E.D., not E.D.





Well, what can I tell you…

Most of my posts recently have been rather heavy, and personal. I thought I would trot out another attempt at medical humor that (actually!) happened to me on the job.

Everyday, before a Medical Assistant begins seeing patients, there’s a litany of things to take care of. Some mornings are busy, some run smooth; but, the ducks need to be in a medical row before showtime can begin and the first patient is seen. You’ve got to meet with your provider and pow-wow the day, make sure every room is stocked, make sure you’ve got equipment set aside for any special procedures that day, and gulp down about a gallon and a half of coffee.

Nearly every hospital or facility uses what’s called an EHR, or: electronic health record. This is essentially the operating system of the clinic. You can see all sorts of nifty PHI (patient health information) here, as well as the schedule for the day. Many facilities use an EHR known as Epic, although there are others. The days of paper system providers are practically an anachronism.

In February of 2009, President Barack Obama signed the HITECH act, or the: Health Information Technology for Economic and Clinical Health Act. The goal of this act was to compel ‘meaningful use’ of electronic health records; that is, to facilitate national healthcare information between different healthcare facilities, and to promote the safety of patients by digitally checking drug interactions, duplicate orders, unrecorded allergies, a current medication list, and a host of other measures.

There are, of course, drawbacks to this measure. Any electronic system of information can be hacked. If you’d rather not be discouraged, please do not read this:

https://www.healthcareitnews.com/news/biggest-healthcare-data-breaches-2021

To be fair, nearly all modern healthcare facilities use state-of-the-art electronic security systems for their internal network, with an army of techies constantly guarding it. The chances of someone cracking into a hospital’s system are extremely low. So please, do not follow this link:

But, by and large, your information is quite safe. Another criticism of the electronic health record system is the difficulty transmitting information from one facility to another. Within the same company, it’s not a problem. But if Epic goes to link a patient’s PHI from another healthcare company, the results can be quite variable. Sometimes, the information is linked immediately. Other times, the targeted EHR does not respond; or, in some cases, it does, but painfully slow. However, when it works, it’s a fantastic tool for healthcare practitioners.

Still another criticism is purely opinion, one I have heard from many in the industry, and not necessarily my own. The Department of Health contributed nearly $37 billion dollars to promote the adoption of EHRs. This was a worthwhile incentive for a worthy endeavor, but essentially, this all but rendered small, private practices extinct. It is extremely expensive for a small provider or a facility to convert from a paper records system to an electronic system, generally running over 6 figures per provider. Thus, the Amazon analogy applies.

Personally, I find the Epic EHR a great system, easy to use, very customizable, and a wealth of PHI. I could not imagine doing my work without it. In my opinion, the developers have done a fine job.

But, back to the matter at hand: the beginning of a Medical Assistant’s day. Within Epic, there is a schedule for the day feature, listing the patient, their pertinent information, the time and length of visit, and, at the click of a button, whatever else you need to know. Perhaps the most useful category on this list is: ‘reason for visit.’

It was early on in my healthcare career, while I was an extern at a primary care clinic, using Epic. My mentor, who had the grace and social skills of a rabid possum trying to do math, asked me what reasons patients were coming in for today. I glanced at the computer monitor showing Epic, looking under the reason for visit column. There is was.

At least 8 of the 14 or so patients coming in that day, for our provider, were listed as ‘ED follow up.’

My God, I thought. These poor patients. So many. One of them was only in his early 20’s…

Erectile dysfunction is no laughing matter. So go ahead, get it out of your system. Go ahead with your vienna sausage problem jokes. Yuck it up. But the truth is, erectile dysfunction can be a very debilitating, and alarmingly frequent condition. It affects over 30 million men in the United States. The causes can be quite varied: diets, medications, neurological disorders, psychological disorders, kidney disease, age, lifestyle habits, and many others.

https://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/symptoms-causes/syc-20355776#:~:text=Erectile%20dysfunction%20(impotence)%20is%20the,necessarily%20a%20cause%20for%20concern.

Sadly, one of its main side effects, other than the ability for a male to perform during sex, is psychological. There are a myriad of of psychological reasons why this is important to men, a topic for another time. But erectile dysfunction can cause seriously debilitating psychological damage to a male. Self-esteem can take a massive hit, and depression can result. A male may feel woefully inadequate, a self-defeating thought which pervades other areas of the man’s life. It is an embarrassing condition, one which men don’t like to talk about, it sucks, it’s no fun, women laugh at you, you think you’re worthless, I hate myself, no one will ever love me again, I am only half a man, why does God hate me, I…. wait, who am I talking about, here? I wasn’t talking about me! WHAT?!? Anyway, I digress.

There are, of course, many treatments available for ED. Depending on the cause and severity, it may range from a simple medication or lifestyle change, all the way up to an unfortunate but life changing surgery. It can be fixed.

https://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/diagnosis-treatment/drc-20355782

So, my mentor asked me the reasons for patient visiting that day. I really didn’t know what to say. I paused, turned to her, recalling that this is healthcare, and said to her: “It looks like we have a lot of patients coming in today for ED.”

She looked even more annoyed than usual, looked at her screen (with the same schedule pulled up), and scowled. Turning back to me, and said, with the tone and temperment of a ferret with a flamethrower: “Some of these patients are female!” Huh? I looked back at Epic. I hovered the mouse cursor over the reason for visit column. (Epic has this neat feature… hover to discover… you pull up more detailed info when hovering the cursor over the subject…) Further information was displayed in an expansion of the display.

“Emergency Department follow up for dog bite.” “Emergency Department follow up for sore lower back.” “Emergency Department follow up for transient tachycardia.”

Ah. Emergency Department follow up. E.D., not E.D. Well, egg on my silly face! I learned that day something very important: in healthcare, what is colloquially known as the ’emergency room’ or ‘ER’ is actually called the ’emergency department.’ Well, that’s good to know. Would have been nice if that had been in the classroom curriculum. Back to you, Jaimers!

So, there you have it. If you need to go to the ER, it’s just fine to call it that. Let’s say you go in for a bad bee sting or something. Then, the staff there will advise you to follow up with your regular provider. When you schedule that follow up appointment, behind the scenes, Epic will list the reason for your visit as an ED follow up. But don’t worry. You don’t have ED. Especially those of you coming in for gynecological exams.

As an aside, my mentor turned out to be a very cool person. She and I keep in touch, years later, as she was very instrumental to my success. Although, I remember more than a few times, while I was turning an exam room (cleaning it and restocking it after a patient’s visit), I overheard her say: “Having an extern rules. He has to do whatever I tell him. I love that!” Heh. She was a great mentor, and a great Medical Assistant, and very much part of my education. Thank you again, KK at Wedgewood.

Well, there you have it! Take care of yourselves! Wash your hands! Get vaccinated! Be good to each other! Bye for now.

TY: KK, UWM – Wedgewood, JP

THE FAILURE OF MENTAL HEALTH TREATMENT: THE DIVORCE OF PSYCHIATRY AND PSYCHOTHERAPY

There is a massive problem with the practice of psychiatry in today’s modern healthcare industry. There are several reasons for this, which I will address in a moment, but first, let’s get a few things out of the way.

Many people have a very reactionary, negative opinion of the field of psychiatry. They feel that it does more harm than good. In today’s healthcare environment, they may have a point, but I am speaking in general terms. Psychiatry, to many, is a dangerous science that can damage your brain. Of course; many medical procedures can damage you if administered improperly. That’s why I went to school. Many people feel that psychiatrists have very little clue as to what they are doing. While it is true that the study of the brain, which has remained a difficult and emerging science for a very long time, and will continue to be so, there are millions of Americans who have benefited from what psychiatry does know, and what treatments it can provide. And still others feel as though psychiatry, and indeed, any treatment of the mind or emotions, should be out of the realm of medicine, and kept in either the family or church. While it is very true, and studies have confirmed this, that those of faith, or at least some level of healthy optimism about life, tend to heal much quicker from whatever affliction they may have, that does not mean that medical intervention is sometimes required. Nor does it mean that atheists do not heal.

Plenty of people have a negative opinion of healthcare in general. That is unfortunate. Many millions of people have benefited from the proper treatment of an affliction, and go on to live healthy and productive lives, despite an illness that would have been a death sentence one hundred years ago. The human body is a machine, an amazing construction, the triumph of life on Earth (although the debate about that is for another time). Whether by evolution or design, you and I, and everyone else on Earth, are amazing creatures, composed of practically countless processes, organs, chemical and electrical reactions, and things still yet to be discovered. However, just like any other form of life, like any artificial machine, like any magnificent creation of geology, things can, quite simply put, break down. Sooner or later, it happens to all of us. Have you ever thrown your back out? Well, so have 65 million other Americans. We are wondrous creations, but not entirely perfect. Healthcare plays a role in our repair, and improving our quality of life.

But back to psychiatry. The negative connotations I mentioned above are not entirely unfounded. The history of psychiatry is replete with practices that today seem barbaric, and would never be considered as an option for treatment. What is worse, in modern history, authoritarian regimes have tortured and killed untold numbers under the guise of psychiatry: Nazi Germany, The Soviet Union; even the CIA is guilty of using psychiatry for nefarious purposes.

However, like all healthcare, psychiatry is an evolving field. Healthcare, in essence, is an applied science. That is, it is a scientific endeavor, used for practical means. Many constructive gains have been made. However, the application of these discoveries, when applied to the practice of modern American healthcare, has been severely misappropriated.

I can’t get into the tired debate of whether or not mental illness exists. Believe what you will. Many people, intelligent people, will claim that there is no definitive diagnostic test to prove whether or not a mental illness exists. It is true that nearly all mental illnesses, particularly the behavioral ones, are diagnosed by interview and observation, or that form you occasionally fill out at your annual exam where you check the corresponding box as to whether you are happy or sad. However, you can get out the fancy medical equipment and see it for yourself. In people with anxiety, a part of the brain called the amygdala is overactive. In cases of depression, insufficient monoamines are developed in the neurons of the brain. One could utilize these ludicrously expensive machines if you want to see the proof, but good luck getting insurance to pay for this.

Mental illness exists. I was once speaking to a friend of mine, who had a negative opinion of psychiatry, and said to just get that person with depression some dancing lessons, a cat, and an exercise program. Okay, Tom Cruise. You tell the guy with the gashes in his wrists who’s hanging from a noose to get some dancing lessons, B-vitamins, and some duct tape, and I’m sure he’ll be fine. Sheesh. But I needn’t be snide. Annually, roughly 49,000 Americans take their lives each year. Suicide is the 10th leading cause of death in the United States; however, it is the second leading cause of death for those between the ages of 15 to 34. There are, on average, 132 suicides per day. Perhaps worst of all, according to the Department of Veterans Affairs, 20 veterans die from suicide every day.

To be fair, engaging in activities that one enjoys that are healthy, socializing with others, becoming involved in a community art or political program; these are great ways to alleviate the symptoms of depression. So too with the natural remedies; regular exercise, a healthy lifestyle, artistic expression, prayer and faith, whatever you might like. But many people are too depressed to even get out of bed.

Besides depression, anxiety disorders are the most common psychiatric disorder in the United States. They affect 40 million people. Untreated, this illness will damage those around the afflicted, cost industry labor, and overburden the healthcare industry. People having panic attacks often end up in the emergency room. The number of those with anxiety disorders is no doubt growing, considering the trauma of the last year and a half.

And we’re not even talking about schizophrenia, ADHD, PTSD, bipolar disorder, panic disorder, and a host of others. Intelligent people with fancy degrees will argue that the DSM, the Diagnostic and Statistic Manual of Mental Disorders, is cluttered with debatable mental disorders. It contains nearly 300 diagnostic entries. It should be noted that the ICD, the International Classification of Diseases, contains about 80,000 entries.

But I am severely digressing. The main point I am getting at with this article is the unfortunate practice of psychiatry that one will often encounter when they visit their regular clinic or provider.

Somewhere along the way, a great disservice was done to the field of mental health. Psychiatry and psychology were divorced. This is profoundly wrong, and does not do nearly enough to heal the mentally and emotionally afflicted.

These two sciences, psychiatry and behavioral psychology, go hand in hand. They are deeply intertwined. You cannot simply address psychiatric needs while at the same time giving little consideration, or even downright ignoring, the psychology that goes along with psychiatric suffering. It is analogous to a physician simply giving a person with diabetes insulin, and telling them to monitor their blood sugar at home, while not counseling them on their dietary habits. So with psychiatry. You cannot simply throw pills at them, without addressing the psychology, usually damaged, that accompanies it. This makes no sense.

Unfortunately, that is the solution of much of modern healthcare: throw a pill at it. Also, due to the profit motive, patients are generally allotted 15 to 20 minutes for a visit with a healthcare provider. That is not enough time. The psychiatrist, or MD with a specialty in psychiatry, may ask them how they’re feeling, how’s the job, etc, but that is insufficient time to dig deep enough to treat the illness.

Psychotherapists exist, of course. However, they are harder to find, as insurance will still balk at their treatment, or they are booked far in advance due to the dire need, owing to the stressful times we live in.

Some clinics will not even have a dedicated psychiatrist. Your primary care physician will treat you. I’m sure that person cares about their patients, and has studied, at whatever length, both psychiatry and psychology, but they are much more likely to just throw pills at you, tell you to keep a journal or do some art or something, and come back and see them in a month.

I was diagnosed with a mental illness in my early 20’s. It should be noted that there is no ‘cure’ per se, but there are treatments to alleviate the symptoms, mental exercises to retrain your thinking, so to go on and live a healthy and happy life. I was able to do so. Despite a crippling depression, in a way, I was very fortunate. I was first treated by a seasoned psychiatrist, whom I called Dr. Dispensapill, who knew that psychiatry and psychology cannot be separated. He would see me for an hour. We would talk briefly about medications. Then we spend the bulk of the visit speaking about psychological challenges I might be facing. Then we would wrap it up with any medication or lifestyle changes to consider.

His is a disappearing style. You can still find psychiatrists like him, but they are rarely covered by insurance, and they are frequently booked far out.

Dr. Dispensapill, north of 80 years old, recently ceased being able to practice. It was difficult to find help for my mental health afterwards, but I have found a combination that works. I see, for 15 minutes at a time every few weeks, Dr. Deer In The Headlights, who knows little of psychotherapy, it seems, but knows all about the different medications and how they work. She got a 4.0 in advanced chemistry, I guess. I have also been able to find a very skilled psychotherapist, Dr. How Many PhD’s Does One Actually Need. She has been fantastic.

More than one of the providers that I work with have complained to their superiors that there is a woefully insufficient staff of human resources to refer psychiatric and deeply troubled psychological patients to. They will help the best they can, but they are there to treat skin rashes and broken bones.

This is a great problem in American healthcare. We have made a damaging mistake. The mentally ill are not getting the proper treatment that they so often need. The separation of psychiatry and psychology is, in my low-level practitioner opinion, the biggest systemic mistake modern American healthcare has made. You can’t treat one without treating the other, and vice versa.

Until we fix this problem, and there are other, massive problems with American healthcare, the treatment of the mentally ill will remain insufficient. Many more will take their lives. Millions will continue to be crippled with anxiety, living tortuous lives. And the dangerously mentally ill, with no options for treatment, will continue to commit violence.

I’m not sure why this happened. It shouldn’t have. Just my opinion.

Be good to each other.

National suicide hot-line: 800-273-8255

Cute Animal Stories and Physiology

cat nursing puppies

The link above is a very cutesy video, but it had me reaching for my textbook.

According to this video, the mother cat had recently lost her kindle (I love collective nouns) and was, quite naturally, profoundly depressed. This animal foster family took the cat in, and found the cat to be needy, sad and distressed. It was only after the introduction of a litter of puppies that had lost their mother (what is this, a Disney movie?) that the cat came around.

There is an endocrine gland (that means it makes hormones) in the middle of your brain called the pituitary gland, answering to your CNS by way of the hypothalamus, a bridge between the CNS and the endocrine system. The pituitary gland is often called the master gland, because it does a lot of stuff, probably gets paid more. One of the hormones it secretes is called oxytocin. In mammalian females, oxytocin plays a major role in commanding the body for pregnancy, birth, and nursing. However, in both genders, oxytocin, by the very nature of its primary function, also engenders feelings of attachment, belonging, and intimacy. This cat was flooded with oxytocin, was depressed, and needed attention. When the puppies were introduced, the oxytocin returned to its primary role, and the cat became a surrogate mother. At this time, the cat’s pituitary gland produced another hormone called prolactin, and enabled the animal to nurse the puppies.

I’m not trying to reduce the powerful emotions this cat felt, emotions that would also easily occur in a human being, by explaining it away in technical terms. I’m not trying to take the ‘awww’ out of it. Just two things:

1: It is profoundly interesting that external, emotional events have a direct, physiological impact on how your body functions. Your emotions are very real, can be very strong, and, if you need proof, take a look inside and see the physiological process. If someone tells you to suck it up, if someone shames you for mental illness, if someone tells you to stop feeling a certain way, then they are A) ignorant of how the body works, and B) an asshole. “It’s all in your head!” Well, of course. Everything is. But that’s ontology, for another time.

2: It’s also profoundly interesting that we’re looking at two completely different species here. That’s incredible. That speaks to the strength of the survival instinct, but that’s for another time.

Well, I’m procrastinating again. Gotta hit the books. Wash your hands!

Fight or Flight in America as a Sociological Phenomenon

Crisis Fatigue

The link above is an interesting article. The physiological phenomenon known as ‘fight or flight’ exists in most living creatures, and is deeply ingrained into every human being. It’s a crucial component of the survival instinct, and has been for hundreds of thousands of years, existing as well as in our progenitor ancestors.

As simply as I can put it: Your 5 senses and your intuition will perceive a threat. This gets crunched in your consciousness, a poorly understood concept. This threat then gets sent to your amygdala, a part of your brain, for verification. This triggers a response in another part of your brain, the hypothalamus. The hypothalamus wears many hats (and we really don’t know how), but it kind of serves as a command center for a lot of things. In this sense, it triggers the fight or flight mechanism. Admiral Hypothalamus will activate your sympathetic nervous system, a part of your electrical wiring, which fires up your adrenal glands, which generally have about 8 cups of coffee in them already. Your adrenal glands will freak out and push the panic button, and secrete a number of hormones, mainly adrenaline, cortisol and norepinephrine. The adrenaline will ramp up your blood pressure and your pulse, and accelerate the actions of your lungs and muscles. The cortisol will adjust your glucose (stuff you get from food) to provide a burst of energy. The norepinephrine will flood your brain, increasing alertness and response times. Every other system takes a back seat, including rational thought. At this point, you’re ready to kick some ass. This goes back to the time when our ancestors had to face off grizzly bears. We don’t have to do that anymore (except for those idiots in Yellowstone who want a better picture), but fight or flight is very much with us today, in response to both physical (a mugger, a mean dog, road rage) or emotional (fight with your spouse, boss wants to see you, the principal called) experiences. Eventually, the response will abate, and you are left exhausted and weak.

Problems happen when people are under constant fight or flight, and the response does not get a chance to wear off. This will result in anxiety, depression, PTSD, heart problems, or all of the above.

I know nothing of sociology. However, this article posits the idea that American society has been living under a steady, constant fight or flight response ever since 2020 started. We are now suffering from the effects of 3 social phenomenons that are causing Americans a huge amount of stress. It started with the emergence of a virus we thought we may be able to control, but we were very wrong. Then, racism reared its ugly head once again, when George Floyd (and, let’s face it, he’s not the only one) was murdered by a police officer. This has triggered a massive social disruption of anger and violence. Perhaps worst of all, the federal leadership (dammit, GOP, I hate to say I told you so… I take no glee in his failures) has been fully exposed as incompetent, dysfunctional, and unwilling or unable to rise to these challenges. In fact, our President’s behavior has gotten worse, and it is clear that he is in way over his head. In the meantime, the violence continues, and the pandemic has now killed 111k Americans. At this point, things do not show any signs of significant improvement or healing. As with an individual, problems will arise when the fight or flight response does not get a chance to settle down. We are seeing that now, in the hatred, anger, depression, isolation, anxiety and general “I’m pissed off today” attitude in nearly every American. If things do not settle down, the damage to society, as with an individual, will be massive, and will take longer to heal than we can imagine.

Well, I’m just babbling instead of doing my homework. Sorry for the long post. I better hit the books. Wash your hands!