Tuesday, March 31, 2009

Still Time To Wish Belatedly

Yesterday was National Doctor's Day. Not that this gets much attention. I didn't even manage to get a single "happy National Doctor's Day!" out of the people who were unabashedly notified, by me, of the fact that it was National Doctor's Day. Even my doctor mother did not wish me a happy National Doctor's Day (nor, to be fair, did her doctor son call to wish her one.)

National Nurses Day, on the other hand, is only a prelude to the festivity-filled National Nurses Week (May 6-12) That one gets a lot more hoopla, or at least it does at Green Acres (donuts every morning, ice cream parties, games, pizza, awards, new car for every nurse, etc.) Not to sound bitter. I know nursing isn't easy. But neither is doctoring, sometimes.

Monday, March 30, 2009

Didn't Work

"Anonymous has left a new comment on your post 'And I May Stop Walking, Too': one word solution to your problem: ipod"

Okay, so I tried Anonymous' suggestion this morning. It seemed at first to be working pretty well. The iPod didn't do anything about the cigarette smoke, or dog-doo, or pedestricidal drivers. But at least the music drowned out some of the city din, and having headphones in seemed to dissuade some of the perennial panhandlers from targeting me for cigarette money.

A few blocks from my office, I was striding rapidly along enjoying some James Taylor, namely "Sun on the Moon". Just as the lyrics "More, more, daddy gimme some, gimme some more, more, daddy gimme some more" came on, a guy approached and, using hand motions, indicated that he needed to speak with me. He was pretty well dressed and groomed; I was a bit annoyed to be interrupted, but on the assumption that he needed directions, or something similar, I stopped and took out my headphones.

"Sorry, do you have 35 cents?", he asked.

"No," I answered quite truthfully, "Sorry, I don't have any change." (All I had with my was one $20 bill.) I started to put my headphones back in, thinking that was the end of the interaction, but he continued. Holding out a hand already full of change, he said, "Really, you don't have 35 cents? Because listen, I..."

At that point I didn't give a flying eff what he was about. I walked off.

Thursday, March 26, 2009

And I May Stop Walking, Too

My scheme of moving my office downtown and becoming a foot-commuter from my urban(ish) home was supposed to reduce my stress level and result in myriad physical and mental health benefits.

Unfortunately, after 15 months on the new plan, I find it isn't really working out. Walking to work is not especially relaxing. In fact, it's turning me into a bit of a crank. I find myself perpetually and increasingly pissed off about the hazards and annoyances that confront me on the walk. They're all small, almost trivial, but they add up. Here are a few:

- People who walk in front of me smoking (almost everyone on the sidewalks of the Smallish City seems to be smoking), wafting the tarry cloud back into my face.
- Ne'er-do-well 20-somethings flying down the sidewalks on BMX-type bicycles built for 8-year-olds.
- Dog poo (this season is the worst.)
- Noise assaults (firetrucks, idling diesels, screaming people, barking dogs...)
- Sidewalks completely obstructed while boats, or hot tubs, or lawn tractors, or whatever, are moved in or out of the city arena for whatever consumer "show" is on this week.
- Drivers who completely ignore the large, day-glo "STATE LAW - STOP FOR PEDESTRIANS" signs at intersections.
- Drivers in Escalades and Grand Cherokees flying out of parking garages without looking for pedestrians (I've taken to bashing them on the rear fender with my fist or umbrella when they do this.)
- People asking me for money (I mean, now and then, fine... but the same people, every day, both directions, starts to wear off.)
- Making mental lists of pedestrian-related maintenance the city has chosen to ignore (e.g., crosswalks which have completely disappeared for lack of re-painting.)
- People who can't figure out how to use the sidewalk (veer side to side when approaching from the opposite direction... gather in an impassable, smoky clump in front of bars and coffee shops... come to a complete and sudden stop in front of you when something interested happens on their cell phone... etc.)

Ironically, I think park of the problem is that we just don't have enough people on the sidewalks. I lived in Manhattan for a year, and always enjoyed walking the city. There was a great energy to the mass pedestrian river there. The sidewalks were crowded, but people knew how to enter the stream, float along with the flow, and ease themselves into a back eddy if they needed to take a phone call or make a turn. Here, not the same. You might have the sidewalk to yourself for 50 yards ahead-- but you can see that one person coming the other way, and you can just tell that, in defiance of all laws of probability, he will at the last moment steer himself in your direction and almost bump into you.

I kind of miss my long, quiet drive to work, listening to the radio, watching the trees. I'm not moving my office. But I need to find some way to get over my sidewalk-rage.

Tuesday, March 24, 2009

Interesting Things I Heard Today

"Wellbutrin is bad. It made me burn a smiley face in my hand with a cigarette."

"I was using three oxycontins a day. But I cut back to one and used the extra money to get cable."

Rant. Only Slightly Like Andy Rooney.

Does anyone walk to school anymore?

When I was in elementary school, my brother and I walked (or biked) to school most days. It was about three miles round-trip, and there were two big hills. There was also one very hazardous intersection, requiring crossing about 8 lanes of traffic via stepping-stones of four traffic islands. It was a lot like playing Frogger. But there was a nice crossing-guard lady who helped us across and said good morning and told us to be safe.

The other day, going to Green Acres, I passed the elementary school of a small town en route. Up and down the street by the school, kids were standing out on the sidewalks waiting for the school bus. None were more than a quarter-mile from the school. Some were within sight of the school. I don't get it.

It's similar in my residential city area. The elementary school is smack in the middle of the neighborhood, surrounded by houses in all directions-- but I almost never see a kid walking to school. We do have crossing guards in the neighborhood-- at least ten of them-- but like the unneeded Maytag repair man, their job is very dull. In cold weather, some just sit in their idling cars parked near their assigned intersection. One fellow (across from my house) lounges in lawn chair in warm weather, listening to the radio. His hand-held STOP sign fits conveniently under the chair. I have never seen him have to get up to walk a kid across the street.

I was particularly appalled yesterday when I saw one of the crossing guards with a cigarette dangling from his lips. He needed both hands free to operate the lottery scratch-ticket he was using. His STOP sign was parked under his armpit.

Cash Extractions

There was a newspaper article this morning discussing how the Smallish City is having some bond-rating issues, and how our City Fathers are taking steps to "increase cash reserves" to address this problem.

The article didn't say how, exactly, the cash reserves are bieng increased, but I can tell you one strategy they're employing: sudden, utter ruthlessness on the part of the Parking Divsion. Reports are coming in from all directions of Machiavellian ticketing practices which seem designed to extract every possible dollar from the city's residents.

I myself have had only one brush with this so far: I tried to appeal a $25 parking ticket from my scooter. It had been parked in an out-of-the-way cranny of a large public plaza while I was at work. My grounds for appeal were: (a) the ticket was for parking "on the sidewalk", but I was obstructing no place that one could walk; (b) there were no signs indicating that scooters could not park in that area; (c) several scooter-commuters had been parking in that area for several months without any issue, until the day they suddenly decided to ticket us all; (d) there is no legal place for a scooter-commuter to park for the day downtown (scooters and motorcycles are banned from the parking garages, and there is a 2-hour limit on all street parking.) Anyway, my appeal was summarily denied.

Next, Housemate had her car towed away for accidentally violating a snow "parking ban". This is not unusual, but it is extremely annoying and costly. What was truly maddening, though, is the city did not actually remove any snow from the street that night. Just towed cars and collected money.

Next, the city suddenly started enforcing the one-hour parking limit on our residential street. In order to avoid this limit, you theoretically need a resident parking sticker-- but for many months, if not years, this has not been enforced. Housemate has lived in the neighborhood and parked on the street sticker-less for several years, she says, without incident. She and was not even aware that there was a parking-sticker program. Indeed there are no signs on the street mentioning resident stickers.

Anyway, Housemate returned home from work one day last week to find a $25 ticket. She wasn't even sure what it was for. The next day she put her car in a different place on the street, but came home to two $25 tickets. Now we're hiding her car in the driveway until she can get to city hall to get the stupid sticker. The irony is, she has a parking space at work. But she got tickets at home because she chose to commute on foot.

Next, I heard of some elderly neighbors down the street who got a parking ticket in their own driveway. They were unloading groceries from the trunk; in order to be able to access the trunk without ice and snowbank obstruction, they had briefly left the rear of the car slightly protruding into the sidewalk area. While they were between grocery loads up stairs to their apartment, BAM!-- ticketed.

Then this finale: I was walking home last night and saw a tumultuous confrontation going on between a couple on the street and a parking officer, whose pickup truck was pulled up behind their car. There was a great deal of agitation and shouting. The woman was sobbing "Why are you doing this?!", and appeared to be trying to physically strike out at the parking guy. The man was physically restraining her from doing so. The parking guy was shouting "NO EXCEPTIONS! THERE ARE NO EXCEPTIONS!"

As I got closer, I realized to my amazement that the man was actually Dr. W., a physician colleague from the neighborhood-- a mild-mannered, grandfatherly teddy-bear of a fellow in his sixties-- and the woman was M., Dr. W's diminutive, kind-hearted, grandmotherly wife. As I finally arrived at the corner, Dr. W and the parking guy were both driving their cars away; M. was on the sidewalk tearful and shaking. I went up to ask what was going on. She grabbed my arm, still crying. She explained that she and Dr. W had been parked at the curb for a minute in order to help her 92-year-old mother out of the car in front of the theater, but in the process, the parking guy had come up, started writing them a ticket, and refused to be dissuaded. "She hasn't been out in town all winter, because she can't walk well and the sidewalks are too dangerous with the ice.", M. said. "She just wanted to go to this concert. But they want to ticket us for it."

I'm giving serious thought to moving out of the city.

Friday, March 20, 2009

Just Weird

Overheard today:

"My husband's business is trying to declare bankruptcy. But it's going very slowly. His lawyers keep putting it off. Apparently they are too busy with bigger, more lucrative bankruptcies."

a further indication of just how bizarre our economic world has become.

Backyard Countdown

Days to Crocuses: 12
Tulips: 50
Lilacs: 56
Clematis: 70
Irises: 77
Poppies: 81
Day lilies: 100
Morning glories: 110

Last frost: 46
First frost: 200

Thursday, March 12, 2009

Economics of Opiates

I've recently started treating some people with opiate dependence in my private practice, using buprenorphine. This is something most docs in the area don't do, partly because you need to get special training and certification, and partly because most docs would just as soon not deal with opiate addicts if they can avoid it.

I decided to give it a try, partly out of curiosity, partly out of civic responsibility (there have been appeals from the state department of substance abuse pleading with us us to get certified and start treating people), and partly because business has been slow and I really need more income.

That last aspect is definitely tricky. Most people doing this treatment in private practice don't take insurance for it, and most of people who call me asking about buprenorphine don't have insurance anyway. Most, if not all, have a terrible story of woe and financial ruin, and would like be seen for reduced fee, or half fee, or free.

I researched what other docs and clinics charge for buprenorphine treatment. It's not cheap-- somewhere on the order of $1,000 for the first month, and $200-500 a month thereafter, for office visits (medication comes from a pharmacy, so is separate-- might be in the $300 a month range depending.) I've set up my rates to be considerably less than what seems to be the national average, but still, I'm not free, because doing this work isn't easy.

So a year's worth of my help in keeping off street drugs might cost someone $2,000, plus another $3,000 for their meds. Seems like a lot, until you compare it with the cost of using street drugs. My last new client told me he spent over $50,000 on oxycontin last year. Heroin isn't free either. So the argument goes, if an opiate user can afford a steady street drug habit, he can surely afford treatment to stop using. Here's a hard-nosed missive on that topic from a doc who is a recovering addict himself.

But here's the rub: to pay for their drug habits, these patients have almost universally done bad stuff. Unless they happen to have a huge trust fund, by the the time they seek serious treatment they've almost certainly drained their own bank accounts. Most likely they've borrowed extensively from friends and family, who are not not going to loan them another nickel. Quite possibly they've been stealing, cheating, and/or dealing in order to pay for their habits. In other words, they do have ways of paying for their street drugs-- but it may not be pretty, or legal, or anything that a doctor wants anything to do with.

That poses a real ethical dilemma for me. Let's say, for example, that someone is embezzling $10,000 a year from his employer to pay for oxys. And he comes to me saying, "I'd really like to kick my habit, and stop being a criminal. I'm totally willing to pay you your full fee-- I'll still have to steal $5,000 a year, but that's okay. If you could see me for half fee, though, I'd probably be able to afford it without stealing. I'd feel really good about that. If you can't help me I guess I'll just go on stealing $10,000 a year and using oxys." The only option that doesn't leave me feeling guilty at all is the one where I don't make a living myself. Of the other two, I'm not sure which makes me feel least guilty.

And this isn't an exceptional scenario. This is, in one form or another, the usual story. A new patient last week had discussed payment with me in detail on the phone prior to her first visit. Then, at the end of the visit, she was shocked to "learn" that payment was due; she said she though I was going to bill Medicare for the fee. She had called so many doctors seeking treatment, she said, that she must've gotten confused about who had which policy. She rummaged in her purse, pulling out some cash, and said she could pay me about half. She went to see if she could borrow some money from her friend in the waiting room, but not surprisingly, he was unable or unwilling to loan her any. She had another $20 she could give me, she said, if I really insisted, but it would mean she couldn't buy diapers for her baby this week (I declined the $20, unsure if that made me compassionate, or a total sucker.) She said she would have more money in five days, and would put an envelope of cash in my mailbox as soon as she did. I didn't expect to see it, and didn't, and didn't hear from her.

But then a month later I found an envelope with $60 in my mailbox. "Sorry this is so late", was scribbled on it, with a smiley face. Sometimes people surprise you. I had a warm and humanity-loving feeling. Until it occurred to me that her kid might be without diapers, or some cash register might be short $60, or one week's worth of the prescription I'd written her might've been sold on the street to pay me. Then I started thinking about getting out of the opiate-dependency treatment business. Then I thought of the plea from the department of substance abuse. Then I went to bed and tried to stop thinking.

Wednesday, March 11, 2009

Canadians... again...

I just discovered that my favorite childhood film was Canadian. Of course.

The scene where the canoe slides down the hill of snow into the icy stream has been in my mind for decades.

The part about having children breathing fumes of molten lead no longer seems like such a good idea, though.

Monday, March 02, 2009

Blizzardy Monday

I'm at Green Acres today. There's a normal-sized blizzard going on this morning. I've noticed that hospital employees' ability to drive in the snow varies considerably based on profession. At least that's the conclusion I draw, based on a survey of who shows up for work on snowy mornings. From highest winter-driving skill to lowest, the ranking is roughly thus:

1) Nurses
2) Housekeepers / Food service workers /Building maintenance (tie)
3) Doctors / Mental Health Techs (tie)
4) Clinical supervisors / Recreation Therapists (tie)
5) Social workers
6) IT department
7) Administrators of all flavors

You should take this list into consideration if you are a young person aspiring to become a good winter driver. If you decide, for example, to become a state human resources administrator, you are very unlikely ever to figure out how to get your car out of the driveway between November and April. If you go to nursing school, on the other hand, you will be able to drive a Yugo with two flat tires and a broken defroster 20 miles through two feet of snow in under 15 minutes.