Wednesday, May 9, 2018

Doctors Running Late

I’m always running late these last years. That wasn’t always the case. When I began in medicine and psychiatry I was mostly on time.  True I’ve become older and slowed down some. A major shift in my urban industrial clock mentality occurred working in the country. There’s a more natural rythym closer to nature. Then working with aboriginal and Inuit in the north and on Polynesian Islands I was struck by the importance of the ‘flow’, time measured more by ‘wave’ than by’particle‘.
More often than not these days that which is systemic is attributed to the personal, especially in medicine and psychiatry where the administration remains in the ‘blame and shame’ mode while the field has moved light years forward out of the dark ages of legalism and power politics.
With that in mind, I considered the changes that made the ‘50 minute’ hour of therapy for the psychiatrist no more in fact.  
1.An American study found that specialists were expected by their authorities to do 90 minutes of activities before the patient arrived to state their ‘complaint’ to be addressed in the 15 - 20 minutes ‘visit’.   The increasing intrusion and side lining of the ‘patient’ and the “doctor’ by administration and insurance company priorities had got that outrageous.  The least important person today in Canadian health care is the patient and after The fact is best expressed by the black humor clinical joke, “You can kill the patient just so long as the chat and records survive!”  
Instead of myself and the patient in a 50 minute hour there’s now a whole administration, bureaucrats,, lawyer, media, state, insurance agents, ideologues, countless third party community concerns,police pushing the patient and doctor out of the hour and taking over the medical office.
2.When I started I was trained beyond the best of best, educated beyond my intelligence and frankly, pretty damn good.  I focused on the patient and patient care and doing the best job I could. Today I’m constantly looking over my back.  The Canadian Health Care System is the poster child for a ‘toxic work place’. It's a place of suffering for patients, nurses and doctors or indeed anyone on the front lines. I’m second guessing everything I say and do because not only am I expected to be perfect, incompetent tasks masters are  constantly moving the ball and changing the rules.
The College of Physicians and Surgeons is the licensing body.  They’re like  the ‘driver’s licensing bureau on steroids.  If you had to get into a car and juggle while driving watching your back all the time and having a million buttons you had to push randomly in the car because of some ‘possible’ concern of someone sitting in a committee, you would understand perhaps why it’s so hard to get the car out of the garage  especially  becaause one minute you’re told to juggle next minute to have your clothes on or off, next minute to go to Saskatchewan and next to Quebec. The administration is responding to media, politics and gastric indigestion with knee jerk reactions and asking high paid cronies to come up with scientific sounding nonsense that simply doesn’t work.  Every demand is threatening officious pedantic and zanier than the last.  
Meanwhile we’ve got a reasonable stream of recommendations and learning coming down from the university which unfortunately is often its own ivory tower because what’s done with poor rats and rich students doesn’t apply to a normal human practice. 
3.So when I started , I was phoned directly by a patient who asked to see me. I talked on the phone about what I did and what they wanted. This model is the same one still in place for lawyers and most other professionals.
In BC the government created a family physician referral process. In The British Columbia model the Family Physician is supposed to be the gate keeper and controller access to specialists.  (Nurses are now competing to displace the family phycian and control all access to doctors while other government administrators want to have access to doctors strictly controlled by an administrator politically deciding wait lists.)
In the past when I tended to be on time patients  had family physicians.  Then walk in clinics with ‘one visit one complaint’ signs changed the primary care model.  Decades back I’d get a referral from a family physician who really knew the patient. They’d send me a whole lot of pertinent information.  That’s rare today. I’m fortunate because I have worked with a collection of the finest family physicians and we had really good working relationships. Those left are now called ‘full service providers ‘. Those family physicians were not trying to ‘dump’ the difficult patients on to me. Today a third of patients don’t have a family physicians and in some psychiatric and drug and alcohol addiction populations 90 to 100% of patients don’t see family physicians. I am now often their only contact with the health care system. That wrecks havoc on the 50 minute psychiatric hour. Psychiatrists haven’t got the one visit one complaint rule yet. The closest thing we have to that is the pharmacological psychiatrist who has reduced psychiatry to the prescription pad. Not a problem for the rich or well insured because they have psychologists but the hoi polloi dont and that’s one of the elephants in the office no one talks about.

4. When I began I could say if I didn’t complete an assessment I’ll see you tomorrow. Now I’m booked 6 months in advance ,often double booked. I have dozens of people begging to be on the ‘cancellation’ lists. I’m not alone. The wait lists in Canada due to beurocratic incompetence and administrative mismanagement and government scandal are the longest in the civilized western world. I’m just a part of the mess. But if I stop and say lets continue it may be weeks or months before I see the person.  I can no longer count on this person having a relationship with a GP or family physician who themselves are frighteningly overworked. The patients are a whole lot sicker, more desperate, at higher risk of suicide (or homicide). 

5.When I started I could get a second opinion from a colleague that day or that week. All my mentors have taken early retirement, the best of the best burnt out and cynical about the system. The suicide of doctors is the highest of professions and two or three times the normal population. The College of Physicians and Surgeons is identified as the principle cause of suicide and yet there's no sense that they even acknoledge their deficits while demanding doctors admit fault and pay exorbitant penalties while they remain safe in  high rise bunkers of denial and poor communication.  

6. I’ve sent two suicidal patients to the emergency in the last couple of years and both were sent home rather than being admitted. Both killed themselves, one by hanging.  I don’t have any sense of ‘support’ in the system. I waited a year for a consult from a sleep specialist for a patient hypoxic with ptsd nightmares and severe heart disease needing medication which would affect their breathing and their heart rate and they were on a dozen medications from other specialists. In any sane system they’d have been admitted to the hospital. There were no beds. Canada has the least hospital beds for population in the civilized western world with administrations and politicians acute hospital beds for   homeless shelters and nursing homes . 'Bed blockers’ are the norm. There is a massive ‘revolving door’ hospital misuse and simply wrong ‘management’.  Meanwhile government overt destruction of the family has resulted in more and more people having no where to go where there is help when they are immobilized by disease.  My patients who post surgery as discharged to community nursing get phone calls rather than visits.  Countless papers point to this but administration in Canada is by political appointment , heavily influenced by post modern tokenism and very low on competence and meritocracy. There are simply no elections where it truly matters.

7.PM Justin Trudeau, is  a living nightmare for the Canadian health care system. For personal aggrandizement and to serve his globalist cronies he has marketed Canadian Health Care to the world inviting all the chronically ill, dangerously , angry, interminably entitled,  addicted and psychiatrically disordered to come to Canada. I and my colleagues already pushed to the edge are without discussion told to work ten times harder because the Trudeau government want's to give away for ‘free’ health care in hope of getting scab voters to keep his party in power.
He’s even claimed counselling can rehabilitate ISIS without listening to psychiatrists who know more than a drama teacher how much care is needed to rehabilitate our own vets let alone those who want to kill us.    Fewer resources are now being fought over by sick and well patients and activists feeling that they are ‘entitled to a daily MRI’ , angry that any doctor would question their right to the highest paid diagnostic tools, because to many health care is a ‘fashion ‘, a prop,  entertainment or commodity.   When the ‘worried well’ and the dying compete for resources the ‘worried well’ , the loud complainers , the entitled , the sociopaths and psychopaths win.  The really sick and the dying don’t have the energy to impress the Minister of Health.  By the time we’re old, sick and dying we’ve used up our resources. The young and angry and political and rich  know how to work the system. The Ontario Liberal Government just offered free pharmacare for the young who generally don't need it while denying the sick and old life maintaining and life saving medications. The despair that psychiatric patients commonly arrive with is  palpable.  It's worse than I’ve witnessed in all the years of my career. Yet my leadership tells me that I'm wrong to care.  They claim that professionalism is the callous disregard for humanity that they maintain. It's this heartlessness that gets them appointed by those above who seem only interested in cutting costs and saving money for their own dachas and jet setter trips. I see the homeless forgotten alone, alienated and very much aware of their ‘worthlessness’ and the ‘hopelessness of their situation’. The time the bean counters alot is gone before they can dry their tears. 

8. A compliant against the doctor like the increasingly  ‘frivolous complaint’s’ we see daily in todays ‘fake news’ takes up 30% to 50% of a doctors energy and time.  Thousands of doctors are now dragging themselves out of bed and going to  work because of the College of Physicians and Surgeons is backing up everyone who is ‘offended’ by anything.  Canada is world renown as the land of the ‘offended’ with the greatest whiners and complainers on the planet.  It’s probably because we’re doing so well. I’m no better. Ingrate. Complainer. Too often unappreciative of the advances.   

9.The cream of health care, the mild complaints, the mild to moderately ill have been taken by counsellors, nurse practitioners,psychologists and everyone but the doctor. The doctor’s share of the pie is now the sickest and most complicated. The case load of the specialist used to include some ‘easy’ cases but the family physicians ensure these are seen by themselves and the counselors. The health food store owners and the masseuses  get all those other people who are rich and need pampering.  These used to go to the family physician but now the anti doctor, anti education, anti authority crowd is trained to be paranoid by the self serving internet media with endless conspiracy theories that sell their latest snake oils.   Some easy cases got through the filter in the past but not today.  People with money go to the expensive health ‘food’ stores and the wealth of ‘alternative ‘ resources. Otherwise they get tourist medicine.  When they get really sick or when all those fashionable services don’t work, they show up for the ‘free’ health care. After Mayo Clinic didn't help they come to me demanding all my attention and care and angry that their taxes can't offer more than Stanford or Cambridge. Sick and dying psychiatric patients look for someone or something to blame and rarely have the community support and psychological acceptance that helps them through.  
The severity of illness in my practice today commonly includes  major psychosomatic illness dual diagnosis, aging populations and is a billion light years beyond what it was 20 years ago. And most of those patients know that if I don't see them no one else will.  So many patients that left my practice have come back and told me harrowing tales of the abruptness and factory ness of what is offered so often today.   That can by most private medical specialists and most family physicians today. The mismanagement of health care services has been such that we’re left with the heavy lifting whereas the ‘cream’ has been skimmed by everyone else. We who have the experience and are there on the front lines are the least likely to be consulted by the ideologies and those generating an endless list of the new professionalism and codes and protocols.  The mismanagement and divide and conquer of the administration takes  the rewards at the back that should have gone the  patients and those on the front lines. Administration has gone out of its way to ensure that the left hand doesn’t know what the right hand is doing.  When I began I’d get discharge summaries from hospitals but not today.  With all the advances electronic records and tech, the miscommunication is worse than ever I recall.  The EMR record is a major source of contention for doctors with it's major administrative benefits and it's major clinical deficits.  It's nearly impossible to scroll through in a timely way and find old data whereas with a paper file I could access original consults and relevant notes in seconds, usually with the patient not knowing what I was doing and continuing to talk.Now we both sit before a screen which sometimes freezes and often simply won't give me the data I want from the past. It's good in the here and now but it's somebody else's idea of what I as a specialist need. And most are set up for general practitioners and there are competing designs and lack of compatibility. A tremendous amount of time and energy and money is going into something I can see will be useful in a decade but right now, it's costly and timely and has me looking at a screen rather than looking at the patient.  

10.This last couple of years I’ve had amazing complications in patients because of the ‘herbs’ they were getting and the herb sales men are not accountable but I have to clean up their mess.  My patient seizuring after a ‘vitamin store’ ‘food’ is just one of many dramatic cases.  I rarely know all that my patients are taking as patients increasingly 'lie' about their 'lifestyle choices'.  I was really surprised by all the drugs a patient was found to be taking at the autopsy. Even our addiction medicine urine screens don't pick up all these new mail order 'herbs' which affect the pharmaceutical medications. We're suppose to know about side effects and take them into consideration but the 'competition' doesn't even care or ask.  Buyer beware is the norm except in modern medicine where the doctor is expected to be a mother more than a physician.

11  Everyone  now is an internet doctor.and they don’t want to be ‘cured’ as much as they want to become a consulting expert on their ‘illness’ . The demand for education of people with gr 12 education and a scanning of the internet is unbelievably time consuming especially when the patents smokes pot and you review your notes and see that you’ve been through the lengthy explanation three times previously.  Patients are increasingly argumentative.  They shop for diagnosis and demand treatments which are contrary to what the College dictates. The media has caused widespread paranoia among patients and the psychiatric patients and the drug addicted were already paranoid. 

12.There is still no patient accountability. It is there in the best health care systems in the world. The British system limits you to a list.  American Kaiser Health Care coordinates all the records.   Canada is very very far from the top in patient accountability  which is a cornerstone of care. In Canada patient's  don’t have to take advice, take medications, follow up,  but they can and do blame the doctor for their persisting illness and complain to the College of Physicians and Surgeons and their lawyers for their not uncommonly self induced illness.  Increasingly patients are rewarded like the illegal aliens.  The good patients who follow the rules and do the best they can are pushed aside by the  the ‘irregular’ patients who all too often are bullies.
If you’re considering resource management  it’s called a shit show but a doctor will be called in for unprofessional language because it's so easy to police the doctors than the malingerers, violently insane, and psychopaths. It's no different with the increasing gun laws that tax and control law abiding citizens while criminals get more and more arms and have less and less consequences for this.   Only the doctor is accountable for illness.  The doctor when he’s with a patient whose a ‘victim’ and ‘blames everyone’ then the doctor is more often than not now trying to avoid becoming the ‘cause celebre’ of the entitled activist. Increasingly these people  trust funds, criminal sources of money  or on disability ,but generally having infinite time and resources  to 'work the system'. and get the bureaucrats working and colluding with  them. Meanwhile the  the doctor  has hundreds more patients and a College and government representatives poised with guns to shoot them in the back if they are not perfect. Only one in a hundred general practice patients fits this description but they concentrate in a psychiatric practice and especially in a dual diagnosis practice.  Psychiatrists are the highest suicide risk in the profession and the College has general practitioners and lawyers talking to them rather than psychiatrists who governments distrust because their own personal insanity, early dementias and various addictions and character flaws are obvious to those trained to see the signs. 

Last month I was asked about a prominent patient who’d seen 6 psychiatrists that year and another patient who’d cut her throat and been discharged to the community to a walk in clinic without a psychiatrist or family physician to see her.  Naturally I saw the woman with the massive scar on her neck but pissed off the entitled woman shopping for the ‘right’ diagnosis and her boutique family physician showering on her whatever she wanted since they were both in the same ‘club’.  

13,Now if I see a person I might be the only one they see until I see them again in 4 to 6 months. I worked as a fly in doctor and all my assessments then were made knowing that no other doctor would be coming to the reserve or island for anywhere from 1-3 months. I was the only psychiatrist who would go to some communities over a decade because some of the drunk and drug addicts would shout 'kill the doctor' when a doctor arrived. I've run the lengths of reserves with shots being fired at me by guys screaming 'kill the whitey' not knowing who or what these people are about. I've been thankful for chiefs who said, "don't kill the doctor.'  All the while I'm just doing my job and afraid of missing some illness and leaving some person behind who really needed to fly out to the hospital with me.

It’s like that now in practice.  I don’t want to miss something. I don’t want to make a mistake. It’s not because i worry about an idiot in the beurocracy with too much ego and too little clinical skill or common sense but it’s the way most of us doctors are wired.  We don’t need this massive industry of watch the doctor any more than the police need a fortune spent double checking on them. But there’s so much more money in ‘policing’ the front line workers and not going after the pedophiles and wankers far from the front lines. I believe we’d eliminate ‘fake news’ if we simply drug tested the media and parliament and congress.    I’m so often afraid when I say good by to a patient at the end of an appointment that they won’t live till I see them again. The fentanyl epidemic has taken some of my young patients. 

14.The vast majority of patients who come to see me are frankly desperate.  They are really sick and they’ve seen a lot of low level help because the system doesn’t ‘triage’ patients like it used to. When there was a family physician who was rewarded for knowing patients and provided comprehensive care then that doctor would know who needed to see the specialist and ensure they got in to a specialist early rather than late. Now a patient will see a junior counselors or a nurse practitioner and muddle about until they see me.  I actually make the ‘correct diagnosis’. Half my patients in psychiatry have the wrong diagnosis or half the diagnosis when they see me. They have depression but mostly they’ve not told anyone about the sexual abuse, rape and how their partner is sleeping about or any of that sad garden variety domestic stuff that fuels daily anxiety. They'll the psychiatrist about the lump on their breast or the boss that's threatening them but they don't readily admit this to others happy to "chat' or worried about 'maintaining' their 'image'.  Hundreds of patients who were crack and opiate addicts were not diagnosed as such despite seeing countless others.  But then everyone is afraid of offending anyone by giving them an unfashionable diagnosis or by even taking a history The College of Physicians guidelines on Sexuality Harassment are so non specific that increasingly we're collectively back in the 19th century not asking women about sexual behaviour and subjecting them to the worst standard of female health care, which I saw given in Indian clinics where their husbands objected to even female physicians examining their wives.

I diagnosis the missed ptsd and head injuries, addictions, the thyroid disorders, cancer sometimes, hep C and a whole burden of illness that previously was seen only in the hospital practices. Psychiatric patients especially drug and alcohol addicted are least likely to wait for 10 hours in the ER or for tests. Some days half my work seems to be convincing patients to get the tests done other doctors ordered or re writing tests the patients lost.   Meanwhile the College and the lawyers are essentially telling doctors with winks and nudges , don’t dare ask about sex because some woman will be offended . Negligence is okay but we’ll deny everything because you’re on your own.  Negligence is the norm in the Canadian Health Care System but no one neglects to 'chart'. The CMPA to help doctors defend against the iniquities of the College one day said for every 15 minutes of health care a doctor should do 15 minutes of charting. Overnight half the medical care in Canada was replaced by charting, yet there is no more time or money allotted for doctors charting. The time and energy comes out of direct patient care. There's no 'fat' in the front lines. All the fat cats are the bureaucrats and they're not taking any cuts or giving up their power or control any time soon.

15.So the ‘ends against the middle’ fallacy, the one complaint which is a nut job rather than being representative results in ‘all women’ or ‘all patients’ being painted with the same brush. I do random surveys like asking my psychiatric patients when they had a full medical exam (we used to call these medical exams or physicals ,no pc is we have to call them 'full' like 'radical terrorists' instead of 'terrorists') . Ten years ago everyone I saw and asked that question had had one in the last couple of years. Now in affluent patients even the answer is 5 or more years. Mostly people just don’t want to face all the wait lists. We’re a really pressured urban society with no slack time in general so more and more people aren’t going to the doctor. They’re going to the gym sometimes but increasingly because the doctor is a walk in clinic rotating young doctor often with poor English and cultural ignorance there’s just less of a relationship there than with the local gym guy or girl.  So health is marginalized.

16.Obviously I could go on.  Whining complaining.  Bitching and lacking gratitude. But I’m late. Most of the best doctors I know are running an hour late now. I don’t think it’s our fault. Whenever I walk into a doctors office they are exhausted out of breath, stretched and crazy eyed.  They smile like soldiers smile. Some have that thousand mile stare. Others smile with the humor of MASH. But when I walk into an administration office they’re moving with elegance, some wearing 4 inch heals, one lawyer had a diamond a doctor couldn't afford with a year's income, there's a  luxuriousness, not a hair out of place,  academic speech, generally irrelevant, reminiscent of schizophrenics on psychiatric wards, all the time in the world on their hands, fat cats, sleek, paw licking, supine. I’m not surprised they’re on time.  They usually move in groups, don't meet alone, have locks on every door, cameras everywhere, thick carpets.  When I visit it’s obvious that they aren’t busy. Busy in their minds but not really busy.  I don’t know any doctor or nurse that isn’t busybody today . We’re killing ourselves and we’re burning out and we’re running late.  The stats don't show administration and bureaucrats killing themselves. Doctors are. 

17. There are a whole bunch of ways to get around all this. Most are ‘cherry picking’.  Many of my colleagues are seeing the same patients , dependent personality disorders, weekly.  Most are avoiding new patients. No one is accepting new patients though I still do. Quebec doctors see the least patients daily and get paid the same. English Canada doctors see the most patients.  Some actually refuse to see patients with insurance claims. Most won’t see or avoid being patients with drug and alcohol complaints. More don’t see personality disorders.  There have actually been signs ‘no borderlines’ and colleagues say, I don’t accept borderline personality disordered patients. No one is jumping up and down to claim the psychopaths and sociopaths who are no longer carried by the massive armed forensic clinics. One day a psychiatrist with a body guard is seeing the patient the next day they are being seen by a psychiatrist in the community with at most a little female MOA who didn't get the feminist memo to be like Wonderwoman and train in Kickboxing and protect her boss. My MOA's have quit because my patients were loud and threatening.  Why shares the pain and risk when you can just avoid all the heavy lifting.
The easiest practice is ‘mood disorders’. Call everything Bipolar II and play ‘let’s make the drug companies money ‘by randomly trying every pill in the pharmacopoeia till the natural history of the disease passes and the patient gets better or leaves.  “The variation of this is “, I can’t treat your depression but I’m really good at treating side effects so I’ll give you something else and make myself look good as a doctor alll the while we’re not addressing your depression or anxiety.  I will make you dependent on me. “I’m reminded of my mother saying if you don’t stop crying I’ll give you something to cry about.
The pain clinic exhaust its box of expensive investigation and treatments and 'fires' the patient who comes back to the family physician and psychiatrist even more jaded and disappointment. These new 'clinic's' don't have the notion that they are 'accountable ' for the patient but rather that they provide a 'treatment' and if that doesn't work the patient is 'somebody else's problem'. The "SEP" is the norm in the Modern Canadian Health Care system. The lack of family physicians is directly associated with the burden of chronic care and difficult patients with no 'solution' who gather in droves at the front lines and wail and keen far from the ears of the government offering 'free health care' to everyone else but denying the obligation to care for individuals who are 'outliers' and don't respond to the cheap standard 19th century approach. 

18. I’m going to be late so I’ll rush out today. People always complain about my lack of editing. I blog because ‘stream of consicousness’ takes less time. Editing takes a lot of time. This is a journal so it's what I want to remember when I someday ask myself what was I thinking and feeling back then. It's subjective. It's emotional reasoning and personal perspective but it's  a snap shot.
 I don’t feel I have time, today. Everyone wanting a piece of me and everyone wanting it ‘free’.  The irony there is that increasingly people think what we’re doing isn’t worth what the health ‘coaches’ do because they ‘cost’ money and ‘health care’ is ‘free’ but then no one goes to the doctor anymore unless they’re really sick or they want to get a second opinion on the internet where the doctors and nurses have left the private face to face health care rat race to become entertainment doctors.  So much of what I read in internet medicine is wrong and political and it's sad when patients find these sites that confirm their erroneous bias.    I even had a bureaucrat describe medicine as " just entertainment". They actually encouraged me to “act”like doctor rather than be a doctor all the while saying that they didn't want me to be inauthentic, while nothing more inauthentic could be stated.  Bureaucrats aren't trained in psychiatry, or psychiatric psychotherapy or psychiatric relationship therapy or advanced communication and obviously knows nothing about psychiatry or psychiatric patients but have all that arrogance that generalists have, like those patients of ours who having looked at the internet know more about their disease than all of us.  When it comes to specialist medicine especially psychiatry which I likened to three dimensional chess compared to the unidimensional chess model of doctor as daddy fixing mom's brain with pills.  The patriarchal nature of this 'i'm good, you no good' 'I'm well, you're not well', i'm police you criminal' 'My brain good, your brain bad' is so 1980's before all the research of transactional analysis and all the modern training in psychotherapy and 'behaviour change ' , but there's no arguing with these people. They have the gun so they need to be respected and doctors pretzel themselves and train themselves and waste years of their lives doing everything increasingly to serve the administration regardless of whether it truly helps the patients because the patients are increasingly the least important people in the new entertainment industry.   It's really sick and creepy from one perspective. But then it's all a matter of perspective because even psychopaths and sociopaths believe they are good people helping others. So psychiatrists like most good doctors learn and turn and twist and do everything including sacrificing themselves by suicide because we're people pleasers and good citizens now at the mercy of psychopaths and sociopaths. Besides it's all fake news and there's an epidemic of 'false witness' deceit and systemic retrospective falsification. 

19.It's now all about popularity. Entertainment paradigm. I once was the ‘most popular guy’ and as a family physician I was outrageously popular but I became a psychiatrist because it was the most challenging with the most needy patients and the most marginalized.  Most of my patients aren’t given time though increasingly these activist bullies, the new order of borderlines backed by the authorities, are getting all the time and more and more the really sick are being pushed aside.  Schizophrenics commonly just want to be left alone, not good health care but what is happening to so many because of lack of advocacy for them. When they closed the asylum the chronically mentally ill were pushed out onto the street to be preyed on by predators and live homeless because the asylum was shut down, another administrative blunder of untold proportion.

 20. f I don’t watch the snakes carefully they’ll complain and by complaining they ensure that if I didn’t give them the attention and time and money and whatever sociopathic fantasy they have, they’re make sure that no one else gets my time because they’ll have me tied up with the garrulous grovelling inexperienced administration.

20.Meanwhile I just want to help the really sick not the patients who know how to beat up doctors and suck the life blood and soul out of care givers.  The Celestine prophecies described these as ‘soul sucker’s" and they’re just a whole lot more resourceful today. The Prochaska “stages of change” model (precontemplation, contemplation, determination and action )strongly suggests putting resources in at the determination or action phase and patient’s coming to specialist in the past were at that point while increasingly patients today are into contemplation, happy to talk to the doctor as infinitismal, entitled to the time and unwilling to leave the office but equally unwilling to change their chronic negative behaviours or thinking. Noncompliance and non adherence to medical regimen in chronic lifestyle disorders the new norm of medicine that generalists and especially specialists face. 

21.Still 90% or more of patients are what makes it all worth it. They’re your neighbour and my neighbour. They’re the person who got into drugs and alcohol and wants out. They’re the schizophrenic afraid of their demons. They’re the bipolar disorder who took their clothes off in the board room and don’t want that to happen any more. They’re the patient with depression whose been really well treated by the generalists but now requires a specialists because they’re rare and unusual and I’ve been around so long I’m an old elephant with just these skills and can tell people what the rare case is and how to treat it.  More and more though I’m fighting an individual bully patient and their advocates with loud speakers, College committees, lawyers and  social workers, none of who will roll up their sleeves to fight disease but are more than happy to claim the limelight for beating up an already beat up caregiver. .  I'm begging for resources and saying yes, till one day, I say no and the hungry patients eats me the closest caregiver and the person who is most hated by the terrified ignorant government.  I'm the 'sacrifice' that Graves wrote about.  It used to be virgins that were sacrificed but now it's doctors.  Psychiatrists are especially yummy. 

21.Every day I wonder if I ‘m wasting my time and experience on a dying health care system ruled by bullying ideologues increasingly out of touch with reality loving their high pay for  moving chairs on the titanic.  It’s an aging population and the refugees are even sicker so the whole system was set up for a completely different sort of folk and illness.  

I’m going to be late today now too. Some days I just get preoccupied and have to push myself to go out the door and face the hostility and despair. I say I’m sorry like the "Dr I’m Sorry" in the classic medical skit. I’ve been seeing patients on the front line, tens of thousands,  for over 30 years. I’m one of the best trained most experienced clinicians with an enviable track record of successful clinical care and outstanding morbidity and mortality rates. I’m not alone. Most of my colleagues , both generalists and specialists are caring, highly trained often extremely experienced extraordinary men and women,  but they are running late too.

 I pray that one day I’ll finally catch up too.

Hail Mary, Mother of God pray for me in the hour of my death. 





When I 
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