The Next Two Weeks

I lived my life in four-year blocks of time for a long time. 

I went to high school for four years, enjoying the studying, the teams, the football Friday nights, the dances, the classroom experiences, the crushes, my first real love, and the teen years. A small mill town in the south. A big fish in a little pond. A girlfriend. A handful of dreams. 

I went to college for three years (yeah, I got credit for four years because I CLEP tested out of a year, but that’s a story for another day). I lived in the organic chemistry lab visited by my professor’s Great Dane, studied late at night at the local Krystal eating chili and cheese Krystals, agonized over making enough As to get into medical school, then took the MCAT to make that dream a reality. 

I went to medical school for four years. I endured the hell of year one, when classmates drop out after two weeks because it’s just too fucking hard. Most of us made it to year two. We made it past professors that told you no matter how you tried you would never get more than a C (then gave you a B if you were lucky). We made it past anatomy, microbiology, pathology “pot cases”. (No, those were not studying people who smoked marijuana, but looking at the diseased tissues of those who had donated their organs to be placed on carts in formaldehyde filled pots for medical students to study in detail.) We enjoyed electives after enduring the compulsories. We graduated, doctors in name only, not knowing how little about life and medicine we actually knew. 

I did a four-year internship/residency/chief residency in psychiatry. I learned just how little Freud knew about people who I now treat who have real psychosis, real depression, and who really kill themselves. I learned more about how to manage and navigate the future systems in my life than I did about the medications available at the time, which is good really, considering that people and systems don’t change that much over the years, but medications become obsolete and get recalled. I learned to work ninety hours a week on very little sleep. I learned who I could trust to have my back, and who would stab me in it. I learned to love my patients for what they would teach me, real things about life and love and sickness and death that no two-hundred-dollar medical textbook could ever show me. 

My preparatory years were measured in four-year increments. 

Now, we are all gathered on the battlefield of a great pandemic. 

There is a virus out there that can infect me, make me sick within fourteen days, and kill me in just a few more. If I am exposed, I must count fourteen days. If I make it that far, then I will likely make it farther. If I don’t, who knows. 

I used to look forward to the next four years.

Now, I count myself among the lucky who make it through the next two weeks. 

Pre-Awfulization

Image

Okay.

Deep breath.

I have to get this one off my chest this morning, and you’re just going to have to bear with me. If you need to skip this tirade and come back for more ED goodness tomorrow, that’s fine with me. Not going to hurt my feelings at all. Really. Shoo.

This acerbic and vitriolic post was inspired by two very specific things. One was the brief but very fine offering by my friend Jordan (please show him some reader love and peruse it here). The other was the occasion of my clinic office staff coming to me yesterday, sheepishly, in great exasperation, tired and beaten, yet another time, asking what I wanted to do about a stack of denials by insurance companies and managed care entities.

A large part of what I do nowadays, if you haven’t figured this one out yet, is talk to people, diagnose mental illnesses and psychiatric problems, huddle with my patients and come up with a workable game plan to help them get better. Now, a big part of that in my profession, since I am a medical doctor by training, is the prescription of pills and potions to effect symptom relief.

I write prescriptions.

I listen, hear about symptoms, try to make sense of them, target the worst ones, find a drug or drugs that might help, IF that is appropriate (another blog post, that. Wait, scribble scribble scribble, note made, okay, fine) and write a prescription for it that I hand to you, my patient. I hand this prescription to you, my patient, because you are the one who came to me complaining that you feel bad, and it is you I want to help get better. This is a contract, an agreement, one might even say a doctor-patient relationship that we have. A sacred trust, a bond that we enter into voluntarily.

You talk to me; I listen to you. You trust me. You give me great leeway, even though you have done your own Googling, to do what is right for you, my patient. After all, what am I doing here if not for that. If I’m not working for you, who am I working for?

Oh, wait, I see a hand in the back. Yes, you in the thousand dollar navy pin stripe suit and rep tie. Yes, go ahead. You have a comment?

Ah.

Could everybody up here in the front hear the gentleman’s comment? No? Well, let me synopsize it for you.

He said that I no longer work for you, my patient, but that I am now beholden to him, as he and his company now manage my clinical decisions for me. They decide which drugs I write for, how many times a year I can see you, which procedures I can order to figure out what is going on with you (so I don’t have to just, like, guess-isn’t that a novel concept?) and when your treatment is over.

Now, one of my readers and friends told me that I was using too many offensive words in a post or two the other day, and I respect her as a lady and a reader so I’m going to tone that down a little.

But…WTF?

I went to school for twenty-three years and paid a heck of a lot of money to go to college, medical school and do four years of residency training. Do you think I did that just for my health? (pun entirely intended) I did it so that I could get a big fancy piece of paper from a Board that said I could call myself a doctor. I then took that piece of paper to a testing center to get another piece of paper from another Board that said I knew what I was doing and was pretty good at it. I keep two other little pieces of paper in my wallet that say I can do this in Georgia and South Carolina. I don’t play a doctor on TV. I AM a doctor.

And now, someone on the other end of the phone, or the fax machine, or the keyboard, sends my office staff other pieces of paper that tell me that I can’t use this drug or that drug. We’d rather you try something from this list instead. How about X or Y or Z?

How about you get the f— out of my office (Apologies to my friend and to all of you, dear readers, but this really makes me so angry) and let me do my job? How about you let me practice medicine? How about you get out of my exam room and let me have this private conversation with my patient, the one who is sitting right there in front of me and is asking for my help because they trust me to make the right choices and do the right thing for them, not for some large company or group that only looks at the bottom line?

I chose to prescribe, oh, let’s say just for kicks, Vyvanse because it is a pro-drug that best serves my patient, is not as likely to be sold or abused, is easy for this child to take once a day in the morning, will most likely be well tolerated and will help his symptoms. No, I do NOT want to use generic methylphenidate or dextroamphetamine instead. If I did, I would most likely have written a prescription for one of those, wouldn’t I?

Oh, I’m sorry, you don’t understand my rationale?

Maybe if you went to medical school for four years and did four years of residency and twenty hours or more of continuing medical education a year and had twenty-six years of clinical experience in this part of the country, you would understand my decisions. Until then, you should really take your high school diploma (you do have one of those, right?) and your scripted responses and your generic fax forms and emails and put them where the sun don’t shine, as we say here in the south.

Back off.

We who practice medicine are getting really tired of this.

We’re getting angry.

We’re getting jaded and cynical and frustrated and we are feeling impotent and powerless.

We are making coerced, default decisions based on what you tell us we must do, not based on what we were taught to do in the best interest of our patients.

Manage what you need to manage. Crunch your numbers. Play with your spreadsheets. Carve out your benefits. Opt in. Opt out. I really don’t care.

Please.

Just let me do what I know how to do. What I am well-trained to do. What I love to do.

Let me be a doctor.