My earliest memory of church is being dressed up. I'm under 5 for sure and wearing a bow tie, probably red and a blue blazer. I remember the adults above bustling about in that getting ready for church way. That bustling cheerfulness was something I'd encounter over and over again on Sunday mornings. People washing. Women putting on best clothes and hats. The hats came out on Sunday. My father and us boys would be kind of dragged along. Mom would be the driving force. When my aunt and their mother were around it was truly a force to contend with. Dad would be in charge of getting everyone in the car. He had on a suit and tie and polished shoes. Mom would mess with his hair like she messed with ours. My brother and I were wishing we were elsewhere.
The car was pulled round the front and we all went out the front together. It wasn't something to hide from the neighbors. Some of the neighbors didn't go to church. I wouldn't put it past my Mom, her mother and sister for wanting to show them what they were 'supposed' to be doing on Sunday morning. Any other occasion we'd have all gone out the back but not for church. It was a front street affair.
Dad would go around the car and make sure the "ladies" were attended to. He didn't do that on shopping trips. My brother, mostly sullen, and myself would 'pile' in the back.
The front of the church was what it was all about. Parking was Dad's job. Letting us off in front of the church occurred if parking was further away. Sometimes we all walked from the car.
The ride wasn't too exciting. Kids and parents in a car with parents talking and asking questions. My brother and I might poke each other and get in trouble on the way. I was usually catching heck as the youngest.
A lot of smiling going around the church. Lots of hugs and kisses on the cheek and sweet waves. I remember adults mussing my hair alot. The Ladies sure liked church especially when they got to wear their hats. Easter hats. Odd because Jesus was dying on the cross and here the whole congregation was all for his being risen. I didn't know any theology back then.
Kids went downstairs and were thankful for it. Ministers were likely to drone on and never had anything relevant to say. Not to a kid's mind. My parents liked listening.
As an adult I've enjoyed the sermons like discussions and lectures so appreciate now that ministers to my parents were like a local professor. There was lots of singing too. The choir had burgundy gowns and black trim. They sat together and the congregation joined in the singing.
I loved best "Onward Christian Soldiers". As a kid I was all for martial activities. Dad had been in the Royal Canadian Air Force in WWII. The television had replays of all the famous war movies. The Cold War was on and any day the dirty commies could be coming over the North Pole just begging to be whipped by us kids and our families. So "Onward Christian Soldiers" was my favorite hymn. I didn't really listen to the words of songs back then either.
Sunday school was where we played games and were told stories in the basement. We even had Sunday School comic books. That how I learned about the Apostles, St. Paul, Peter and Mary and such.
Later we'd all traipse back up stairs and join our parents for the end of the service. They actually all looked happy to see us and we felt all that warm all over reunited experience there in the church.
If someone was going to be dunked and drowned in what they called a baptism we got to stay. It was pretty gruesome and frightening but pretty exciting too.
I remember the parents waists were above my head when I first went to church. It was like trying to move through a bunch of close together trees when they began to file out of the church and we tried to catch up with either Dad or Mom. They'd start talking to someone and get separated.
After church if we didn't go home for sandwiches and tea we'd go out to a restaurant or for a drive around the park. My grandmother was pretty old then and she liked the drive around the park.
There were a whole lot of Sunday morning church services when I was growing up. There must have been some bad times. I can't remember them now. When I got to adolescence things looked awry in a lot of directions. Pretty much the whole adult world looked askance to me. I didn't want to do anything adults did. Before that though church was okay.
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Wednesday, July 21, 2010
Wednesday Morning Workday
Wednesday is the hump in the middle of the week. If I can get through Wednesday I'm on the other side of the work week. Wednesday I go to a street clinic where it's mostly general medicine and addiction medicine. This kind of work is predominantly 'doing' work. There's immense amounts of government defined paper work. It's mostly filling out prescriptions. The focus is limited. There are really good people who I work with. It's another fine fellow's clinic so I'm not in charge. The work is raw. It's not nearly as complicated in some ways as the work I do in my own clinic. Partly that's because the people are younger with very specific diseases as opposed to the vague and amorphous diseases, mostly psychosomatics, I see in my other practice. It's physical medicine mostly. There's psychiatry too but more at the 'brain' disease level rather than the 'mind'. I see immediate results or at least know that my 'regimented' response is what it's 'supposed' to be. I don't feel the 'weight' of 'curing' that I feel in my own practice. I don't have that co dependency sense that comes with one's own practice and long term patients referred who have been to so many other people. In this clinic it's apparent that the patient or client as one is called is the rate determining step and we are there to offer resources and provide encouragement but it's not like the wrestle with the devil that goes on in long term psychotherapy. It's really like family medicine. I feel alot like I did when I was a country gp and it's a good feeling. The work is 'different' in that way and 'refreshing' as a change. It's far more busy. I see 20 patients in an afternoon as compared to 5 in my own clinic. There's not the intensity that comes with the longer contact but over time there's the familiarity which comes with repeated brief meetings. The efficacy is achieved in a different way but it's clear that there is good work being done. Every day there's a very clear reason for being there. Some life actually gets 'saved' in a kind of way that's different from my own clinic where I usually think I'm pulling logs out log jams to get the person back in the flow or perhaps re directing them or getting them off a bad detour. In this clinic some of the people are climbing in and out of the abyss and it's a bit like being a medic in a war zone. You don't really get to have much say in whether they go over the top of the trenches and enter no man's land but you're there to bandage survivors and point them out of the fray.
I kind of look forward to Wednesday. Because of my afternoon clinic my morning is fixed with on going therapy patients who aren't likely to present major surprises. I've only a couple of hours and can't go over time and am often alone without staff. So commonly the patients that come in on Wednesday are higher functioning and less threatening.
The new unknown patient is the most threatening. Referrals that have waited months to see you and come through the door as unknown powder kegs. Just getting a history from a suicidal crack addict is a struggle and so many emergency level decisions are needing to be made in too little time. Yet so many patients are no shows for referrals that you can't book long time slots on the first visit because you only get paid if the patient shows. The 'no show' rate is highest in the drug and alcohol crowd and mentally ill and unemployed. Yet that same population is such an unknown. I feel like I'm alone in a psychiatric emergency at times seeing the patients that I once saw surrounded by staff. Maybe it's because my life has been threatened too many times and I've had too many people suddenly tell me they're going to kill themselves now. And I'm always afraid I'll miss something in the silences.
I don't. I'm surprisingly well trained and experienced, so wearisomely experienced but there's so much political pressure on one to please everyone and any word you say can be taken out of context by a person angry with the world looking for somewhere to rest their anger on. And so many patients are so angry and entitled today and as usual they often have hidden agendas. It seems a day or week doesn't go by that I'm not trying to save a life or diagnose or cure when I get presented with the real reason for the visit 'could you sign this note for my employer', "I really just wanted oxycontin", "I don't really have any illness, but my insurance company says I have to see a doctor." There are signs up all over saying that paper work should be given to the staff but the patient figures they can best get their needs met by presenting this 'form' at their own timing. It's invariably too late to do anything and then they're angry that you can't complete a 'book' of writing that's not paid for by any agency and they don't think they should have to pay for you "just to write a letter' and it's a battle, an ugly battle where you suddenly are the bad guy because the patient doesn't have money and wants you to work for free because they pay taxes but the taxes don't pay me.
And there are 10 million agencies and a billion people employed to destroy doctors and they are all in the 'business' of medicine with no responsibility for the 'life and death' issues but love 'advocacy' and all that military stuff and the doctor is the enemy and these forces are always poised to bring their batallions to bear on your little practice where you are just trying to do your best with every form of safeguard known to man and decades of advanced educations and mountains of laws over your head. And you're supposed to please psychopaths and crack addicts and psychotic people and you're afraid alone and trying desperately not to upset a person who you don't know who came without any of the past information of assaults, jail time or asylum time or even just on drugs that make them paranoid and youre' the object of their paranoia this minute and the waiting room is full and you're on a schedule and they're shouting at you.
Thankfully that happens only every month or so. It';s weekly at the other clinic, people shouting because they're asked to wait. But there there's more of us.
It's strange.
The truth is that the vast majority are what you work for. You love to work for the many. It's good. Wednesday is a good day too.
I like wednesdays.
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I kind of look forward to Wednesday. Because of my afternoon clinic my morning is fixed with on going therapy patients who aren't likely to present major surprises. I've only a couple of hours and can't go over time and am often alone without staff. So commonly the patients that come in on Wednesday are higher functioning and less threatening.
The new unknown patient is the most threatening. Referrals that have waited months to see you and come through the door as unknown powder kegs. Just getting a history from a suicidal crack addict is a struggle and so many emergency level decisions are needing to be made in too little time. Yet so many patients are no shows for referrals that you can't book long time slots on the first visit because you only get paid if the patient shows. The 'no show' rate is highest in the drug and alcohol crowd and mentally ill and unemployed. Yet that same population is such an unknown. I feel like I'm alone in a psychiatric emergency at times seeing the patients that I once saw surrounded by staff. Maybe it's because my life has been threatened too many times and I've had too many people suddenly tell me they're going to kill themselves now. And I'm always afraid I'll miss something in the silences.
I don't. I'm surprisingly well trained and experienced, so wearisomely experienced but there's so much political pressure on one to please everyone and any word you say can be taken out of context by a person angry with the world looking for somewhere to rest their anger on. And so many patients are so angry and entitled today and as usual they often have hidden agendas. It seems a day or week doesn't go by that I'm not trying to save a life or diagnose or cure when I get presented with the real reason for the visit 'could you sign this note for my employer', "I really just wanted oxycontin", "I don't really have any illness, but my insurance company says I have to see a doctor." There are signs up all over saying that paper work should be given to the staff but the patient figures they can best get their needs met by presenting this 'form' at their own timing. It's invariably too late to do anything and then they're angry that you can't complete a 'book' of writing that's not paid for by any agency and they don't think they should have to pay for you "just to write a letter' and it's a battle, an ugly battle where you suddenly are the bad guy because the patient doesn't have money and wants you to work for free because they pay taxes but the taxes don't pay me.
And there are 10 million agencies and a billion people employed to destroy doctors and they are all in the 'business' of medicine with no responsibility for the 'life and death' issues but love 'advocacy' and all that military stuff and the doctor is the enemy and these forces are always poised to bring their batallions to bear on your little practice where you are just trying to do your best with every form of safeguard known to man and decades of advanced educations and mountains of laws over your head. And you're supposed to please psychopaths and crack addicts and psychotic people and you're afraid alone and trying desperately not to upset a person who you don't know who came without any of the past information of assaults, jail time or asylum time or even just on drugs that make them paranoid and youre' the object of their paranoia this minute and the waiting room is full and you're on a schedule and they're shouting at you.
Thankfully that happens only every month or so. It';s weekly at the other clinic, people shouting because they're asked to wait. But there there's more of us.
It's strange.
The truth is that the vast majority are what you work for. You love to work for the many. It's good. Wednesday is a good day too.
I like wednesdays.
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Tuesday, July 20, 2010
Losers
This is a rush of a movie with dirty CIA, the good soldiers, smart and not so smart Hindoos,Bolivians, a really good bad girl, gratuitous violence and girls soccer. I really liked the characters and guns.
- Posted using BlogPress from my iPhone
- Posted using BlogPress from my iPhone
Transparency
When Ralf Nader exposed that the car industry was aware of faults with cars that would cause death, the industry spent millions of dollars on private investigators trying to collect 'dirt' on Ralf Nader. Bean counters had shown that a recall of cars would cost x million dollars and that cover ups of the death and denial and legal fees would cost less. The problem was Ralf Nader was making them look bad and exposing the corporate bad boy behaviour. So the simple solution was to do an 'ad hominem' and smear the individual. The only trouble there was that Ralf Nader was squeaky clean.
This is so common in politics today that in the Southern United States where politics has reached a whole new level of sophistication it's said that even a congressman can do anything except be caught with a boy in his bed or a dead woman.
The Ralf Nader's of the world are rare and some might say 'boring' since apparently they didn't even 'not inhale' a marijuana cigarette.
Transparency is used in the social sense as representing openess, communication and accountability. The very rich and powerful have always been able to 'cover up' and commonly 'discredit' anyone who attempts to expose any of the irregularities of their behaviour. Corporations employ 'fixers" for the very purpose of maintaining the 'appearances' for the sake of profits. Tiger Woods naturally lacked transparency and didn't pay his 'fixers' so Nike and others distanced themselves from him.
Most citizens can't afford the amount of money that will cover up 'sextings, stories of abuse of crack cocaine or any manner of indiscretion. Ralf Nader's are rare. What is common is for the powerful to have the power to 'cover up'.
By being open, being transparent, and having accountability individuals protect themselves ironically from those who are closed and have no accountability themselves. "We are as sick as our secrets'.
The end of the Cold War was supposed to be the end of the era of secrecy. In the new era of transparency hypocrisy was supposed to be dead. The Cold War era taught us all that you could only trust those who had been exposed. The Nelson Mandela's of the world had been stripped and laid bare so they could be trusted. It was right instead to be suspicious of those who played their cards close to their chest.
Ralf Nader's are rare. Cover ups are common. The rest of us had best rely on transparency otherwise everyone for example, who is on Facebook today will one day be excluded from public appointment.
Once again, the Shadow Men and Women will be ascendant and the light will go out from Public Affairs. That is unless we continue to act with transparency ourselves, demand it of leadership and get beyond expecting everyone to be Ralf Nader. At best we can be less judgemental and appreciate the Nelson Mandelas.
- Posted using BlogPress from my iPhone
This is so common in politics today that in the Southern United States where politics has reached a whole new level of sophistication it's said that even a congressman can do anything except be caught with a boy in his bed or a dead woman.
The Ralf Nader's of the world are rare and some might say 'boring' since apparently they didn't even 'not inhale' a marijuana cigarette.
Transparency is used in the social sense as representing openess, communication and accountability. The very rich and powerful have always been able to 'cover up' and commonly 'discredit' anyone who attempts to expose any of the irregularities of their behaviour. Corporations employ 'fixers" for the very purpose of maintaining the 'appearances' for the sake of profits. Tiger Woods naturally lacked transparency and didn't pay his 'fixers' so Nike and others distanced themselves from him.
Most citizens can't afford the amount of money that will cover up 'sextings, stories of abuse of crack cocaine or any manner of indiscretion. Ralf Nader's are rare. What is common is for the powerful to have the power to 'cover up'.
By being open, being transparent, and having accountability individuals protect themselves ironically from those who are closed and have no accountability themselves. "We are as sick as our secrets'.
The end of the Cold War was supposed to be the end of the era of secrecy. In the new era of transparency hypocrisy was supposed to be dead. The Cold War era taught us all that you could only trust those who had been exposed. The Nelson Mandela's of the world had been stripped and laid bare so they could be trusted. It was right instead to be suspicious of those who played their cards close to their chest.
Ralf Nader's are rare. Cover ups are common. The rest of us had best rely on transparency otherwise everyone for example, who is on Facebook today will one day be excluded from public appointment.
Once again, the Shadow Men and Women will be ascendant and the light will go out from Public Affairs. That is unless we continue to act with transparency ourselves, demand it of leadership and get beyond expecting everyone to be Ralf Nader. At best we can be less judgemental and appreciate the Nelson Mandelas.
- Posted using BlogPress from my iPhone
Tuesday Morning Workday
Tuesday Morning is a little like Monday morning except I'm more tired. The next weekend is closer.
I'm reminded of internship and residency when I'd felt like everyday was a race, 36 hour marathons, barely living from sleep to sleep. Years of chronic fatigue.
The country practice was worse really. Days without sleep, call for 7 days at a time then 2 weeks off call working only 12 hour days,only to be followed for seven days of call and weekends of all night emergencies. We were young then.
When I graduated psychiatry I didn't know anything really. I had my family physician papers and a couple of years of public health and community medicine training plus the newly minted speciality diploma given out by the Royal College of Physicians. I was now a family physician and a psychiatrist with special training in Community Medicine. As a psychiatrist I was fully trained as a psychopharmacologist and a psychiatric psychotherapist.
I started as an assistant professor and was Head of Family Therapy when my own divorce made that all seem such hypocrisy. So I did my American exams and was offered jobs in Carolina, Stanford and Berkeley but stayed at University of British Columbia to study the 'new' psychiatry, "Emergency" and "Crisis Management".
I'd already had a private practice for 6 or 7 years by then, my first patients being psychotherapy patients I saw in the evening. I worked out of my home. Freud always worked out of his home. I saw some people in coffee shops. Adolescents always seemed to be best spoken with at drive ins, eating burgers. If you didn't buy a kid food he didn't talk to you. Those were the rules. That was the profession. I'd been doing home visits as a family physician for years before that. Sometimes I saw people in homes. Not the women. Even then you had to beware of them. Couples were okay. Often I'd go with a nurse, sometimes with the police. The RCMP were the best to go out with late at night.
It was all so different. I didn't know anything. Family medicine simply didn't train one for the insanity or the systemic abuses that transferred to the unconscious workings. I'll never forget the day I stepped in blood and felt how sticky it was, walking through the goo and knowing why it was here and not there.
Hospital psychiatry was so much easier. It was so straight forward. The new doctors always were started in the hospitals. Doctors who couldn't get their full licenses were alllowed to practice there. It was so regimented. All the answers were somewhere in protocol manuals, not that anyone looked in the heat of the moment. But after you could find out what should have gone down, if one had the resources, the personnel, the time or had seen it coming.
I wish sometimes I'd stayed with the easy. I was always moving on to more and more difficult and complex cases.
It was different though. In the north I'd been utterly alone. There were no other specialists or even doctors for days. I'd arrive in a place and a hundred patients would be crowded into the nursing station while the pilot would be saying we had to leave because bad weather was closing in. There'd not been doctor for a month and there'd not be another for another month. Blizzards would make it impossible to fly someone in and out even if there was an emergency. I'd be stranded for days at a time myself.
I never liked dead babies. Didn't like the feel of them in my hands. Didn't like to look at their dead eyes. Skin the wrong temperature as the heat escaped so quickly.
It was then I became disillusioned. I'd studied the laws and politics of health care and saw that it wasn't 'universal'. There were 'haves and have nots' and the dead had no voice and could be quickly forgotten.
Out in the wilderness there were few resources but back in the centres of power and prestige there was infinitely more.
I remember especially that I always could admit someone. As a doctor I was promised resources and the resources I started my career with were hospital beds. A hospital bed is like a gun to a soldier. Since time immemorial doctors had hospitals to fall back on. They could admit people to hospitals so they wouldn't die.
It's like a hockey team without hockey rinks or a football team without a ball.
Overnight, some 20 years ago I was told to practice medicine and psychiatry but that I'd have to do it without any back up. There would be no hospital beds. It wasn't that I'd used them always but it was something that I used and needed.
I think it hit me when I was in the United States and I could admit a sick person overnight or admit someone for the adjustment of their medication for a couple of days. Elective admissions made my life so sweet. For years now I've adjusted medications, sometimes juggling a dozen at a time, in the community without the benefit of a hospital and these days without the patient having family or friends to watch over them.
It's been a decade or two since I've admitted a patient to hospital anyway but with a committal forcing the emergency psychiatrists to keep the patient at least overnight. Also the only patients that have been admitted were acutely suicidal. Suicidality is just one of many reasons for admitting a person to a psychiatric hospital. My patients are often grossly psychotic today walking about on other planets and I'm adjusting their medications relying on a blister pack and sometimes a home visit to see if they are even taking the medications I'm prescribing. Most of these patients have been suicidal many times before and many have been homicidal.
I remembered the WWI soldiers I treated my first years in practice who told me that they'd been sent into war by our government with rifles that didn't work. I think of them sometimes as the years roll on and I remember that I was promised hospital beds when I started medical practice. I remember too there were nurses in the hospital and nurses in the community. I saw a community nurse for the first time in months last week and remembered how there were so many more once. I liked their experience too.
A policeman told me bitterly how she was driving alone in the police car and missed having a partner, how she'd been given a computer but lost her partner and didn't feel safe at night.
I called a colleague and we talked on the phone for 15 minutes about a patient. I remembered how decades back I could call a colleague and they'd see my patient that week. The neurologist I phoned about the patient with the slow growing brain tumor said he could see him in a year. I know psychiatrists who will see my patients for a second opinion in a month or two. If I pulled favours and jumped and shouted and carried on I know I could get a friend to see someone in a day or two, maybe a week. But I know that they're like me. I tell even friends it will be a month or two before I can see their patients.
I remember too when I could see a patient and book them back a week later or even the next day. I feel badly for my secretary who tries to find another slot in the next month or so and I feel that this half hour with this unknown stranger who is suicidal and waited a couple of months to see me and is that much more sicker is going to need therapy but the government wants me to do 'consultations' and refer the patient back to the family physician. The family physician is already seeing people for 5 minute visits and is overbooked because millions upon millions can't get a family physician in Canada. Now a third of my patients only go to walk in clinics where the doctors hand out band aids and referrals.
I liked the sense that I was not so alone in practice. I worked alone for years in the wilderness, no other doctor for hundreds of miles, specialists and facilities thousands of miles away, but I'm in the centre of the city and it's even lonelier. I talk on the phone to family physicians who are as harried as me.
The man was shouting at me that he needed to see me more. He was threatening me saying he needed to see me more and saying that I was a piece of shit to be accepting patients and not having time to see them. I tried to explain that I was a specialist and doing consultations and then offering therapy where possible but that increasingly I could only recommend therapy and the individual had to pay for the therapy I recommended. Half the medications I recommend to people aren't 'covered' by some plan. Only the 'old and used' medications are 'covered'. There's usually reams of paperwork to be done to get anything out of the usual and there's never any time or money for the paperwork. Hundreds of emails.
I remember when my patients had one medication. We were all young then. Now my patients are mostly physically ill with chronic disease and that is coupled with psychiatric illness and more often than not addiction. Increasingly I don't know the names of medications used by cardiologists, nephrologists, endocrinologists. I am daily looking up obscure new medications that we never heard about when I originally studied pharmacology. There's a cocktail of antibiotics for my patients with multiple resistant infections and my HIV patients are always on something new I'm looking up to see if there's a conflict with a medication I'm prescribing.
And the man tells me his father died. He doesn't think he can go on. We sit awhile and there's no one for him to talk to. He'll go home to be with his one friend. He's afraid this one sick friend might die one day and then he'd be truly alone. So many are alienated in the city today.
I'm going to work as a doctor today. I will be in the wilderness of the city again with no hospital, waitlists, and patients without the money for half the things I prescribe and no one with time.
Like all the other doctors we'll be criticized too. Scapegoats. Not good enough. They're bringing in a law that says that doctors can't talk about the conditions they work in. My colleague who complained about his patients dying on the waitlists was called a 'disruptive physician'. Like all doctors today he's afraid for his license.
It was only a decade a go doctors had 'freedom of speech' too but some say that's gone as well.
I talked to the minister of health recently and he really understood. The minister of health really was aware of what was happening and trying to do everything in his power to make things better. I don't know that his superiors were but he was. What was worse though was that those under him were holier than thou. Their attitudes had no place in the scarcity that everyone else was experiencing.
My colleague told me that minions should have to live like normal people for a week or two so they don't have that attitude but then we all know that's their defence. They're usually just young, book learned and inexperinced.They're hurting too. Everyone wants to be loved and no one is loving them any more than they're loving us.
Meanwhile it's time to go to work. It's going to be a good day. We've got along for decades like this. It should be possible to live in the scarcity for another decade. At least I've not bailed out for administration or some other safe and cozy place. I think of going back to the hospital. I love that my friend is doing so well as head of a drug company division. He took the new mandates to heart and gave up old time medicine for the real 'business' of medicine. "I'm in charge of a whole bunch of salesman and it's a whole lot better than the confusion I used to live in with all that criticism from people who thought they knew but had never been where the rubber hit the road." "I paid my dues', he said.
We all have.
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I'm reminded of internship and residency when I'd felt like everyday was a race, 36 hour marathons, barely living from sleep to sleep. Years of chronic fatigue.
The country practice was worse really. Days without sleep, call for 7 days at a time then 2 weeks off call working only 12 hour days,only to be followed for seven days of call and weekends of all night emergencies. We were young then.
When I graduated psychiatry I didn't know anything really. I had my family physician papers and a couple of years of public health and community medicine training plus the newly minted speciality diploma given out by the Royal College of Physicians. I was now a family physician and a psychiatrist with special training in Community Medicine. As a psychiatrist I was fully trained as a psychopharmacologist and a psychiatric psychotherapist.
I started as an assistant professor and was Head of Family Therapy when my own divorce made that all seem such hypocrisy. So I did my American exams and was offered jobs in Carolina, Stanford and Berkeley but stayed at University of British Columbia to study the 'new' psychiatry, "Emergency" and "Crisis Management".
I'd already had a private practice for 6 or 7 years by then, my first patients being psychotherapy patients I saw in the evening. I worked out of my home. Freud always worked out of his home. I saw some people in coffee shops. Adolescents always seemed to be best spoken with at drive ins, eating burgers. If you didn't buy a kid food he didn't talk to you. Those were the rules. That was the profession. I'd been doing home visits as a family physician for years before that. Sometimes I saw people in homes. Not the women. Even then you had to beware of them. Couples were okay. Often I'd go with a nurse, sometimes with the police. The RCMP were the best to go out with late at night.
It was all so different. I didn't know anything. Family medicine simply didn't train one for the insanity or the systemic abuses that transferred to the unconscious workings. I'll never forget the day I stepped in blood and felt how sticky it was, walking through the goo and knowing why it was here and not there.
Hospital psychiatry was so much easier. It was so straight forward. The new doctors always were started in the hospitals. Doctors who couldn't get their full licenses were alllowed to practice there. It was so regimented. All the answers were somewhere in protocol manuals, not that anyone looked in the heat of the moment. But after you could find out what should have gone down, if one had the resources, the personnel, the time or had seen it coming.
I wish sometimes I'd stayed with the easy. I was always moving on to more and more difficult and complex cases.
It was different though. In the north I'd been utterly alone. There were no other specialists or even doctors for days. I'd arrive in a place and a hundred patients would be crowded into the nursing station while the pilot would be saying we had to leave because bad weather was closing in. There'd not been doctor for a month and there'd not be another for another month. Blizzards would make it impossible to fly someone in and out even if there was an emergency. I'd be stranded for days at a time myself.
I never liked dead babies. Didn't like the feel of them in my hands. Didn't like to look at their dead eyes. Skin the wrong temperature as the heat escaped so quickly.
It was then I became disillusioned. I'd studied the laws and politics of health care and saw that it wasn't 'universal'. There were 'haves and have nots' and the dead had no voice and could be quickly forgotten.
Out in the wilderness there were few resources but back in the centres of power and prestige there was infinitely more.
I remember especially that I always could admit someone. As a doctor I was promised resources and the resources I started my career with were hospital beds. A hospital bed is like a gun to a soldier. Since time immemorial doctors had hospitals to fall back on. They could admit people to hospitals so they wouldn't die.
It's like a hockey team without hockey rinks or a football team without a ball.
Overnight, some 20 years ago I was told to practice medicine and psychiatry but that I'd have to do it without any back up. There would be no hospital beds. It wasn't that I'd used them always but it was something that I used and needed.
I think it hit me when I was in the United States and I could admit a sick person overnight or admit someone for the adjustment of their medication for a couple of days. Elective admissions made my life so sweet. For years now I've adjusted medications, sometimes juggling a dozen at a time, in the community without the benefit of a hospital and these days without the patient having family or friends to watch over them.
It's been a decade or two since I've admitted a patient to hospital anyway but with a committal forcing the emergency psychiatrists to keep the patient at least overnight. Also the only patients that have been admitted were acutely suicidal. Suicidality is just one of many reasons for admitting a person to a psychiatric hospital. My patients are often grossly psychotic today walking about on other planets and I'm adjusting their medications relying on a blister pack and sometimes a home visit to see if they are even taking the medications I'm prescribing. Most of these patients have been suicidal many times before and many have been homicidal.
I remembered the WWI soldiers I treated my first years in practice who told me that they'd been sent into war by our government with rifles that didn't work. I think of them sometimes as the years roll on and I remember that I was promised hospital beds when I started medical practice. I remember too there were nurses in the hospital and nurses in the community. I saw a community nurse for the first time in months last week and remembered how there were so many more once. I liked their experience too.
A policeman told me bitterly how she was driving alone in the police car and missed having a partner, how she'd been given a computer but lost her partner and didn't feel safe at night.
I called a colleague and we talked on the phone for 15 minutes about a patient. I remembered how decades back I could call a colleague and they'd see my patient that week. The neurologist I phoned about the patient with the slow growing brain tumor said he could see him in a year. I know psychiatrists who will see my patients for a second opinion in a month or two. If I pulled favours and jumped and shouted and carried on I know I could get a friend to see someone in a day or two, maybe a week. But I know that they're like me. I tell even friends it will be a month or two before I can see their patients.
I remember too when I could see a patient and book them back a week later or even the next day. I feel badly for my secretary who tries to find another slot in the next month or so and I feel that this half hour with this unknown stranger who is suicidal and waited a couple of months to see me and is that much more sicker is going to need therapy but the government wants me to do 'consultations' and refer the patient back to the family physician. The family physician is already seeing people for 5 minute visits and is overbooked because millions upon millions can't get a family physician in Canada. Now a third of my patients only go to walk in clinics where the doctors hand out band aids and referrals.
I liked the sense that I was not so alone in practice. I worked alone for years in the wilderness, no other doctor for hundreds of miles, specialists and facilities thousands of miles away, but I'm in the centre of the city and it's even lonelier. I talk on the phone to family physicians who are as harried as me.
The man was shouting at me that he needed to see me more. He was threatening me saying he needed to see me more and saying that I was a piece of shit to be accepting patients and not having time to see them. I tried to explain that I was a specialist and doing consultations and then offering therapy where possible but that increasingly I could only recommend therapy and the individual had to pay for the therapy I recommended. Half the medications I recommend to people aren't 'covered' by some plan. Only the 'old and used' medications are 'covered'. There's usually reams of paperwork to be done to get anything out of the usual and there's never any time or money for the paperwork. Hundreds of emails.
I remember when my patients had one medication. We were all young then. Now my patients are mostly physically ill with chronic disease and that is coupled with psychiatric illness and more often than not addiction. Increasingly I don't know the names of medications used by cardiologists, nephrologists, endocrinologists. I am daily looking up obscure new medications that we never heard about when I originally studied pharmacology. There's a cocktail of antibiotics for my patients with multiple resistant infections and my HIV patients are always on something new I'm looking up to see if there's a conflict with a medication I'm prescribing.
And the man tells me his father died. He doesn't think he can go on. We sit awhile and there's no one for him to talk to. He'll go home to be with his one friend. He's afraid this one sick friend might die one day and then he'd be truly alone. So many are alienated in the city today.
I'm going to work as a doctor today. I will be in the wilderness of the city again with no hospital, waitlists, and patients without the money for half the things I prescribe and no one with time.
Like all the other doctors we'll be criticized too. Scapegoats. Not good enough. They're bringing in a law that says that doctors can't talk about the conditions they work in. My colleague who complained about his patients dying on the waitlists was called a 'disruptive physician'. Like all doctors today he's afraid for his license.
It was only a decade a go doctors had 'freedom of speech' too but some say that's gone as well.
I talked to the minister of health recently and he really understood. The minister of health really was aware of what was happening and trying to do everything in his power to make things better. I don't know that his superiors were but he was. What was worse though was that those under him were holier than thou. Their attitudes had no place in the scarcity that everyone else was experiencing.
My colleague told me that minions should have to live like normal people for a week or two so they don't have that attitude but then we all know that's their defence. They're usually just young, book learned and inexperinced.They're hurting too. Everyone wants to be loved and no one is loving them any more than they're loving us.
Meanwhile it's time to go to work. It's going to be a good day. We've got along for decades like this. It should be possible to live in the scarcity for another decade. At least I've not bailed out for administration or some other safe and cozy place. I think of going back to the hospital. I love that my friend is doing so well as head of a drug company division. He took the new mandates to heart and gave up old time medicine for the real 'business' of medicine. "I'm in charge of a whole bunch of salesman and it's a whole lot better than the confusion I used to live in with all that criticism from people who thought they knew but had never been where the rubber hit the road." "I paid my dues', he said.
We all have.
- Posted using BlogPress from my iPhone
Monday, July 19, 2010
Entitlement
Entitlement is a term commonly used in psychiatry, psychology and social services. Psychoanalysts referred to 'narcissistic entitlement'. It's often used in this sense when a person with long standing personality disorder or characterological flaw, is referred to as 'entitled'.
In addiction literature it refers to the addicts regression to the child like state. "King Baby" is a term used for such an 'entitled' one.
The demands of the 'station' of babyhood are that it reasonably or unreasonably expects and needs parents to provide for it's food, clothing, shelter and increasingly luxuries. At the opposite end of the social spectrum the Aristocracy were described as "entitled' by 'sanction of God' or later 'genetics' to superior treatment.
Entitlement is further a legal term referring to the 'rights' of an individual to 'guaranteed benefits under a government program' or rights to benefits granted especially by law or contract.
It refers to 'special status' and 'special treatment'. The term 'Culture of Entitlement' was used by conservatives who noted that so called 'disabled' and "unemployed' appeared more than capable of doing quite impressive "work' to 'seek' and 'ensure' 'entitlements' while at the same time claiming 'dysfunction' or 'disability' to serve others or work for the greater good.
Further governments and beaurocracies have to some extent hampered the lot of the many by catering to the lot of a very few, offering 'entitlements' to certain thereby "priviledged' groups who thence "co-opted' support the disenfranchisement of the many. This 'divide and conquer' strategy has served to ensure no broad base response to the overall inequity in such systems as the 'entitled' few are thereby part of the status quo.
Given the number of people dependent on government at one time in Canada these were collectively called "Chretien's Children" or even "Chretien's Harem" as so many of these people were women. Previously people had demanded 'jobs' but rather than 'work' which gave independence, freedom and dignity the government moved to providing the equivalent of the 'allowance' that the parent gave the adolescent child. Once seen as a liberal/conservative 'issue' it's long beyond partisan politics. 1 in 8 Americans today are thought to be collecting 'food' stamps, ie being fed at the breast of 'big government'. Big government is now both conservative and liberal as the State controlls the individual.
Social order and social control can thereby be maintained by 'entitlements'. When one depends on 'daddy' or "mommy" government one is not in any position to 'rock the boat'. There's a lot of 'bravado' but no 'biting the hand that feeds'
Further for every person obtaining an entitlement in Canada there are usually 2 or 3 bureaucrats making 2 to 3 times the entitlement income giving out the entitlement. The result is an 'economy' based on entitlement. Why work when others get by for 'free' is the natural outgrowth of this.
Individually entitlement is the interpersonal interaction where one adult assumes or 'presumes' baby ship and demands overtly or covertly that the other adults acknowledge their 'special status'. The expectation in this case is that others consistently supply emotional, social and financial support for this person who might already be receiving 'entitlements' from various other agencies.
People with 'narcissistic entitlement' have rather elaborate explanations for why others should 'serve' them in various ways. Often there is an actual 'competition for a disease classification.' Hence, when Clinton was governor of Arkansas there apparently was federal money for mentally retarded children with the result that for generations after school teachers complained about the 'dumb acting' kids. Compensation 'schemes' can , like the entitlement for mentally retarded, be an area where those truly 'needy' are indeed 'displaced' by those chameleon 'wanty's".
There is no easy solution to 'entitlement' issues. Increasingly parents are faced with kids who 'don't want to leave home', 'won't grow up', 'won't go to work', 'won't support themselves'. These parents frustrated show up in psychiatrists offices after decades of service to their children only to find that their childen feel entitled to 'life long' support especially where 'luxuries' are involved.
The very nature of 'luxury' has been altered so that what was thought to be the 'product' of 'saving and hard work' is now thought of as 'entitled'. Increasingly 'welfare recipients' need a 'vacation'. People collecting 'unemployment insurance' will complain that they're offered a 'job before their EI is used up". Increasingly with aging and chronic illness people are finding it harder and harder to work when so many people are 'entitled' to be on any number of "pension's starting the 'government indexed white collar pension entitlement' to the 'blue collar Canada pension entitlement'. Working people and people who save or have any number of conservative or traditional values feel in these settings 'punished' for working with pain, working in less than desirable conditions or working at all.
Further the government treats the elderly poorly punishing those with savings while rewarding those who rather than have savings 'squandered' their incomes in the classic 'King Baby" 'Big Shot" ways.
In the Canadian hospital the street person without resources may indeed get a 'bed' while the worker who has 'saved' money will be expected to 'buy' health care across the border.
Increasingly, especially with the aging populations and immigrations and various 'entitlement' ideologies, and those whose work depends on perpetuating this disparity, the system begins to implode. While some children will leave the tit others must be weaned. Alot of nipple biting goes on in the process, I'm told. Individually, socially and politically alot of growing up occurs.
Meanwhile emperors, kings, queens and all the aristocracy feel 'entitled' too.
- Posted using BlogPress from my iPhone
In addiction literature it refers to the addicts regression to the child like state. "King Baby" is a term used for such an 'entitled' one.
The demands of the 'station' of babyhood are that it reasonably or unreasonably expects and needs parents to provide for it's food, clothing, shelter and increasingly luxuries. At the opposite end of the social spectrum the Aristocracy were described as "entitled' by 'sanction of God' or later 'genetics' to superior treatment.
Entitlement is further a legal term referring to the 'rights' of an individual to 'guaranteed benefits under a government program' or rights to benefits granted especially by law or contract.
It refers to 'special status' and 'special treatment'. The term 'Culture of Entitlement' was used by conservatives who noted that so called 'disabled' and "unemployed' appeared more than capable of doing quite impressive "work' to 'seek' and 'ensure' 'entitlements' while at the same time claiming 'dysfunction' or 'disability' to serve others or work for the greater good.
Further governments and beaurocracies have to some extent hampered the lot of the many by catering to the lot of a very few, offering 'entitlements' to certain thereby "priviledged' groups who thence "co-opted' support the disenfranchisement of the many. This 'divide and conquer' strategy has served to ensure no broad base response to the overall inequity in such systems as the 'entitled' few are thereby part of the status quo.
Given the number of people dependent on government at one time in Canada these were collectively called "Chretien's Children" or even "Chretien's Harem" as so many of these people were women. Previously people had demanded 'jobs' but rather than 'work' which gave independence, freedom and dignity the government moved to providing the equivalent of the 'allowance' that the parent gave the adolescent child. Once seen as a liberal/conservative 'issue' it's long beyond partisan politics. 1 in 8 Americans today are thought to be collecting 'food' stamps, ie being fed at the breast of 'big government'. Big government is now both conservative and liberal as the State controlls the individual.
Social order and social control can thereby be maintained by 'entitlements'. When one depends on 'daddy' or "mommy" government one is not in any position to 'rock the boat'. There's a lot of 'bravado' but no 'biting the hand that feeds'
Further for every person obtaining an entitlement in Canada there are usually 2 or 3 bureaucrats making 2 to 3 times the entitlement income giving out the entitlement. The result is an 'economy' based on entitlement. Why work when others get by for 'free' is the natural outgrowth of this.
Individually entitlement is the interpersonal interaction where one adult assumes or 'presumes' baby ship and demands overtly or covertly that the other adults acknowledge their 'special status'. The expectation in this case is that others consistently supply emotional, social and financial support for this person who might already be receiving 'entitlements' from various other agencies.
People with 'narcissistic entitlement' have rather elaborate explanations for why others should 'serve' them in various ways. Often there is an actual 'competition for a disease classification.' Hence, when Clinton was governor of Arkansas there apparently was federal money for mentally retarded children with the result that for generations after school teachers complained about the 'dumb acting' kids. Compensation 'schemes' can , like the entitlement for mentally retarded, be an area where those truly 'needy' are indeed 'displaced' by those chameleon 'wanty's".
There is no easy solution to 'entitlement' issues. Increasingly parents are faced with kids who 'don't want to leave home', 'won't grow up', 'won't go to work', 'won't support themselves'. These parents frustrated show up in psychiatrists offices after decades of service to their children only to find that their childen feel entitled to 'life long' support especially where 'luxuries' are involved.
The very nature of 'luxury' has been altered so that what was thought to be the 'product' of 'saving and hard work' is now thought of as 'entitled'. Increasingly 'welfare recipients' need a 'vacation'. People collecting 'unemployment insurance' will complain that they're offered a 'job before their EI is used up". Increasingly with aging and chronic illness people are finding it harder and harder to work when so many people are 'entitled' to be on any number of "pension's starting the 'government indexed white collar pension entitlement' to the 'blue collar Canada pension entitlement'. Working people and people who save or have any number of conservative or traditional values feel in these settings 'punished' for working with pain, working in less than desirable conditions or working at all.
Further the government treats the elderly poorly punishing those with savings while rewarding those who rather than have savings 'squandered' their incomes in the classic 'King Baby" 'Big Shot" ways.
In the Canadian hospital the street person without resources may indeed get a 'bed' while the worker who has 'saved' money will be expected to 'buy' health care across the border.
Increasingly, especially with the aging populations and immigrations and various 'entitlement' ideologies, and those whose work depends on perpetuating this disparity, the system begins to implode. While some children will leave the tit others must be weaned. Alot of nipple biting goes on in the process, I'm told. Individually, socially and politically alot of growing up occurs.
Meanwhile emperors, kings, queens and all the aristocracy feel 'entitled' too.
- Posted using BlogPress from my iPhone
Monday Morning Workday
Awake. Sunshine and warmth. Hard to get out of bed. I love bed. Gilbert the dog has visited several times. Leaps of fur and fun and lots of licks. Can't read a calendar. Likes work. Doesn't feel all the new aches and pains from weekend of fun and exercise. Coffee will work. Always works. Shower follows. Routine too. Mustn't break the routine. Know too many people that stopped going to work and lost the habit. Mostly complainers. But what it comes down to is discipline. Hardest part is putting on the shoes. Work boots. Doesn't matter if they're sandals. If they take you to work. Work boots. Lacing harder. Velcro a god send. Bending and getting the feet on board. From bed to work, the longest mile. Work itself a fun shoot. Bit like rapids. Once you're in the chair the day explodes around you. Just a matter of getting there and then holding on. The details aren't important. It's mostly in the main strokes.
Workmen's Compensation Vancouver opened a club house. Workers off work needed to report to the clubhouse. Stopped all the secondary jobs that the disabled seemed to prefer to the main stream. I'd be a ships captain for sure for the summer were I collecting disability. But Workman's Compensation brings them into the clubhouse and so much sooner people are back at work. Reminds me of my mother saying that if I was so sick I couldn't go to school then I had to stay in bed. Now I'd be wheeling dealing on Craig's List or babysitting my neighbors grandkids. How to collect two pay cheques and justify it. But there's the clubhouse instead. Kind of like 'detention room'. But then if I'm paying do I really want to be paying for someone to be their own boss, to sleep in and work for themselves at my expense. Easy to say it's not stealing. Easy to explain it away.
I'm afraid of retirement. The government workers got light weight jobs, paid their dues by being goody good two shoes, working to order, and having mostly boring jobs, but indexed pensions and all the health benefits. I'm private sector. We do all the work in Canada but are hated and abused. Taxed to the nth degree to pay for the dead weight of government. I know there are those who work in government. I worked in government but it's a cakewalk compared to real work and only those in government who've worked private get my respect. They know. The evidence of their knowing is in the respect they give to those of us in private sector and how they accept their good fortune with grace. We know and they know that we're down here in the trenches and they're up there on easy street.
Though recently job security hasn't been good anywhere. And the French Canadians who had the partisan jobs without the skills and only had to have the language ability to get to be the chief of rocket science with a gr 9 education are rocking and reeling with all the smart French speaking phd black women coming here from Africa. Even the Quebecois swagger is struggling in these changing times.
On the west coast, the Pot Dealers can't compete with the Crack dealers who have dropped their prices in a bid to get greater control of the market. Reminiscent of the beaver pelt trade in England that had Londoners looking askance at Hedgehog headwear. What better evidence of global economy than that imported cocaine is cheaper than bathtub meth.
If I turn on the news, and I do some Monday mornings on the way to work, it will even be more bizarre. There are Canadian soldiers in Afghanistan. Catch 22 and all. Kandahar. I just learned that word and now wonder what it will be called when they change the name of Ho Chi Minn City or will democracy stick this time. Democracy with it's jails and jails and jails and jails. Freedom with it's lack of free speech and Christianity banned in public places. New churches filling as the old one ossify in political correctness and social communism.
I will have to think seriously, put on character armour. Watch myself. Go out into the workplace where there's competition and 'beatniks are out to make it rich.'
Getting there is so much part of the equation. Especially after time in the wilderness, out by the timber line, on the seas or anywhere near the portals of escape. l've come back again. And everyday I'm thankful for the priviledge of work, and the joys of meetings and the positives outweigh the negatives if I let myself see that. There will be all the attitude especially the phone people who put all their negative personality into little packets of darkness demanding this or that. But there will be the glimpses of light. Only last week several people had miraculous cures. There have been a half dozen diagnosed with cancer these last months and it's been removed or remitted. Good is happening all around us. Even obesity and alcoholism are being cured. Remember how everyone smoked and the rooms were full of tobacco clouds. Change is possible. Humans are advancing.
Now get to the shower. It would be so easy to stay at the computer. Make it seem like work. Convince oneself that whatever one is doing is valuable. But the reality is that it doesn't pay the rent. What pays the rent and food comes first. Those are the rules. Started out with hunter gatherers and continues today. Even the rich gangster would rather play at the computer than smack about a dishonest pimp holding back some of the ho's money, not divying in the cut the way it's supposed to be. He's got to pistol whip this guy when he'd rather be playing at his computer. It's all relative at one level. At the other level it's all God but that's a different story. God's more likely to be in the workplace than anywhere else.
- Posted using BlogPress from my iPhone
Workmen's Compensation Vancouver opened a club house. Workers off work needed to report to the clubhouse. Stopped all the secondary jobs that the disabled seemed to prefer to the main stream. I'd be a ships captain for sure for the summer were I collecting disability. But Workman's Compensation brings them into the clubhouse and so much sooner people are back at work. Reminds me of my mother saying that if I was so sick I couldn't go to school then I had to stay in bed. Now I'd be wheeling dealing on Craig's List or babysitting my neighbors grandkids. How to collect two pay cheques and justify it. But there's the clubhouse instead. Kind of like 'detention room'. But then if I'm paying do I really want to be paying for someone to be their own boss, to sleep in and work for themselves at my expense. Easy to say it's not stealing. Easy to explain it away.
I'm afraid of retirement. The government workers got light weight jobs, paid their dues by being goody good two shoes, working to order, and having mostly boring jobs, but indexed pensions and all the health benefits. I'm private sector. We do all the work in Canada but are hated and abused. Taxed to the nth degree to pay for the dead weight of government. I know there are those who work in government. I worked in government but it's a cakewalk compared to real work and only those in government who've worked private get my respect. They know. The evidence of their knowing is in the respect they give to those of us in private sector and how they accept their good fortune with grace. We know and they know that we're down here in the trenches and they're up there on easy street.
Though recently job security hasn't been good anywhere. And the French Canadians who had the partisan jobs without the skills and only had to have the language ability to get to be the chief of rocket science with a gr 9 education are rocking and reeling with all the smart French speaking phd black women coming here from Africa. Even the Quebecois swagger is struggling in these changing times.
On the west coast, the Pot Dealers can't compete with the Crack dealers who have dropped their prices in a bid to get greater control of the market. Reminiscent of the beaver pelt trade in England that had Londoners looking askance at Hedgehog headwear. What better evidence of global economy than that imported cocaine is cheaper than bathtub meth.
If I turn on the news, and I do some Monday mornings on the way to work, it will even be more bizarre. There are Canadian soldiers in Afghanistan. Catch 22 and all. Kandahar. I just learned that word and now wonder what it will be called when they change the name of Ho Chi Minn City or will democracy stick this time. Democracy with it's jails and jails and jails and jails. Freedom with it's lack of free speech and Christianity banned in public places. New churches filling as the old one ossify in political correctness and social communism.
I will have to think seriously, put on character armour. Watch myself. Go out into the workplace where there's competition and 'beatniks are out to make it rich.'
Getting there is so much part of the equation. Especially after time in the wilderness, out by the timber line, on the seas or anywhere near the portals of escape. l've come back again. And everyday I'm thankful for the priviledge of work, and the joys of meetings and the positives outweigh the negatives if I let myself see that. There will be all the attitude especially the phone people who put all their negative personality into little packets of darkness demanding this or that. But there will be the glimpses of light. Only last week several people had miraculous cures. There have been a half dozen diagnosed with cancer these last months and it's been removed or remitted. Good is happening all around us. Even obesity and alcoholism are being cured. Remember how everyone smoked and the rooms were full of tobacco clouds. Change is possible. Humans are advancing.
Now get to the shower. It would be so easy to stay at the computer. Make it seem like work. Convince oneself that whatever one is doing is valuable. But the reality is that it doesn't pay the rent. What pays the rent and food comes first. Those are the rules. Started out with hunter gatherers and continues today. Even the rich gangster would rather play at the computer than smack about a dishonest pimp holding back some of the ho's money, not divying in the cut the way it's supposed to be. He's got to pistol whip this guy when he'd rather be playing at his computer. It's all relative at one level. At the other level it's all God but that's a different story. God's more likely to be in the workplace than anywhere else.
- Posted using BlogPress from my iPhone
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