Chronic Illness vs The Medical Establishment

First, the artwork. I considered using Eduard Munch’s “The Scream.” But by now, that’s probably the most overused and parodied piece of art from any period. So what I have here: a drawing by the English novelist, William Makepeace Thackeray. No joke: he was also a fairly skilled artist. Here, then: a guy in bed with a fiddling donkey sitting on him makes a lot more sense. Some days we’re all surrounded by asses and assholes.

Well, assholes. Yesterday afternoon, I spent some hideous time with my primary care doctor.bad dream

Hideous, indeed. I’m good for a rant as it is, and that is what this is. Rant moods usually dissipate overnight. But now, even after a good night’s sleep, I’m furious. Yes, I’ve petted the cat and I’m listening to Debussy piano music. Gornisht helfen. I feel like Stagolee or the vulture on a fence surveying an empty landscape: Patience, yer ass, I’m gonna kill something.patience

taz

So if I’m still ripshit, I will represent myself as a Tasmanian Devil. Not the cartoon character, the real deal. Not a friendly puppy.

The Medical Industry

Perhaps I’m a slow study. Maybe I’m among the last to figure out that contemporary medical practice is more about the fine art of covering your ass than it is about helping heal people. Maybe it’s more about hyperspecialization and “It’s not my job” than about compassion. Maybe it’s all about looking over your shoulder at the insurance companies who really manage medical care in this country. Maybe it’s all about following the holy rules of the Federal government and the Social Security Administration rather than behaving ethically. But there we are.

Nothing should surprise me anymore, but it does anyway.

My doctor has been treating me for neuropathy as well as high blood pressure. We’ve got the BP issue pretty well-handled. With medication. Oh, don’t tell me about how a diet can fix it. No, it can’t. So just don’t start.

Anyhow, I went to see him with more than one issue. See, I am a “complex.” Most people with chronic conditions have more than one. It’s the nested Chinese boxes again.

I’m not one chronic illness. First, there are the magic feet. Stevie Wonder could see that I am neuropathic, and that both feet are affected. This is an extension of Type 2 diabetes. The act of walking cycles between effortful and agonizing. I don’t imagine I’m putting on running shoes again anytime in the foreseeable future. Yes, I used to run: that discussion is for another time. So someone from a shoe company came here and fitted me for my annual allowed pair of Medicare-approved of funny shoes. The shoe might not help a great deal. Probably it would act like an enema in the Jewish old joke about the dead actor in a Yiddish theater, circa 1910. Can’t help him! Can’t hoit him!

So the doctor examined my feet, poked me to insure I had sensation, looked at my callused soles (not my callused soul), and finally approved the shoes. Well, that’s lovely. It wasn’t enough that I said so, or that he could see the damage for himself when I tried to walk into his office. He had to tickle me with a feather. In some ancient cultures that was a form of torture.

Footnote/update, January 7, 2015: The Medicare-issue shoes are hideous, more uncomfortable and painful to wear than regular walking shoes from Brooks and New Balance. Out they go.

Subspecialty Comedy: 19th Nervous Breakdown

Reason #2: I also needed a reauthorization for divalproex, known by its trade name, Depakote, a bipolar med I was prescribed. Like most medications used for mental illness, it has more than one application. It’s used for seizures, for  convulsions, and for a range of mood disorders, including bipolar. Somehow, in my travels between Hither and Yon, remembering to get a reauthorization got away from me–it slipped through a crack in my head. Take your meds. They might save your life.

So I’d run out. The label on the vial said there were no refills left. Which meant I’d have to get a doctor to issue a new authorization. Well, finding a psychiatrist in Western Massachusetts is sort of like being Demosthenes with the lantern looking for an honest man.

That bad.

Iss No My Yob, Mon

That’s another dirty little secret about the mental health industry. Most psychiatrists will not do psychotherapy or full-blown psychoanalysis. Not anymore. They can’t. Either they’re not trained for it nowadays, or it’s too expensive and open-ended. That’s relatively recent as the history of psychiatry goes. Sigmund Freud, M.D., was an analyst. In fact, he pretty much invented the theory and practice. So was Donald Winnicott, a trailblazer in attachment theory and child psychoanalysis whose work also applies to the world of adult psychotherapy. Winnicott was a medical doctor who’d served on shipboard in the Royal Navy during World War One. Doctors of Medicine: so was Wilfred Bion and one of his contemporary disciples, James Grotstein.

The big secret is that insurance companies will almost never reimburse for psychoanalysis. Medications are measurable. Talk therapy is not. Medicine gets doled out like Cialis or Viagra, so you can get a brain-boner. But when do you finally cum in psychotherapy? Was it good for you too?

The therapy of the “talking cure” has become the purview of psychotherapists, some of whom are wonderful (ask me), but whose hands are tied because they cannot prescribe medications even if they have figured out the patient’s issues. Yes, it’s short-sighted and downright stupid. But that’s what happens when insurance companies stick their fingers into medical issues. They don’t know what they’re doing but they keep on doing it.

“You’re Just Feeling Sorry for Yourself”

For all the talk about treatment, mental illness is not judged by insurers as an illness on a par with measles or even our current overblown bogeyman, Ebola. Mental illness is somehow the patient’s fault. It’s a flaw, a failure of will, not a medical condition. And so reimbursement, if it happens at all, is of far lesser importance and a smaller amount than would prevail if the condition were purely medical. Insurance companies like quickie cures. Cut out your appendix. Amputate something. It’s like Civil War surgery. Wham, bam, thank you ma’am.

Even psychiatric in-hospital confinements have been shortened, often to the detriment of the patient and society at large. Unkind as this may sound, some patients simply don’t belong out in the street. They come out of Creedmoor or Pilgrim State before they’re ready, because medical treatment is not about the patient. It’s about “throughput” and getting the patient out of the hospital or office to free up the bed and time for someone else. Some 20 years ago, a women waiting for a subway was pushed onto the tracks in front of a train by some poor maniac with schizophrenia. He hadn’t taken his meds for awhile. Nobody was there to monitor him. The medical system let him fall through the cracks. He was fine when he was medicated. When he wasn’t, he became a murderer.

Anyway, back to our show

My primary care doctor was unwilling to reauthorize Depakote because he’s not a psychiatrist. Wrong specialty. Well, he’s an internist. But he has those letters after his name: M.D. I have letters after my name too: Ph.D. But as far as insurance (and I) are concerned, that stands for Piled Higher and Deeper.

I had to remind him that I cannot prescribe for myself, I can only tell him my extensive and often horrible history with psychotropic drugs going back to the late 1980s: Ativan, Buspar, Paxil, Xanax, lithium, Topomax, clonazepam, Seroquel, Prozac, and finally divalproex. That was to establish my street cred. I know all those names, I know what I’m talking about. And divalproex, keeps me from turning into a zombie or, alternately, a raving wackadoodle. The latter is how I feel now: Mr. Mixed States. I am not happy.

He finally agreed to a one-time reauthorization with the caveat that my talk therapist (I really love him, no kidding) refers me to a prescribing shrink on the staff. Well, that’s why I went to him yesterday. It was the long way around. I felt like the stranger who gets off the plane at Newark Airport and takes a cab because he wants to go from Terminal A to Terminal C. The driver, seeing an easy mark, takes him to Terminal C by way of Norwalk, Connecticut.

The Sometime Necessity of Lying

I seriously misjudged the doctor. Here is a word to the wise: never tell a primary care physician that you are in recovery. Yes, I’ve done that for years because I believe in being truthful with medical providers. But I have learned the hardest of all lessons. Don’t say anything. My doctor is a major league coward, for instance, when it comes to pain medications. Oh, you might get addicted! He had a patient who ground up and injected pain meds. The man died of an overdose. If I have to deal with people like you too much longer, Doctor Dulcamara, I’ll for sure get readdicted and I’ll love it. One evening I had to get ambulanced over to the Southwestern Vermont Medical Center in Bennington because the pain was so intense that I was crying. The doctor on call in the e-room prescribed the real deal, oxycodone. It certainly helped. My feet still ached but I didn’t much care. Tylenol #3, the kind with codeine, is for comparative sissies. I would have swapped the pain that night for addiction any day of the week. Screw 12-stepping and the stuff I’ve heard in almost 15 years of presumptive sobriety.

Yes, I follow the prime directive for mental health: I stroke my cat. He is worth a lot of therapy time. He is loving and instinctive. But he portraitcan’t write prescriptions. The little beast doesn’t have opposable thumbs and he’s not  medical doctor or osteopath. I love him to death but he has his limitations. Just like the rest of us.

So for the moment I’m back whence I began. I am looking for a replacement medical practitioner, being her or she a doctor or a Nurse Practitioner. I am looking for a “drug connection” as well as someone who will take one look at me and ask, “Mr. Wolman, how the fuck can you even walk?” That is the person who can can testify that I am in over my head and will authorize high levels of financial relief. I refuse to believe this is Mission Impossible. I’m stubborn and I don’t know anymore how to take No for an answer.

The first and most important thing for any chronic illness patient is how to be patient, to learn how to fight back with courtesy and stubbornness. If you take shit, you will have more shit flung at you. And in the words of e.e. cummings’ Olaf, There is some shit I will not eat. This has been some of it.

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About Ken Wolman

Sit still, shut up, and listen. We might both learn something.
This entry was posted in anger, disability, disease, fighting back, pain. Bookmark the permalink.

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