Thursday, January 25, 2007

My Three Shrinks Podcast 7: Fireside Chat

[6] . . . [7] . . . [8] . . . [All]

Blame Roy on the delay in getting this podcast out. We strive to get these out on Sundays, but life just gets in the way sometimes. We recorded this on Sunday, Jan 21, in front of Dinah's fireside studio, when we had our first snow of the season (not even an inch). Go to the bottom of these Show Notes for a picture of us in front of the fire (the crackles and pops you hear in the audio are from the fire).
Roy (our podcast producer) has added a new "feature" where the music which is played as we transition from one carefully planned subject to the next will change from week to week. Feel free to figure out where each week's song snippet comes from. The first one to figure it out will receive the dubious distinction of a link to their blog or site in the following week's Show Notes. (Extra points if you can find some connection between the song and a topic from the podcast.)

January 24, 2007:
Topics include:
  • Dinah's post on the "Well-Worried Well" provokes dissension amongst the Shrink Rappers. Are folks who go to high-end hospital units, such as The Retreat at Sheppard Pratt, just the worried well, or are they "rich people with mental illness"?
  • Paying for Psychotherapy: "That's the problem with reimbursement for psychotherapy. How do you decide what is and isn't valid psychotherapy?"
  • BusinessWeek, 1/29/07: "Held Hostage by Health Care", by Michelle Conlin. Article about people who stay in jobs they hate due to fear of losing their health insurance coverage.
  • Movie: Idiocracy [IMDB link] from Roy's post of YouTube video, Hospital of the Future.
  • National health care system.

Find show notes with links at:
This podcast is available on iTunes. You can also listen to or download the .mp3 or the MPEG-4 file from Thank you for listening.

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NeoNurseChic said...

Great podcast. I think I like this one the best yet because you all had very strong opinions about the topics that you discussed, and you stuck to your guns! I really enjoyed listening to the discussions and viewpoints.

Favorite line has to be: "You don't really have headaches..." hehe We don't have to wait for a national health system to hear that line - there are plenty of ER docs (not every ER doc - just certain ones!!) and primary care docs (again - only a select few) who are willing to toss that phrase around just because they are frustrated that they can't get rid of somebody's headache - so therefore it must not be real. I'll never forget (and I know the PA-C's name still) being in the ER 8 days into my constant headache (which has now been here for 6 years as of last Thursday) and the ER PA announced to the entire ER that I had a headache for attention since it didn't resolve with her chosen treatment of dumping 3 different mega painkillers in me in a period of just a few hours - so then I had to be admitted for intractible vomiting. Once I had to be admitted, she also threatened that they were going to have to put an NG tube in because of how much I'd been throwing up - which was not true...I hadn't thrown up at all before coming to the hospital and had only thrown up a few times as a direct result of the pain medication. What a .... you know ;)

But anyway - I have so much I want to say on this topic, but want to say it quickly or maybe just a few quick things because even though I'm commenting at about 5 minutes till 4am, I actually am sleeping better tonight. And the improvement is solely that I'm sleeping at all. I've still been waking up about every 30-45 minutes for some nutty reason.

With respect to the NHS and private health insurance - some companies in England do actually offer private health insurance as part of the benefits package. It's just that that isn't going to be the one thing that makes or breaks somebody's life because if they do not chose to opt into that (and having to pay some part of their salary towards the premium), then they always have the NHS to just go ahead and lean on. When I told my friend Helen (who I was visiting in England) about how much Dr. Crippen and SHP hate the NHS, she was shocked. She said that for the most part, patients absolutely love the system. It has a few snafus that she has run into on occasion, but she is thrilled to be provided with health insurance, no matter what. Nobody in England is going bankrupt over medical care. (And I should state here that Helen is not someone who has minimal contact with the system - she has had MAJOR health problems and just got out of quite a lengthy hospital stay for new issues... So with her history, she was bound to experience the whole speectrum of what the system is like from the patient's perspective...)

Now - one issue we have seen amongst cluster headache patients (and possibly some migraine patients, but more often clusters) is this issue with rationing of prescriptions. Each physician in the NHS is given an allotted budget, and I cannot remember if this budget is solely for prescriptions or if it is the entire allotted budget and prescriptions make up a part of it. At any rate - triptans are expensive. For many cluster patients, the only thing that aborts their headaches are imigran (sumatriptan) injections...or jabs as they call them! I have another friend over there whose GP will only give him 2 injections at a time and forces him to come back in any time he needs more than that. That's a complete joke. 2 injections is the minimum that a CH'er might use in a day...and the product information be damned - because the literature shows that CH'ers have been able to take larger amounts of triptans - they have to get the attacks aborted. (I'd like to state that I am not personally recommending going above and beyond the recommended 2 doses of triptans in 24 hour period - or whatever restriction placed by a prescribing physician...) The doc told my friend that he was restricting him because "he shouldn't need" that many - but in truth it is because the imigran is expensive (because glaxo is money hungry and keeps inventing ways to extend the patent...afterall, people can just TAKE some aleve with the imigran...), and the GP doesn't want his budget decimated by it...and therefore has placed a lower value on headaches than on other conditions. This is discriminatory. Now that is one way the system will screw you. Fortunately, Helen's GP is not like that at all. She can get 60 imigran a month. In the US, you couldn't get that if you tried. No insurance company here will ever pay for 60 imitrex in a month. You'd be fortunate to get more than 6 of the injections in a month. I'm fortunate to get 18 tabs of amerge AND 18 tabs of frova a month.

One of the other things that Helen has said is that when it comes to procedures, oftentimes people think that if you go through and use your private insurance (if you have that), that you will get the procedure done more quickly than if you go through the government, but this is a misconception in a lot of cases. One must ask the doctor how many days a week they practice for the privately insured, since they have a required amt of time to devote to the NHS - which can be mainly limited by the fact that certain conditions deem receiving treatment within a certain number of days or weeks. So when she was waiting for an endoscopy (I think) - her GI doc said that if she went through private insurance, it might take 6-8 weeks to get it, whereas if she went through the NHS, then it might just take 2-4. Now this is different than Canada's health system. When I was in junior high, I actually one 1st place in a forensics competition for best speech, and my speech was on comparing health care systems in various countries. At the time, I compared that of the US to Canada, the UK, and Germany. But these days, many things have changed. When I did the speech, Canada's system was ideal. However, I don't really know much about their system anymore - only that lots of Canadians have flocked to the US because waiting lists for doctors and procedures and medical care are too long. I don't think that this is as much of a problem in England.

Now one area that I know Dr. Crippen and SHP are extremely unhappy with in the NHS is psychiatric care. So I will also say at this time that Helen has not had a need (knock on wood) to use psychiatric services, so she has not dealt with that profession's issues in the NHS. That's one of the few areas she has escaped dealing with in all her troubles! And both Dr. Crippen and SHP are "spot on" about the quality of quite a number of 'nurse practitioners' in the UK. That system is not at all what it is in the US. Any nurse can take a 2-day certification course and call themself a nurse specialist - and nurse practitioners there are not at all what they are here. They do not require masters level education and certain amounts of clinical and educational time, supervision, and training. So when they bash nurse practitioners, they are bashing an entirely different group of individuals that we do not have in the United States, do to our more advanced regulating.

I'd like to comment on some of the other topics (especially about who should receive psychiatric services under insurance coverage versus who shouold not!!), but not right now as I want my last 50 minutes of sleep or so, if I can get it! But I will allude to the fact that even though, once I meet a $2000 deductibe (I believe) of out-of-network costs, I can get reimbursed, I have not yet submitted my psychiatric bills. This is not to say that I do not intend to - it's just one of those things that was just one thing too many for me to stay on top of. But I have saved all of the receipts. I personally want to comment on the topic because of the fact that I've been working with my psychiatrist quite a lot and for a decently long period of time now, and I'm sure there are some who might say that because right this moment I am not actually in the midst of one of my more major depressive periods, then maybe I shouldn't be allowed to be reimbursed. However, if I do not continue to work with him in the way that I am at present, then I believe that I tend to fall very quickly back into my own depressions. I hate that I have become dependent on another person, but at this time, that is why I need. I don't plan for it to always be this way, but it does seem that I've escaped the use of an antidepressant, but instead have substituted that with my psychiatrist - and my therapy has adequately helped me survive the dark periods of depression (albeit not without a truckload of emotional pain and then times) without having to go on medication at this time. I have a lot of thoughts as to why, but I can't get into it at this hour and this comment is getting long enough! I am constantly being med managed for ADD, but we don't make enough changes for that to warrant my seeing my psychiatrist 2-3 times a week for's not for ADD alone. Even though my billing statement does not have anxiety circled as a diagnosis, I would actually say that this is one of the absolute biggest things that we are working on these days, so I would hope that that does qualify as legitimate, necessary therapy and not just "day to day" chit chat, but I am one who also does not believe that reimbursement should be based on talking about acceptible things. If that were the case, then I should never get reimbursed because I have spent a large part of my therapy discussing things that happen week to week - but these are in general things I've had a hard time dealing with.

OK - gotta go back to sleep. 45 more precious minutes.

The best news I got all week (and maybe for longer than that) is that I found out at my psychiatry appt today (well, yesterday now) that my psychiatrist will not be moving far far away at the end of his fellowship, which was a big fear of mine. He will be relocating to New Jersey, and while it will be a bit of a hike, it is not an unreasonable distance, and I will certainly be willing to make the commute versus the alternative of having to start all over again working with somebody new. It's funny but he almost seems surprised that I don't even need to think about that. It's a no given for me. OK - g'nite again. Thanks for the great podcast discussion!

Take care,
Carrie :)

Sarebear said...

Woohoo! Fresh 'cast!

I just started it, and as you said what was on Clink's shirt and Roy's 'puter, I then thought, and what, Dinah has one on her head? And where's William Tell when you need him . . .

hee hee!

Thanks, Clink, for the color. Great image in my head!!! NOT. hee hee.

on with the cast . . .

ooo, just looked at the length. Nice long 'cast this time!

(listens s'more; oh hey, maybe that fire is making me hungry for s'mores, can you make me some next time? thanks!) . . . .

Ha!! Dinah! You said, "These are either mentally ill rich people, or the CHILDREN of mentally ill rich people." What, the kids need to get a break from their ill parents? Hee hee.

Clink, you SEEEM to be implying, after saying that Mood Disorders obviously are serious illnesses, that anxiety disorders are not, or something.

I LIVE IN FEAR EVERY MOMENT OF EVERY DAY, PRACTICALLY. IT SUCKS. The fears are a maze that I work through and combat and use tremendous energy and effort to get past, and frequently fail, or frequently use myself up so much that after a while, I collapse in mental exhaustion in this maze, and it overtakes and assaults me even more, ala the hostile maze in Harry Potter and the Goblet of Fire.

Um. Lemme back off a bit. I don't think you were trying to insult me, so let me say that I realize I'm personalizing this too much. . . .whew . . . ok, though just wondering what's up with your perspective on this, exactly what IS your perspective on this, and perhaps, again, it's partly a function of the population you are exposed to daily in your occupation, vs. free society.

It's just . . . like having a ball and chain clamped on my leg, except instead of the "standard issue" ball and chain (if there is such!!), it's more the Christmas Carol Bob Marley (Ok I'm probably getting his name wrong!) all covered in chains, version, that I'm dragging around with me. Crippling. Actually, I'm walking around in and with my own prison, and the layers of bars and bars and gates and checkpoints and doors is exhaustive and exhausting.

Ok, enough about that. Mebbe I'll find out more about your perspective if I PUSH THE DANG PLAY BUTTON AND LISTEN FURTHER, hee hee! (caps for funny effect, not for being mad or anything effect.)

Ok. The weeks to months time frame for that stuff seems long! Although . . . if someone really wants to make some good progress on some of this stuff, and not string things out on a once a week therapy appt on stuff, because, heck, they've got the money to access this sort of more intensive and also sushi environment . . . I think that'd be cool.

I can see your point about the jarring juxtaposition of oh, hey, I'm worried about x, y, z, let's go inpatient for ar coupla months. I see that.

Clink, you wouldn't go to Hopkins . . . would you go to Roy's hospital? Hrm, that brings up an interesting question. About mental health professionals, who are probably known by others in same or related professions in their area . . . where do you go, and what happens if a shrink you know who has a grudge against you or you sent their underwear up the flagpole in college, walks in and is the shrink for your case in the hospital? These are hypotheticals. Just wonderin!!

(listening more . . .)

Healthcare may be a right . . . but it's a privilege, in practical terms, quite often. And that is BEYOND sad. Mental Healthcare seems to be seen as "optional" by many of the ins. co's, and that's beyond sad too.

listening more

Nope, NO idea on the music!

EXACTLY, Dinah! I talk about and work on relationship stuff, talk about stuff from the past, talk about nightmares or dreams (sometimes in passing, about twice every six months it's more in-depth; there is some, well, in crude vernacular, sick $hi7 that goes on in my nightmares, see, I feel like I have to justify and u guys aren't my ins company!), even tell a joke from time to time, at the beginning, and engage in "practicing" how I am w/someone that way, sort of like a skills practice; I haven't done that in a long time, tho. I think if the ins. companies ever had a right (I don't think they do, but then again they pay) to know what goes on in my sessions, they'd have probs w/some of it, but it's all intertwined, anyway!!!!! Hell, the stupid meds cause the horrid nightmares, anyway. So that IS a symptom/side effect, lol!!! So I'm right there w/you, where do you separate it out? I don't think a person should be asked to.

listening s'more

HA! Dinah, again, I'd be that patient that says, HEY I want exploratory psychotherapy. Hee. I want to learn about myself. Psychodynamic therapy or whatnot. Obviously, there's some illness stuff going on, but this intense need for me to figure out WHY THE HELL I'm this way, it's in my cells like the need to breathe. And I'm so afraid that God only wants me to get a little CBT and bootstrap myself on out the door. Then again, I know God led me to the help I'm getting, so hopefully he's behind me on this. I hope. Thing is, I DO NOT WANT ANY HORROR TO HAVE HAPPENED TO ME. I used to have a morbid curiousity about what kind of horror could have happened to me, until a "blackness" and the associated feelings, experience, and content of it, that I had in August of 2005. That kind of horror that is fathomless, overpowering, all-encompassing, BURNED into your bones . . . I'd never wish for any cause for that. The only thing I can say, since I still have this intense need to understand myself, is that I know, whatever "little Sara", the child inside who may have experience something, needs to share with me, I need to accept as her experience, I need to accept totally anything she shares with me.

Now I probably sound crazy; I talked a bit about that very early in therapy, but not much since. So don't know if my inner child thing going on here is kosher, but I gotta accept what this frightened, young, innocent, beautiful part of me needs to tell me.

Anyway! (listening more . . .)

Clink, a large part of me sees your point, about potentially problematic people coming in to just chat for the 50 mins or whatever, and then getting ins. reimbursement, and potentially driving up premiums for others, using resources etc. Part of me says, though, I'd rather have the "filter", the "cheesecloth", have holes in it that are too big, rather than too small.

See, one thing the judge at my hearing told me, at the end, (and I could tell he felt really bad for me, as I was sobbing, body-wrenching, uncontrollable sobs), that there needs to be this burden of evidence, or people would game the system, and people who didn't deserve it, would get the benefits.

He also rattled off that there's various resources I could have used (I wish I could have answered that as to why there WASN'T, for me, like the free clinic that CHARGED me to see the psychiatrist there, two weeks or less after my suicide attempt, and he basically said I had no resources of where to go, either, so I was screwed that way too) . . . . and stuff I found out thru talking w/my governer on the radio on air and then what followed from THAT, about funding for the only method of help I DID ever get, back then, and how that was cut . . . there WERE NO FRICKIN' RESOURCES; I WALKED OUT THE DOOR, LOOKED AT THE WORLD, AND REALIZED IT DID NOT WANT ME TO GET BETTER, BECAUSE IF I COULD GET BETTER, I COULD BE A PRODUCTIVE MEMBER OF SOCIETY; BUT IT DID NOT WANT THAT, BECAUSE SOCIETY WOULD NOT FUND ANYTHING TO HELP, BECAUSE THERE WAS NOWHERE @#$@#$@# NOWHERE LEFT FOR ME TO TURN.

Sorry for shouting. Can you imagine what kind of a place that is to be in, for a person? Sucks Royally. (Aaagh, Camilla's face is in my head, NOT a pretty sight, nor is what she's doing). Lol.

SO. I would rather that, for access to mental help, the filter be too big, than too small . . . I know the too small route, and it ain't fun, and it led to almost a decade of me being mostly a hermit. Well, I guess I still am, but I've got some help through unusual means and stuff.

Okay, shutting up and listening more -

Clink is saying, hey, this person isn't who I was talking about, she's coming in and in therapy, talking about issues (the lady w/axis 1 under control, but lots o stressors).

Where does one draw the line between THAT situation, and the person who comes in and just lists the price of beef at the market? There's gotta be a blurry line somewhere, or so it seems, . . . but that would mean that sometimes the people close to the line would not really fit Clink's feeling of people who aren't taking resources and maybe driving up premiums unnecessarly, and sometimes they would fit that.

I just really, really, really would rather the filter have holes too large, than too small.

WHO would be the judge of all this, anyway? It seems like it would be really subjective, and I really do not want the insurance industry stepping in to police that (although they do to a limited extent, for purposes of claims eligibility, pre-authorizing and crud, already, but what the ins. co's do for mental health already is little enough . . . don't let them get a bigger foot in the door of being set up in judgement over people going in for help (well, ok, that's what managed care IS . . . but they've mangled it ENOUGH, thank you, there's little enough access as it IS . . . which might be part of Clink's problem, that there's little enough access as it is, don't use up resources others need more (but the comparing game is problematic; see what I typed above about how Clink maybe had a perspective on anxiety disorders compared to what she sees in the prison pop, as it being not as serious, or even A serious, thing, and then what I had to say to that perception I had of what she was saying).

As for who to judge . . . it really all depends; point of view is king, and I err on the more generous side (not that Clink is stingy! Just couldn't think of another word).

listening more

You know what, I've said ALOT here. I'll listen to the rest tomorrow (or later), and comment more later.

Thanks if you've read this far; you guys stimulated ALOT of stuff for me to think about and talk about and stuff; thanks!

Sarebear said...

Oh, and I'm not finishing later cause it's too long; same thing as Carrie, I can't sleep lately.

But I'm going to take a stab at it in a minute (well, if I do that the raised aerobed in the livingroom will deflate!). Think sleepy thoughts for me.

Lately I'm only getting sleep every other night, out of sheer exhaustion from bein gup 40 hours or whatever.

I don't have an iatrist yet, and I can't call my GP (commented on THAT in a recent comment at Dr. A's.) So I have nowhere to turn medically, or for anything to fix this, or the fact that I'm doing half doses of pills to stretch the meds. I s'pose I could crash pretty badly w/all this stuff happening at once. When ya got nowhere to turn, it sucks. My ologist left on vacation for three weeks, he forgot to tell me until right before leaving. So I'm figuring the best I can.

Woops, sorry to go on so long, there.

NeoNurseChic said...

Haha with regards to the anxiety topic - now that Sara brought it up. I'm the child of a mom who is the picture of GAD, although undiagnosed, and a dad with a panic disorder diagnosed within the last year and a half. His was actually diagnosed because he had a massive panic attack and collapsed in the driveway and was nonverbal for like 5 hours - and they treated him for a suspected heart attack until they ruled out cardiac causes. (Although I saw such a ton of PVCs and PACs on the monitor in the ER...) I think they just never found out exactly what happened, but we're pretty sure now that it is the panic disorder. He went off his meds once (he's on wellbutrin and then xanax prn) and then had another major attack. He's just really high strung, but he's not a worrier - just has a short fuse more than anything. And my mom is a worrier...

And I am their firstborn. LOL And the only girl. I used to have really bad anxiety attacks in high school complete with palpitations and just racing thoughts and shaking hands, etc. I still think that anxiety plays a part in my headaches because when my heart starts pounding and racing, it really kills my head, too.

So - I definitely think there's some legitimacy to anxiety disorders! One of the things that has affected me most the past few years is more of a social anxiety thing. I didn't always have this, but I do now. I cannot be in large hoardes of people without really having some issues. I don't like anyone in my space, and I avoid going out and doing things if I don't know exactly how things work. For example, I didn't go to the gym for 6 months because I just didn't know how things worked with going to the lockers and the pool, etc. So even though I no longer really have anxiety attacks like I did in high school, I still definitely have some impairment due to anxiety. Working on it - but I'm also quite high strung - kinda a mix between parents!! I don't think I'm quite as much of a worrier as my mom is - and I'm also a procrastinator, and that makes things harder for me. I am my own worst enemy! lol

Anyway - gotta get ready for work. I'm so incredibly exhausted from not sleeping yesterday and not sleeping well last night. I'm definitely DVR'ing any new shows on tonight and totally crashing for most of tomorrow, except for my appt in the late afternoon.

Take care!
Carrie :)

Dinah said...

Where are our new feet pic??

For the record: ClinkShrink is the only psychiatrist in the world who would question the validity of treating Anxiety Disorders (and I have a feeling even she didn't mean it).

I'm still stewing about the question of who warrants care and what it's valid to talk about with whom and why. Another post coming soon I think.

Neonursechic & Sarebear: no one begrudges the fact that you seek psychiatric care, you both have plenty to say and to process. Maybe I shouldn't speak for Clink...

Sarebear said...

Thanks Dinah. Sometimes you two sound alike, anyway, hee hee hee!

Maybe CLINK is beneath the floorboard today, whee!

Anyway, I also mean and use my experiences, to illustrate my point of view, and opinion(s) on what you say here, and in the 'casts. So it's not just about me saying HEY, I have THIS experience, so this means I am justifiably suffering/being treated, etc. I mean it also to illustrate part of WHY I think things about the issues, regarding mental health in general, and people who seek care, fighting stigma, or whatever other issue is up for discussion.

Anyway, my personal examples are both about me, and about the larger issue (not always about the larger issue, but I try to write so that what I'm saying, pertains to the larger picture, or the larger picture of a specific portion of what is being discussed.)

Make sense? Anyway, I don't mean any offense, just clarifying! Saying I'm fully participating in the discussions and debates that go on, and not just being a mental patient that comments on various blogs, including mental health ones.

And I think Carrie would say the same (but I sound NOTHING like her, hee hee! And can't speak for her anyway.)

Next, we'll have Roy speaking for the Duck. And Clink, speaking for, hrm. Max? hee hee.

Steve & Barb said...


Anonymous said...

Shut up.

Dinah said...

play nice.

sophizo said...

Ok...I vote for no more "fireside" chats. I jumped every single time there was a pop. I wish you guys got all our snow and ice on Sunday (2 inches this time). Can't stand the stuff!

What the heck is that song???

ClinkShrink said...

Aack, I never questioned the validity of treating anxiety disorders. My post was intended to comment on the service, not the patients. Oy. I may need to blog to clarify my blog. I have a headache.

I need to clarify I would not go to Hopkins because of distance, not quality. If I were sick enough to go to the hospital (and I've had reason to think about this lately) I'd go to the nearest, not necessarily the best. And I wouldn't care if I was sharing my room with the Internet or Bobo the Dancing Clown (as long as she kept her floppy shoes on her side of the room). Actually I'd prefer Dinah for a hospital roommate except I wouldn't wish a disease on her for that.

And who's telling poor sweet Roy to shut up? I'll moida da bum!

And where's the new pic of our feet?

NeoNurseChic said...

Haha I like that last comment there...very funny :)

Now - me? Issues? Nah... LOL ;)

I've thought about this a few times today. I have a couple of different thoughts as of late, and I suppose some of them are relevant! When I think about what Clink had to say with regards to those who come in to talk about day-to events and how they don't deserve reimbursement, I feel like I personally can interpret it two different ways. And if I can interpret it two different ways, then I bet other people can interpret it in other ways, too. Guess that means that it's not so much about what we really meant, but rather what people perceive we mean. There is the part of me that jumps to the gut reaction that I automatically fall into the category of one who shouldn't be reimbursed because of the fact that I do not have an extremely severe mental illness that serves as the focus of each and every appt I have - in a life or death kind of way.

But - there is another part of me that looks at Clink's comment about Dinah's patient who continues to see her, despite having her axis 1 under control but still having a lot of stressors and sees that this isn't a contradiction of Clink's point on the issue. Rather it is a clarification, and if we take time to examine it, it shows a bit of a deeper meaning. If I'm interpreting this correctly, then Clink isn't saying that this patient or Sara or myself or any of the rest of us who fall into the category of talking about day-to-day issues but are working in therapy to achieve some goal and maintain control of our psychiatric ailments are the ones that do not deserve reimbursement. I think instead she could be referring to those who, let me choose some random example, go through a rough period - say they go through a bad divorce. Say this person needs some help, possibly even medication, while going through this divorce. While they are having this very rough time, it is very imperitive that they see a shrink and of course they should be reimbursed. This period may even last for quite a long time - some people move through major life stressors at a faster or slower clip than others. But let's go on to say that this person, months down the line, is over the divorce. In fact, maybe she's happy with her life - dating again, doing well at work, or whatever. But yet - she still hangs onto that therapy appointment, and at that appointment, she recounts the events of her day or discusses how she feels about the war in Iraq or whatever.... My gut feeling about that comment makes me think that Clink is referring more to these types of people when she says they shouldn't be reimbursed - not so much people like me or Sara or others who do have diagnoses and, even if we may be in a "remission" period or stable or whatever at a particular time, still go to therapy to work on a lot of issues. Those issues may not be something as serious as constantly talking about hearing voices or paranoia or seeing things that aren't really there or other things like that. I, myself, am actually pretty high functioning - I still go to work - which means that I'm not completely disabled by my own illness. But I somehow don't think that Clink would discount my reasons for going to therapy or even say that I should not be reimbursed by my insurance company if I continue to go when I don't feel suicidal or I'm not as depressed and not on meds for depression or whatever.

But still - even if I view it that way (which is the view I have chosen to stick with in my mind!), where does one draw the line? Even a practitioner is subjective - and if that weren't the case, then concepts like counter-transference wouldn't even exist! It is very much like the pain analogy that Roy brought up. And that makes a lot of sense to me because I can put it in terms of headaches. In my own headache world, I can honestly say that the first 6 months of the headache, I know that I did not have pain that is as severe as the pain I deal with now. But after I took a shower, I couldn't even run a comb through my hair. I just laid on the couch all day. I cried a lot. I couldn't take it. I thought the end was near. Pain to that intensity now doesn't slow me down a bit. Because I've done a lot of work with headache patients, I have listened to a lot of stories about what people have gone through. I like hearing other people's stories (and not because I like hearing that people are in pain - I just like hearing about headaches and I enjoy being able to be there to listen to others who are going through problems with headaches), and I have always been a person who feels that every person with headaches is experiencing bad pain - in their own way. Some cluster headache sufferers get very anti-migraine or anti-tension headache. Why? Because they don't like listening to people with migraines complain about how bad their pain is when they know damn well that the headache part of a migraine - the direct measure of pain - cannot touch the pain of a cluster. It truly is like a pin prick compared to shoving a stake through your hand. And that's not to say that migraines don't hurt. Oh they do - and they make us end up in bed for days on end - puking, in pain, upset, etc. They are incredibly disabling. So - some cluster sufferers have this chip on their shoulder about clusters being called the worst pain known to man - they almost feel like those with other headache types don't even have the right to complain because they don't know pain until they have clusters.

I find that line of thinking to be bull. The pain is what the patient says it is. I have clusters - does that mean I tell every migraine patient I meet to go stuff it? No! Do migraine patients experience level 10 pain? Yes..... We must think of our experience of the 1-10 pain scale. My 10 is my worst cluster headache. Prior to having cluster headaches, my 10 was a very bad spell of my migraine. Say I never got cluster headaches....I wouldn't go back and rate my worst migraine as an 8 just because it could never be as bad as a cluster - when I had never experienced a cluster. My worst pain to me is just that - the worst pain I have ever personally experienced. So say the worst I had ever experienced was a hang nail - well then....that would be my 10! Some might laugh at that or scoff at that or be infuriated that someone would compare the pain of their hangnail to that of other truly painful conditions. But seriously - it isn't about comparing - pain is relative and pain is unique to each individual's experience.

I think I really came to know this concept when I worked in the ER and the headache center. It would have been really easy for me to be angry all the time at people who came in for things that I thought were dumb. Someone has a headache for an hour and they come to the ER - and they're talking and laughing. But what good does it do me to be angry? To that person, that is their 10. They might even be ignorant and claim that their 10 is as bad as my 10. But I know darn well that if they experienced my 10, they wouldn't be sitting their talking and laughing. They'd be pacing amogst the seats, fists clenched, eye tearing and red and droopy...feeling as though someone took needlenose pliers and ripped out every tooth on the right half of their mouth and took a sledge hammer and repeatedly slammed it against the right frontal skull bone above my eye.

But how can I be an empathetic nurse if I let that kind of thing cloud my judgement? Does that mean that a person in less pain than me doesn't deserve treatment because they are wasting resources for those of us who are truly suffering? Why do I have to wait for 2 hours to see my neurologist and then only get 5 minutes of his attention when that exact same attention is awarded to someone who gets migraines maybe twice a month and is completely pain free the rest of the time? I could easily say that they are wasting resources - that if my neurologist didn't see that person (which they probably wouldn't if insurance didn't pay, since these appts are too expensive for the majority to pay for out of pocket), then he could afford to spend 10 minutes with me...and maybe we'd actually get farther in figuring out how to treat my pain.

I can't see it that way though. I feel bad for someone who experiences headaches - even if it is a bad ice cream headache and that's all they've ever had! Even the hangover headaches can really suck! If a person goes to a doctor for a headache as severe as mine or one that is a very mild problem in comparison, the insurance company pays either way. They don't just say, "Oh sorry - yours isn't as serious as hers - so you just shouldn't be reimbursed. If you want to seek treatment, then you're just going to have to pay out of pocket." But what if that less severe pain is all that person can bear? What if that person cannot handle that 1-hour tension headache and feels like they're going to kill themselves if they don't get help?

So can I stop the headache analogy yet? I think it should be clear where I'm going with this. The worst problem in my life is somebody's least problem. When my mom used to get upset about things when she was younger, my grandma used to tell her to get over it and to look at my mom's cousin Kathy and then think about how bad her own problems were. That's very unfair. While it is good to acknowledge that other people have worse problems than we do sometimes, the fact that my aunt lost 3 children and has 2 with a fatal illness should not mean that my mom has no right to feel sad or upset about something that isn't going well in her own life. Just because one person isn't suffering from paranoid delusions doesn't mean that their own experience isn't just as severe to them....

It is easy to look at teenagers and to see how this applies. My mom never understood why I let my boyfriend in 11th grade get to me as much as I did. It took me a year to get over him. I had to call out sick from school for a couple days because I was so upset. It affected me big time. And it was nothing. I mean - the guy was a jerk, but in the grand scheme of things, it was nothing. But I was extremely upset and actually at times feeling suicidal as a direct result of how I felt at the time. So even though my boy issue was actually kinda a dumb issue, I had a very strong reaction to it.

If we start saying that some people cannot reimburse their psychotherapy, then the insurance companies will take this and run. They will have somebody sitting in a nice cushy office, reading claims and playing God with who deserves help in affording therapy and who does not. They will be doing the equivalent of telling that patient that their problems aren't serious and aren't worth anybody else's time. How does that make that person feel? They might have some insignificant problem, but to them, it might be really hard to deal with and life-changing. They might go to therapy and talk about the weather, but maybe that's how they're coping and staying out of a more severe emotional state. Maybe they don't have direction in therapy at the moment - but look at our lives - is everything in our own lives done because it moves us in an upward direction? Don't we all sometimes cease to move forward at times? I don't think that anybody can objectively judge whose suffering is worth compensation and whose is not.

And that could lead to a house divided concept. As has already been pointed out, insurance has already snubbed their noses to the field of psychiatry in a big way. I don't understand why my psychiatrist, who went to medical school and is an MD, is not covered by my medical insurance - but rather by the mental health clause connected to my medical insurance - which doesn't cover squat and most providers absolutely flat out refuse to participate in. That's a pretty rude way to treat someone who has devoted their life to helping others and has earned their MD - same as any other doctor! So - then if those in psychiatry start putting out the idea that some people don't deserve reimbursement because that's a waste of resources, then the insurance company will jump all over that. They will see a weakness in psychiatry and will be all over it like white on rice. A house divided cannot stand...

But then I go back to Clink's comment that Dinah's patient is not who she means when she says people shouldn't get reimbursed for certain things. So who does she mean? Does she mean the person who just goes to therapy but truly has no point in being there? They don't have any problems that they are addressing, but rather just going to therapy because they want to have a cup of coffee with a person they get along with? Then I additionally have to say - what's wrong with that, even? What if somebody really does need friendship and that's what they are looking for - even if that isn't the point of therapy....couldn't they still serve to learn something from that?

OK - I've posed far too many questions here - and I still have so many more things I'd like to say... (like how recently I realized that if we're going to have universal health care coverage in this country - as much as I have always thought that was a good thing - I'm now starting to wonder - would that mean that people like me, who really use their insurance for all it is worth - because they HAVE to - would have to move forward with less coverage and way higher costs so that coverage can be universal? I really would like to see health care be accessible to every person - but I'm starting to wonder if my desire to see that happen might conflict with my own best interests... That's why I like England's system where everybody is covered at baseline, and then if you want more, you have to pay for more. But the best thing about the NHS is that it doesn't leave anybody with nothing. In this country, we have a ton of people with nothing. So how about we give everybody least a little something - and then keep on with private insurance for those who can and wish to pay into it. The problem in countries like England is that they see that as discriminatory because they think that it's not fair that some people should just have to rely on the NHS but don't get to reap the benefits of private insurance because they can't afford it. The grass is always greener, honey - is all I have to say to that. At least those people have the NHS and coverage at all. They could be living in the USA where they wouldn't even get that much. And besides - the NHS is actually far better than a lot of HMO programs!! I suffered with Aetna HMO for 2 months - and had I lived in England and only had coverage by the NHS, I would not have gone bankrupt and would not have nearly had a nervous breakdown because of the problems with the HMO. I don't propose that we move to a communist state where everybody must have exactly the same - I don't see a problem with myself paying part of my salary for excellent coverage and using that coverage because my health (or lack thereof) requires that I use it....but what I do see a problem with is people who are uninsured at all. England's system is ideal - cover everybody at baseline and then allow those who want more and can afford more to continue to have access to it. At least nobody is left completely uncovered - nobody has to die in England because they cannot afford their beta blocker. And that right there makes it a better system.)

I need to turn some of this into fodder for my own blog!! Sorry to go on and on and on and on - but I really am enjoying discussing these topics because they truly are inspiring strong feelings from all of us who are participating in the discussion. It is nice to have a truly engaging discussion where not everybody sees it the same way. I'm enjoying having my eyes opened to other points of view and possibilities.

Take care!
Carrie :)

NeoNurseChic said...

Sheesh - it took me so long to type that comment and then re-read it and edit a few things that my very first sentence no longer really fits. When I was saying that that last bit was very funny, I was referring to the duck comment! That was the last comment when I started typing mine!! haha.... ;)

Clink - I think the only reason it sounded like you were saying anxiety wasn't a real problem had something to do with maybe the wording you were using not so much in the retreat post itself - but in the podcast - I can't even remember what it was right now - but obviously both Sara and I misinterpreted something to sort of sound like you were questioning the seriousness (not necessarily the validity, but rather the seriousness) of anxiety disorders. I need to go back to listen to it to find exactly what triggered me to think that way, at least!!

And for the record, I didn't personally think that you really felt that way. When I took that out of whatever you said in the podcast, I thought maybe you just weren't coming across as meaning what it really sounded like you were saying. I didn't think that you thought anxiety disorders were no big deal, but I did think that's how some comment (which I can't recall at the moment without re-listening) made it sound.

Take care!
Carrie :)

Dinah said...

Oh my gosh, you are so wrong here. You don't pick a hospital based on closeness. I will never be your roommate with thinking like this.

I have had the privlege of studying at the best of institutions, and I'm grateful for my education. Working in even a great institution lends you to see it's faults and so here are my thoughts on where I would be hospitalized:

I would not go to my own hospital (and I'll leave it nameless) because I don't want everyone I know having access to my medical records through the electronic records. I also don't want to be treated by residents because I am a medical snob (there, I've admitted it).

I wouldn't be admitted to a hospital except in dire circumstances because I hate being out of control, and hospitals kill people. Not intentionally, but the micro-organisms they have in hospitals are not good for sick people and there is a lot of room for errors. I've been responsible for some (none of any great medical consequence, but still, it's humbling) and I know they are made. Sort of like all my spelling errors.

If I had anything weird or rare or not obviously curable instantly, I'd go to Hopkins and anything else I was concerned about, I'd get over.

Otherwise, I'd find some hospital I've never worked at so I wouldn't know the shortcomings. Baltimore has no shortage of hospitals.

NeoNurseChic said...

Yeah I see the negatives of going to my own hospital....I could list them, but I don't feel like it. However, my own hospital has the only multidisciplinary headache center in the city of Philadelphia. There is just one other semi-large headache center, and it does not have the availability to do inpatient or infusion therapies for headache. During a time when I needed a break from the center where I go, I went to that other headache center, but ultimately went back to the mothership because the other center did not have the same resources and wasn't as on the cutting edge as the center at my hospital. Because I have not one, but TWO very rare headache types, I need somewhere on the cutting edge. I need the best of the best. And our center has the big names in the field - the innovators.

And then there's the fact that because I'm a hospital employee, my insurance has one other stipulation. I am actually insured by the same plan (#2 PPO in the nation or something like that...BCBS PC) that I was covered by when I was covered under my mom's insurance, but when I was on my mom's plan, I could go to a wider variety of doctors and hospitals. We have a further restriction (except they present it as a benefit) that we have to go to hospitals in our hospital system. The only doctors that I have outside my hospital's health system are ones that I do'nt expect to need hospitalization with. I have a $20 copay to see specialists in my health system, but I pay $25 for those that are outside of it...even though they are still covered under the BCBS plan. If I were to be hospitalized or seek emergency treatment at another hospital outside my hospital's system, then I would have a $2000 deductible and would have to pay 20% of all remaining bills. So most people would think that you'd be okay after meeeting the deductible, and for some - $2000 wouldn't be the worst thing in the world... But think about this - I've had hospital stays cost $100,000 (this is when I get the insurance statements...I see that's how much it costs!!)... So that means that after my $2000 deductible, I'd owe an additional $20,000!!! Bigger deal than it originally looks!

My orthopedic who did my bilateral knee surgery is phenomenal. He is the #1 doc recommended in the Philadelphia area (and a broader area than this actually!) for avascular necrosis of the knees and hips. Hopkins is actually the only other major AVN subspecialty center besides Penn. My core decompression will not be the last surgery I will ever have to have for AVN - but now I can't go to my surgeon anymore because there's no way I could afford the bills if I had it done at the hospital I went to before. I was covered equally as long as the doc and hospital took the BCBS plan when I had my mom's insurance - I could go to whatever hospital I wanted, as long as it was on the plan. That's why I was glad I had my surgery while still on her insurance!! I know there are doctors at my hospital who can do the surgery (afterall, the hospital I work at basically has the #1 orthopedic center in the country), but nobody here specializes in AVN - and AVN is a very scary and badass bone disease. Frankly, I want surgery done by someone who specializes in it! So that's the only thing that truly sucks about my plan. Otherwise, I have chosen an excellent team of doctors within my hospital system because it saves me money!! Only my rheumatologist, psychiatrist, and OB/Gyn are outside my hospital system - and when it comes time for me to get pregnant someday, I'll switch to an OB/Gyn within our system since that will ultimately lead to a hopefully short and uncomplicated hospital stay at some point, someday in the future....I hope. ;)

I will say that I chose my hospital way before I worked at it...and I went to nursing school at this university because of how happy I was with the nursing care I had received. I wanted to go to medical school here when that was my plan - and I was thrilled to see that they had a nursing school that fit my needs when I made the decision to go into nursing school instead. I think it really says something about the hospital you work at if you go there as a patient, too. And I'm truly positive that nobody I work with would ever access my EMR - and if someone I know or am friends with accessess my EMR, then I know it will only because they are directly involved in my care - in which case I want them to have access!! I've always been very open about the majority of my health issues (aspects of my psychiatric issues are the only thing I'm not open with amongst others...), so I really have no problem with somebody I know taking care of me and seeing certain details about my medical long as they are directly involved in my care. It's actually already happened dozens of times.

I guess the fact that I chose the hospital before I was an employee there makes it really quite a lot different from choosing it after being an employee there for a long amount of time. That would change things up quite a bit more!

Rambling away again..... Let me just say that I'm so happy I'm off tomorrow and that I have a good feeling that I'm actually going to sleep tonight! ;)

Take care,
Carrie :)


I'm going to step back from the content and comment on the form of this podcast. This has got to be the best 'cast yet: purposeful, lively and direct. I think that to justify creating a podcast requires that its special potentials be utilized, that the substance and style of the material go beyond what could be
expressed in a regular blog entry. I think you achieved that here.

Midwife with a Knife said...

I liked this podcast the best. I think that the more in-depth discussion of fewer issues works well in this format.

You should do a question and answer podcast! It could be fun. Or, I guess, it could also be a disaster.

Sarebear said...

Nice feet! Toasty toes.

Mine are freezing every day! (my computer is three feet in front of the front door; even w/draft stopper, the 10 degree cold just seeps in anyway!)

Brr! (btw, had a dream about y'all last night! You three were teachers in some sort of a giant high school. Highly paid psychiatrists doing some teaching work too. And I was in your class, of course (all 3 of you taught the same class at once.) You all seemed very nice, altho at one point I was carrying around Dinah's talking mannequin-like head . . . hee hee!)

Steve & Barb said...

Wow, lots of discussion here (some more than others, lol).

Thank you all for the great comments on the podcast. I've inserted our Fireplace Chat picture at the bottom of the post (I admit, the fire is "enhanced", as the pic I took showed mostly glowing embers... thank you, Photoshop Elements... our feet, of course, look exactly as they do in the real world ;-)

As for the whole going-to-the-hospital discussion, I have been admitted thrice to the hospital as an adult. The first was at the hospital where I was a med student... mostly because the chair of the department specialized in the type of ear surgery I needed. I'll never forget my roomate, who was going through DT's, engaging my father in an intense discussion about the kangaroo outside the window. I recall ringing for the nurse to get him some Ativan.

The other two were at a hospital where I worked. I chose it mostly because I knew the docs and felt comfortable with their skills. My confidence in their abilities outweighed any privacy concerns (despite the fact that a nurse I knew had to give me Dilaudid shots in the butt).

Last chance on the song snippet. I'll reveal it in tomorrow's show notes. (Hint: keyword = "fire")


Fire Corner, by King Stitt?

NeoNurseChic said...

Roy - Nurse you knew giving you a shot in the butt - how about a male cardiac tech about my age giving me an EKG daily for 12 days? haha.... I still see him all the time in the hospital as I work 2 floors below the cardiac unit where I was a patient and also a nursing student in my tele rotation. I've had friends of mine show up to take care of me when I was in the OR and recovery. I've had people in the ER that I used to work with knowing my entire health history because I have to be registered when I come in and then have to give my brief medical history to those who work in the ER and are involved in my care. Fortunately, the times I had to be cathed, it was when I had my bilat knee surgery, which was out at Penn Presbyterian, and not where I work! Thank goodness! But at any rate - if I can go through all that (and I haven't even gotten into the part where I was in the tele ICU and had to ring for someone to shut the door so I could use the bedside commode and also they then had to empty it - and I was very sick due to total electrolyte depletion from lasix) and STILL go to the hospital where I work when I need hospitalization, then....that's saying a lot about my hospital - I guess I like it a lot! LOL...

Take care,
Carrie :)