Vacations are important

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Definitions of vacation include ” a period spent away from home or business in travel or recreation”  I just had a long vacation.  It started on a Friday a and ended on a Wednesday 12 days later.  I a great deal of my time being asked and answering questions for my patients, residents, staff and administrators. I think vacations are important. I think I waited too long to take this one. I had so many tasks to complete to end one academic year and start a new one.  Research day completed, new rotations updated and arranged and lectures planned.  Also starting our new resiliency curriculum.  Last year at this time, I was starting a yoga instructor training program.  I completed it in December.

It started with delayed flights on Friday.  Finally arriving in Puerto Rico.  I had a brief rest after getting to the hotel at 5 am on Saturday.  We had a beautiful walk on the nearby public beach (all the beaches in PR are public).

Then a  tour of Old San Juan.  I am ashamed to say this was my first visit but it will not be my last one.  We had traditional food at Raices Restaurant in Old San Juan.  It was so good we went back on Sunday.

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We boarded our Carnival Cruise ship, the Fascination.  We were off to celebrate my stepdaughter’s 40th birthday.  I started the cruise with a long massage. It set the tone for what would be a very relaxing vacation.  We embarked to our first destination.

 

 

St. Thomas was sunny and beautiful.

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View of ship docked in St. Thomas

After a rainy day at see, we were rained out in Barbados and St. Lucia.  We did brave the rain but ended up getting a ride back to the ship.

St. Kitts was sunny and we did the Island tour.

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We spent the last day in beautiful St. Maarten

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We ended up back in Old San Juan with a tour of Bacardi.  It was living history through the story of rum.

I will not wait so long for another vacation.  I hope to stay connected to this sweet feeling of relaxation and calm. The best part of the trip was spending it with the ones you love.

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The War on Drugs or Not?

I try to reinforce to my doctors in training the importance of getting a social history from their patients.  Where do they work, what are they job responsibilities, where they live, do they drive and of course family connection?  This also includes a sexual and history.  The last is the substance abuse history.  More and more, patients are admitting to use of marijuana which doesn’t surprise me.  The opioid pain-killer and heroin use is hidden from us when we ask but we have to start pushing to get the answer.   We have to be more comfortable discussing opioid misuse and abuse with our patients.

I have found that our Black and Latino population does not use drugs in the numbers we would think.  The myth of their increased use had been perpetuated in the news media until recently. We have a large Latino population in our practice.  Most of our Black and Latino female patients do not smoke drink much less use drug.  Our Caucasian patients are more likely to be smoking marijuana, drinking socially, using opioid pain killers and heroin.  That is a fact that is now just being openly discussed and represented in the news media.  This graph shows the shift.  You would be wrong to think this represents more Non-Hispanic whites seeking help than Non-Hispanic blacks.  It clearly shows the dramatic increase in the number of addicted white patientsOpioid Stats

I was a medical student and a resident during the devastation of the Black community from drug addiction and AIDS and the cruelty of the “War on Drugs.” We asked for more drug treatment and needle exchange programs.  We got more prisons, harsher jail sentences and cutting of funding for treatment.  Now the face of the addiction epidemic has morphed from the Crack Cocaine addicted black face to the Opioid Addicted white face with an epidemic proportion of overdoses and deaths.  No jail time.  I remember that tragic scene from “Lady Sings the Blues” as Billy Holiday (Diana Ross) is locked up and withdrawing in such pain and agony.  Congress has the opportunity to right a terrible wrong by increasing the funding for the Opioid epidemic.  That will not erase the harm done to our community but it will finally acknowledge that addiction is a medical problem. The psychosocial problems that Americans face and are now leading to lack of hope must also be addressed.

Death rates

The other issues in the Health Bill such as keeping funding for Planned Parenthood, keeping the mandate for coverage of contraception and maternity care are crucial to the health of women. White females are dying at higher rates from opioid overdoses.  Their rate is higher than that of Black and Latino women.  White males now have the highest rate at present.  Drug use among white suburban teenagers is increasing while it is decreasing in Black and Latino teens.  These are just the facts.

Some part of me is angry that the Black community had to suffer such devastation without much help.  Black and Latino teens will always be arrested and serve time for drugs.  They can’t get into medical or law school. They are limited in their career choices. Now whites, are still less likely to serve time because their parents call for treatment and less strict drug enforcement is being heard.

I started reading The New Jim Crow: Mass Incarceration in the Age of Colorblindness by legal scholar Michelle Alexander. I had to put it down because it evoked such emotion.  All the people in the on-line book group I was in had the same feelings. “Black people comprise just 13 percent of the U.S. population and use drugs at a similar rate as other racial and ethnic groups – but they comprise 29 percent of those arrested for drug law violations and roughly 35 percent of those incarcerated in state prison for drug possession only.”  These are the facts.  Until we as a country address this issue, we cannot move forward in the treatment of addiction as a medical not legal problem.

It is compassionate care but if we punish one group and have leniency with the other it is not justice and medical care is not provided equally

 

 

Happy Father’s Day

Father’s Day is a time to honor those men who love and support their families. I remember admitting a dad who had developed pertussis (whooping cough). The pediatrician admitted the infant daughter.  He was so upset that he had been the one to make his child sick.  We explained this can happen.  Back then it was a few cases and now there are more.

Loving husbands and fathers make a difference during difficult times. My husband spent many days taking our son to the Pediatrician alone for shots.  It was difficult for me to get away from my training and later the office.  He did the soccer games, tennis lessons and all the homework.  He was the Book Fair volunteer; he and another Dad would make sure the kids made smart book choices.  He was the chaperone on the school trips. He made all the visits to the orthodontist for the brace, found the Barber for the haircuts and scheduled the music lessons.  He cooked all our meals and even did the laundry.   He also was very involved with his children from his first marriage.  I met him a few years after the divorce.  After we started dating, I met his son and daughter when they were age 7 and 8.  I took the liberty of putting his daughter’s hair in a neater style.  She was so cute. We have celebrated 32 Father’s days together.  I think he still has many of the cards.

Two black male journalist and fathers look at the myth surrounding the absent Black father. Ta-nehesi Coates writes eloquently about this is his article Understanding Out-of-Wedlock Births in Black America He revisits the Moynihan report and sheds new light on the findings. Charles Blow sheds light on this subject in his article Black Dads Are Doing Best of All. 

Black fathers have been the victim of stereotypes of being absent and uninvolved.  The LA times in December 2013, published an article covering a report released by the National Center for Health Statistics.  The table highlights some important statistics.  The report was based on a federal survey that included more than 3,900 fathers between 2006 and 2010.

Fathers

So let’s just celebrate all fathers today.

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Why I love my Mother- Reason 2

“I try not to say too much and stay out of it but you know I will give my opinion.”

This is the basic philosophy of my mother and her sisters, my aunts. I think it was passed on by my grandmother.  Our Saturday check-ins always includes this great line “Now that I have talked about everybody, I will let you go.”  I have always looked forward to talking with her and catching up.  When I graduated college and went off to medical school, I knew I would never return to Birmingham to live.  So my mother kept me in touch with my family.  Back then, there were no cell phones so I had to wait until the rates were low and call nights and on weekends.

I want to let you know that my family is by no means perfect. We have recovered drug addicts, alcoholics, ex-prisoners along with doctor, lawyers, a judge, politicians, healthcare workers, steel workers, people in banking and ministers. I consider my mother and her sisters our family’s moral compasses.  So, when someone gets out of line, one of them will try to set you back on the right path.  One of my relatives was not in the mood to have my mother interfere.  So he told her to “shut-up and mind her own business.” When she called to relate the story, I told her he was right.  I had just finished reading one of my many self-help books and I told her about “the art of allowing” In essence, it is allowing people to be themselves.  She was not about hearing that.  In her mind that is not an option. I did tell her to stay out of it because I did not want her to get hurt. She is such a loving person.  She said she was not going to let him mess up his life with letting him know she cared. When she told my aunts what I had said, to my surprise, they agreed with me.

I have learned from them that it is important to standup for what is right and not be afraid to voice your opinion. You have to try to keep others from harming themselves and if you can’t then be there to help them get back on their feet.  They are there for each other with love.  For us, they always have love and good advice.

“[My mother] had handed down respect for the possibilities—and the will to grasp them.” – Alice Walker

“Grown don’t mean nothing to a mother. A child is a child. They get bigger, older, but grown. In my heart it don’t mean a thing.” – Toni Morrison

Why I love my Mother- Reason 1

MomaThis is one of my favorite pictures.

This is a pre-Mother’s Day shout out to my mother. I think my mother and her sisters are the embodiment of “Loving kindness.”  My mother called for her usual Saturday check-in and recount of all the family news.  She updated me on my uncle’s fight with lung cancer and her new job.  At age 79, she has decided to work 5 hours a day.  She said she just wants to get out of the house. She has been caring for people since I was born.  She was the primary caregiver and health proxy for my grandparents, church members and my late stepfather.  We always laugh and end the call but this time, the conversation shifted to the embattled ex-governor of Alabama.  Of course, we all should know about the scandal and his resignation.  Alabama has a long history of governors who have not shown love and kindness for African Americans.  So, to my surprise, she said “Have you heard about our governor? Don’t you feel sorry for him?”  Well, my initial response was to smile and remain silent.  I wanted to hear what she had to say.  And once again, “loving kindness “and “judge not lest you be judged” was on full display.

She said” I feel so sorry for him. He has lost everything.  I think he meant well.”   I smiled and listened.

“His wife left him and his children are refusing to talk to him. He moved out of the Governor’s Mansion today.  There were only two men and a pick-up truck helping him.”  If anyone else had said this, I would have been laughing out loud. Yet, I listened to my mother and smiled.  As I heard these remarks, I flashed back to all the hate that has defined the political seen in Alabama.  Yet, at 79, that is not what she is focusing on.  She always encouraged us to be decent, loving and respectful.  My grandmother always said ‘if you can’t find anything good to say then just keep quiet.” I found myself reflecting on this and just not saying anything but “I guess you are right.”

I had the honor of participating in a five-series program sponsored by my hospital. We had two hospital chaplains who are Buddhist monks lead us in resiliency and transformation sessions.  The sessions focused on contemplative medicine through refection and meditation. I do find myself really listening to my patients, residents, friends and family members better.  It is caused being present. In his TED talk Julian Treasure talked about “conscious listening”.  You can use this acronym to help you listen and communicate better. RASA stands for “Receive,” which means pay attention to the person; “Appreciate,” making little noises like “hmm,” “oh,” “OK”; “Summarize” — the word “so” is very important in communication; and “Ask,” ask questions afterwards. So, I use this as much as possible to be a better listener.

So, I love my mother because she always reminds me to be a better person by displaying all the attributes I need to accomplish this. I even found myself feeling sympathy and empathy realizing that we all can make mistakes and one day will need someone to show us “loving kindness” and forgiveness

Biology and Chemistry got me into Medical School but the Arts made me a better doctor

I am an avid watcher of Public TV. My senior year in HS, my English teacher was such a brilliant man.  We were reading Shakespeare’s plays.  One assignment was King Lear.  I so enjoyed the play but it came to life for me when the PBS Great Performances series aired the play with James Earl Jones as King Lear, Ellen Holly as Reagan, Rosalind Cash as Goneril and as Cordelia.  It was my first to experience an all-Black cast performing Shakespeare.  I was mesmerized.  PBS has provided many memorable experiences for me such as Dance in America: Martha Graham Dance Company, Brideshead Revisited, and The Six Wives of Henry VIII.   I watched Upstairs, Downstairs and even Poldark I. Who could forget How Green Was My Valley and Madame Bovary?

Public TV has always been part of my life. I watched those early cooking shows with Julia Childs.  What is there for a girl growing up in the South who loved to read books to do?  I was a Premed major in college but after my sophomore year, I changed my major and minored in English.  I took a course in Shakespeare, English Romanticism, Chaucer and Southern Literature.  I was rejuvenated by writing and just reading.  I needed the science to get into medical school but I needed the Arts to make me a better doctor.  The Arts fed my soul and helped me become more altruistic and empathetic.  PBS allowed me to see performances that I never would have had the opportunity to experience because we did not have the money.  In college, I saw plays and live performances that were once in a life-time.  I saw the Martha Graham, Alvin Ailey, and Paul Taylor Dance Companies.  The concerts included Roberta Flack and Randy Crawford.

My life was enriched by funds from the National Endowment for the Arts and I fear that if the funds are cut, other children will be deprived of their opportunity to have their lives enriched. In elementary school, we had trips to the Symphony and arts programs. I spent many hours at the Public Library during the summer.  The Library was our unofficial babysitter. The NEA was created by the US Congress in 1965. Roger L. Stevens was the first Chairperson appointed by Lyndon B. Johnson.  The National Endowment for the Humanities provides grants for high-quality humanities projects to cultural institutions such as museums, archives, libraries, colleges, universities, public television, and radio stations, and to individual scholars. It was created in 1965 under the National Foundation on the Arts and Humanities, which included the National Endowment for the Arts.  The programs I benefitted from in college were funded by the NEH.

I will continue to support PBS every opportunity I get. We buy our favorite shows and give during the Annual Fund drives.  I can’t imagine my life without it.  From Foyle’s War to Downton Abbey, I have been educated and entertained.  What would I do without all those Ken Burns’ documentaries and Henry Louis Gates?  Oh my, how could I live without Nature? After a long day of seeing patients, I get a great laugh from Father Brown and Death in Paradise.

We don’t need more warships, aircraft or a wall on the border. We need the arts to allow us to dream and enrich our lives.  A little girl from the South can go to college, medical school and finish her medical training while maintaining her love of the arts because with the remote in her hand and right in her living room on her TV set, she could see a world that she never would have had the time or money to see.  That is what we may lose if these funds are cut.

Meals on Wheels

This month marks the 45th anniversary of the Older Americans Act Nutrition Program has been the primary piece of federal legislation supporting social and nutrition services to Americans age 60 and older since 1965. We have to  protect the critical funding for the Meals on Wheels programs that are working tirelessly day in and day out to provide nearly 218 million meals, either at home or in group settings, to more than 2.4 million seniors each year.  OAA programs are vital for seniors who are at significant risk of hunger, isolation and losing their ability to live independently. Services provided include:

  • Home-delivered meals and meals served in group settings such as senior centers
  • Transportation
  • Personal care and homemaker support
  •  Caregiver assistance
  • Preventative health

Did you know 1 in 6 seniors struggles with hunger. Meals on Wheels can provide a senior meals for 1 year for about the same cost as 1 day in the hospital.

Nationally, Meals on Wheels serves more than 500,000 veterans each year. The OAA covers 35% of the total cost to provide nutritious meals, safety checks and friendly visits to more than 54,000 Seniors. Programs rely on contributions from state, local, private donations and other resources to cover the rest.

I have worked with seniors in three different states.  This program kept them in their home and out of the nursing home.  It also prevented hospitalization and malnutrition.  I remember admitting several seniors to the hospital for dehydration which was due to lack of food and support services. Instead of going to nursing homes they went home.  Medicaid is the major funding source for covering the cost of nursing home care. Meals on Wheels  decreases the rate of falls, which cost our nation $34 billion each year. When a senior falls, they have serious injury that leads to hospitalization, admission to a Rehabilitation Center and then too often to a nursing home.

Sign the petition by 3/31/2017

http://www.mealsonwheelsamerica.org/take-action/advocate/sign-our-petition-to-protect-meals-on-wheels

Yes, Health Care is Complicated!!

“We must come to see that the end we seek is a society at peace with itself, a society that can live with its conscience.”  Dr. Martin Luther King, Jr.

When I launched my private practice, it was on the eastern shore of Maryland in a small town. I joined a physician who had been in practice for several years.  I managed to keep my schedule light for a few weeks so I could study for my Board Examination.  I had just finished my residency training but I was no stranger to outpatient practice.  After my return from the test which I opted to take in Orlando, I never saw fewer than 20 patients a session.  The busiest days saw us seeing 30 or more patients.  I admit that many walked in but most were scheduled.  This was in 1990 which was the beginning of the rise of HMO’s.  My practice was hospital sponsored.  In less than 1 year, I had repaid the hospital the loan and started to make a profit.  Many of my patients were uninsured but a significant number were Medicaid, Medicare and HMO. I welcomed the Clinton Health Plan and even was interviewed by local newspapers.  Sadly, for my community, it never happened.

While I was on the Eastern Shore in the 90’s, it was apparent that many of the residents had no way out of the cycle of poverty and the health problems neglected from being uninsured.  The reality played out in the Emergency Room of the local hospital day and night.  Being uninsured affected every family. Our community had business owners who were farmers, fisherman, mechanics, contractors and shop owners.  Many made too much money for Medicaid but they could not afford the cost of private insurance.  Many of them landed in the ER with serious medical conditions they had ignored.  Some even called my office and were seen as emergency visits.  One particular case was a bit scary.  One of my staff called and brought her brother in.  He was complaining of chest pain and would not go to the ER. They came to the office and I did an EKG.  To my surprise the brother was having an acute myocardial infarction.  He was uninsured and was still refusing to go to the ER even as the ambulance arrived.  We did get him there.  He and I had a tense ambulance ride together to the tertiary care hospital and I handed him off to the cardiologist who greeted us both and whisked him off to the Cardiac Intensive Care Unit.  Weeks later, the community came together for a fund-raiser.  I attended and was to my surprise honored by everyone for my excellent care.  Unfortunately, I had to leave to go to the ER to care for a patient that was not so fortunate.

I had hoped that the HMO’s would make healthcare affordable but that did not happen. The reality for patients then and now is that if you lack insurance, you end up in the ER.  I worked with the local health department.  My office was ground-zero for many programs.  We saw patients enrolled in the Breast and Cervical Cancer Screening Program, Vaccines for Children and participated in every pharmaceutical company sponsored free medication program. We saw patients from the Mental Health programs, Drug treatment programs, and Adult Daycare.  My office was such a high utilizer of one Pharmaceutical Company Patient Assistance Programs; one company invited me to give a presentation to a group of providers.

I was part of the steering committee and a board member of the new Federally Qualified Community Health Center (FQHC). It was our answer to tacking the rate of uninsured patients.  It was hard work to get the grant written, not by me thankfully but I did read it and had to give input on the clinical operation.  I also had to pledge my service which meant clinical sessions, on call coverage and hospital admissions.  I was also involved in recruiting the first full-time provider.  We were fortunate to be designated a National Health Service Corp (NHSC) site.  This allowed us to recruit a NHSC scholar who could use our site and a 3-year commitment to repay medical school loans. The good news is that built into the Affordable Care Act is increased funding for the NHSC.  The program is now expanded and will allow an increase in primary care providers in areas where they are needed.  We were fortunate to get a brilliant young Family Physician in our community. The CHC is still there but it is now part of a bigger network. Across the US, FQCHC are providing care to uninsured and underinsured patients.

Medicine for me has always been about helping my patients. The Affordable Care Act has changed the delivery of medical care in the US. There is no restriction for preexisting conditions. The Affordable Care Act (ACA) decreased the number of uninsured patients in the US.   The dilemma was increasing the number of providers to care for all of the patients.  Across the country this has happened. The defeat of the Republican’s health care plan was a victory.  I knew it would fail. It was written without the input of anyone with experience in the present health care climate.  After 34 years in medicine, I know how complicated health care is.  I live the reality everyday as I see patients and teach residents and medical students.  The problem is that the history behind all those social programs is not passed on.  Medicaid, Medicare and the Children’s Health Insurance Plan have saved lives and provided care to so many Americans of all ages.

I work with my residents in a Health Start Clinic that provides maternity care to uninsured women. They can get emergency Medicaid for prenatal care.  The Republican plan would have cut this program. We already have poor perinatal health outcomes for an industrialized nation.

Let’s continue to be vigilant and keep up the fight. We must never fail to uphold our democratic process and institutions and remember  what happened when the Germans ignored Adolf Hitler.

 “When a man assumes a public trust, he should consider himself as public property.” Thomas Jefferson

“There comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must take it because conscience tells him it is right.” Dr. Martin Luther King, Jr

Medicaid Expansion under the ACA

 

Under the Affordable Care Act, health insurance coverage increased. Between 2010 and 2015, the uninsured rate among women ages 18 to 64 decreased from 19.3 percent to 10.8 percent, a relative reduction of 44 percent.

As of 2016, national enrollment in Medicaid has grown to 75.2 million from 57.7 million in 2013, or total growth of 17.6 million (31%). Nine states have posted over 50% growth, with Nevada just shy of doubling at 97%, Colorado 89%, Montana 82%, Kentucky 73%, and California up 71%.

https://aspe.hhs.gov/sites/default/files/pdf/187551/ACA2010-2016.pdf

Medicaid is the nation’s largest insurer. It is the centerpiece of the U.S. health care safety net, providing benefits to adults and children who would otherwise have difficulty getting and paying for care. Yet the program is not well understood by the public

  • Nearly 16 million people have gained Medicaid coverage under the Affordable Care Act’s expansions; most had previously been uninsured
  • Most people are satisfied with their Medicaid coverage. A recent Commonwealth Fund survey found that 88 percent of adults are satisfied with their new Medicaid coverage: 77 percent rate it as either good, very good, or excellent (Exhibit 2). These ratings have remained consistent since 2014, when states began expanding their programs
  • Medicaid helps people get care and improve their health.
  • Medicaid provides access to timely care.
  • Medicaid provides comprehensive benefits and financial protection from large medical bills.

http://www.commonwealthfund.org/publications/blog/2016/dec/~/media/5b2abe91c9b74cec8b4a24c90ea6826b.ashx

Did you know?

A “block grant” is a fixed amount of money that the federal government gives to a state for a specific purpose.

The Republicans propose that the Federal Government would fund Medicaid as a block grant. Counter to what proponents claim, block grants don’t give states more flexibility with their Medicaid programs.

What does this mean for state Medicaid expansion?

The federal government would set each state’s Medicaid spending amount in advance. That amount would be based on some estimate of state Medicaid spending.  This would mean a significant cut in federal Medicaid support and an increase in state funding.  Most states would meet this need by limiting eligibility.

http://www.cbpp.org/blog/medicaid-block-grant-would-add-millions-to-uninsured-and-underinsured

Overall, hospitals in Medicaid expansion states saw increased Medicaid discharges, increased Medicaid revenue, and decreased cost of care for the poor, while hospitals in non-expansion states saw a very small increase in Medicaid discharges, a decline in Medicaid revenue, and growth in cost of care to the poor

http://kff.org/health-reform/issue-brief/how-are-hospitals-faring-under-the-affordable-care-act-early-experiences-from-ascension-health/