Medical Marijuana

First, I live in one of the medical marijuana states. I believe for a few individuals it could be a useful medicine. It helps cancer patients, glaucoma patients and some others. But let’s get real most people who claim they use it for medical purposes are just getting stoned.

I was thinking about this again today because I heard on the radio that San Jose had 70 pot club or medical marijuana dispensaries and only 41 Starbucks. They want to regulate and close many of them. So a quick Google search revealed this is common in many big cities like Denver and LA, where medical marijuana is legal. They also have almost twice as many pot clubs or medical marijuana dispensaries as Starbucks. Funny they use Starbucks as a gauge, because we all know they are everywhere. 

If you have ever seen or been in a pot club or medical marijuana dispensary then you know 95% of them are a joke pretending to be clinics selling medicine. Remember the Speakeasy’s during prohibition or the 1800’s traveling snake oil salesman, that sold alcohol tinctures to cure everything from your libido to the mother-in-law visiting. Well probably cured both of those at times.

Anyway, most of these medical marijuana clinics and pot clubs are nothing more than bars with pot instead of booze.  They have counters, menus of different way to smoke or eat your marijuana, and tables to hang-out with your friends.  Does this sound like a clinic or an Applebee's. 

Two states have now legalized marijuana and a bunch more pretend that it is only distributed as medicine. In addition more than twenty states will fine you less than $100 for getting caught with less than an ounce or growing a few plants. Not even a slap on the wrist.





Outside of a few cases, people need to stop pretending it is some kind of wonder drug for everything from hangnails to gonorrhea,  and the states need to just legalize and tax the shit out of it, like alcohol.

Nurse Practitioners are not Medical Doctors

There is a national bill in the House of Representative called "Truth in Healthcare Marketing Act of 2013," (HR 1427). This would clarify for patients’ who someone is in healthcare.

Even if they have a doctorate or PhD, a nurse practitioner, chiropractor, physician assistant or psychologists is not a medical doctor. If you are treating someone in my family I want to know your background. I am proud to be a nurse practitioner and we have a lot of power as NPs. We perform physical examinations, diagnose and treat illnesses, order and interpret tests, prescribe medications in most states, and plan and implement therapeutic interventions.

On the other hand, I am not foolish enough to put myself in a class with most medical doctors, and patients should not guess who is wearing the white coat. I have met only one NP who was narcissistic and insisted she be called doctor by staff. Beside setting herself up for a lawsuit, I won’t tell you what the staff called her behind her back.  

This is a relevant topic because to be blunt, many patients are not educated enough, and have no clue to know the difference between the people in white coats. I wear a white coat now, but even in my nursing scrubs with my RN badge on, patients regularly call me doctor, and probably only because I am a male. Talk about confused.

Truthfully, anyone with a PhD or doctorate can call themselves a doctor, but that does not make them a medical doctor. In fact there are a lot of people out there in the world with PhDs and doctorates who like to be called doctor, and that is fine. However, I would never have them touch or get close to a real human being.  Thousands of people have Honorary Doctorate degrees like Stephen Colbert or Bill Cosby and can call themselves doctors. Do you really want them, a psychologist like Dr. Phil or the guy at the gas station with a PhD diagnosing your intracranial bleeding or cardiovascular disease?  

Thank God I know some doctors well enough to ask them medical questions, and I do so often. I am not a fool and will not pretend that I have the same education as a medical doctor.

MD's learn the medical model and as medical students they spend 10-15 years in higher education, medical schools and residency, and if they specialize add more years to that.

A nurse practitioner learns the nursing model and may spend 6-8 years in school.

 However, nurse practitioners are better and more equipped to deal with patients in several ways. We were trained to treat people more holistically and not just in a narrow allopathic or western form of medicine. We communicate better with patients and their families. We see the big picture more often. In most hospitals I have worked and research papers I have read, nurse practitioners consistently have a higher overall patient satisfaction score.  

Most docs love us and as NPs and PAs we are part of the solution to the primary care shortage. But a few bad apples can ruin it for a lot of people when it comes to trust and working together.  

Nurse Practitioner Scope of Practice Grades by State

NP's scope of practice varies widely from state to state. I know where I live and many states have current bills trying to improve NP scope of practice. Primarily because of the new Affordable Care Act, the shortage of primary care doctors and an aging population.

The state ranking below are from the Pearson Report. The most interesting thing I found was that only 24 states restrict Doctorate and PhD NP's from calling themselves Doctors. This is a pet peeve of mine, because as an NP you should never imply to a patient that you are a doctor without clarifying you are a NP. (more on that another time)

Hopefully change happens sooner rather than later in more of these states.

2011 Pearson Report
NP scope of practice laws


Alabama:  F                       Alaska:  A                      Arizona:  A                     Arkansas:   D
California:   C                    Colorado:  A-                 Connecticut:  B               Delaware:  C  
Florida:   F                        Georgia: F                       Hawaii:  B                      Idaho:  B
Illinois:   D                         Indiana:  D                       Iowa:  B                        Kansas:  C
Kentucky:  B                     Louisiana:  D                    Maine: A-                     Maryland: A-
Massachusetts: D              Michigan: F                     Minnesota: C                 Mississippi: C
Missouri:  F+                    Montana: A                     Nebraska: D+                 Nevada: C
New Hampshire: A+         New Jersey:  B                New Mexico:  A             New York:  B
North Carolina: F             North Dakota:  A             Ohio:  C                       Oklahoma:  C
Oregon:  A+                     Pennsylvania:  C               Rhode Island:  A          South Carolina:  F
South Dakota:  D              Tennessee:  C                   Texas:  D                         Utah:  B
Vermont:  C                      Virginia:  D                       Washington: A+           West Virginia:  C
Washington DC:   A          Wisconsin:  C                   Wyoming:  A

Recovery

 In early 2009 when the economy tanked and unemployment was over 10% I decided this was a good time to go back to school while things recover. The plan then was to graduate, get experience and settle down. Now the economy is recovering and I will be graduating, but I do not know where I want to settle. I am torn because I like my current location and everything about it. On the other hand my mother is getting older and I do want to be closer to her. 

I'm attracted to the west coast and it feels like I still have unfinished business here. But in the end I guess any job offers will still be the biggest influence of where I end up. Hopefully it does not take as long for me to recover from school as it has the economy. 

Confidentiality

 I’m assuming most NP programs are similar to this one and that we meet weekly with our instructor to discuss patients, clinicals and any concerns. For our primary care we are all located in different large busy clinics throughout the metropolitan area. These clinics are not in any way upscale or suburban; they provide services to the inner-city and underserved populations. But this is also where we get the best experience, because many of these patients are train wrecks with extensive problem lists.
 
Nobody has dropped out, so my cohort remains the same ten people after 18 months. We now know each other all too well. These weekly sessions lead by our instructor is a chance for us to decompress from the stresses of everything going on. Of course our favorite topic is patients and their comorbidities.

Everything we talk about is confidential. But we laugh at our patients, we feel for our patients, we get frustrated with our patients and we really care about them. It helps because we know we are not alone in the decisions and mistakes that we make. They are learning points. Our instructor with her decades of experience has some of the best and funny stories about patients and mistakes from her past.   

I want to blog about some of my patient encounters, but it still feels uncomfortable to post anything outside of the classroom for fear of being recognized. Even without identifying points in a post, all those confidentiality, HIPAA and ADA laws make me overly cautious while still in school.

Take what I can get

Feel so mentally beat up lately that even a card in the mail from Southwest Airlines made me feel better.  I Luv you too Southwest, now take me the #%*+ away.  

Paths of Life



As I continue to walk the bigger path of life, it is hard not to look back at the smaller paths and exit ramps taken along the way. People, places and experiences are what shape your life.
And many times I have wondered how one decision, made years ago, along one of the numerous side paths, would have changed everything.

Would I be walking this current path of life to become a nurse practitioner, probably not. And who knows where I would be if one of a thousand decisions had been made differently. Honestly, life’s little journeys can have positive and negative effects, but they are only part of the aspects that make you who you are.

As easy as it is to look back at paths not taken and decisions that could have been made differently, so it is with looking forward on my current path. Sometimes I think that I should never be here, but yet the path is still beneath my feet.

Even though the end is close and I think I will see it just around the next ridge. There waiting for me is another creek to cross or hill to climb. So I will keep walking. Sometimes on a smooth trail, sometimes on a path that is overgrown and strewed with hazards. Life is just that way, and there will be a day when I will look back and wonder if I should have made different choices I have yet to make.  

Sick and Tired

Sick for 10 days or so, but since then I have been unbelievably tired. After school and clinicals all I wanted to do is sleep. So now it is catch-up mode for presentations and papers due.  

But it made me think, why don’t nurses get sick more often?

My sister the teacher always says she gets sick from being around the kids, and granted kids can be like little Petri dishes of germs. And at the clinic patients often say they must have caught something at work. Maybe that is true.

But what other profession depends on a business model that involves their staff having direct contact with sick, infectious and injured people. Clinics and hospitals rely on and persuade the sick to visit them. In fact they relish the various and obscure contagious diseases. Nurses and healthcare professionals must be hardy, because we get exposed to this daily. Next time I hear my sister talking about catching something at work I'll have to bite my tongue.

Gargle with Salt Water

Tried to avoid it, but to no avail. Some little virus or bacteria found its way inside of me and then kicked my ass, and left me wandering between my couch and bed for three days.  Most of it was in my respiratory system with accompanying throat pain, coughing and phlegm. The occasional headaches and muscle pains were just bonuses. 
     
The generic OTC cold and flu medication in my cupboard that expired six months ago can attest that I do not get sick often. Probably not the flu, but I will never know. Because like any good nurse I will try to avoid a doctor or urgent care visit, and self treat first. FYI, hermetically sealed expired medications still work fine. So I prescribed alternating acetaminophen, NSAIDS and Robitussin DM that seemed to keep things tolerable. 
 
However let’s be honest, the true secret weapon was gargling with warm salt water. Why does this always work so well on a throat that feels and probably looks like ground beef?

The holistic approach is still the best, because besides my salt water gargling, drinking hot tea with fresh lemon and honey was a good thing. Sympathy from others was appreciated, but not as much as a comforter on the couch, time and the occasional bowl of warm chicken soup with saltine crackers. Those things probably helped me as much as any over the counter medications. Chicken soup and saltine crackers no lack of sodium there.

McDonaldization of Healthcare

McDonaldization is a term coined by George Ritzer, when he wrote about the McDonaldization of Society. Basically, you rationalize a task and break it down into smaller parts to make it more efficient, faster and cheaper. Think of a time when a craftsman took time to manufacture a piece of furniture from start to finish. He would take a piece of oak and measure, cut, plain, chisel, border, stain and a dozen other step to make something of quality. Or a chef making something as simple as a good hamburger, there are a lot of steps. Start with good quality meat you have to grind, form and fry or grill properly. Fresh tomatoes, lettuce, onions and other produce to selected, washed and sliced. And fresh baked buns. Now think the opposite, McDonald's and IKEA. 


To increase production and profits companies turned to the McDonald's or assembly line method. A product comes down the line and a person does one thing. No thinking involved.

Most fast-food places operate this way. Frozen preformed burger, fries and food is delivered from a large factory somewhere. On the same truck comes, pre-chopped lettuce, tomatoes and onions in something that looks like a clear garbage bag. No real cooking going on, only the timers and beeps that tell the worker when everything is ready. One person takes your order and money, one person drops the fries, one person flips the burgers, one person assembles the food, and one person puts it in a bag and gives it to you. Efficiency without deviation or thinking. They even figured out how to have the customers work free, by filling their own drinks and clearing their own tables. IKEA has you pull and assemble you own furniture.

Yes assembly lines have their place and make things cheaper. Can’t imagine making millions of a cars or computers without an assembly line.
  
Healthcare has been McDonaldized. CEOs and bean counters see patients and care as products to streamline. Get them in and get them out. Like a fancy restaurant, the more times they can turn over a table during a shift, the more money made. Hospitals use beds instead tables. Healthcare has been broken down into small parts, like an assembly line of care. 

In any hospital, on any unit, you cannot avoid hearing the charge nurse, staffing and the shift manager referring to and arguing about the Bed Board. It keeps track of all the hospitals beds and who is in them. We shuffle patients in the hospital 24/7. A doctor orders a bed on a particular full unit, or a new patient needs a bed on the already full specialty unit. The shuffle begins. The people ordering the patients to be moved at midnight never see the patients. The shift manager says take the 35-year-old male on B5 to CVPCU. Then take the new admit to A3, because we are moving a patient from there to the med/surg floor. The ER patient on hold can then go to the neuro ICU, and the semi-stable ICU patient from neuro ICU can go to B5. . . checkmate. 

In the hospital, you will see every specialist there is because nobody deals with the whole person anymore. Chest pain cardiologist, a little confused neurologist and trouble peeing, a urologist or nephrologists will see you. They all specialize, one flips, one assembles and one hands you the order. Try to get a patient discharged and you need 3 different specialists to agree and sign off.


In the hospital, like Target, everything is computerized and bar coded, and we will scan patients, medications, supplies, equipment and staff.

I am in a large clinic now and it is the same. A person will check in, see a nurse for triage, see a practitioner and then the discharge person. If they need labs, pharm, x-rays or behavioral health, they can see from 4-8 people during their visit.  

In some clinics the provider has a set schedule and every 15-minutes they have to see a patient; 10:00, 10:15, 10:30, etc.  Unless you are a new patient and I am doing a complete history and physical, but those are only on Tuesdays. A regularly scheduled visit and you are limited to one problem. If you have another problem, you will need to make another appointment. You came in for a cough I will treat that. So the sore leg or mole you want me to evaluate. Sorry, no time. I will make sure it is not life threatening and can refer you to dermatology or orthopedics.

In my surgical rotations to observe, they have their own unique spins on assembly lines to make things quick and efficient.

Yes, again there are times when it is productive and makes sense to use some of these methods. However, people are not products to be flipped and hurried along to the next station in the assembly line.