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Last Wednesday at lunch a pharmaceutical representative presented a ‘new’ medication which is really an old medication (long time in generic form costing ~ 15-20$/month) repackaged with some sort of substance or microchip which, once swallowed, a tracking device (a patch to the ribcage) monitors if the patient has taken the daily dose. The information is transmitted to the patient’s app  “and to three or four others as they wish” including the doctor. In his/her copious spare time the physician gets to monitor adherence via an app or through the pharmaceutical website. Presumably one of these watchmen contacts the noncompliant patient to inquire why aren’t they taking their medication and do so now. The medication/system isn’t prescribed like other medications but requires an application (ironically a paper one) and the Rx can only be filled at specialty pharmacies not with the usual pharmacies the patients are already using for their other meds. By the way, the price of this system is 1,700$/month.

What could possibly go wrong?

It took a lot of composure for me not to choke on my sandwich as I listened to this Orwellian situation. I distilled all my questions into one simple inquiry: is there any evidence this system improves adherence compared to setting a daily alarm (as I do) to take your meds. There isn’t any. Ah well.

This is why we can’t have nice things. Once in a while I read about some effort to ‘reduce the rising cost of medication’ like capping the price of insulin or epi-pens but these are quaint band-aids that don’t address the real problem: advances in medications are driven by private industry and they based on profit to please the stockholders not patients. In their defense pharmaceutical companies spend billions on creating meds so they want their money back. The makers of medications lose their patents and have come up with these sci-fi situations and send out salespeople to convince me it is something groovy.

In the USA we are bedazzled by technology and think applying it makes things better. How long though before Rx adherent app information is hacked or sold to others like advertisers or insurance companies. There is something Borg-like about walking around with a patch on monitoring what’s in us. On the other hand we seem OK to walk around with our phones shouting our whereabouts and goings-on to anyone who wants it.

While I am ranting about medications and the machinations mated to them let me add here I have enough money to retire. But if I stopped work I would lose health insurance particularly prescription coverage. I’ve down the sums: the amount of money I would have to pay per month would skyrocket making retirement unaffordable.

Sadly the main reason why this medication won’t be used much isn’t the cost or concerns about privacy but the doctor’s emotional sensation ‘this is going to be more work for me”. They imagine a clinic-full of patients’ electronic information coming in daily and feeling obliged to watch/record it all.  And they are not wrong.

When The Other Doctor at our clinic retires I plan on pulling the plug on pharmacy lunches and samples. The patients will howl like an orchestra of scorched cats not to have samples I suppose, but the set up contributes to the national problem of outrageous costs and pharmaceutical shenanigans.

This piece was inspired by (of all things!) through sewing.  Palm Springs coming in March; I became anxious to make a new shirt. I imagined wearing it to the resort and all turning their heads to see and admire it. I had some angst about getting one or two done in time lest I make an ingress without ‘anything new’ and showing up in (gasp) last year’s ensemble. Then my anxiety was assuaged by the realization no one at the resort will be looking at me and none in my party will give a damn if my shirt is new or not. From that I composed this –

It was in my internship when I learned no one cares. It was a difficult year but when I look back on those sorrowful twelve months the worst part was this awful anagnorosis. For the first time in my life I was doing badly, I was struggling, and I wasn’t doing a good job – and the powers that be didn’t try to help or show sympathy but got rid of me. They did not care about my welfare. It was my first time I had experiencing this. All through my life I had been surrounded by family and friends and teachers who did care allowing me the charming illusion life would be like this. Looking back I was quite naif if downright foolish to think this. Going to professional school delayed a truism most others learn earlier in life: no one cares.

When we are out and about no one is minding us let alone concerned about our well-being.  Think on the folks who are not able to find work or pay their bills. The poor, the lonely, the homeless – most of these we dismiss as not our problem.

When we realize no one cares this leads to a depression or disillusionment with elements of bewilderment perhaps even betrayal. If the illusion wasn’t too long or profound to begin with this falling apart isn’t too bad. Regardless of when and how our trains arrive at the same station: if we are lucky we may have some family, friends or loved ones who care for us but that’s all.

If we look closely growing pains have an element of comfort to them. It is no coincidence in the Myth of Pandora along with all the world’s woes is the faint glimmer of hope. If no one cares about us then it doesn’t matter what we do/are – we can stop worrying what others think about us as they don’t. We are released from the awful yoke of custom and convention. This is sometimes called The Spotlight effect”: we walk around worrying what others are thinking about us; we avoid going to parties as ‘everyone will be looking at me’ with my so-called faults. We may have some deficits and disproportionate bodies (and last year’s Spo-shirts) but no one cares. What a comfort. The Golden Child departs with it goes Vanity. We don’t have to live up to anyone’s expectations or views for no one cares. And that isn’t as horrible as it was once thought to be.

OfficeThis morning I fixed the printer in my Mesa office. The warning light was correct after all: there was a paper jam. I’ve disassembled the villainous device several times only to find not a shred of stuck paper. Before I threw it out I tried again and lo! There is was obvious as otters.* It was extracted and Brother 450 is running as if nothing was the matter. I am pleased as punch I didn’t give up. Better yet, I can print prescriptions again. Sometimes patients want paper scripts so they can shop around for the lowest price. Without a handy in-office printer  I’ve had to run back and forth from my office to the main office printer to load the special paper and go back to press the print button; it was all a lot of fuss.

The ability to send prescriptions electronically  is a god-send. It’s like having a calculator or the microwave oven: how on earth did we function before it existed. All day long the empires of CVS and Walgreens send me scripts which I lob back quick as quarter notes. I call this “Prescription Pong”. Mind! I have to be careful as pharmacies may ask me to renew Dicky Purdy’s Prozac – and I haven’t seen Mr. Purdy in years and he’s overdue to come in for an appointment. I send back the polite note no meds until he shows his ass in my office.

Back to the printer.

In the bad old days all prescriptions had to be hand-writtern oh the pain. These were often illegible and they prone to forgery. Rx pads had to be locked up lest they were stolen.  It iwas an awful nuisance for folks to call monthly to announce they have to drive in – again – to pick up their prescriptions. No more of this now thank goodness.

It’s 2020: weren’t we supposed to be paperless, all things whizzing around the internet? I guess it is merely a matter of time it becomes law all prescriptions be electronic not hand-written.  I used to have a stylish prescription case made of leather not unlike an ipad cover.  I don’t know what happened to this quaint accessory; I probably threw it out with the Sony Walk-man single CD player.

Today is Tuesday:  I will see over thirty ‘med check’ patients, many of them well over four feet and most in need of a prescription.  At least one of them will want a hand job.** I’m ready for’em. It is nice to hear the printer humming behind me once again.

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*I don’t know what is so obvious about an otter, but there it is.

**hohoho

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The work day before a long weekend or major holiday is usually a frantic one. There are often a lot of ‘no-shows’ as people forget they have an appointment today. There are also lots of frantic telephone calls from folks in hysterics about to leave for the airport needing their medications renewed right now – usually valium. I wrote this entry in piecemeal when people failed to make their appointments.

What I should be doing now is rummaging through my office desk and cupboards to discard old journals and such, the things I’ve squirrel away ‘for later’, papers I’ve completely forgotten about and are outdated anyway so into the rubbish they go.

I just saw a patient with “SAD” which is seasonal affective disorder. This means depression/anxiety worsens in the winter months. When I lived in Michigan I had a lot of patients with SAD. There are not as many of these cases in Arizona. All the same the lack of light this time of year makes even the locals sluggish and logy. On top of SAD are the ‘holidays’ with all their stressful elements hohoho. Unfortunately hibernation is not a feasible option for most: the co-pay on this prescription is outrageous.

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My office – PHX branch

Speaking of winter my office is as cold as witch-tit. As you can see I have the corner office is half windows. When we moved into the place everyone was initially mad-jealous that I got the corner office with its view of the mountains and Evita-balcony. We soon discovered for half the year in the summer months the morning sun bakes it hot as an easy-bake oven and in the other half of the year it’s positively arctic. No one will swap rooms with me now for love or money. I need to remember next week to bring in a little space heater as I am freezing my wrists off even as I type.

Today at noon we are having a telephone conference sales pitch about some sort of device or metric flogged as something useful to my practice. At the moment I can’t think of anything useful I want right now other than someone or something that fills out prior-authorization forms.  The salesman has already lost a few points by putting this at lunch time and not providing food. Thrall #1 (the dear!) went out to fetch us some tuna fish sandwiches served on buns and things.

Later – the  teleconference zoomed in and out in half an hour and I still don’t know what it was about. Imagine someone trying to explain quantum mechanics in thirty minutes. It seems to be an on-line do-it-yourself cognitive exam for patients. It has all sorts of fancy charts ups and do-dads apparently to see how bad is your memory. My soul swoons with questions on its use, privacy issues/HIPPA laws, and the price of such shenanigans. Imagine me telling an elderly patient struggling with memory to go on line to a website and follow the instructions to set up an account and do all the tasks and have it generate a report to send to my office. The saleslady wanted me to sign up before I hung up and she wasn’t one to take no for answer. I’m afraid she had to live with disappointment – at least until I can figure out what the hell she was talking about.

It looks like I may get out today on time enough to go to the gym and then head home for my four days introverted cocoon weekend. This evening I plan on making some bread. It shall be my Thanksgiving treat.

I meet a lot of people (professionally and personally) who remonstrate they are not very happy.  When I ask them what this means it invariably leads to the same nebulous statement they want happiness in their lives and this isn’t happening. Oh the pain. I’ve often wondered if we should eliminate the word ‘happiness’ from the lexicon. We would be better off without the wicked word – or at least narrowing and defining it. ‘Happiness’ is too vague a concept yet we all strive for it. It’s like hunting for an animal you are unsure what it looks like and where to find it but I am damned determined to go out and hunt and capture it and hang its stuffed head over the fireplace. See! You say to the world. I got happiness!  Adding to the difficulty is the erroneous sense happiness is an end-product, a trophy for having accomplish something. If only I had “X” I would be happy. *

Let me try to help.

We ought to do is limit the definition. Happiness is a temporary positive emotion of enjoyment. This morning I had a lovely breakfast followed by a dog walk.  These activities made me feel happy. Yesterday my GI system was tempest tossed from too much hot sauce. I was not happy.  

What people usually mean when they say they want happiness is better defined by the word ‘well-being’.  Happily (pun intended) there is nothing complicated about well-being.  Well-being is the state of being loved, secure, and fed. **  

Well-being is not a ‘reward’ nor an outcome. It has a general sense of feeling content about your lot in life. Some may be shocked to hear well-being is NOT correlated to having wealth, celebrity status, or power. Studies reveal being a lottery-winner or a movie star or a dictator doesn’t create well-being per se.

This is a good time as any to point out the number one asset towards well-being is a good social connection. From it come all that makes well-being.  Your tribes and loved ones should be guarded as if your whole life depends on it – which in fact it does. 

Another problem with well-being is it doesn’t come with fireworks and obvious signs of congratulations. There is no euphoria to it. As a consequence people don’t often recognize it when they have it  but only when it is lost.  Yet if they went back in time they remember being happy and ask their former selves ‘are you happy?’ the former would be bewildered by the question. “Can’t you see I’m busy here running errands and managing my life? No time for happiness now!”  

Be mindful!  Keep tabs on the differences between happiness vs. well-being.  It’s nice to have a big bag of nasty chips and dip*** but that’s not well-being.  Work on well-being.

Forget the rubbish and cultivate your connections – and recognizing it all when it happens. 

iu

 

*In psychology this is referred to as “The Promised Land” fallacy. I see it often in folks who feel once they retire all will be well.  Variants include getting a new job, moving to that city, finding Mr./Ms. Right.  If ‘X” is achieved, then happiness starts.

**Feeling secure is what’s missing most in people’s lives. It’s worth a blog entry in itself.

***That would make me quite happy right now. 

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One of the challenges of my job is I don’t see things ‘abnormal’ but normal things out of proportion or out of control. I spend a lot of time determining if behaviors and symptoms are beyond acceptable and now into pathology.  Eating is an example.  We have to eat so when is eating a pathology?  This morning’s symposium was on the topic of binge eating disorder. When is eating too much considered a disorder and in need of help? 

Not too long ago doctors never asked patients about their food intake (quality or quantity) unless the patient looked overweight.  Then the doctor would tell an overweight person “Quit stuffing yourself Joe” – and Joe either did or didn’t. 

We now know telling a person who is overweight* or binge eats** to stop eating so much is as useful as King Cnut ordering back the tide. Binge eating is about a loss of control about eating.  It is mostly done at night while no one is looking; it is associated with shame. Patients don’t usually bring this up and docs aren’t good at asking about it.  Folks who shovel food right from the refrigerator aren’t coming to see me with this as the ‘chief complaint’. They are coming in with depression, anxiety, insomnia, low energy etc. About 90% of folks with binge eating have other disorders but treating these co-morbid conditions don’t necessarily cause the binge eating to improve.  It needs to be directly addressed and directly treated. 

Like a lot of mental illnesses binge eating suffers from stigma. It is seen as a lack of willpower and your own damn fault.  Men are not as often to have binge eating but they are less likely to bring it up and if they do they are told merely to man up and stop it as dammit men have the ability to do so.*** 

I have a bit of a binge eating problem.I  have a nightly battle to not go to the kitchen and eat bread stuffs like bagels – which I hide from Someone. He would not judge yet I hide it all the same from shame.  When confronted with nasty chips I react in the same emotional way as an abstaining addict confronted by his drug of choice. The momentary pleasure of a starch binge is nothing to the shame the happens afterwards and the self-chastisement for succumbing.  My ‘case’ is mild; it is a fraction of the type and severity I see in clinic.  Part of seeking help is admitting the problem and ‘coming out’ to longer hide.  

It is hoped by going to medical conferences I will go back to work with improved ways to treat patients. Once in a while I get a bit of help myself; this morning I got some. 

*The lecturers spent some time teaching us to be careful with words. Being overweight is bad and it needs to be addressed – but don’t use words like  ‘fat’,  ‘obese”, or ‘large”. 

**It turns out only 50% of thems who binge eat are overweight. One can’t screen out the binge eaters simply by sizing up their stature. 

***Women ironically are more likely to get treatment compared to men as women are more likely to ask for help – and they are seen as less able to do things on their own.  Oh the pain. 

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My life seems to be a series of discoveries in which credos turn out to be codswallop. Every time I feel assured I’ve finally separated reality from the rubbish another so-called truism is exposed for the claptrap it is and always has been. You think by now I’d be used to it. I shouldn’t be surprised anymore when another is discovered to be a humbug. All the same, it irks me to realize I’ve been sold again another set of cheap goods.

Today’s metanoia is about Time Management. Not since the invention of The Wizard of Oz has there been such a sham. If the point of time saving devices is to free up our lives for leisure this has failed utterly. Indeed! It seems whenever there is so-called progress at time saving it creates more work – and expectations that go higher and become (in my opinion) more inimical to our health.  I remember Grandmother shook the rugs out once a month on a certain set day . It took time to do so this but in between beatings she was content to live with carpets not looking their best. She made cookies and played the piano instead. Along came the vacuum and she felt obliged to vacuum frequently to keep up the new standard of having spotless floors and rugs.  Another example of time sucking disguised as time saving is texting. People were once content to call a place and leave a message on a phone machine, knowing these wouldn’t be returned right away. Nowadays if a text/email isn’t instantly returned it is a great anxiety and upset.  It is Lucy and Ethel at the chocolate wrapping conveyor belt at its worst: when you get people to work more efficiently this merely ups the ante.  Making machines work faster and better is well and good but the human brain is probably not wired to work this way – and we are seeing signs of discontent in the worker – at least the ones in the States.

In response to time saving devices have taken over our lives we’ve developed the art of Time Management.  This principle rests upon the erroneous axiom we ought to do as much as possible and as efficient as possible when we do it.  The gist of Time Management is trying to deduce how to incorporate everything  in a better way.  The common sense conclusions to unload things or abandon the axiom aren’t ever considered. Rather we channel the Red Queen who has to run as fast as she can just to stay in one place; to get anywhere she had to run faster.

In my line of work I often see patients with ‘control issues”. This often means they feel out of control of everything they think they should be handling/doing.  I sometimes make the comment it’s as if the gods are trying to get them to learn the lesson doing and being all is not worth it – the gods are aggravating you until you connect the dots and let go of control and efficiency.  When my patients let up they report feeling so much better and their worlds don’t implode either.

I am planning to practice being more at peace with not needing to do everything for everyone right away. Things can wait or not happen. The rugs can have some dirt for awhile and the emails don’t need instantaneous attention.  I may not get as much done and not as on time but I think I will feel better.  I can wave at the unwrapped chocolates as they whiz by. Either the gods will slow down the conveyor belt in response or I will be fired.  Either way sound good.

 

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One of my psychiatry professors liked to use new-age lexicon to illustrate theories of psychology and psychotherapy. It was often difficult to determine if she was being literal or figurative about her points. She sounded like Professor Trelawney but her advice was sensible and useful. I use her teachings more than any other of my mentors. One tip she taught was ‘reaching out to the third chakra”. I won’t go into the theory of chakras here, only to illustrate her point: apparently #3 is where empathy and intuition reside. In order to connect with others and to bring out their worth one had to connect to their third chakra. What she meant by this was when confronted with someone you find odious you must find within them something / anything that is ‘good’ to connect with. This had to be done otherwise a therapeutic alliance couldn’t happen and no good would come from psychotherapy.  I remember she illustrated this point using a patient of hers who had done so in order to save himself while out hitchhiking. A trucker had picked him up – someone the patient immediately intuited was dangerous and going to do him some sort of harm. The patient thought quickly and stated he was glad you had picked me up and not someone else had stopped as I could sense right off  you (the trucker) was a good man and I feel safe in your truck. After looking around for guidance the man commented he saw the trucker was a music lover please tell me about your music. This trip ended with them ‘bonding’ rather than becoming the victim of a robbery or rape or both.

“Connecting to the third chakra” is sometimes a challenge in my line of work as I see a lot of people not easy to connect with. Many see me for this reason: their rough demeanor is causing friction – which is often duplicated within the appointments with me. When someone is irritable, immature, or downright nasty I need to somehow see past this terse Personae into the person to their suffering terrible psychic wounds within.

In Disney’s ‘Beauty and the beast’ there is a marvelous scene where Belle (playing the role of therapist) is approaching The Beast’s most vulnerable center, the fading rose. He lashes out at her attempt in a violent defense. My professor would argue the entire movie illustrates the therapeutic process of getting in touch with the third charka and succeeding doing so – resulting in true connection and healing.

I can usually find this third chakra in most patients but not all of them. There are a handful with whom I’ve had no luck at connecting with. Either I can’t (a failure on my part) or there is nothing there to connect with. Happily these are not many who are missing third chakra energy and I am seeing them only for meds management and not for counseling. Some of them sensing a lack of ‘bond’ or empathy on my part go elsewhere but a few stay for reasons often bewildering to me. They challenge my training and skills to do some good under this handicap.

Outside of the office whenever I encounter a Yahoo I try to remember their Persona may not be anything like what they are. If they are being awful I try to assume they are hurting somehow. After all when I am irascible I explain it is situational (tired, hungry, bad day etc.) and it is NOT a sign of my true well-being. Yet I assume similar moods/behaviors in others is a sign of who they truly are? Not good and not fair.

I fear over time I am becoming less skilled at connecting with third chakras. Perhaps I am encountering more and more people whose chakras are either missing or have degenerated beyond redemption. From a psychological point of view this is illustrated by the current president with whom I can make no connection, find no ‘good’ within other than pathological narcissism. This is true as well for his die-hard fans and minions. On his campaign he mocked a man on with cerebral palsy and his disciples – rather than be horrified at this terrible matter – laughed along with him. I think the Rubicon was crossed and the nation lost right there. He has no third chakra and neither do his followers – or the nation is seems.

All the same I continue to strive to connect with patients and strangers hoping they have enough good within them to plug in with. Without I might as well give up.

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All doctors think they are smart enough not to be swayed by sweet-talking pharm reps but the research supports the opposite: we are far more likely to prescribe something when a salesperson drops by to schmooze and give out samples and (best yet) something to eat. As a consequence I try to be vigilant towards these devious drug dealers. Most of the time I do a good job (I hope) sticking to evidence-based and science-supported statistics. The representatives who drop in at the office have learned not to talk rubbish or push things. There is one exception. A particular pharmaceutical representative is being especially insatiable in her pursuit to get me to make her product my number one prescribed medication. Unfortunately the prescription is very expensive, seldom covered, and causes side effects (despite her insisting it does not). There are cheaper alternatives that do just as good so why use it? Brand name medications are more expensive than generic meds; patients often complain these are not affordable.

Perhaps she is under pressure from her bosses to produce sales. Maybe it’s a personal matter; she sees me as a challenge like the Duke of Edinburgh award. I have to get on board and prescribe it. Whatever her motives she pops in a lot like a nefarious jack-in-the-box to inquire if I am using her product.

So far her means of persuasion have fallen flat. Someone didn’t do her homework that feminine charms and flattery may work well for on my colleagues but not with Urs Truly. The standard graphs and charts she presents I see right through (all of them produced by the same folks who make the drug). Poor reasoning and straw man arguments make my eyes cross. Her point ‘so many others use it as their main drug” does not move me onto the bandwagon.

Sorry lady but your product just isn’t my favorite. It isn’t as clean as you report and ny patients find it ‘too expensive”* It’s not a bad drug it’s just at the end of the line of my choices.

The Wonder Receptionist informs me said rep is bringing to her next luncheon** a physician to talk to me about the medication. The manifest reason is for me to ask a colleague any questions off-label something she is not allowed to do. Fair enough. The real reason to bring in Dr. Bigwig is for me to be dazzled so I too will want to be just like Dr. Bigwig and be swell too via using the product.

I could ask the Boss-man and Boss-lady to tell her and her ilk to go away but The Other Doctor likes having them in. I like the samples they provide; I use these for patients who can’t afford “X” when “X” is the only thing that works for them.

Salespeople come and go quickly as they are frequently sacked or reassigned to other areas. Ms. Persistence is more likely to be transferred than succeed. Perhaps someone higher up the food chain will connect the dots and replace her with a big burly bear-type salesman. I hope I am up to the challenge.

 

*In reply she asked me to ‘define expensive”. I explained when my patient says their medication is too expensive for them they want something cheaper I take this at face value and not argue.

**Poor thing. She always brings in the same food, not my favorite. If she brought in something better / something I liked perhaps her sales would go up?

I am not a fan of Robert Heinlein. There are many reasons for this but one of them is about the traits of his novels’ heroes. They are often ‘The self-sufficient man’. The fellows could do everything themselves thus never needing help from others. Mr. Heinlein extols his readers (mostly boys) to be likewise and he castigates thems who do not. Asking for help is a sign of failure. The truth is the opposite: we continually need help. We are a species that evolved to live in groups and cooperate to achieve our survival. All day long we seek assistance from others.

Throughout my workday I listen to patients’ fears. There are usual ones like public speaking, flying, and animals with nasty pointed teeth. “Asking for help” is a subtle but ubiquitous anxiety for most, which is odd as we all do it and need to. Many people avoid asking for help as they fear rejection or the judgment of others for doing so. I think men suffer most from the Shadow side of the Self-sufficient Man archetype.*

I try to teach patients it is OK to ask for help. To better their chances of getting results and feeling good about the process I give’m a few tips. We tend to ask for help badly, You would think by now we would be good at it. Many ask do so in an apologetic manner (I’m sooo sorry to bother you) and don’t communicate the specifics.  We often ask for help via text or email thinking this is the best way. Studies support the opposite: we are much more likely to get a ‘yes’ reply if we ask for help face to face or a phone call. Another matter to consider: we are awful at registering a person wants or needs help, yet people often assume our loved ones can sense we need help so they don’t directly ask and become upset when the others don’t pick up on our allegedly obvious vibes. I can’t remember the exact term for thi, but it is based on the illusion of transparency. Bottom line: you have to ask, even those you think should be able to read your mind.

When I need help I first tell my Self-Sufficient Man Complex shaming me yeah, I hear you but buzz off. Then find the person I want to ask and do so face to face. “I need your help” I say. Then I state in simple, realistic, and clear words what I want. “I need you to call this patient back for me to say she needs to come in” or “I want you please to call Hector (the groundskeeper) to come tidy up the yard” or “Thank you! I can’t get into my account I want you to help me figure out why not”.   Another tip: if there help was helpful, tell them about it later. “I wanted to let you know your help was really helpful, thank you”.

Let’s stop giving The Self-Sufficient Man more libido (psychic energy) than he needs or deserves.

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*The cliché of men not asking for directions touches spot-on this archetype.

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