Added complexities...

Some days you're just wrong.

Daisy Coleman, you go girl.

I read what happened to Daisy Coleman, and what was done to her family.  I am thrilled that she refuses to be silenced.  I provide reproductive health care to young women and too often I have to deal with the aftermath of exactly this sort of rape.  For those of you who want to tell me that she could have avoided it, blah blah blah.  He would have done it to someone else, because the "undetected serial rapist" leaves an average of 14 victims behind.  These perpetrators  seek out and groom victims;  they use alcohol as a tool.  He is in many ways more like a child molester than like our mythical image of a knife wielding stranger.

What excites me about Daisy's public stand is my feeling that this reflects a fundamental shift.  Young women have "gotten the message" and their attackers had best beware:  

It's not her fault, 

and she knows it.

Avoiding unnecessary antibiotics, my answer to a student question:

This student posted a general question about why doctors over-prescribed antibiotics and I responded that I did not.  So then the little bugger asked me "How do you handle patients that insist on needing them?"  My response:

Variously.  And being not-flip, I have on occasion prescribed antibiotics I suspected were not needed. One of my tactics is to schedule a follow up appointment. Patient comes in, has had "sinusitis" or "Bronchitis" for 10 days. I suspect it will be better in another 10 days, or then they may need antibiotics. So I schedule another appointment and tell them to cancel if they're all better. I work in a setting without co-pays. If I were in a different set up, I would have them call the nurse in 10 days, or I might have the nurse call them with a checklist of questions.

I NEVER prescribe the newest and greatest in the outpatient setting. Most people in the outpatient setting will get better with or without antibiotics. I remember when azithromycin cured everything (it now cures very little but it has an anti-inflammatory effect). When I see folks treated with Levoquin for an uncomplicated urinary tract infections I want to scream.

People with COPD (Chronic Obstructive Pulmonary Disease) are different as well; they are more likely to need/benefit antibiotics. I was taught to keep a rotation of basic antibiotics with them, but when I looked into it recently there don’t seem to be any studies supporting this, but the antibiotics involved are all old and out of patent so it might be hard to get them funded. Note: When reading a study that says new, expensive antibiotic works best on outpatient issue, be VERY suspicious.

Two things I was taught, one is never work harder than the patient. This is why symptom diaries rock. If the patient isn’t willing to fill them out, it can’t be that bad.

The second: The medical art is to distract the patient while nature cures the disease. (L'art de la médecine consiste à distraire le malade pendant que la nature le guérit.) Voltaire (1694 - 1778)

I write prescriptions for fresh ginger, lemon and honey hot drinks. I smile and make silly jokes. I tell them I get paid to do the worrying will they will kindly leave it to me and me to it.

I also tell the story of my aunt, killed by inappropriate use of antibiotics at the dentist. (This is a true story. She was 80 and ended up septic due to C. dif.)

I also keep in mind that I could be wrong. I give them things to watch out for and tell them to call me if that happens. Patients are remarkably forgiving if you care. (You can’t fake it. You have to really mean it, if only for the time in the room. And the nastiest most difficult ones are the ones most afraid that you don’t care.) And in the long term I build a practice of patients who trust me. The ones I can’t educate or who don’t develop confidence in me move on to someone else. And that’s okay.

Please re-open my government...

I wrote to my congressman today.  I do it regularly, both of my senators are people I agree with politically, so poor Rob Wittman of the Virginia First gets all my spleen vented upon him.

He is donating his salary to charity during the shut down.  I appreciate the gesture.

He is NOT on the list of the 32 Republicans responsible for the shut down.  That's nice.

He supports back pay for workers affected by the shut down.  And while that is nice, I want to know if he also supports them making up the lost work? (I realize this is unfair and impossible, but you see my point.)

The sheer waste going on in scientific research laboratories makes me want to weep.

The ACA or "Obamacare" is not perfect.  But its a start.  The majority of Tea Partiers intend to collect Medicare and Social Security, programs that were controversial in their day.

Every single person I meet who opposes "Obamacare" has health insurance.

I am uninsured, it is not offered through my job.  I support the ACA.  I may pay the fine this year, but I am so excited about being able to shop for insurance.

Interesting twists

I watched Agents of SHIELD last week and one particular scene keeps sticking with me.  When Coulson and Ward are questioning Skye, Coulson gets out the truth serum.  Then is a really nice twist, he gives it to Ward and lets Sky question him.  Why do I like this so much?

1. Lois McMaster Bujold uses a substance called FastPenta in her fiction.  Her protagonist (male) acknowledges at one point that interrogation with it can be a form of "mind rape".  
2. Ward is just the sort of power-happy creep who needs to get smacked down hard when he's young in order to grow up into a decent human being.
3. The truth serum with all its ugly implications comes out, Ward looks excited (yuck) and then the power dynamic is gleefully subverted.

Later in the week another new show, The Blacklist twisted the dynamic a different way when Liz is asked to profile herself.  There were several moments in the pilot, including this one, that reserved agency to Liz  even when it was uncomfortable.  The Liz character could have been a Mary Sue.  She's not.  I hope it continues.

Why contraceptive coverage matters...

...its about a woman's right to privacy.  No woman should have to detail to anyone except her doctor, whether she is taking birth control pills for acne or contraception.  Your employer should not have the right to decide what kind of medical care you get.  And it is important because if you empower the bigots, they get worse.

When I was a young resident, a patient came into the ER in the throws of a miscarriage.  I had some lab and imaging reports that supported the diagnosis and she was bleeding fairly profusely so  I wanted to give her medication that would complete the process more quickly and hopefully avoid a trip to the operating room.  (D&C is not an entirely benign procedure in either the moment or the effects on future pregnancy, it is however very safe.)

A nurse informed me, in self righteous tones, that she would not administer the medication as her religious beliefs prohibited abortions.  As a sleep deprived second year I simply goggled at her.  I've honestly forgotten how I worked it out. All I remember is my wrath that my poor patient, who was loosing a wanted pregnancy, had to deal with the narrow minded bitch.

Also, go see Pope Francis on uncertainty in my last post.  I'm a Buddhist, have been for over 20 years.  That soft open uncertain mind is one of the goals I seek.

The most important thing Pope Francis said:

I have taken these from different parts of the interview, but I think I retain his meaning:

" If a person says that he met God with total certainty and is not touched by a margin of uncertainty, then this is not good. For me, this is an important key. If one has the answers to all the questions—that is the proof that God is not with him. It means that he is a false prophet using religion for himself. The great leaders of the people of God, like Moses, have always left room for doubt. You must leave room for the Lord, not for our certainties; we must be humble. Uncertainty is in every true discernment that is open to finding confirmation in spiritual consolation."

“The risk in seeking and finding God in all things, then, is the willingness to explain too much, to say with human certainty and arrogance: ‘God is here.’ We will find only a god that fits our measure."

This captures what makes me so uncomfortable about many fundamentalists.  They are so certain that their understanding of God is complete and correct, that they create a God in their own image, instead of seeking to recreate themselves in God's.

(I am neither supporting nor refuting that there is a God, to me the case remains open.)

What is wrong with our world that Jon Stewart makes more sense than anyone else?

I have re-ordered these quotes for effect.  Daily Show 9/10/2012

I get that Fox opposes the Syria peace plan because its modus operandi is to foment dissent in the form of a relentless, irrational contrarianism to Barack Obama and all things Democratic to advance its ultimate objective of creating a deliberately misinformed body politic whose fear, anger, mistrust and discontent is the manna upon which it sustains its parasitic, succubus like existence, BUT ...
Who cares how we avoided a war and got a dictator to give up his chemical weapons if we avoided a war and got a dictator to give up his chemical weapons?

Day of Fasting and Prayer for Syria

I am very sad about what is happening in Syria.  The Pope, who runs a church I do not belong to, has very sensibly suggested a day of Prayer and Fasting on September 7th.  I don't know what he intended to mean by fasting, but since Syria is a predominantly Muslim country, I am going to try and abstain from food and water from sunrise to sunset.  I have nothing big to do that day, so it should be possible.  I encourage anyone who reads this to do whatever seems right to you.

Christianity with more questions, fewer answers.

I feel for conservative Catholics, cleric and lay, in this time.  But I encourage them to not confuse style with content.  What Francis is saying isn't anything all that earth shattering:

Judge not lest ye be judged. 

Worry about the beam in your own eye before worry about the splinter in your brother’s.

Let he who is without sin cast the first stone.

It’s only radical because he seems to mean it.  And if it makes you uncomfortable, good.

I also want to applaud Benedict for the truly humble act of stepping down.  Benedict has given us the gift of Francis, I truly believe Benedict’s resignation was moved by the spirit.  By tossing the church a curve ball, and not giving the politics time to set in, he allowed them to respond from the spirit.  

Things I love:

1. My Mom
2. Dan Savage
3. The Python loose on Dartmouth Campus.
4. Sandra Bullock and Melissa McCarthy.

I don't love all these things equally.  And I expect that I won't love them all for as long.  But there you are.

Why do some people spend so much energy on hate?

I have been pondering the pro-life anti-gay marriage movement for a while.  That there is a fear in their motivation has long seemed likely to me.  But what they are afraid of has eluded me.  I’m sure some are hiding their own homosexual leanings or curiosity.  Some of the pro-lifers probably feel trapped in their own lives and wish they could have had other choices and are angry and those who did.  I’ve been looking for a unifying thread.  Today at lunch my mother was telling a story about a man whose step-daughter died and his family’s ongoing relationship with the recipient of her heart. 

                This got me thinking about the irregular and lumpy shapes of families today.  The element of choice in family.  Most of us have non-relatives to whom we are solidly attached and think of as “family-by-choice”.  It is an idea that was at the root of gay families for years.

                So, these people who oppose abortion and gay marriage, if families all were to have an element of choice, are they afraid no one would choose them?  Is their hatred of others a reflection of their own feelings of being un-loveable?  

Ann Curry, For Better, For Worse

I like Ann Curry well enough.  She reminds me of myself, good and bad.  I felt very sorry for her when she was forced out of the Today show; I've been fired a time or two.  But my sympathy has not been so great afterwards.

She behaved like a fragile damsel.  There's nothing to put people off the victim of a situation than acting like a victim.  Also, despite the difficulties, she still had a job with an income.  A rather good income.  My mother used to tell me that bosses hire you to solve their problems, not to solve yours.  No one made Ann Curry work in the highly competitive realm of network news.

I had not realized that Ann Curry had a husband and two children.  I visualized her as a single, childless woman whose whole identity was the job. Okay, now I'm over it.  Sorry your job didn't work out.  Time to woman up.

Email I sent to the principal of the Catholic School in Columbus, OH

Sorry, my two cents worth.

When I first heard about Ms. Hale, my thought was, you're a private school, you can do as you want.  But when I heard about how it came about and that she had been with you for 19 years?  Well.

Please remember that the bible counsels us to worry about the beam in our own eye before we worry about the splinter in our brother's.  I don't like that you rewarded the nasty behavior on the anonymous tipster's part.  (If that story is accurate.)

If she were discussing it in the classroom it would be different.  But she is obviously a naturally discrete person.  I hope you are struggling with this.  If you're not, well you should be.  

Good luck.  

It may be too late in this situation, but the Japanese had a saying, back when their lives were more communal, that nakedness is often seen but seldom noticed.  You don't have to notice everything someone tells you.

Charles Magnus 

This week, on the second anniversary of my father’s death, my beloved dog Chuck had a cerebral accident of some sort and was put down to spare him the miserable hours of dying.

     He was perfectly well the night before and when I woke up (he did not wake me, which was unusual) his left leg was paralyzed and he writhed when he was moved.  Linda, my landlady, took us to the vet, both she and I still in pajamas.  Dr. Amy pointed out the vertical nystagmus* and we noticed that one eye was coming out of his head and the other was not.  He was drooling at this point, and leaking stool.

     She was able to give him the shot while he lay in my arms.  I am grateful it was clear what needed to happen.  I'm grateful it was quick.  I'm grateful that he was well until the end.
    I never mistook Chuck for a human, he was my much loved dog, and I was his person.  I feel as if a part of me has been amputated.  I think of the walks not taken, the times I didn't take him into work on the weekends, and I hope that the biscuits and the brushing, the walks we did take, I hope they were enough.   He will be cremated and I am going to sneak him into Hollywood Cemetery to rest with my father, and eventually my mother and eventually myself.

http://www.hollywoodcemetery.org/ 

*fast, uncontrollable movements of the eyes, in this case up and down.

Random Gun Control Quotes

 “Their paranoid fear of a possible dystopic future prevents us from addressing our actual dystopic present. We can’t even begin to address 30,000 gun deaths that are actually, in reality, happening in this country every year — because a few of us must remain vigilant against the rise of Imaginary Hitler.”

Jon Stewart "The Daily Show"

Comedian Chris Rock, when asked about gun violence said:

 “I believe you should have to have a mortgage to buy a gun. Nobody with a mortgage has ever gone on a killing spree. Because a mortgage is a real background check; and you know if you go to jail for 30 years you still have to pay your f–king mortgage.” 

My comment on Rock:  If we are trying to do what the founders wished, this is certainly in line with their sentiments that property owners were the true citizens.  But I wish to caution against using the founders as our absolute measuring stick.  It was a very different time and place, one to which I as an educated, voting woman, have no wish to return.

My comment on the second amendment:  I truly believe that [it] was intended as a civic and collective responsibility: to allow New Jersey to protect itself against New York, for Maine to fight off Canada, and For New England to withstand the Federal Gov’t if FDR had stood for a fifth term.  The regulation of the individual right to bear arms outside of the well ordered militia, should be reserved to the state.  However, in order for the state to be able to assert its sovereign rights, the federal government needs to regulate the interstate commerce of guns, its job.  If Virginia allows anyone to buy 100 automatic handguns, how can Rhode Island require each gun owner to be properly licensed?  

Gun Control

I drove home to Northern New England from the Mid-Atlantic in December of 2012.  I got hung up in traffic on Route 84 during the day on a Saturday.  I called my sister, not sure why, wondering if there was some holiday or natural disaster I was unaware of.  Then I saw cops on motorcycles.  I knew before I saw the hearse and before I saw the sign to Sandy Hook/Newtown.  

      To my own surprise I burst into convulsive sobs.  I'm not much of a crier.  I later looked online and figured out that I was watching the funeral procession of Josephine Gay. Above my desk I now have a sweet picture of her on a swing with a slightly older someone who might be a sibling.  Its going to stay there for awhile.  It inspired me to write this list, with the intention of sending it to my congresspeople and governor.  Haven't done it yet, but here you go.

 

1. I support requiring all guns to be sold by dealers licensed in the state of sale.  I support a limit on the number of guns an individual may buy in a given time period.

2. I support all sellers and buyers to be required to register change of title, just like I did when I sold my car.

3. I support a written and practical test, financed with licensing fees, for gun licenses, and for licenses to be required prior to purchase.  Background checks could be done with the licensing, eliminating the need for waiting periods to purchase guns. 

4. I support requiring gun owners to have liability insurance.  This will give rise to gun safety classes to lower the liability.

5. I support periodic renewals and inspections. 

6. I support banning sale and ownership of high capacity magazines with exceptions for training facilities and law enforcement.

7. I support the appointment of a director to the Bureau of Alcohol, Tobacco and Firearms.

8. I support state or federal databases of firearms.  Choice to the state, make your own or delegate.

9. I DO NOT support armed guards in schools.  I have lived in a country experiencing the end of the rule of law.  That is not my country, and it must not become so.

How Wrong Can You Be?

Without ever realizing it, I had lumped my three favorite NPR hosts into the category of gay New York Jews.  This is a prejudice, but it is a category of people I am generally fond of, so it is a relatively benign prejudice.  After finding out that Ira Glass was married, I checked on the other two.  Married to women with children.  While that is not necessarily make them not gay, it doesn't seem very likely.  So, none of them are gay.  Whoops.

So now I have to wonder, where are they from?  Ira is from Baltimore, and Michael Feldman, with his wife and two daughters, born and raised in Madison, Wisconsin.  Which leaves me with Peter Sagal, resident of Chicago and married father of three.  He was born in New Jersey.  30 miles from New York.  At this point, I'll take it. 

Thankfully (?)  they are in fact, all Jewish.  I am reminded of that awful woman on the West Wing who equated New York with being Jewish.  Pissing off Toby and/or Josh (Jewish character played by an Episcopalian.)  I don't like thinking of myself as being in the same category.  I will think on this.

This week in the Supreme Court

I expect the Supreme Court to pronounce that states may explicitly allow or fail to explicitly allow same sex marriage, but they may not ban it, and they must recognize it when performed in another polity.  So, Arkansas doesn't have to allow gays to marry, but they cannot forbid them and must recognize it when they get married in Kansas.  (States selected at random.)

Three Perfect Movies

1. Moonstruck 
2. Princess Bride
3. Nobody's Fool

The first two are well known.  The third is Paul Newman and Jessica Tandy.  And a nice little surprise.