RANT RAVE RANT RAVE true confessions, identity crisis fun, and the jungle patrol, with poetry, video, and song lyrics through the ages.

for starters,

When I say 'hit it,' I want you to go two up and two back, double cross, and come out of it with the rifleman.

Hit it.

Crazy. Now when I say 'hit it,' I want the strong M, erase it, and back to the Madison. Hit it.
Walk on. You're lookin' good.

Now then when I say 'hit it,' it'll be T-time. Hit it. Big strong line!

Now when I say 'hit it,' I want the Cleveland box, and back to the Madison.
Hit it. Crazy.

Now when I say 'hit it,' I want the big strong basketball, with the Wilt Chamberlain hook.
Hit it. Two points!

-- Madison Time, the Ray Bryant Combo, 1960



oh, the madison, yes, it can brighten up the gloomiest most disaffected february day. better men than i have come this way, bloody feet have trodden smooth the path by which i came here, sisters, and still found it in them to do the madison.

so in the past month two acutely mentally ill women (manic episode, atypical postpartum depression) have asked me nicely for psychotropic medication that they have taken successfully in the past (adderall and depakote), and i was sternly prohibited from giving these by three panicked attendings who stated "this is way, way, way outside our sphere of practice," "our" presumably meaning "all of us family doctors."

so instead, following directions, i told them to go away "referred them" to psychiatrists, which they never did see...



couldn't get in to see; couldn't face the half-hour call to their insurance company (their medicaid h.m.o.) to find out how much, how long, and how they could get coverage for assessment and by whom; couldn't scrape up the copay and figure out how to get the bus, ten miles to the suburb where the psych clinic (at the medical school) would be...

so they're "noncompliant" now, and i have been reassured, "the patient has to take some responsibility for their own health," which lets me off the hook. (not my own [or the patients'] hook - everyone else's - meaning - my preceptors'.)

following orders, i also told these young women, alternatively, to go away they could go to the psych e.r. (same suburb). in the unlikely event they do go to the e.r. or clinic, who'll see them? residents (like me), who will do what? prescribe the medication they asked me for - since the best indication for a psych med is a previously successful psych med. it's a no-brainer.

but i was not allowed to to the prescribing, because, as one physician told me regarding the second patient, "she could go and blow somebody's head off, and it would be our fault!" and as another said regarding the first, "there was a family doctor in town who got sued for millions of dollars for continuing a prescription of antipsychotics for a schizophrenic - the patient developed severe side effects, and the physician was nailed to the wall. the head of the medical college was called as an expert witness, and had to admit that even a third-year medical student would recognize" these side effects.



POETRY BREAK

I am done with apologies.
If contrariness is my inheritance and destiny, so be it.
If it is my mission to go in at exits and come out at entrances, so be it.
I have planted by the stars in defiance of the experts and tilled somewhat by incantation and by singing, and reaped, as I knew, by luck and Heaven's favor in spite of the best advice.

...When they asked me to join them I wouldn't and then went off by myself and did more than they would have asked.
"Well, then" they said "go and organize the International Brotherhood of Contraries." I said "Did you finish killing everybody who was against peace?" So be it.
Going against men, I have heard at time a deep harmony thrumming in the mixture, and when they ask me what I say I don't know. It is not the only or the easiest way to come to the truth. It is one way.

--The Contrariness of the Mad Farmer, Wendell Berry, 1967



SO in the interest of avoiding heads-blown-off and to-the-walls-nailed, i followed the "standard of care" of my betters and did nothing, politely and professionally, and so must pretend presume that it is less dangerous to leave mania and postpartum depression untreated - and that "referral" is, relatively speaking (i guess), treatment. i followed the "standard of care" and became a puppet of my preceptors although i disagreed with their assessments (among other things, these women were not objectively or subjectively on the verge, as they say, AND nowhere in 'the literature' do i find the aforementioned prescribing to be out of the sphere of 'our' practice), partly because my preceptors are obliged to sign off on my decisions at the end of the day - but mainly because three of them at once cornered me in the hall and told me to do what they said.

i am a polite person and i play by the rules - a statement that might surprise those who know me well - the thing is - i have this particular set of rules.



i think i can go on record as consistently nonparticipating in systems of violence. i dislike being tricked into participating in them. i get a little, as we say, "reactive."

...when i first became interested in health care, it was because of midwifery. i was vividly struck by a dream in which i walked down to the park by half-moon lake, and came across a large group of midwives, all sitting at a long, long picnic table (they'd pushed two tables together). i wanted to walk by and spy on them, but they saw me and called me over - all scooting down the long long bench to made a seat for me.

i think the image must have come from years of girl scout picnics - and from living next to half moon lake, skating alone all the way across it to the high cliffs in the winter, playing on the sandy shore by the railroad tracks, with my baby and the cat and our little plastic animals, all summer. the image of those ladies at the long, long picnic table, and the particular way you have to scoot, to make room on a bench - it's so vivid and iconic to me, i was surprised not to zip right to it on the google image search. but it's not there. it's in my heart.



later when i became a single mom with three kids - a high-school dropout with a 12-year hole in my resume (and it was more cost-efficient to get loans and grants and go to college, than to get a waitressing job) - i thought well maybe i could be a nurse-practitioner, because they give the best care anyway. i didn't want to be a nurse-midwife and do hospital births. hospital births are so different from home births, they're like the difference between a restaurant and home cooking. just completely different, including different clientele, different standards, different ingredients...

anyway - my town didn't have a registered nursing school at that time. so then i thought well as a doctor, i could could back up the work of midwives and nurse practitioners. so i went to medical school. but then it seemed like i could only back up midwives if i became an obstetrician - and i was absolutely unwilling to enter that particular reindoctrination camp.



i feel like i have something to offer childbearing women, but every time i go to a hospital labor-and-delivery unit, my heart sinks. every room, there they are, lined up like hospital patients in every other unit: gowned in identical dreary cotton gowns and lying on disposable paper pads, tethered to the iv pole and the monitor, staring up at the television in the ceiling, asking why can't they eat something, accompanied - maybe - by a loved one wearing a coat. worse than restaurant food - bland anonymous institutional cafeteria food, same thing, every day.

so i don't like birth much anymore. oh, i'm nice to everyone. and i try to compensate. i keep the lights down. i minimize the amount of gowning and masking. i sit on the bed. i catch the baby and put her in my lap and wipe her face off with a cloth and then hand her to her mom. if you don't know how different this is than (normal? regular? ordinary?) the other kind of delivery, you'll just have to take my word for it.



and i tell ladies they can take their own clothes to the hospital and they can sit wherever they want, etc, but most of them are really uncomfortable bucking the system. and the nurses - well, i only just now got a clue that i am not, as a physician, actually supposed to be hanging around during the labor. that's nurse territory. they really do not like it. i could be cynical and say, they just hate trying to talk a mother into an epidural while i'm sitting on the bed. except - it wouldn't be cynical - it would just be true. it messes up their plan to avoid having to readjust the monitor every ten minutes, if i keep tempting the mother to sit in the rocking chair instead of lying quietly in bed. and they drum their fingers waiting for the mother to demand the epidural, a process i greatly impede. so it gets rather unpleasant to go to a birth in a hospital where the nurses are unfriendly. to me! i wanted to be a nurse myself!



yeah, i kind of hate childbirth now.

...last week a guy came into the clinic with a red puffy knee, clearly not normal. it wasn't very painful, but he generally felt like crap, a little feverish, etc. sad but true, by any objective medical standard we needed to tap that knee - i.e., drain off the effusion of infected joint fluid (and send it for culture). he asked nervously, "h-h-how do you 'drain it'?" and i replied soothingly, "in a way that doesn't hurt, as much as possible - we'll use spray to freeze the skin, and then inject local anesthetic, so when we tap the joint, it shouldn't hurt. let me know if it does hurt."

then i went to get my preceptor. bummer - (do you understand that the preceptor is supposed to instruct and observe and make sure nothing goes wrong, while i do the deed?) - the preceptor doesn't think pain medication is necessary ("it's not a long procedure," he explains). he doesn't even think sterile gloves are necessary, which is kind of living on the edge. and he seems to like the larger-caliber needle. long story short, excruciating pain for the patient (multiple pokes - we call them "pokes"), all presided over by yours truly. not my fault? but my responsibility.



now, the preceptor, if you asked him, would say, "never (ever) make promises to patients," so i didn't mention, in front of the patient, my prior conversation with the patient... and i certainly didn't say, later, to the preceptor, how bad i felt. i did apologize to the patient. not for the change of plan, although i feel awfully guilty - for what? change of plan? for not preparing the patient that anything can happen? but i didn't know anything could happen. i apologized for the pain, but that's not all i was sorry for.

after that, i said nothing. you're not supposed to feel guilty about what happened to your patient - it's one of the unwritten rules. express it and you will be met with shocked silence. you aren't supposed to have anything to be guilty for. if you do, you're a bad doctor. but instead of suppressing bad doctoring, we suppress guilt. i lied to my patient, trying to do what i understood to be the right thing. i pretended to 'first do no harm,' but i wasn't allowed to 'first do no harm.' and needles in joints give me the creeps under the best circumstances.



it was strangely reminiscent of attending hospital births. my point is i don't know if i'll keep doing births after i enter full practice. but this seems ass-backward crazy to me! why did i even start any of this? not because i love formulating complicated insulin regimens! not because i want to do more throat swabs!

it was because i wanted to back up midwives. but as a fam doc, i don't think i can, medicolegally, provide much in the way of technical backup. however - ray of hope - my own primary doc (fam doc) recently told me she's one of 3 local lady fam docs who do provide home midwife backup - they basically consult on confusing cases, and order labs, and do ultrasounds and newborn screens and so on. they don't do cesareans, but i guess then if a lady needed to transfer to the hospital, she could be cared for by the midwife (over cover as "doula") and the fam doc, who would call in the cavalry if surgery was needed.

so i could kind of see that...

right now what i'm visualizing would be something like a lifespan women's health center, me solo beside a midwife practice - i can do the gynecology and the pediatrics and the geriatrics (not to mention the irritable bowel, fibromyalgia, and chronic fatigue), and they can catch babies. maybe they'd let me help out sometimes. you know who else should have a room down the hall? a social worker/psychologist. hang a big old rainbow flag out front, and we're set.



so whenever i have a little free time, i'm reading up on solo practice, putting ekg and ultrasound machines on my amazon wish list [note: do NOT buy any expensive equipment from my wish list without talking to me about it first. not that you can afford it, ha ha], and visualizing, as hard as i can, some way to reconcile ethical practice with the material medical world as we know it.

recently i was google-surfing phrases we all use (current favorite source for found poetry), like "do i really need to go to the doctor?" and "i hate doctors," and it really reminded me of... of reality. reality is not rolling your eyes angrily at the drug-seeking crock who came back for the third time this weekend. reality is not "time for your iv - it's routine, dear." reality is not "a two-year-old male with pyelonephritis, a really interesting case, check it out!"



reality is "i tried to be good and stay sick for 2 weeks before coming in, but the doctor laughed at me anyway." reality is "i hate western medicine, nobody knows who you are and nobody gives a shit about you." reality is not knowing how much of the truth you can tell your doctor, and deciding not to tell any of it. y'all know this. but with the thick soft wooly blanket of medical culture over your head, you wouldn't remember it either.



every day, in every way, as i am regarded more and more as a "real doctor," the pull of indoctrination, the pressure to look at people the doctors' way, gets more intense. it makes me angry. i visualize visualize visualize to resist.

and why am i being regarded as more and more of a "real doctor"? is it because i go ahead and drill a fat sharp needle under the kneecap without anesthetic? because i use the word "hypertension" and "episiotomy" when i could have said "high blood pressure" and "cut open your vagina with a pair of scissors"? because i worry i could get sued, ostracized, or assaulted, for first doing no harm?

what a life!

SONG LYRIC TIME

She tells me about last night and her hundred and third first date.
She counted, she counted her pairs of pants again, "I’ve only got fifty-three, minus the ones I’ve got on."

I want a restorative beer to take my mind off these tears.
I want a restorative beer.

Get the catalogue free from Desert House HD3 Box 111111 Albuquerque.
Talked to my 25-foot phone extension cord about the needlepoint therapy blues.
And then I knew: I want a restorative beer to take my mind off these tears.
I want a restorative beer.



I want a restorative beer to take my mind off these tears.
I want a restorative beer.

--Restorative Beer, the Fiery Furnaces, 2004

that's it! we're joining the jungle patrol.