Posts Tagged ‘formulary’

Surviving grizzly bear attacks, controlling drug prices, and training a Dragon.

July 13, 2017

The thought that gives me a scare

Has do to with a grizzly bear

For he’s big and he’s massive

And pretty aggressive

And, out here, not terribly rare.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to travel and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent US assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Some people survive events far beyond the usual human experience.

Lightning strikes more citizens of New Mexico than any other state, and when I worked there I met several. The Natives hold such survivors in high esteem; some tribes elevate them, obligatorily, to Medicine Man status.

Alaska, with the highest percentage of licensed pilots in the country, seemed to have a disproportionately large number of people who lived to tell about plane crashes. I met survivors of gunshot wounds there and in Nebraska.

Today I spoke with a person who survived a grizzly bear encounter.

Most of the bears around here are black bears. Though they’ll eat anything, the majority of their diet comes from plants.  They climb trees, and do their best to avoid people.

Grizzlies are different. The largest land predator on the planet, they have an aggressive temperament.

The bear only bit my patient once, then retreated to keep track of her cubs (the person gave me permission to write a good deal more than I have). If you’re in bear country with the inexperienced, before you start out, make sure everyone knows to freeze if a grizzly approaches, and never to run.  Carry either bear spray or a rifle, and be prepared to use it.

I really wanted to talk to the patient about life and work in this area, but my primary job, fixing people, comes first.


Price of medication exceeds the price for physician services. In the US, the prices have escalated beyond reason, making the drug company stocks some of the best.  Insurance leaves a lot of Americans without adequate medical coverage, and the cost of medication becomes an important consideration.  When I worked Community Health, all our prescriptions went through our pharmacy. The pharmacists determined the formulary (the choice of drugs), and did a good job of containing costs.  The facilities in Alaska have a similar system; in those places the people don’t pay for their prescriptions.

For most in this town, employers pay for health insurance to cover what the Province’s Medical Service Plan (MSP) doesn’t, like medications.  PharmaCare, a government program, buys the meds  for the low income segment.  Only a very few lack money for drugs, and most of those are self-employed.  The Indigenous and Metis (of mixed Native and other descent) have all their drugs paid for.


Over the weekend the facility got new dictation software installed. The previous version had worked just well enough to let you think you wouldn’t have to proofread, but still made glaring errors.  Today I used the system for the first time, training my Dragon over the lunch hour.  It did pretty well, but, once, when I said Prince George it typed first gorge.


What’s a doctor to do without acamprosate? Drama and irony, alcoholism and manic-depression, and strength versus resilience

May 5, 2011

When you stop to add up the score

My day is never a bore.

    It was my impression

    That manic-depression

Affected patients one out of four.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  On sabbatical and back from the brink of burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  Currently I’m finishing an assignment in Matakana and Wellsford, north of Auckland, on the North Island of New Zealand.

I have a touchstone question to diagnose bipolar disease, which used to be called manic-depression.  I ask, “Have you ever had an episode lasting at least four days during which you felt great, got a lot done, slept less than four hours a night and didn’t miss the sleep?”

I find the disease equally common, under-diagnosed, and hard to treat.  Those affected tend to reject medication, because doing away with their depression means doing away with their euphoria; people don’t want to exorcise the devil if it means they can’t dance with the angel.

Doctors talking amongst themselves will shake their heads and talk about the co-morbidities of bipolarity, especially alcoholism, drug abuse, and schizophrenia.

Alcoholism romping through a family by itself causes enough damage, linking it to Richter-scale mood swings shatters family structures and warps children’s personalities.

One quarter of the patients I cared for today came to me because of the direct or indirect effects of bipolar illness.  If you want to understand something, you have to understand its context; though one patient at a time has an appointment, each exists in a family.  The best treatment I can recommend frequently comes down to Alcoholics Anonymous, Alanon, and Alateen.

“Strong” children, the ones who can hold a family together before the age of fourteen, alarm me because strength acquired early comes at the expense of resilience.  Those children who take on the super-responsibility of keeping things together in the face of chaos in later life tend to snap rather than bounce back from life’s inevitable traumas.

Until recently, AA stood as the best, most-tested treatment for alcoholism.  In the US, Campral (acamprosate) has shown itself safe and effective for a number of addictive disorders, including gambling.  Best if used with a support group like Alcoholics Anonymous, it established itself as the drug of choice.  It does not exist in New Zealand, and I had to discuss that with more than one patient.

The absence of Campral as a therapeutic alternative constitutes my sole disagreement with New Zealand’s formulary.

I cannot recommend people get the medication outside the country, and Internet pharmacies are notorious for inaccuracies and counterfeits; I do not know of a single reliable one.  Yet I found myself listening to my patients talk, and saying that I couldn’t imagine a jury convicting someone for trying to bring Campral in illegally.

Throughout the morning I watched the agony caused by self-destructive behavior, dramatic in a family member and ironic in the patient.

But I had energy left over when I finished my clinic; my schedule permitted me enough time to talk with patients.  I drove away with Bethany in the afternoon to visit the Kauri Museum, dedicated to the spectacular tree that dominated the north part of New Zealand before logging destroyed the forests.

I’m working on my resilience.