you know what I am not?  A “healer.”  To be honest, I don’t like it when members of traditional Western medical pracice dub themselves healers.  I like to think of myself as a straight talker.  I don’t like to sugarcoat my life with cutesy language (another example of what I am not?  A “dog mommy”)  I understand why people in the health care professions might want to proclaim themselves healers.  It sounds much more holistic and touchy-feely than, “I’m a nurse who spends my days saying the same thing over and over again to people who may not remember anything.”  Or, “I’m a NP who dispenses blood pressure medicines and pain pills in hopes of prolonging people’s lives for a few more sickly years.”  Yeah, ‘healing’ sounds a lot better than ‘trying to empty the ocean with a spoon.’  But I’m not sure how much healing I really do in the course of a day.  Sure, there are a few things here and there that I can actually cure–for example, I do a great job of healing chlamydia.  But most of what I do doesn’t result in healing per se.  I do a lot of listening, which arguably can result in a slow kind of healing.  And I do a lot of teaching, which possibly could lead to healing if people take my advice to heart.  But a “healer”?  I’m not so sure.

Do not have sex with this man! July 3, 2008

Today I saw a middle-age woman for her pap. After a long visit in which we talked about her efforts to lose weight, her pending divorce, her medical history and her inconsistent medication use, I could see her muster up her courage to ask me a final question at the end of her exam. Her question was, “Is it normal to have pain every time you have sex?” I answered, “It’s not normal, but it’s very common.” I then asked her a bunch of questions about position changes, lubricant use, foreplay and previous sexual trauma. After a few therapeutic prompts from me (ex: “Many women tell me that if their partner doesn’t spend enough time making sure they’re aroused, sex is uncomfortable for them.”) we finally got to the reason for her pain: “My husband never touches me down there, and he told me I was sick because I wanted him to do stuff. He just gets on top of me and we have sex, and that’s it. He told me there was something wrong with me because it hurts all the time.” I felt that I had developed a friendly rapport with the patient, so I only had to censor myself a little bit. Instead of my first response (“Honey, your husband is an asshole!”) I went with the second (“Listen, he’s totally wrong about that! You’re perfectly normal!”). I also couldn’t hold back from a little dating advice: “If you start dating again and you find another guy that thinks like that, dump him right away, alright?” That’s right, I’m a primary care provider, a spiritual advisor and now a dating guru!

More healthcare haiku July 1, 2008

Patient wants to change

to “English-speaking doctor.”

Racist or ok?

Asthma follow-up–

Never got controller med.

Surprise!  Still can’t breathe

First day of July:

Flock of fresh-faced residents

wandering the halls.

Woman has seizure–

Doctor yells “Get the crash cart!”

We have a crash cart??