Green Acres Mobius Strip

Yesterday I became lost in the morass of the Smallish State bureaucracy which tries to reduce Medicare medication expenditures by limiting doctors’ prescriptions to certain drugs, and requiring “prior authorization” for alternatives. The patient involved was just discharged after being hospitalized more than a year. The medication involved costs about 25 cents a day (retail). I have spent over an hour and a half calling 800 numbers, filling in forms, faxing, receiving faxes, reading replies, looking for allegedly faxed forms that did not arrive in my mailbox, re-filling in other forms, and re-faxing them. So far, I estimate that the Smallish State has spent enough paying me to do this to purchase roughly two to four years of the medication—which may be longer the patient’s life expectancy. Meanwhile, he still does not have the medication, which helps him sleep. If he’s not sleeping—and I bet he isn’t—he’ll probably be back at Green Acres in a week or two. Where he will cost the State upwards of $800 a day.

And the greatest irony is, the person trying to prescribe this medication, and the people in charge of trying to deny it, work for the same state agency. Your (my) tax dollars at work.

Update On Staff Holiday Gift

Shrink or Fade thanks all readers who sent creative suggestions on what I should give my hospital ward staff for Christmas. In the end, I put together a big box containing 25lbs of Dunkin’ Donuts coffee (a ward favorite), 50 packets of hot chocolate, and several boxes of “Tension Tamer” tea.

The gift seemed to go over well—particularly the coffee. Some staffers were seen scurrying away with the gold-colored DD bags, to “put them in a safe place”, in a fashion that reminded an onlooker of Gollum with his Precious. In a move that I did not particularly condone, the Day shift secreted roughly 15 pounds of coffee for itself, allocating 5lbs each to the Evening and Night shifts.

A review of the kitchen stores this morning revealed that the coffee is being rapidly consumed. A few of the hot chocolates have disappeared. The “Tension Tamer” boxes, however, remain in their plastic wrappers.

Deforesting Green Acres

Patients admitted to Green Acres arrive under one of three legal situations: Voluntary, Emergency Involuntary, or Court Committed. The distribution is roughly equivalent between the categories.

As part of my admission (tree-killing) process, I have to fill in a form where I check off the legal status of the new patient. The only check-off options on the form are Voluntary and Emergency Involuntary. So for five years, each time I received a Court Committed patient, I have been drawing my own check-off box, writing in “Court Committed”, and checking the box. I brought it up once or twice, but no one cared. Such problems are small potatoes in the ever-simmering rancid stew of absurdity that is Green Acres.

But last week, one of the Ladies Who Are In Charge Of Checking Things brought one of these completed forms back to me, saying “You can’t just write extra things in on these forms!” I protested that with three possible realities, but only two check boxes, there was no other option. She said, “Well, I will bring it up in Inefficient And Preposterous Committee next time we meet, but in the meantime, you will just have to choose the best option from what’s there.”

Not liking to lie on paperwork over my signature, I continued doing what I’ve always done. Today the person found me again. She reported, “I brought up your new idea for the form in I&P Committee! They really liked it! They thought it made sense. I think they’re going to change the form!”

The tone of voice, and body language, implied that I should be about as excited by this as by, say, having my proposed design for a permanent lunar base selected by NASA. I am trying to hold back my joy. But I had to share it with you.

This Is Still Not A Cat Blog, But...

You might be a "cat-person" if:

Your monthly cat medication bill exceeds your electricity bill, and you are on a first-name basis with all three pharmacists at the veterinary pharmacy.

A Rant From a Chef Trying to Make "Winter Stew"

What is the problem with parsnips? Why can I never find them at the market? It seems parsnips have gone out of fashion. It is a pity.

Parsnips, by the way, should not be confused with turnip, which is similarly out of favor, but for much better reason, as no one really ever liked turnip to begin with.

Advanced Minds

Sometimes it fascinates me that certain arrangements of pixels on a computer screen, certain oscillations of pressure waves in the air, or certain patterns of light and dark on a slip of paper can drive a human being to destroy himself. I know of no other animal who will behave thus. What does it say about us?

Naus

Snippet of lyric stuck in my head for the past two days:

"You nauseate me, Mr. Grinch.
With a nauseaus super-naus."

[Slaid Cleaves version]

I just love that phrase-- "a nauseaus super-naus". That Dr. Seuss, he was a genius with the language.

I Just Work Here

I deleted the post from last week in which I complained about the disrespect (mockery might be a better word) I received from a hearing officer. After a day or two it sounded whiny. I still think that sitting for several hours in such a meeting is a waste of my medical degree, but then, so is much of what I do every day. So are the hours a cardiologist spends on the phone with insurance companies to get prior authorizations for heart procedures, and the hours doctors in private practice spend filling in billing forms, and so on.

Thoreau wrote, “You are paid for being something less than a man.” I see this is generally true. I get paid the (relative) big bucks here, and often I have to accept being something less than a man—that is to say, swallow my pride, or my ideals, my knowledge, or, at times, even my ethics and morals. I did less of that when I first got here, but, perhaps not coincidentally, I am paid better now. I am starting to see, however, the hot-spots where being less than a man is wearing on me, causing blisters as it were.

On a related note, I was doing a bit of perusing the other day and discovered a court case in which a client had sued GA for violating his rights. The rights violation in question: being awakened at 8am on weekdays. This case was first decided in superior court, but then appealed to Smallish State supreme court. I kid you not. In such a climate, it is hard not to think constantly about the likelihood of lawsuits.

Advance Directive

Compared to other shrinks working with severe and chronic mental illness, I am probably less prone than average to rely on medications. But there are a few treatments that have, at times, produced such miraculous, positve change that I cannot help but consider them almost magical under the right circumstances. So herewith I would just like to mention that if I ever become incapacitated due to one of the illnesses below, I request the treatment noted be administered to me as rapidly as possible.

Psychosis: Clozapine
Mania: Lithium
Severe depression: ECT
Agoraphobia, social anxiety, panic: SSRI (your choice)
Rage attacks, "losing it", throwing flower pots: Clonidine

All the rest are dubious.

Question For Fellow Shrinks

Do you ever feel that there is just no hope of truly knowing whether a given person has a mental illness—let alone what the illness is? I mean, with all the possible confounding factors inherent in the history of any adult who has had even a moderately tough life— and with the fragility of the human brain (have you ever looked at this organ, out of a skull? It’s as sturdy as slightly overcooked oatmeal)-- how can you ever winnow out a diagnosis?

Example (purely fictitious, but hardly unusual in my practice): A 32 year old man presents with a wide variety of mental symptoms. Doesn’t even matter what they are—just assume they are many and varied—a mixture of mood, thought, cognitive, behavioral, and personality features.

You are lucky enough to get the following (unusually detailed) history: His mother was a smoker and drank heavily. He says “I almost died when I was being born.” He remembers his father beating his mother, but doesn’t know if his father ever beat him— he can’t recall anything before about age 6. The family lived in a run-down neighborhood and he had little supervision. When he was 9 he had an accident of some sort. He thinks he was unconscious for a time. He doesn’t remember the accident. His parents told him he fell off a deck. He also fell off a moped at some point and hit his head, without a helmet. In high school he drank heavily and used marijuana daily. He had few friends, but he hung out with a group who huffed inhalants (he says he “never tried it.”) He enjoyed asphyxiating himself for erotic arousal. His grades were always poor and he was frequently disciplined for bullying smaller children. He dropped out before graduation. He worked in a string of blue collar jobs including a smelting plant, an industrial cleaning service, and a cannery. He was arrested for possession of crack (which he says he was “holding” for a friend), as well as assault vs. the arresting officer. He was imprisoned for 9 months. He reports being raped in prison. He had a girlfriend but she took out a restraining order after accusing him of killing her ferret with a shotgun (which he denies). He says he has never been able to concentrate on anything, but felt this improved when he snorted cocaine (which he states he did only once.) He feels “jumpy” all the time.

The diagnos(es) is/are:

(a) Fetal alcohol syndrome
(b) PTSD from physical abuse from his parents
(c) PTSD from an accident
(d) PTSD from rape
(e) ADHD, lifelong, untreated
(f) Antisocial personality disorder
(g) Mild mental retardation, congenital.
(h) Mental disorder due to traumatic brain injury (“fall”)
(i) Mental disorder due to traumatic brain injury (moped accident)
(j) Mental disorder due to acute cerebral anoxia (at birth)
(k) Mental disorder due to repeated cerebral anoxia (autoasphyxiation)
(l) Mental disorder due to substances (childhood lead poisoning)
(m) Mental disorder due to substances (chronic alcoholism)
(n) Mental disorder due to substances (marijuana, crack, coke, PCP, heroin, LSD, mushrooms, god knows what.)
(o) Mental disorder due to substances (hydrocarbon inhalants)
(p) Mental disorder due to substances (heavy metals or other industrial toxins)
(q) Bipolar Disorder of any flavor
(r) Psychotic Disorder of any flavor
(s) Anxiety Disorder, of any flavor

Without some kind of time-machine, or magic CSI brain pathology decoder lab, it seems simply impossible to sort this out. So frustrating.

Urban Mountaineering V (But Who's Counting?)

Tonight I went to the gym to simulate an ascent of Mt. Washington on the StairMaster. That contsitutes 3,588 vertical feet (assuming an approach via the Ammonoosuc Ravine-- it's a little longer from Pinkham Notch). For those unfamiliar with our mountains, that is roughly 3.6 Eiffel Towers. On the StairMaster, this equals 4,305 ten-inch steps, or 269 "flights" of 16 stairs.

The task was surprisingly easy, and clearly needs to be made harder to approximate the actual effort of climbing Washington. I wonder if the other gym-goers would object if I wore my heavy winter climbing boots and a 30lb backpack. I suspect someone might call Homeland Security.

Thanks to girltuesday, Shrink or Fade's in-house legal counsel, for coming along to prevent any liability issues. The gym is a dangerous place. I feel safer in the mountains.

Distillation

Sometimes, when I boil things down in my mind until they reach their most distilled form, I find that the finished product is toxic in its purity.

Today I was trying to isolate the source of a specific flavor of job stress. “Why do these [particular type of] meetings make me so anxious?”, I wondered. At the bottom of the process, I found that this scenario is entirely possible: By forgetting to circle one word in a particularly complex, tedious, repetitive, poorly-photocopied, 10-page-long application form involved in these meetings, someone could quite plausibly die. And, what’s more, there are lawyers actively promoting that scenario. It’s really as direct as that. I could go into the details, but they are just dilution, just fluff. What looks like paperwork is actually a matter of life and death. That’s why it stresses me.

You Just Might Find You Get What You Need

Yesterday was a crummy day, full of being cursed, screamed at, having fists raised at. Then I had a long, dark, rainy drive home, and finally a really rotten night.

This morning I needed something good, and it appeared. The only radio station worth listening to—a local, underpowered, semi-public university station—usually only reaches halfway through my hour-long commute north. But today, due to whatever sort of atmospherics, it stuck it out all the way to the interstate exit. Live Elvis Costello. A “deep cut” from London Calling. Some kind of instrumental surf-grunge guitar piece related to a particle accelerator at Stanford. A 10-minute-long extended remix of a The The song (on vinyl). And so on.

Then, at GA, the ward clerk delivered me a formally enveloped and addressed Christmas card. It was from a patient on a different ward, with whom I’d worked some years ago. He is arguably the smartest person in the hospital, medical staff included, but seems to have virtually no connection with the real world, let alone connection with real people. So I was shocked to read the handwritten message: “May your love and goodness be forever thine aid in times of trouble, and your support as you travel through life, giving love and help.” I still cannot quite reconcile the writer with the writing. I think it will be the best Christmas present I get this year.