Through a Glass Darkly

For now we see through a glass, darkly, but then face to face…

1 Corinthians 13:12

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I have been asked one question about my work in telepsychiatry more that any other, hands down.

“Can you really help a mental health patient like that, through a television screen?”

The quick and dirty answer? Yes, absolutely.

The extended answer? Read on.

Psychiatry is an intensely personal specialty. It requires knowing yourself as a doctor, as a therapist, as a consultant, and as a person more than any other kind of medical practice I have ever been exposed to.

It requires four years of residency after four years of medical school to train to become a psychiatrist for a reason. You must not only master the big picture and the fine points of the specialty. You must understand what makes you tick. You must know how you respond to stress, challenge and adversity. Without this knowledge and training, one makes a very marginally competent psychiatrist at best.

As a psychiatric consultant, I ask questions that in normal social discourse would be considered forward, intrusive, even bordering on abusive. I ask about the intimate details of your medical history. I ask about your work history and why you were fired from your last job. I ask about your sexual history and yes, I usually want to know if you’re straight or gay. Not to pry, but because it gives me a tremendous window on your life, how you perceive yourself, and how others perceive you.

I want to know about your legal history. I ask how many DUIs you’ve had and what lead to the Criminal Domestic Violence charge. I want to know the details of your last suicide attempt. Why did you cut yourself instead of overdosing this time? Was your intent to die, or just to reach out and make a statement to someone who had wronged you?

Think about the last really deep conversation you had with a very close friend, a sibling, a parent, a spouse, a lover. What made it special? What made it real? What made it possible for you to let that person have access to a very deep part of you that no one else knows about?

It is the connection, the intimate connection between two people that allows these kinds of conversations to happen. Pure and simple. You know it. I know it. In our friendship, if you are not willing to let me in, to share your hopes, your fears, your dreams with me on the very deepest levels, we might as well be two strangers who met in an airport bar and had a chat during a layover.

Now, several of you have argued with me over the last few years that relationships on social media cannot be real in that sense. You cannot have that kind of deep, emotional and spiritual connection with another human being over Facebook, Twitter or any other social media platform. Many of you have said the same about telepsychiatry. You can’t possibly talk to someone and learn enough about them over a television screen to help them.

All I can tell you is that over the last four years my colleagues and I have done almost fifteen thousand consults via high speed lines and high definition video monitors. Personally, out of the thousands of consults I have completed myself, only two patients that I can recall now refused to talk to me over this medium. Both were very ill and their level of paranoia precluded them connecting on a meaningful level with anyone, in person or via video.

The flip side of that coin? I remember very well, with great pride and a very deep sense of fulfillment, the father of the emotionally sick child I had just interviewed. He was at the end of his rope. His child was suffering, dying in a very real way before his eyes. He did not know what else to do.

After our interview I went over the treatment plan with him. I told him that there were things that could be done to help his child, and that we were going to do them, starting at that very moment. His face changed. He smiled a very weak smile. I could see the hope in his eyes.

Spontaneously, he jumped up out his seat, two hundred miles away from me, and reached out to shake my hand.

I knew at that moment that the medium was powerful, the connection real and the intervention worthwhile.

We had seen each other through a glass darkly, and then face to face.

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Breaking a Few Eggs

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“Most EDs do not have separate secure areas in which psychiatric patients can be held. They typically don’t have a psychiatrist immediately available to evaluate the patient and provide guidance on management, and they do not have extra nursing staff to monitor often unpredictable patients.”

azmd, in a comment on one of my blog posts  on KevinMD.com.

Well, we have been talking for a few weeks now about the way psychiatric patients get to the ED and what happens or does not happen when they do. Many of you have lamented the lack of personnel, the dearth of services and the waits that these patients experience because of dwindling inpatient resources. What can be done about this deplorable set of circumstances?

First and foremost, I believe that hospitals are going to have to provide separate service areas for these patients.

The stark white room with only a gurney and a chair, with no television or magazines or anything stimulating to do, must go. Replace it with a hallway or a suite of rooms with a centrally located nurses station and a common area that give patients a little more room to walk, space to interact and even a special area for visitations from family. The lone guard outside the door, symbolizing both threat and security, must be replaced with trained mental health staff in this special area, staff who know about the signs of escalating agitation and potential for violence in these patients. A small emergency room within the main ED, this area could be secure and therapeutic at the same time, much as an inpatient psychiatric unit might be. This should become a standard for emergency departments who wish to receive mental health patients.

Psychiatric coverage is going to be needed for these service areas.

As many commenters have pointed out, both patients and providers alike, it seems that there are never enough psychiatrists around to see mental health patients when they do come to the ED for help. One criticism, spot on in some cases, is that psychiatrists do not respond in a timely manner to requests from the ED physician for consultation and help in the management of difficult psychiatric presentations. They do not come out in the middle of the night to see patients and they do not give timely input that would be helpful to the ED staff. In many rural areas, even if there  is a small community hospital, there are no psychiatrists anywhere. There are no mental health centers to send a screening clinician.

Services such as telepsychiatry may be the answer to psychiatrist shortages in the future.

Being able to see multiple patients in multiple hospital EDs over a regular or extended shift, without the hassle of driving from place to place, is one of the virtues of telepsychiatry. A patient who might have sat for days waiting for an inpatient admission because no mental health input was available to begin treatment in the ED, may be the beneficiary of a mental health consultation and initiation of services from the first day they are evaluated. A fair number of these patients, their treatment begun in the ED, may actually be improved enough to go home directly from the hospital after a few days.

Now, I know what is going to  happen as soon as these kinds of changes are proposed.

There will not be enough space. There will not be enough money (when is there ever enough money?). We can’t dedicate an entire area of precious emergency department real estate for a babysitting service for mental health patients. Psych patients will be running amok all over the department, threatening and yelling and getting into other patients’ business. We can’t spare staff for this in the ED. Psychiatrists will never come down to see these patients even if we do set them up in their own place. Telepsychiatry equipment is expensive and we’ll never be able to afford it.

The fact is, as my old mentor Everett Kuglar MD used to tell me, these patients are not going to go away. Someone is going to have to treat them.

No matter how much hospital administration tries to ignore their existence, no matter how little funding state legislatures provide for their care, people with schizophrenia and depression and substance abuse problems and other mental health problems are going to be with us.

We can choose to ignore them, but the problem will only get worse. We can choose to maintain the present day status quo, which in my opinion will only lead to more frustration for patient and provider alike.

We can choose to spend a little money, time and physical and human resources to turn this around.

Sometimes if you want to make an omelet, you have to break some eggs.

Sock It To Me

Call me crazy. Call me old. Call me a dinosaur. I don’t care.

I feel that after all my years of education and training and experience that I deserve a little respect from my patients. There. I said it. I will wait for the collective gasp from all of you. Okay, may we move on now?

I have seen the gamut of suffering souls in the emergency departments of South Carolina in the past week or two. Short ones, tall ones, fat ones, skinny ones, depressed ones, manic ones, drugged  ones, inebriated ones. Psychotic ones, aggressive ones, agitated ones, quiet ones. Hands uplifted to Heaven and eyes downcast toward the floor. The sweet words of a child and the foul-mouthed derogatory rantings of a narcissistic drug addict.

What makes me keep doing this? What makes me go back to seeing patients, sixteen-hour-Monday after sixteen-hour-Monday? Sixteen hours is a long shift. You can process a lot of pain in sixteen hours. You can become an angst-absorbing sponge in two-thirds of a day.

Well, there’s the satisfaction of helping people. There’s the feeling that maybe I can pick up on something that somebody else missed. There’s that blessed feeling of taking away medications instead of adding just one more drug because we really don’t know what’s going on here anyway so why don’t we just snow him and see what happens.

And then, there’s that one sweet patient, that one who has just done something heinous, something awful, something that nobody would have expected. That patient, who because of the ravages of time and illness has been robbed of intellect and reasoning and normal cognitive processing. The patient who still maintains, deep down in the depths of their tormented soul, that part of themselves that is civil and decent and human enough to extend common courtesies to the doctor who is trying to help them.

“May I continue, Doctor?” (Note the capital “D”. It’s there. Make no mistake.)

“I’m sorry, Doctor, but I don’t usually look like this. They gave me some medicine, and I was asleep and they woke me up to come talk to you. I’m sorry for my appearance…”

“I’m sorry, Doctor, but this is important. May I start back at the beginning? Do you have time for me to tell you about this?”

Okay, okay, my false sense of importance and the need to harvest respect from the fields of misery is not exactly what this post is about, is it? You read me. You know how I think. You knew I was setting you up way back there at I don’t care.

It’s not about the respect I get from my patients. Not really. It’s nice, yes, to have someone treat me nicely and call me Doctor with an audible capital D. It’s nice to have one’s education and experience acknowledged once in a while. It’s nice to score a diagnostic coup. All those things are nice.

The most important thing I learned in my sixteen hour work day yesterday was that even in the midst of terrible suffering, a story is a story.

Even when a blood alcohol level is four times legal, I’m sorry can come through loud and clear.

Even when someone is cursing me for everything but making the sun come up in the morning, pain comes through loud and clear as pain.

I’m having a long, hard day.

You’re having maybe the very worst day of your entire life. One that brought you to the emergency department of a hospital. One that has you talking to me, trying to make sense of it all.

I don’t need your respect.

I need your trust.

I can take it.

Let’s work this through. Together.

Sock it to me.

They Were Soldiers Once…

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Yesterday was the sixty-ninth anniversary of D-Day, to the day, to be exact.

Today is the eighteenth anniversary of my father’s sudden death of a brain aneurysm at age sixty-two. I can remember the exact date that my father died, because it was one year and one day after the fiftieth anniversary of D-Day. Yeah, I’m a history nerd. I’m weird like that.

I watched Saving Private Ryan last night for the umpteenth time. Helluva movie.

That movie always gets me thinking about a lot of things.

War. Death. Country. Patriotism. Sacrifice. Loss. Courage. Family. Teamwork.

Lots of good themes that Mr. Spielberg and Mr. Hanks really made us consider as we watched the utter horror of the beach landing, the carnage wrought by bullets and shells, and the intense, painful, agonizing up-close look at death that is hand-to-hand combat.

Sixty-nine years ago. Wow. Ancient history, right? Yes…and no.

We still fight each other. Some say we have dumber people but smarter bombs. We send in drones where no rational human would dare to fly. We kill from thousands of feet in the air or hundreds of miles away, instead of making one last, glorious stand before blowing the bridge. That “whites of their eyes” thing is so eighteenth century.

One thing that hasn’t changed?

Human casualties of war.

Not just the dead. We don’t have the daily Vietnam body counts any more or even a wall or monument yet built to those who have served in the choking deserts or the arid plains. School children and many adults still struggle to find the places on a globe where all our modern-day soldiers serve.

I see them in the emergency department sometime. They come in quietly, suffering in silence as they were trained to do. They drink too much. They smoke pot and do coke and they cope. They get depressed. They have panic attacks. They want to kill themselves. 

They were soldiers once.

When I was a very young intern, and later a slightly less young resident, a wallet biopsy was always the first procedure performed on a vet as he (it was always a he back then, but not so much now, of course) hit the door of the Life Support Unit, as the downtown emergency room was called in those days. A purple 100% service connected card was golden. A blue card, not so much. Services were rendered by staff as services had been given by the vets. Orders followed, no questions asked, no cost too high, no river too deep or mountain too high. Semper fi. No man left behind. That was then.

This is  now.

Where did we go wrong?

Vets are struggling to get the services they need. They are dying in droves by their own hand. Sometimes they take a loved one with them. Oh, I exaggerate, I hear you say. Read this.

They call the veterans hot line and talk to a nice person who directs them to the closest local emergency department. Outsourcing, I guess you could call it. Something like that. Admission? Maybe, at a veterans’ hospital in this state or one over. Groups, drugs, counseling, the usual bill of fare. Suicide prevention classes and education. More hot line numbers just in case.

I always try to thank them for their service. Sometimes I forget, or they are too out of it or psychotic or hopped up on drugs to hear me or understand. But I try. It’s the right thing to do.

Can you imagine what it must have been like, sixty-nine years ago, being propelled out of that Higgins boat, feet not touching ground but water, sinking, not hearing but seeing, seeing bullets whiz past your head underwater? Coming up for air and struggling to make the beach just to struggle again for shelter from the hailstorm of lead and fire and spattered blood and brains? Trying to survive?

Can you imagine what it must be like now, coming back from the desert heat and the sand and the glaring sun and the mountain posts and thinking that death is the best option to get you out of the hailstorm of routine life-after-living-death? Not knowing where to turn or who to call? Trying to survive?

They were soldiers once.

They didn’t fail us then.

Will we fail them now?

On the Road Again

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Morning folks.

Let’s talk about travel today. 

We have an interstate highway system in the United States, conceived and built back in the nineteen fifties during the Eisenhower days. I’ve heard tell it was originally devised as a network of roads that could most efficiently and quickly mobilize a column of military vehicles from one part of the country to the other in case of attack or invasion (or get Dwight David from one golf course to another with the least amount of effort and Secret Service protection). If you look at a big map of the country and squint just a little, it looks like a big arterial system, nowadays bringing goods, services and millions of Amazon.com packages to people all over the nation.

An arterial system moves blood, and the lifeblood of modern-day America is her people, pure and simple. This system of four-lanes-and-up highways moves, when it’s all said and done, people from one place to another. 

In the emergency department, this phenomenon manifests itself as the itinerant patient, the traveler (not to be mistaken for the Travelers, the life insurance company or the Travelers, a group of Irish folks who patch driveways and paint houses for oddly large amounts of money). He (and he is usually a he) shows up in the EDs that happen to be close to the interstate highway system. Which reminds me of that old question: Why do Civil War battlefields always seem to be close to exit ramps off major interstate highways these days? But, I digress.

This peripatetic fellow is usually on his way down south when the cold winds blow up north and winter is coming (cue Game of Thrones music and awesome, awesome opening sequence-I’ll wait), and traveling back up stream like a spawning Chinook when the stifling humid heat of a southern summer is gripping the lower tier in July (coinciding with another Game of Thrones episode coming up in Season Four, titled The Interns Beyond the Wall)

He gets to us in one of several ways. He is sometimes found by local law enforcement sleeping on a park bench or living under a bridge. He is sometimes brought to the ED by a well-meaning soup kitchen volunteer who sees the nasty, festering hole in his lower leg (battle scar from a late night run-in with an old metal carnival tent stake left in the ground in a field) and says “You really need to get that looked at”. 

He is sometimes picked up by EMS after he unceremoniously passes out outside a local WalMart, dehydrated and not even able to sweat to cool himself against the southern heat wave any more. Sometimes, he hitchhikes, getting himself to the place with the bright red cross glowing in the night like a beacon (Bring me your poor, your tired, your masses yearning to breathe free and get a meal and a place to crash for the night. I can’t remember exactly how the tattoo under Lady Liberty’s left arm reads, but that’s close enough for this post), sure that he will find a kind doctor, a pretty nurse, an IV with a banana bag, and a couple of Lortabs there before the sun rises the next morning. 

This guy is the dirty, smelly, rode-hard-and-put-up-wet guy in Bed Three. He is “not from around here” as they say. He is a traveler, a gypsy in the broadest term, a guy who uses the health care system like his own personal chain of Motel 6’s, knowing that in every big city and little town, somebody is always leaving the light on for him. (Good night, Mr. Bodett, wherever you are)

He’s not really an unpleasant guy, at least after he gets a shower. He smiles, jokes with the nurses (male and female), is respectful of the doctors (male and female), takes the medications ordered for him, eats the food offered with nary a peep about the shade of green of today’s Jello, and sleeps when told to sleep. He asks for nothing special, gives the staff no problems, and is the subject of not more than two lines in the nurses’ morning report (Mr. Jones slept well all night, has eaten 100% of his breakfast tray, and has no complaints today). 

So, you’re asking me now, as you tire of my early morning, I-haven’t-had-enough-coffee-yet blog humor, why is this guy in the ED? Is he for real? Is he sick? Why don’t you just kick him to the curb? He’s wasting taxpayer dollars! He’s a malingerer

Well, Kemosabe (you hear the Johnny Depp in my voice, don’t you? C’mon, go with me here…), yes, and no. No, and yes.

My opinion? As a shrink?

Sometimes these guys really are sick. Just because you travel the eastern seaboard via Trailways and not by air-conditioned SUV doesn’t mean that you can’t develop DKA from untreated diabetes or have your blood pressure spike or have a seizure. Remember when I told you that a good doctor will take the same critical approach to working up a smelly, unwashed, slightly obnoxious patient that she will in dealing with a perfumed mother of three who has gold bracelets dripping from her arms as she tells you about her migraine? Yep. That.

Sometimes they need three hots and a cot. Really. They have no family. They have no money. They have no job. They are truly homeless. What would it feel like to be that guy? At Thanksgiving? With the snow starting to come down and the warm lights in warm houses going up and the smell of pan dressing cooking in the oven pervading the den where Dad is pretending to watch the Lions lose again behind closed eyelids? Put yourself there, in that situation, for just a moment. 

Sometimes I think they crave human contact. I really do. I have heard more fascinating stories from these traveling symptom shysters than from almost any other group. They can tell you where all the soup kitchens are, the best VA hospitals to get admitted to at Christmas time, the bus schedules in North Carolina, and the airspeed of an African or European swallow. Okay, I made that last one up, but the others are all true. I swear. 

These guys are just one more in a a group of special patients you’ll find in the emergency department. 

You may not find much wrong with them physically or emotionally. You may spend a few bucks out of the health care budget working them up and feeding them overnight. You may send them on their way feeling like you haven’t really done that much to help them.

But, you’ll never forget them.

Manipulus

“Well then, if you won’t prescribe the Xanax for me, I guess I’ll just have to get it off the street.”

“If you send me home, I promise you’ll be reading about me in the obituaries tomorrow.”

“I’m in terrible pain. You have to treat me. You have to give me narcotics. If you don’t, I’ll call the state medical board and report you.”

I hate to be manipulated. 

Hate. it. 

There is a certain subset of patients, many of whom have primary personality disorder problems or abuse substances, who come to the ED with nothing more in mind that getting exactly what they want. They will say anything, do anything, act any way, pull any stunt to get their way. 

These are the folks who will hit themselves to cause bruises to make it look like they are being abused. The man who will prick his finger and squeeze drops of blood into his urine sample to create hematuria, bolster his story about having kidney stones, and get that morphine that he craves. The woman who will inject small amounts of feces into her  young child to cause the temperature spike that will get the child admitted to the hospital for a fever workup. (Not to do anything for the child, but to satisfy the mother’s own need for attention via the hospital admission. You may have heard of this one-Munchausen syndrome by proxy)

These folks often know that they have you over a barrel, and they enjoy getting and maintaining the upper hand. Coming to the hospital ED is not a traumatic experience for them. It’s a challenge, an adventure, and a game to be played and won. They want to see you squirm, make you sweat and make it difficult for you just because they can.

Oddly enough, you might think that once one of these folks is discovered, it would be easy to dispatch them and move on to the next case. Not so. It actually takes more time  with this kind of presentation that with other, more straightforward cases. 

Why? The person may actually have an illness that needs to be diagnosed and treated, and this is just the way they respond to the stress. They might actually go out and accidentally kill themselves, not really meaning to, after your call their bluff and release them. They may be going into a serious narcotic withdrawal, or delirium tremens (DTs) and you miss it because you were so focused on their demands for painkillers that you neglected the fact that they also drink a case of beer a day.

If you come into the ED and tell me a story, a reasonable story of pain and suffering and need for psychological treatment and comfort, I will do all in my power to help you. I will give you the proverbial shirt off my back. I will willingly spend emotional, physical and financial capital to find out what’s wrong with you and help you.

If you come in and try to scam me, lie to me, manipulate me and make me bend to your will just for kicks or your own secondary gain, I will go cold as ice. Now the caveat here is that I will work up your complaint and figure out what is going on and why. I will figure out that this is a personality thing, a need for attention, an unconscious need to be sick, or some such. I’ll figure that out, as that is what I’m trained to do. 

I’ll treat you professionally and the same way I would treat anyone else. But keep in mind that you have changed the game for us. You have set this up as us against them, protagonist against antagonist, cop versus robber. 

The doctor-patient relationship should be one that consists of mutual respect, achieving a common goal, honesty and teamwork. 

Where there is true pain and suffering, physical or emotional, there is no place for manipulation.

Buddy, Can You Spare a Dime?

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Okay, so this morning I want you to think about something with me. I want you to be honest, as honest as you can, as I will be with you too. Deal? We can’t move forward until you agree.

Right.

What do you feel when you’re driving along, you come to the next busy intersection, stop for the red light, and see that homeless guy? You know the very one I’m talking about. That homeless guy with his grimy, almost blackened clothes, week’s growth of beard, and the cardboard sign that says Will work for food or some such?

Nope, nope, nope, come back here. You said you would be honest with me, and I’m not going to let you weasel out of this one that easily. Your second cup of coffee can wait.

You don’t know this man. You don’t know his story. You don’t know if he’s a scammer (you really think that likely he is), a deadbeat dad (how could he not be, you think, dressed like that and begging?), or just a really, really lazy person (Of course he is-I work for food every day. It’s called a job!). Do you look at him critically, looking for clues to his story in that brief minute that the light is red? Do you look on him with compassion, feeling a sense of urgency to help? Do you look at him with a sense of guilt, knowing that if you don’t help him, right now, that nobody else is likely to for the rest of this day?

Now, take that feeling that you had at the red light, or those feelings, because my hunch is of you’re like me you had a smattering of all of them, and sit with them a minute. How do they hit you? Do they make you feel empowered? Sad? Angry at society? Helpless? Energetic? Depressed. Full of empathy? Disengaged?

Take those feelings and multiply them by a hundred, a thousand, ten thousand. Doesn’t feel so good, does it? Feels downright bad. You want to stop feeling that way. You want to get back to feeling good again, driving away from that intersection and going shopping and spending your money and hugging your children and smelling the fabric softener in your clean clothes.

Indigent patients, truly indigent patients, hit us like that in the emergency department hundreds or thousand of times each month. They are the truly poor, the truly needy. The ones who will be with us always, no matter the party in power or the stock market close. Homeless, down on their luck, no job, no money, no place to stay. Using drugs. Coming in with blood alcohol levels of three, four hundred. Dirty. Smelly. Reeking of alcohol and sweat and vomit and street grime.

I’m sorry, but my part of this bargain is to be honest with you since you stuck around with me.

We all know that being a doctor is glamorous, right? It’s all about Patch Adams and House and ER and Marcus Welby and Grey’s Anatomy. It’s about quickie sex in the supply closet between exciting traumas. It’s about magic tricks and starched white coats and throwing your weight around because you’re a star surgeon who saves lives. It’s about sterile environments and bright lights and making that once in a lifetime diagnosis that gets you noticed and makes you a hospital legend.

Come on. You know better.

ED medicine is about grueling hours and long shifts and inexhaustible waiting rooms full of patients with chest pain and bleeding and suicide attempts and drug overdoses. It’s brutal, folks. A lot of the time it’s just brutal. I hate to burst your bubble, but there it is.

Indigent patients are one of those special groups I was telling you about the other day.

I got to the office yesterday and saw that there had been about a dozen psychiatric consults remaining to be seen when my colleague had gone off shift at midnight the night before. From midnight until eight AM the next morning, another thirteen or so had *dinged* into the work queue. Twenty-five patients with their own stories. A good number of them that guy. The one holding the sign at the intersection, or someone a lot like him.

How can we show compassion to the old, tired, smelly guy with the sign when we are tired before we even get started with the day’s shift? When we see the never-ending line of misery staring back at us on the computer screen and we just want to hit the gas and burn rubber and drive off?

I’ll tell you how.

First, we don’t go into this line of work unless we really want to help people. Sounds all rose colored glasses and kittens and sparkles and unicorns, but it must be true. It has to be. You don’t put up with this shit unless you want to be a doctor.

We train and train hard for a reason. We learn our craft and how to do it backwards, forwards, upside down and sideways, blindfolded and with one hand tied behind our backs. We take long hours of call, we work days on end with little rest and we see patients back to back to back so that we develop toughness. When the fifth indigent patient comes in with the same-old same-old story at midnight on a Saturday when we are so bone-tired that we can’t see straight, we give him the same ear and the same critical workup we’d give the lady with full insurance coverage who drove herself to the ED in the Lexus to have her arthritis checked out. If we’re good doctors we do, that is.

We care for each patient as a person, a person with worth. I don’t care if you’re down on your luck, if you have no money, if you have no job, and if you curse me for everything I’m worth as I tell you I’m going to commit you for your own safety after you drunkenly sliced your wrists opened and guzzled a mixed drink of Tylenol and scotch. I’m going to take care of you the way my excellent mentors taught me to, the same way I would want my own mother or daughters to be taken care of.

Being indigent is not a crime.

Being an arrogant, thoughtless, cold, uncaring doctor should be.