Friday, September 16, 2016


Family Practice
601 1st Av N 
Great Falls, MT

AIDS has been a point of focus for my global thinking because it touches on so many relevant issues, many of them issues no one considers because they're so scary that we ghettoize and deny many things about it.  For example small rural hospitals struggle today, not with the issue of what they do to handle AIDS, but how they affect people with AIDS as a mirror for the way they affect ALL people, because all people can contract any disease.  But small towns themselves are often facing local problems with resources, confidentiality, and political pressure.

HIV exposure is both a source and a cause of stigma.  HIV is quite like addressing cancer once was: it is connected to the idea of punishment for bad behavior, which causes shunning and denial.  When I’m around medical people, I ask them questions about the local scene.  They tell me there is HIV everywhere, but they were startled to hear about meth in Valier. Yesterday I drove the eighty miles to Great Falls to see my doctor, who was originally my doctor at the Valier Clinic, three blocks up the street.  It is a hardship to drive so far in an aging pickup, but good weather and low gas prices certainly help. 

Dr. Lance Stewart

Dr. Michelle Marler

Dr. Shawn Nesbo

The Valier Clinic was an extension of the Marias Medical Center in Shelby where I worked as ward clerk for about six months.  The Marias outfit “blew up” over short-staffing, maintenance issues, and other money problems in the background — but mostly about the deteriorating temperament and judgment of one old original male DO.  (A DO degree is meant to be an equivalent alternative to MD, but it is still a minority option.)  I begin to think that there needs to some test and maybe some restrictions of aging authorities and politicians.  I think an fMRI might be shocking in some cases. 

Some employees fled.  (I was gone from the job by that time.)  The best docs, all MD’s, had formed a true solidarity, so they moved to Great Falls where they regrouped as:  http://www.familypracticeandcentralmontanalaboratory.comI have bypassed every close-by county clinic in order to follow Dr. Michelle Marler.  I gave up on the Valier Clinic when they sent “Princess Leia”, who was a Physician’s Assistant with a Ph.D. rather than a medical doctor.  She finally told me flatly that unless I were obedient, she would refuse to prescribe.

Sometimes big hospitals and clinics, especially in Montana, make me feel that they’re just testing whether they can throw me onto the conveyor belt that extracts money through insurance-backed tests and procedures until one gets to the roaring furnace of the crematorium, not the Nazi version, but the one in BBC murder mysteries where all is disguised with decoration until the little doors open and the coffin slides through.  A matter of sad propriety.

But Dr. Marler is not one to call a horse a zebra for the sake of the higher insurance value.  “The field of integrative health and medicine reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and professions to achieve optimal health and healing.”  Andrew Weil, MD is the leading representative.  Marler claims this point of view.

Speaking practically, I’m a feisty patient because I read so much medical material but don’t have the formal training to be a medical person.  I know just enough to have a lot of wary opinions.  I am a zebra or maybe a giraffe (Neck sticks out.)  With insecure female doctors, I immediately have to grapple with power issues.  Dr. Marler saw that I bristled over her basic explanations of things like my swelling leg  (I already KNOW that stuff about veins weakening) when I’m too long at the keyboard.  But she didn’t abandon or confront me.

Instead she stepped over to the position of collaborator, explaining what she saw and asking me for my ideas.  We pretty much agreed.  I mean, I’m on automated subscription lists meant for doctors and usually keep up with them pretty well, though much of the terminology and even some of the existence of subtler body parts and processes — much of the work is on the molecular and sub-molecular level (like HIV) — is beyond my once-useful medical dictionary.  Luckily Google goes everywhere.  And I think some docs are as dated as my medical dictionary.  

When I did my hospital chaplaincy, I read every patient case (which was only possible because of vows of confidentiality) and attended all the doctor self-examination sessions where they challenged and explored new concepts, but that was in 1980.  Much has happened since then.  At that time they were just noticing the grouping of strange symptoms among gay men in San Francisco, which was the canary in the coal mine.  I'm watching for today's canary.  Autoimmune?

Yesterday for my examination I was given an open-backed gown and a paper lap sheet.  First time in maybe thirty years!  They even closed the Venetian blinds though we were far above the ground and no other building was high.  But country women are of two types:  those who brush modesty aside as interference with their work, and those who pursue Victorian modesty as an indicator of their value.  Anyway small towns teach a person to pursue an impossible privacy.  No one has taken any vows of any kind.  Everyone feels entitled to know everything.

We didn’t hit a snag until the nurse had trouble drawing blood.  She didn’t ask me for advice, which the younger phlebotomists do, so she started on my left arm and was stumped by my rolling veins.  I suggested the right arm and the best vein and that some people use a special needle.  A butterfly needle worked, but she felt badly and kept apologizing until I said she was making ME feel badly about making HER feel badly.

I had to explain my feminist opinion that calling me “young lady” was mocking and patronizing which she grasped when I asked her to imagine some pot-bellied old white man in a suit with a cigar calling her “young lady”.  But she had a hard time not saying it.  She is an experienced and skillful nurse with hard-core dedication to “her” doc, but rather patronizing to patients.

I thought I recognized her.  She was the nurse for the female doctor who had a lot of trouble with me.  She gave me my diabetes diagnosis and put me on drugs so powerful that I was barely able to focus enough to drive home.  When I called for a correction, she was angry at the challenge.  She said my blood glucose reading was 350, which I would question now.  In the years since I’ve rarely gone over 200 and usually am about 130 except right after a meal.

This nurse would not be skillful with a kid who had been forced underground into survival sexwork where he caught HIV.  She’s a country mom who believes that kids are cubs.  But in the meantime, she’s a good nurse for the local assumptions and I have no objections, even though I’m not young and only a lady intermittently.  

As for Integrative Medicine, it’s a good idea that depends on the interpretation of the practitioner.  With a practical, alert doctor, it avoids the robot syndrome of the doc trying to please the clinic manager who wants more patients in less time and total obedience to “best practices” insurance dictates.  But it can degenerate into something like folk medicine.  Andrew Weil, MD, has been pretty thoroughly commodified until sometimes his outfit sounds like Weight Watchers. 

It was encouraging that when I talked about some new study, Dr. Marler always knew about it and had thought about it.  This Family Practice avoids the steam-rollers of the two medical behemoths in town, who are both the end result and cause of consolidating medical care so that a solitary old person like me has to drive far.  Easy right now — but it won’t be for long this season.  What happens when my eyes are too bad, or I’m just weak and woozy?  It’s unfortunate that so many chronic conditions now require frequent trips to the doc for blood draws, dialysis, or some kind of therapy.  We need to rethink the whole big picture.  Everyone agrees with that.  We just need specifics and imagination.  An “integrative” approach.  An inclusive, private, and supportive way.

PAGE TWO:  Today I drove up to my usual pharmacy in Shelby (30 miles) and discovered with dismay that the faithful, skillful, reassuring pharmacist had finally retired.  She deserved it.  Her replacement is just out of school.  She could easily model for a high-end fashion mag, but she couldn't operate either the till or the computer.  She knew the composition and uses of meds, but that's the least of her job now.  She has to go by the insurance company's best practices, which are not necessarily medically indicated.  

I had three prescriptions.  She wouldn't fill one because the insurance company said I had already had enough.  She couldn't fill the next one because they didn't have any of the pills -- would have to order them. She did fill the third.  

A little kid had broken the "magic pen" for the credit cards machine so she told me to sign it with my finger.  That worked -- unless you expected human writing.  I've transferred my pharmacy -- you have to do that formally -- to the Cut Bank pharmacist, but I won't get the pills until next week.  At least I'll never have to drive to Shelby again.

This is also the kind of service people get when they attend government clinics for HIV meds -- pills not on hand, refusal of service for this and that.  Policy is developed by urban, detached, non-medical people who don't understand long distances in bad weather but understand politics a little too well.  Death by pencil.

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