Albuquerque and Psychiatry 1994

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It is Thursday Feb 9. I'm pain free using fentanyl patches. I have completed the course of radiation on my left ribs with good results. I'm continuing daily radiation for my spine and I'm much better able to lift my leg. My chief problem is shortness of breath. This does not appear related to the amount of lung tissue that I have remaining and is likely the result of some chemical product of the tumor itself.
Dr. Palchak has convinced me to give Alimta another try. I have moved my therapy from Stanford to a town 25 miles away and I will receive chemotherapy there tomorrow.
The weather in Morro Bay is perfect. It is about 70 degrees at 4 PM and I'm about to go sit outside and enjoy the late afternoon.

Albuquerque and Psychiatry 1994

In June 1994 I moved from Pocomoke City, Maryland to Albuquerque, New Mexico to begin a residency in psychiatry at the University of New Mexico.  In the five months prior I had made three trips from the East Coast to New Mexico--to sign a contract for a house, to do an inspection on the construction, and to move a car and a few belongings into storage.

It had been 24 years since I had completed my internship--my last formal year of medical training. I was to begin as a second year resident  in psychiatry on July 1, 1994 and the program length was three years. I had always been curious about the Southwest and had looked forward to an opportunity to live in the region since the 1950s and 1960s when my Uncle Earl worked as a hospital administrator for the Indian Health Service. Normally he was stationed in Washington, D.C., but when he returned from Albuquerque, he had gone native with the cowboy boots, the Stetson had, the Indian String ties, and the Turquoise watch band. Cool!
Perhaps the best decision in my life was to return to a training program in my early fifties. When I had started medical school in 1965, one of my instructors was a psychiatry resident who was 65. He had been a family physician in Frederick Md for more than 30 years. He radiated happiness and enthusiasm. After starting my retraining, I had many wonderful experiences both medical and life experiences. I also learned quite a bit about myself including my interpersonal scripting that had guaranteed problems in relationships with women. Mostly, it was an opportunity to learn by reading and doing. Perhaps the most important force was exposure to the young and really listening to their various takes on the practice of medicine.

The usual general psychiatry residence programs in the United States require four years of training before completion. Each of these four years is a "Post Graduate Year" (PGY). The first year of training is called PGY-1, the second year is PGY-2, etc.The program at New Mexico promised to get me out of training and back to work in 3 years by giving me one year credit for my internship of a quarter century before. I was expected to begin at PGY-2 level rather than PGY-1. 

Although the pay for residents was very bad, about $30K per year, the cost of living in Albuquerque was moderate. The climate was wonderful. Although I was not used to spending so much time at temperatures over 100 F, Albuquerque at a mile altitude, is very dry, and there is generally a little bit of a breeze. I found that I was almost always comfortable in open shade on the hottest of days.

The low humidity enabled general use of evaporative cooling for the house and eliminated the need for expensive air-conditioners on all but 5 to 7 days a year. So utility bills were reasonable as well.

I was joining an existing group of residents--primarily the first year residents who had begun their postgraduate training the prior year--1993. I believe that three of us were new, one of whom was Roger O, an internist a few years younger than myself. By coincidence, Roger had practiced in Montana at Butte. Roger and I are still in touch. He is also struggling with Stage IV Adenocarcinoma of the lung. I had been attempting to visit him around the time I received my own bad news.

A week before the year was to begin, a camping trip scheduled for all newly arriving psychiatry residents. Most of these folks were the incoming PGY-1 folks, fresh from graduation from medical school. So, my first contacts with the program were with these youngest members, a very lively and diverse group. The camping site was near Los Alamos. The days were spent hiking and exploring Bandolier Park with cliffside Native American dwellings of the past. As we hiked and camped we were given an orientation to the residency program.

A big change for me over the next three years was an enormous increase in the amount of walking that I did on a daily basis. The parking lot was quite a trek from the County Mental Health Building. In the evenings I began walking a few miles several times a week on the mesa west of town, not too far from my house. Hiking was wonderful in New Mexico. There was a lot of insensible sweat loss which meant personal evaporative cooling and a sense of coolness. However, the water loss has to be replaced and ongoing hydration was important.

Albuquerque is situated at about 1 mile in altitude. The Rio Grande River runs from North to South through the town. A few miles east of the river, the Sandia Mountains rise to over 10,000 feet and most of the population of the city lives between the mountains and the river. On the west side of the river stretches a long mesa, often depicted in the cable TV show, "Breaking Bad." There are five small volcanic cinder cones easily visible and running in a line north-south parallel to the direction of the river.

I purchased a little house on the West Side of the River. I built a little ramada in my back yard which had excellent views of downtown and the Sandia Mountains. I spent many evenings relaxing in my yard watching the Sandia (Sp. watermelon) turn colors during the sunset. Then, at nightfall, I could see the lights of the tram as it ran up and down the mountain at the North of the city.

The Bernalillo County Mental Health Center

The county mental health center was located on the campus of the University of New Mexico and it was the primary teaching center for the department of psychiatry. There were 4 wards for inpatients including two adult wards, an adolescent ward, and a geriatric unit. In addition to the inpatient units, there was a psychiatry emergency room that was open 24 hours a day, and several interview and conference rooms for outpatient work. Finally, there was office space for some of the faculty. The Department of Psychiatry had several other teaching assets, including a Children's Hospital, and a main office building that housed much of the faculty and residents' offices.

My first rotation was on the adult inpatient ward of the County Mental Health Center. The usual census was about 20 patients and the turn-over was fairly rapid. The purpose of inpatient treatment was stabilization so that treatment could continue outside of the hospital within the patient's general living situation.

The day started in the Mental Health Center with a staff meeting scheduled for 8 A.M. during which all of the admissions since the end of the last work day were reviewed. Each ward had an "attending psychiatrist" and two assigned residents. Frequently there were medical students assigned to a ward. All were expected to attend the morning meetings--generally up to 20 participants.

The morning meeting exposed me immediately to a different concept of time prevalent in New Mexico. Some of my friends described it as the "mañana" syndrome, where any specific mention of time is only a suggestion. The meeting seldom started before 8:10 and occasionally started as late as 8:20. Some of us out-of-staters were quick to point out that some of this thinking applied to New Mexico driving habits as well. For example, the yellow light at an intersection meant to speed up rather than try to come to a safe stop. We also noted that the common practice of entering an intersection immediately after the light had changed to red was frequently practiced in Albuquerque under to the dictum of "fresh red." Our resident Judy complained that the natives used bread wrappers and rope rather than trailer hitches to attach their trailers to the vehicles.
The Locked Ward and Violence
My previous experiences on a locked psychiatric ward occurred in medical school, more than 25 years prior. Then, as a student, I did not have keys to the doors. In Albuquerque we were issued keys to the wards on the first day of residency. 
In medical school, I had been assigned to a rather laid-back locked ward and never saw any violence. Things were much rougher in Albuquerque. People were committed from the street with a variety of problems, from acute drug withdrawal to severe paranoia. The staff of nurses and psychiatric technicians were expected to use listening skills, medications, and force if necessary to maintain safety within the ward.
I drew call duty for the county mental health center on the first weekend of July. I was responsible for emergency visits and admissions of patients from Friday night until Monday morning. As I recall things were hopping. Charles, a patient with severe bipolar disease, had been brought to the hospital by police after they arrested him on a golf course where he was trying to run people down with his Toyota truck. While the police were there during his admission interview, Charles had permitted one dose of medication. But after the police left, he refused to continue it. He was scary, being a very large, strong young man who was paranoid and isolating himself in the bathroom. Early Saturday evening, he stripped naked and remained in the bathroom lathering up his body. He was yelling and screaming curses at the nursing staff and daring them to attempt to restrain him.
The nursing staff had to do something about "slippery" Charles. They called for backup and used a mattress to contain him to the point where they could apply restraints. His attempts to punch staff made him a "danger to others" and an immediate candidate for chemical intervention.

Dr. Hammond's Ward

I was fortunate to do my first rotation under Lee Hammond, M.D. a bright, sensitive, quiet and competent psychiatrist. He was self-deprecating and spent some of his free time working with the homeless mentally ill at the Salvation Army. He was a very trim man, not an ounce of fat and apparently able to wear the same clothes that he used in college. His pants had a slight flair at the bottom and he wore short sleeved shirts with a tie. His particular academic interest appeared to be neuronal migration and the neuropathology of schizophrenia. I don't recall his specific title but he was acknowledged as the chief of the inpatient services. He was very quiet but the wit would shine through at times in conversation.

I particularly enjoyed watching him begin to establish a diagnosis for new admissions. There are two particular incidents that I recall--I think of them as "birds of a feather" and "he wouldn't have been able to keep the secret."

Birds of A Feather

You might be surprised that an inpatient mental health unit would be of any interest to people without mental disorders. However, it was very common for there to be one or two people on the ward who were hiding from police in the sense that they were avoiding questioning. 

There were also addicts and alcoholics who were not interested in specific programs for addictions, but wanted the 24 hour support from an inpatient hospitalization to dry out or detox or even to avoid detoxification. They would generally present as the "suicidal addict," claiming to need help to prevent them from giving in to their overwhelming desire to kill themselves. It was common for their behavior to be motivated by drug seeking.

There were also patients who were totally overwhelmed by their life situation and who lacked the emotional and problem-solving resources to overcome their circumstances. Some of these were too afraid to consider the use of shelters or food lines and preferred the security of an inpatient facility. Sometimes these patients were the ones who would resort to cutting on themselves if not admitted. 

The diagnoses were generally sorted out pretty quickly, but some of the difficult cases were the patients whose behaviors were particularly impulsive and self-destructive. For these patients one had to consider severe mood and anxiety disorders as an alternative or accompanying diagnosis.

Dr. Hammond pointed out to us that patients often sorted themselves out by diagnoses. He noted that the two refugees from the criminal justice system were spending their free time together as were many of the patients with personality disorders. It was a lesson that has been useful to me for many years.
He Wouldn't Have Been Able to Keep the Secret

Kenny was living on social security disability for mental illness. He had a history of many acute hospital admissions for psychosis. During these episodes, he would be stabilized on a medication for his psychosis and eventually released whereupon he would avoid further treatment.

He had been living in a motel in downtown Albuquerque. One day the landlord entered Kenny's room because of a complaint of noises. The room contained 40 tires that had been patiently gathered from around town. In addition there was a large quantity of uneaten and spoiled food neatly stacked in containers around the  baseboards of his room. Kenny was very agitated, was screaming at the landlord, and he continued screaming at the two policeman who had been called to the scene.

Kenny was brought to the Bernalillo County Mental Health Center. He was heavily sunburned. His lips were fissured and cracked. He weighed 20 lbs less than on a hospitalization the previous year. 
In the first few days after Kenny's arrival, the staff engaged in discussions about his underlying illness. Was it a bipolar disorder with psychosis or was it schizophrenia? If it was bipolar disorder, a drug like Lithium of Depakote was indicated in addition to whatever was required for his psychosis. If the illness was Schizophrenia, he would likely improve with anti-psychotic medications and have no need for the Lithium.
Dr. Hammond's belief was that he was schizophrenia. His argument had to do with the nature of bipolar illness and its effect on relationships. A manic patient is often "intrusive" and may take liberties with the social space of others with unwanted touching or invasion of personal space or the revelation of secrets. Dr. Hammond pointed out that Kenny had managed to bring 40 tires into his hotel room without anyone being the wiser. Since a manic patient was unlikely to be able to manage such a task without telling several people about it, it was more likely that Kenny was best labelled as Schizophrenia.
Kenny and Close Enough
Finally, Dr. Hammond intervened on my behalf in the treatment of Kenny. Kenny had been committed to the hospital with a condition called "grave disability."  This leads us into a little discussion of the criteria for "involuntary hospitalization." 
In order to take away the right to freedom of movement and to place an adult in a mental hospital, there must be a demonstrable of probable cause that one of the following risks is present:

• danger to self
• danger to others
• grave disability

Danger to self is the suicidal patient. Danger to others means a current risk of serious injury to another. Grave disability is the inability on the part of the patient to utilize the essential means for preserving life, such as taking fluids and nourishment, seeking shelter from elements, or navigating known and common dangers in the environment such as busy highways.
In the case Kenny, he was not threatening others or self. However, his sunburn and dehydration indicated that he was not paying much attention to his physical well-being. The spoiled food in his room buttressed this argument and demonstrated that he was not able to utilize food in a safe fashion. He was judged to have "grave disability" and he was placed on a mental health "hold," a commitment to a psychiatric facility based upon sworn affidavits from two mental health professionals. This "hold" provided the legal basis for placing him in the locked facility. Within a few business days he would have a judicial hearing where a the judge would listen to testimony and decide whether Kenny could be held involuntarily for 90 days.
Although patients could be held in the hospital involuntarily for several months, an initial court order for commitment did not allow psychiatrists to administer psychotropic medications over the objections of the patient unless there was imminent danger to self, to others, or grave disability--our familiar criteria.
In the case of Kenny, his admission to the hospital itself had relieved the grave disability. He was being fed three times a day. The sun wasn't shining inside the hospital. Although he attempted to hoard food in his hospital room, the nurses kept cleaning it out.
Kenny was an imposing man. He was about 300 lbs. He was agitated, loud, and religiously preoccupied. He paced the halls at night and got less than 3 hours of sleep at night. His speech was rapid and there was a flight of ideas. He sometimes "dogged" nursing staff and made them nervous.
Kenny was assigned to me as a patient and I was not getting anywhere after a week or so. One afternoon he became increasingly religiously preoccupied and more argumentative when I tried to change the subject. He walked up to me and shouted "My god is going to blind you and kill you!"
Dr. Hammond heard him and ordered the staff to medicate Kenny. 
Kenny knew the law pretty well: "I didn't say I would do it. I said my God would do it."
Dr. Hammond: "That's close enough!"

Status Report February 4

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On Thursday I visited Dr. Palchak my local oncologist who practices out of an office in Arroyo Grande, about 25 miles down the coast from Morro Bay. He has been very helpful right along. He was aggressive in persuading me to begin radiation of my my ribs and spine for pain and he has always been straight forward with providing information.

I am a big believer in finding the most experienced, cutting edge physicians and facility for any "bad" illness. I've spent most of my professional life in rural settings. Practice makes perfect. In general, I want the surgeon who has done two hundred procedures rather than the surgeon with ten under his belt. With bad illnesses, I'll opt for the large center that is specialized for the treatment of that particular disease entity. It also makes sense to go there from the start. I was particularly fortunate. Within an hour or two of the CT that showed my tumor, I had an appointment with the thoracic oncology service at Stanford for the 2nd business day. 

In my previous posts, I have provided an accurate picture of the wonderful treatment that I have received to date at Stanford and I have been particularly pleased with Dr. Neal.

However, my tumor has not responded to the chemotherapy in the hoped-for manner and the disease is progressing as indicated by the increase in bone destruction from metastases. I have related the very miserable time since my last chemo round and my thoughts about abandoning chemotherapy. 

Finally, Stanford is 200 miles away and treatment there is a 14 hour day when the drive is considered. Dr. Palchak is 30 minutes away and treatment done here will be much easier. 

The bottom line is that I've had the advantage of treatment at the Mecca (Stanford) and it seems to have made little difference to me physically. However, I am secure in the knowledge that I have received top-notch care and that my failure to respond has nothing to do with the quality of my care and everything to do with the fact that I have a tumor that is minimally responsive or non-responsive. So, I have no residual doubts about my medical care having failed me.

In addition to close proximity by car, Dr. Palchak appears to be in his early 50's. Dr. Neal is in his mid to late 30's. I think it would be hard to find anyone more knowledgeable than Dr. Neal about the science that is being applied in my case. However, I have reached the point where science must take the back seat to my end of life considerations and preparations. So, I want to tap into Dr. Palchak's many years of experience with patients who fail chemo or have particularly difficult times.

I saw him Thursday morning. He reviewed my case and examined the most recent CTs. He was very surprised that I had such a difficult time with Alimta, particularly in view of the mild previous round. However, when we reviewed the medications, I also received Zometa on my last visit to Stanford. Dr. Palchak pointed out that this could have been the real culprit.

So, on Thursday I walked into Dr. Palchak's office expecting to stop the chemotherapy. I walked out agreeing to repeat the Alimta for another cycle on February 10.

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Yesterday I was chopping some onions and dropped a scrap on the floor. I knelt down to pick it up and found that my leg strength was barely sufficient to get me back up. As I look at myself in the mirror I see the loss of muscle mass in my arms and legs. The cancer is consuming me from the inside. I will need to be much more careful about walking because I'm not so confident about being able to get up from a fall.

People are aware of my sickly appearance. I catch them glancing at me sideways. Some smile warmly and even joke at one of my hats that has fake hair. Most pretend to see nothing.

I know that Jasmine is under a lot of stress. She works full time and has been ferrying me back and forth to my appointments. While I am getting radiation to my bones, I have to appear daily at 8:45 A.M. 

She never complains. "It's a chance for us to spend time together."

So, I am more aware of things slipping away. For most of my life, the practice of medicine was an essential central theme and provided a sense of meaning. Today I am looking at the renewal paperwork for my medical license in California. Do I want to spend $800 to renew it for another two years? 

Radiation for Pain

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Thur Feb 2. I am becoming even more comfortable pain-wise as my radiation oncology treatments continue. I've had three requests to explain more about this option and so this post will be of a more general nature.

General versus Local Analgesia
When I swallow morphine for chest pain, the morphine will enter my bloodstream and be available to all parts of my body.  This is an example of a "general analgesic."
If I go to the dentist who injects novocaine into my lower jaw so that he can do a root canal, the novocaine is being used to block the nerves around the tooth in question--"local analgesia."
In the case of my cancer, it has spread to my bones--both my ribs and my spine. The rib pain has been around since October. The back (spine) pain had been gradually increasing for several weeks until I reached the point a couple of weeks ago where I was unable to lift my left leg without pain in the back.
Since October, I had been managing my pain with the drug Oxycodone and its long-acting form, Oxycontin. Up until New Years weekend, I had been making do with about 50 to 60 mg of oxycodone a day. Suddenly my pain increased markedly to the point where 120 mg of oxycodone was not controlling the pain. At that time, I was put on fentanyl patches. These patches release a steady stream of the morphine-like drug, fentanyl. Although the fentanyl did control the chest pain and did help with the back pain, I was experiencing weakness in my left leg. Pain control did not help with the weakness. Here is an image from a CT of my abdomen in December.

Sohr L Spine Dec 2012

The CT of the Lumbar Spine from December shows a lot of old degeneration--I've had disk disease and intermittent episodes of back pain for almost 30 years. The Lumbar vertebrae are labeled from L1 to L5. In the middle of the L spine, there are two vertebrae where some of the bone outlines have "disappeared." They are labelled L2 and L3. (This may be an error on my part...they may be L1 and L2). However, the essential point is that part of these vertebrae appear to have been replaced by something else...the something else is tumor.

Up until two weeks ago, I was treating my lumbar spine "generally" by taking oxycodone and then fentanyl. However, the pain was continuing to increase and there was an associated weakness in my leg muscle because of the tumor's presence in this area. At that point, I elected to try a local treatment, radiation to my Lumbar spine.

General Principles
Tumors generally multiply faster than ordinary tissues. While cells are multiplying (by dividing) they are very sensitive to radiation, like x-rays. Treatment with direct x-ray tries to deliver enough radiation to the tumor to kill it but not enough radiation to kill the surrounding tissue. You can see where this is tricky. In my case, I want radiation to the bony spine, but I want to minimize radiation to my spinal cord. One way of accomplishing this is to find two pathways to the area to be treated.

High Energy Beam X-Ray Machine

The high energy beam x-ray machine fills a room. There is a brownish colored cabinet to the rear of the machine which contains electric motors and controls.

This is the actual machine being used for my treatment.

Adrienne and Dale who do my treatments each morning.

The front part of the machine is shaped like a block letter C. The top stem of the C is the "gun" that delivers the x-rays. It is labelled "VARIAN" in the picture. The entire "C" rotates 360 degrees so that radiation can be delivered at any angle. The patient remains stationary on the table and this enormous x-ray machine rotates about.
The high energy beam x-ray is too powerful for decent imaging. Above Dale's head there is another x-ray gun that generates low energy rays for imaging.
On my first visit, about an hour was spent aligning my body to the table and to the machine. Several low energy x-rays were taken to hone in on the treatment window--the precise area of  the body where the x-ray was to be delivered. Once this was identified, I received a series of tattoos that permitted a much more rapid alignment in the future.
With my current visits, I am placed on the table. The tattoo marks on my chest and abdomen are used to make sure that I am properly aligned to the table and machine. Then a low beam x-ray is taken to demonstrate that the treatment portal is accurate--this is the second check on location. For my spine treatment, I am given about 30 seconds of high energy radiation from the front. Then the machine is rotated 180 degrees and I receive a similar dose from the back. By splitting the total dose into two segments, the surrounding tissues are spared 50% of the dose while the treatment area is treated twice.
These treatments are working very well. I have much better leg mobility than 2 weeks ago and much less pain as well.
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Later this morning I have an appointment with Dr. Palchak. I am hoping to use his experience and wisdom to lay out a reasonable treatment plan for the next month or so.

Out of Heart

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The Smith Islanders use the expression “out of heart” to describe a state of discouragement, disappointment, or depression. Looking back on the last week, it’s a reasonable description of where I’ve been since my last chemotherapy treatment. I described my miserable weekend where I was unable to appreciate the NFL Conference Championships. For the past week, I felt overwhelmed by an odd, faint, noxious smell. The thought of writing in the blog was a turn-off.  I have been too weak and short of breath to climb the stairs and have relied upon the elevator that the home builder installed for his wheelchair-bound wife.

At the time of my 4^th round of chemotherapy on Dec 30, the drug “Alimta” was substituted for Taxol. The reasoning was that the combination of Carboplatin, Taxol, and Avastin had not arrested the disease.  Therefore, I no long met criteria for the study which continues to be open to those who get some remission of illness and then go on to test a maintenance treatment. So, the 4^th round was changed to Carboplatin, Alimta, and Avastin.

The 4^th round seemed to be the easiest with respect to chemotherapy side-effects. However, my pain level shot up particularly in my left chest and mid-back. On my 5^th round, my last visit on Jan 20, Dr. Neal told me that I had gotten the four doses of Carboplatin and had likely reached maximum benefit.  He believed that Avastin was not likely to be offering much and we decided on Alimta alone for the 5^th and 6^th rounds.  After the 6^th round, I would be offered another clinical trial.

I’m currently rethinking this strategy. Chemotherapy for this stage of the disease is more about “quality of life.” Chemo is minimally effective for extending life. Its major purpose is the reduction in symptoms that arise from the tumor and it’s byproducts—most recently that has been back and chest pain. But I’ve just gone through more than a week where the side-effects from the chemo took the joy out of every day. And, as far as pain control was concerned, I seem to have stopped receiving any benefits from chemo a few weeks ago. In order to achieve pain control, I am using large doses of opiates via fentanyl patch and I’m receiving local irradiation to the spots in my lumbar spine and left chest. These local treatments appear to be working.  I’m not sure of the likelihood that the treatments are contributing to my symptoms.

So, why continue chemotherapy? If the purpose is not life-prolonging but symptom sparing, and if the therapy is not sparing symptoms, and if the therapy appears to be causing symptoms and reducing my number of quality time, what is the rationale for continuation? How likely am I to catch a break that will increase time or quality without an exorbitant penalty in side-effects?

This is the issue that I will be focused on for the next few weeks. Stopping chemotherapy might make me eligible for enrollment in hospice. I’ll discuss this with Dr. Ward who manages my pain medication and is a medical director for a local Hospice. I’m particularly anxious to speak to Dr. Palchak about this. He is in his early 50s and  he has a wealth of experience with this cancer. I’m hoping that we can sort through the facts together and incorporate my preferences into another treatment plan.

Sunday January 29... It is early afternoon. It's a beautiful day on the Central Coast. I wanted to let people know why there hasn't been a recent post. If I'm feeling well enough, I'll get back to the blog tomorrow.

Career Change at 50

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As I'm beginning this on Wed Jan 18, I have to report that I've needed short-acting pain medication--one dose each day-- on Monday and Tuesday. The chest pain remains well controlled but I am having low back pain and weakness in my left leg to the point that I cannot lift my leg into the auto when I want to drive. So I'm scheduled for an MRI of the lumbar spine today to see if there is nerve compression.

Thu Jan 19. Yesterday was one of those mixed bags that makes it impossible to predict either short term or long-term future. I got the report from the Chest CT scan from last week and it showed shrinkage of the chest tumor and the lymph nodes in the chest. However, there was a significant increase in the amount of bone destruction in the spine. Yesterday afternoon, I had an MRI of Lumbar spine which demonstrated the increase in destruction and growth of the tumor into the psoas muscle, a large, powerful muscle that attaches inside the body cavity from the spine to the thighs. So, today, Dr. Stella, the radiation oncologist will go to work to develop a treatment plan for attacking the tumor around the spine and around the painful rib. He warned me to be sure that I took analgesics before coming to see him today. I'm very curious about this process and I'll do my best to relate it to you.

Fri Jan 20. I visited Dr. Stella yesterday. They use a very high voltage x-ray machine to deliver energy to the area of tumor. Because high energy beams are not particularly good for providing images, the high-voltage machine is attached in tandem to an imaging machine. I was positioned on the table and several pictures were taken with the imaging machine to obtain the exact area to deliver the radiation. In my case, there are two areas, one to my Lumbar spine where the tumor is destroying the vertebrae and pushing aside the muscle. The other area is to my left 5th rib which has been eaten away by tumor at the place where it hooks into the spine.

Dale is the technician at Dr. Stella's office that does the positioning and pulls the trigger for the high beam radiation. Once I had been positioned, another test picture was taken "just to be sure." Then I was zapped for about a minute in each of the windows. An India ink tattoo was placed on a few spots on my belly and chest so that I can be more easily repositioned on my next visit which will be Monday.

The reason that radiation works is because of the differences in growth rate between normal tissue and tumor. Tumor is reproducing much faster than normal tissue. In order to reproduce, the tumor cell has to go through "mitosis" where the chromosomes line up next to each other and copy themselves. While in mitosis, the cells are particularly vulnerable to radiation that causes mutations in the cells. One hopes that the mutation will prevent the cell from surviving.

In addition to a direct beam of radiation through my abdominal wall to hit the Lumbar Spine, the high beam machine can rotate through a full circle and attack the same area from the back. So the Lumbar treatment is split into front and back blasts of energy. The rib is only a centimeter or so away from the skin in my back. The treatment to the rib is from the back.

I was told that I might notice improvement in as little as 2 weeks. A normal course of treatment may be from 4-8 weeks. I was glad to get started yesterday. I'm hoping to be able to reduce the amount of pain medication. I think that will make me less tired.

Today, Jan 20,  is my chemotherapy day at Stanford. A CT of the chest was done locally on January 13. The radiologist in San Luis Obispo thought that there was some overall improvement in things inside the chest with continued progression outside, in the spine and in the ribs. However, the radiologists at Stanford did not share that optimism and continue to call the disease "progressive." Dr. Neal, the oncologist, decided to stop the carboplatin and the Avastin and to continue the Alimta for two more cycles...today Jan 20 and again on Feb 10. I'll then get another CT to assess progress. He mentioned something about being offered another clinical trial of chemotherapy after Feb 20.

Mon Jan 23 The lost weekend. I had no symptoms from chemotherapy other than a change in sense of taste on Friday night. I awoke early on Saturday feeling well and started to work on taxes. Late in the morning I felt overwhelmingly tired. We had visitors coming at 2 P.M. and I wanted to get a nap, but I couldn't manage to get out of bed. I would awaken for a few minutes then doze off to sleep. Company came and went but I still couldn't get up. Over the next 12 hours or so, I was up and down with prostate symptoms as well and I  ran a fever of around 100.6 with sweats.
Early Sunday morning I noticed that I was having low back pain that had escaped control of the Fentanyl patches and I began to take short-acting oxycodone and I've been using it off and on up until now. Since I am scheduled for a radiation treatment, I want to make sure that my pain medication is adequate to allow me to move around on the flat, hard surface of the x-ray table this morning. Yesterday afternoon I could not pay attention to the NFL games and I napped through most of them except the last half of the 4th quarter of the Giants game.
Believe it or not, the most annoying symptom is a strange smell that is faint and metallic. It makes me feel nauseous and like a crybaby. If I can sit outside in the sea breeze, the ocean smells block it out. I decided to see if pot were any help. Instead of using a vaporizer, I took a small pipe and took 1 hit. About 30 minutes later, I found myself eating. I was able to sit down with Jasmine for an hour or so afterwards and then I went and took another hit. It seems to let me tune out the smell.
This morning I am weak and shaky, but I am able to eat and the odd smell is much less prominent.

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Career Change at 50
In 1992 I had been working as a prison medical director for five years. It was probably the most challenging and interesting work that I had done in medical practice. It required hands-on medical practice, oversight of medical services, supervision of physician assistants and nurse practitioners, responding to complaints from a variety of sources, and resource management. It also gave me the opportunity to do a fun project by developing a computer-based inmate locator and reminder system for routine sick call and chronic disease clinics. I was also writing a small handbook for dealing with "Difficult Patients."
I had become very much interested in "relationships" in medical practice--particularly between doctors and patients. Of course the driving force for the relationship was "the patient's disease," a process that begins when the patient recognizes some change in his body. Most of the literature in this area came from psychiatry and I was increasingly drawn to fantasies about retraining in psychiatry. I was in a mood to return to an academic environment and to have an opportunity to learn new skills and to read extensively in the field.
With my two boys, there were two college education responsibilities heading in my direction, but Molly and I had agreed upon our separation that we would share these costs. I had made a decision many years before that it would be reasonable to bear the full costs for a state university and that any desire for something more expensive would be on the child who wanted to go that direction. My thinking at the time was that expensive undergraduate degrees were no better than state diplomas (I'm not as sure of that now) and that the child could find a way through academic achievement, work, and borrowing if something more was desired. I assumed that a choice of professional or graduate school was the most significant decision, far overshadowing the actual selection of 4 year university study.
Finally, the health care agreement between Maryland and our prison contractor, Correctional Medical Services (CMS), was in the final year. There were several companies that intended to bid for the new contract. All of this came to a head in 1992 and I began to look seriously at a career change. I have given my reasoning previously, but I'll repeat some of it here.

1993: I'm 50 and wondering if I can do this anymore

I have reached the age of 50 and realized that I had been a much better family doctor at age 40, when I moved to Smith Island. At the age of 40, I was still delivering a few babies each month, taking care of newborns and children, doing routine GYN work, particularly pap smears, assisting in surgeries, etc. I was still reading a lot of general medicine. By age 50 I had moved out of family practice to prison work, all adult males and administrative duties. As the medical director of a prison for 6 years, I had seen our wonderful psychiatrist, 70 year-old Charlie Bagley, in action . He came to work a few hours after I did and went home a few hours before I did and took no call which I did for me and for him. He was making twice my hourly rate. It was time to think about retraining for the home stretch of my career.

Psychiatry had great appeal. I had always been interested in it, particularly so when working in a prison and discovering that most of sick call was about something other than being physically sick. Not many physicians were curious about this, but I was.

Consider the difference between medical and psychiatry emergencies in sheer volume of the number different types of medical and surgical problems that come racing through emergency room doors. Chest pain can be heart attacks, pulmonary emboli, pneumonia, a cracked rib, shingles, peptic ulcer, dissecting aortic aneurysm, etc. What about abdominal pain? Appendicitis, cholecystitis, liver abscess, peptic ulcer, celiac or superior mesenteric thrombosis, Crohn's disease, ruptured spleen, kidney stone, inguinal hernia, etc, etc. There are severe time restrictions on making the diagnosis since survival with some of these conditions is predicated upon very early recognition and intervention.

Compare these medical emergencies with the treatments that must be provided the psychiatric patient? The primary tools that are useful in psychiatry are threefold...

1. talk to the patient, see if you can de-escalate the situation
2. if the patient is threatening self or others, you may grab the patient and try to control the situation with overwhelming physical force humanely supplied and applied
3. medicate the patient with one of about 4 or 5 various cocktails of proven effectiveness

Voila! My goal at 50 was to practice medicine as long as possible. Psychiatry was the most attractive. It is also a discipline where experience gradually increases personal effectiveness. The wisdom of interaction with other humans is collective. I could be a better psychiatrist at 70 or 80 than at 55. I was sure that this was not possible for me in family practice.

Retraining meant that I would have to move. I had hoped to wait until Keith completed high school because he was active in basketball in a small school where he was guaranteed some playing time in his junior and senior years. He had a good group of friends--he was just a great kid with a wonderful temperament (it sure balanced out mine).  He was very smart and funny.
In the last year of the health care contract at the prison, CMS decided that they could not afford to give raises to staff. Instead of raises, the company decided that they would do other things for employees, like sponsor picnics and group outings. The big bonus for the year was to take us Eastern Shore yokels to a Baltimore Oriole baseball game in Baltimore, 150 miles up the road to the gentrified part of Maryland.

Keith's Wisdom and Humor
Love Those Os
On a late spring day in 1992 there was a company-sponsored outing for our prison health workers. At about 8:00 we boarded a large bus in Princess Anne Maryland and made the trip to Baltimore Camden Yards, the home of the Orioles. It was a part of Baltimore that I knew well, a few blocks away from my medical school. We had made good time and we were told that we about 90 minutes to kill before entering the stadium. I took the boys for a quick trip to Burke's bar, an old hangout from time in Baltimore. It was a lot cheaper feeding and filling up two teen-age boys at a restaurant than trying to accomplish the same feat at a ball park.


We made it back to the bus in plenty of time and we were met by the CMS regional manager who was to escort us to our block of seats where the president of the company would greet us. As I recall we were parked near far left field while our seats were in far right field.  So we started walking--a rather long walk through the crowds--down from left field, around the home plate area, and then another hundred plus yards down the right field line. When we reached the general area of our seats, we started to climb. And we climbed and we climbed to the top tier. Near the top of the stairs, we were greeted by the CMS president. 


It was at this time that I could hear my son, Keith call out to me. He was a couple of rows down. He has a booming voice. "Hey, Dad. Your company spared no expense!"


I got a laugh out of watching the major leaguers do their pre-game calisthenics and stretches. I thought about Babe Ruth whose row house at birth was just a few blocks west. It had been turned into a bar and grill, named Ruth's, and was two blocks from University Hospital. It was a favorite watering hole with medical students, at least for my class. It had a pinball machine and good roast beef sandwiches. It was also a hang-out for people coming off call and frequently filled with resident physicians wearing various colored scrub suits and drinking draft beer at 8 A.M. Rather than being out there stretching before the game, the Babe would have been at a place like Ruth's bar, knocking back a couple of beers with hot dogs. Then he would look at his watch and say to his pals, "Let's go play some ball."


Finally, the game came. In the second inning I saw a line drive pass above the second baseman's outstretched glove at the same time that I heard the sound of the ball coming off the bat. The ball had traveled 127 feet before the sound had reached me. Keith was right.


On Being Fortunate
Selfish knave that I am, I had a significant self-interest in my boys making it to the age of 21 without being a participant in an unwanted pregnancy. I wanted no part of more child responsibility. So, I was the parent who would give the lectures about condoms on a yearly basis. To the disclaimer, "Dad, we know all that" my response was "If you know all that then show me right now how you will remove a condom." 
The usual response to this query was "YUK."
The last time I asked Keith about his condom use was his first year of college. "Keith, are you practicing safe sex?" His response: "When I get lucky."


On Bereavement

A middle aged woman is sitting with her husband at my kitchen table. I'm serving cake and coffee. The lady is complaining about her 82 year old father who buried his wife of more than 50 years only 6 months prior and has just taken up with an old flame with plans of marriage. "I can't believe it is only 6 months," she said.  Keith piped up in a consoling voice, "Maybe he mourns quickly."

Keith plays things close to the vest. He is wonderfully good natured and met the girl of his dreams midway through college. I've never seen them bicker. As far as I can determine, they are still in love after after more than 10 years. He works as an economist and he is able to balance his work with his family life.  He loves to cook and has followed his wife's path into the veggie world. I admire this kind of ethical decision, but I suspect I will prefer warmed over bleeding beef until the day I day. I can't imagine the thought of life without a hamburger in my future. Should bovines go suddenly extinct, I'm likely to pull the plug.

BRIAN
Brian is very deep. As a child he was hard to soothe. In addition, his parents were engaged in their own struggles and he was in leg casts for much of his first year. He needed little sleep and didn't want to nap. His care could be very wearing. He also had recurrent, painful ear infections that added another dimension to the mix--really messy diapers from the antibiotics in addition to his pain.

He is mathematically gifted. I'm pretty good at doing mathematical estimates in my head. He is several times faster. While on Smith Island, he won the Math prize for the region that included several counties on the Eastern Shore. He received a similar award and scholarship in high school. He loved playing basketball and I think that he worked hard getting the most out of his physical attributes. (After all, we know that "White Men Can't Jump"--aren't you tired of all the bullshit that fails to recognize African-American superiority in many areas of Athletics? What is that denial all about? The Soviet Union was great at ignoring science that contradicted the various versions of Marxism that were fashionable in different eras. Don't we do the same thing with ignoring what we see in the NBA and NFL every day?)

In a much earlier post, I mentioned Racism and fessed up to some of mine. There is no way I can look into my childrens' heart of hearts and claim that there is no vestige of racism. However, I have good knowledge of how they spent their time and treated friends and acquaintances for the past 25 years. In 1987 they were very concerned about moving from a "lily white" insular culture and going to a larger school that was about 50% African American. However, they were basketball players and this was a sport that in Pocomoke was dominated by blacks with a sprinkling of whites. We had a color-blind basketball court in our back yard that was located close to the geometric center of town. I think that my boys are close to color-blind today but remain aware of what their black friends must still deal with in our society.

Brian married a Lorena, a woman from Guadalajara who is intelligent, has great people skills, and exerts  a calming influence on this smart, restless guy. I didn't meet her until going to Guadalajara a few days before their wedding. I liked her from the start. She was very direct. "How do you explain having been married five times?" was perhaps the second question after "How was your trip?" That made me like her even more. I don't remember exactly what I said but I do know that it was equally direct. I may have pointed out that she owed me some gratitude for my first divorce and marriage to Molly thereafter.

Brian has been enveloped by his wife's large extended family. He is fluent enough to pass for a native speaker. A day after his wedding, there was a party with a mariachi band outside of the city. I remember looking at him sitting with his friends in light hearted conversation. He appeared to be so relaxed and to be in such a good place emotionally that I had one of those "Peak Moments," a place that is so good that it can't really be described very well in words. Seeing your children in a good place is hard to beat.

Their first child, Oliver, is "almost perfect" according to Brian. He is big, curious, bilingual, and stubborn. Two years ago, Brian and Lorena found out that she was carrying a "Down's Baby." This was confirmed by chromosomal analysis showing Trisomy 21 after birth. This was quite a blow to their sense of the future. Lorena is very close to her mother and I suspect that she had hopes for a similar intimacy with her daughter.

The baby, Ana Paola, was very sick. She had congestive failure to the point that she did not cry because of the additional exertion required by the heart. Surgical intervention was required but the heart was too small for several months. Surgery was finally done on October 2010. She was in the intensive care unit for a week. She required doubly synchronized electronic heart pacing--both atrium and ventricle. There were concerns that she may have had a stroke on the fifth or sixth day but the symptoms passed.

It has been eye-opening to see Lorena's and Brian's response to all of this--the blossoming of love for the child, the acceptance of the limitations. It was so gratifying  to see my child demonstrate a level of love and concern that exceeds anything that I have been able to find within myself--and to see it done with such pleasure and grace is remarkable.

Privatized Medicine in Prisons
States have found that it is very difficult to use state employees to run a 24/7 medical operation--it becomes particularly expensive to staff nights and weekends because of overtime costs. With seniority considerations, the cost of labor increases yearly. The specter of rising pension entitlements is also as a negative.
California uses state employees to run prisons. The prison closest to my house in California is typical. There is a "chief of mental health" who supervises psychologist and psychiatrist supervisors, who then  supervise psychologists and supervisors.
Above the "chief of mental health" is a "health care administrator at the prison," a set of regional administrators above that, a chief psychiatrist in Sacramento above that, and an assistant director of medical services above that.
So there are at least 4 layers of supervision above the chief of mental health. Of course no service work, i.e. face to face care, occurs except at the lowest levels--psychologists and psychiatrists, 2 levels below the chief of mental health. Lot's of layers on top of the folks who actually provide the services.
The Maryland system was much tighter. In Maryland, there was a headquarters staff that was headed by an Assistant Director of the Department of Corrections for the state. Below this there was a management team--experts in Medicine, Psychiatry, Nursing, Social Work, Pharmacy, Accounting, and Contract Monitoring. They were not there to supervise. They were there for planning, oversight, program direction, and quality evaluations. There were several nursing field workers who were capable of going to an institution and doing investigations of various complaints. So there was an essentially bare bones organization at the top. All of the supervision of medical line staff was pushed down onto the contractor who was given quite a bit of latitude provided that the medical care was considered acceptable.

The Maryland contract included staffing numbers of specific health care personnel during certain shifts for the various institutions. The contract was expected to staff at that level and to provide an adequate level of care. Accounting was done using reports from time cards with spot audits as well. Maryland imposed stiff penalties on the contractor for failing to provide any mandated coverage. I don't remember the exact rates. Nursing was the largest staff of employees. The penalty for failure to provide a contracted hour of nurse care might have been as much as twice the going rate from the standpoint of salary. This imposed a significant financial incentive on the part of the contractor to fill the positions or to fill shifts from contract or "registry" staff.

Musical Contractor Chairs.
In 1993 I saw how a changeover from one contractor to another comes about. It was not pretty. Nurses who had come when the prison opened had now worked five years for CMS. They had started at the entry level and had acquired raises along the way. In addition to increases in pay with seniority, there often comes some other benefits like more sick time or annual leave.
The new contractor was not bound by any arrangements made under the former contract. While the new company was anxious to keep good staff and to make sure that they would be able to deliver services from day 1, there was no obligation on their part to do it with the same personnel. This was a time of high anxiety for the healthcare staff as they were interviewed individually by the management team for the new contractor which in this case was Prison Health Services (PHS). The first concern was keeping their current job, the second being the reimbursement.
As it turned out, anyone hired by PHS was a "new employee" with benefits fixed to the company's policies. Everyone started over. It didn't matter that a number of employees were on the verge of celebrating a work anniversary with the prior company, Correctional Medical Services (CMS). All were back to square 1.
I came to believe that it might be beneficial to "lose" a contract from time to timed since it destroyed long-term seniority for any employee and prevented "benefits creep."

Looking at Residency Programs
My personal finances remained solid even with the new company. They tried to play hardball and would have if they could. I trusted my instinct that very few physicians would want the job. I negotiated a very good contract for myself but I immediately began searching actively for psychiatry residency programs. Normally, these are four year programs with the first year spent in general medicine with emphasis in neurology.
I was hoping to find an institution that would give me credit for my internship of 1969-1970.  At the time Brian was beginning college at William and Mary in Virginia and Keith was entering 10th grade. Molly was a resident of Virginia which has an excellent state school system that included William and Mary (where Jefferson studied law), the University of Virginia, Virginia Tech, and others. Anyway, these state schools seemed to match up well with the more expensive private Universities.
My first choice of programs was Virginia Commonwealth University. It is located in Richmond within about an hour of William and Mary. I went for an interview. They would accept me if I chose to enter as a first year resident--meaning I would need to spend four years there to complete the program. There were no openings for me in the second year. It wasn't negotiable and this closed the door to the possibility of remaining within 90 minutes from the boys while I was retraining. Keith was not pleased at the idea of moving but he was stoic. I did want to know from him whether there was some geographic location that would be appealing to him for a couple of years, but he was non-committal. It was more likely that he would go to live with Molly.
At this point, everything seemed open. Without day to day parenting responsibilities, I could live anywhere and retrain anywhere. "Anywhere" was very attractive. After almost 10 years of East Coast weather, the thought of a dry Western U.S. environment was most appealing. I was particularly interested in New Mexico, Nevada, Texas, and Arizona. I looked at programs in Texas and Arizona as a visitor and I was encouraged to apply. However, I liked the atmosphere better in New Mexico and Nevada and I applied to those two institutions.
I liked both programs. Each had different strengths and weaknesses. The weakness in Reno was the small size of the department and the fact that the program was in its infancy--just a year old. There was an existing class of 1st year residents that I could join in the second year. This would be the first "graduating" class from the psychiatry residency program. Residency programs often supply "cheap" doctor manpower to the hospitals and clinics served by the program. If a typical psychiatrist was making $120K in 1993, a resident might be making $30K. It is cost efficient to use the resident whenever practical. New Mexico was excellent at squeezing residents in this way. The advantage of Reno was that the psychiatrists there were used to doing all the work themselves--I judged them to be less likely to be effective exploiters.
I was accepted by both programs. I chose New Mexico primarily because of the culture and history. It was a well-established department and the living conditions in Albuquerque and Santa Fe had attracted retired academic psychiatrists who enjoyed doing part-time teaching. If you check out the authors of various standard textbooks in psychiatry, it is surprising to see the number of contributors from the University of New Mexico.



I

Some Notes for Prison Physicians

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medical          *
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None reported in this post

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Here are some observations and suggestions for physicians engaged in Correctional Medicine based upon experiences in prisons and psychiatric hospitals for the criminally insane in Maryland, Nevada, and California.

Some General Observations:


1.  It is very expensive to attempt to control the activities of human beings, especially antisocial human beings with energy enough to throw themselves into a battle with health care providers and other authority figures.

2. Inmates have an excellent communication system within the prison and they possess a large fund of knowledge about employees. If prisoners care to know they can easily find out what car you drive, where you live, and how much money you make. They will know who your friends are among other staff.

3. Some of your co-workers in prison have a great need to feel loved and respected and will establish relationships to fulfill those needs with inmates who are wonderful at providing compliments and flattery. Mental health staff are just as vulnerable as other staff and correctional officers. Inmate-staff relationships  include the passing of information about staff.  Last year I was angry at having a prisoner ask me about my upcoming vacation. He wanted to know if I was going any place or just staying home. It meant that some staff member had been blabbing this information and gave an inmate an "opening line" in an attempt to become "familiar" and to break out of something other than a formal relationship.

4. Inmates sometimes work in teams to "set-up" prison staff. Once a staff member violates a regulation,  that if known to the warden would result in dismissal, the inmates can bring pressure upon the worker. Typically the blackmail will take the form of bringing contraband, like money, drugs, and cellphones into the facility.

5. A very good and interesting book on the subject of staff-inmate relationships is Games Criminals Play: How You Can Profit by Knowing Them by Allen and Bosta. I think it is a must read for anyone working in a prison. It was very helpful in orienting me.

6. A prison is a part of the criminal justice system. However, the Criminal Justice System is less about justice and more about convincing.  Given the adversarial system, the inmate quickly separates himself from "his case." It is no longer about responsibility for the murder, but about the ability to "convince," and "plead the case." This is a perfect situation for antisocial persons who refuse to take responsibility for actions. However, something approaching the "truth" is pretty important for making medical decisions.


7. I've mentioned previously that there is often friction between correctional officers and health care staff who may be looked down upon as do-gooders. Many correctional officers have come to their profession after failing to find jobs in other police forces. In California I believe that the only requirement is a high school education. The occupation can be high stress, particularly when working around young, violent offenders in lock-up units. It is easy for health care workers to consider their own roles to trump security concerns and to make decisions that infringe upon the discretion of the correctional officers. Correctional officers are taught from day 1 that the primary purpose of the prison is the maintenance of security. This difference in perspective is a source of irritation for both groups.
Training can go a long way toward smoothing over such differences by allowing each group to grasp the point of view of the other. For example, it frequently occurs that an inmate refuses to leave the cell for a physician to do an evaluation. If a newly hired physician merely tells the correctional officers to remove the patient from the cell and put him in an examination room, things are likely to heat up. Extracting an inmate from a cell is not a trivial exercise. It will require a "use of force." A situation involving such force will result in a number of correctional officers participating in the exercise who will then be spending hours writing a report detailing their activities and observations during the "use of force." 
Rather than merely demanding that the patient be removed, a physician will do better by approaching custody and stating the problem: "I need to see inmate so and so in the examination room. He doesn't want to come, but I really need to see him. How can we accomplish this?" Correctional officers will often have a solution. "Inmate x has a good relationship with C.O. John. Let me see if John can come down here and help us." If John is able to easily persuade the inmate, then a lot of time has been saved. If the inmate continues to refuse, correctional staff have at least had a shot at the problem. The supervisor might discuss the use of gases like pepper spray as opposed to the use of battle gear and shields to enter the cell. Cell extraction is frequently associated with injuries. In many institutions, all cell extractions are recorded both for training and as evidence in the event that claims of injury are made by the inmate. I worked in a prison at the time that cameras were first introduced for this purpose--it makes an incredible difference. Everyone is on their best behavior.

Some General Rules for Physicians:

1. It's best to maintain your distance from inmates when you are not in a professional setting. When hailed by inmates as you pass through the yard, you can say "hello" and even mutter something about the Jets-Dolphin score when asked, but I try not to allow an inmate to fall in beside me and begin a conversation about his medical condition or anything else. Rather than walk across the yard with the inmate, I stop and tell him that I can't discuss anyone's medical information in a public place but that I would be happy to continue the discussion at a sick call visit. I wish him a good day and leave him.  When you are passing through a place where there are inmates, you are part of the public theater. Giving an inmate (particularly a healthy one) attention other than a greeting may be seen as reflecting a special relationship with the inmate in question. When you say goodbye to an inmate after stopping his attempts at conversation, don't fall for the hang dog "I'm being disrespected" bullshit. The inmate knows very well what is going on--that others are watching a performance. And he'll also know that you're aware of the game and that you won't give the appearance of having any special relationship. But say hello in reply to every greeting and give respectful nods to all. There is nothing more that is required. With severely mentally ill, this rule can be modified as necessary.

2. Make sure that your medical department is running a clean operation. One needs to be practicing good medicine. If not, the rest is just a scam, isn't it? Is this medical care that you would feel comfortable with for you and your family? If not, you need to look at your ethical compass. 
Sometimes inmates will attempt to prove that your medical department has denied them care by neglecting them or not honoring their request for sick call. Most of the time when an inmate says that he "already put in a sick call slip" for some problem, he will be lying and blaming someone in the system. However, you need to make sure that sick call slips are getting to the medical department in a prompt fashion and that they are being acted upon. 
The inmate is basically powerless when it comes to accessing medical services and needs the assistance of custody or a sick call slip. After several months or a year or two, inmates will have created a report card on you. If you practice as a caring physician, they will know that. If they see what appears to be poor or uncaring medical services, they will develop a poor opinion of your dedication to your profession. If they see you as bowing to every inmate pressure, they will see you as a fool and a soft touch and wonder about your medical abilities to see through what all the inmates know to be a scam.

3. Don't grease the squeaky wheel, but do gather information. The physician must also be a "cross examiner." When an inmate claims a prior medical condition and states that he had a prior schedule for a medical service that was interrupted by prison, those records must be gathered. Inmates claims about medical conditions and other medical problems that will affect conditions of his incarceration must be corroborated. Should the inmate refuse to comply with that reasonable request to obtain the prior medical records, the inmate must be informed that without that information, a decision will have to be made based on the data currently in front of you. By the way, never trust written information provided directly by the inmate. Data about the prior medical history must come from an original source.

4. Practice medicine up to the limits of your capacities, particularly in urgent situations. If there is any way that a medical problem can be managed in the institution, it should be done there. Physicians on call, whenever possible, should be expected to come to the facility to see any patient where transfer is being considered unless it is a life or death emergency. One wants to avoid involving a naive, free-world physician in the care of the correctional patient whenever possible. 
Physicians are trained to take their patient at face value at all times. As prison physicians we know that is a mistake in our special population--a little more evidence is required. Antisocial individuals are less likely to be as concerned with the notion of truth and are more likely than others to exaggerate or lie in order to seek an edge or a special accommodation.

5. Don't Avoid the Difficult Patients. There will be a set of patients who appear weekly on the sick call list. Some of these patients are attempting to "establish a case," creating a paper trail that "proves" that they have a serious medical condition (as indicated by the multiple visits for the same complaints that were not successfully addressed.)  In Maryland, this was much easier to manage than in California. In Maryland, we could admit a patient to the infirmary for a few days to better observe the behaviors. A lot of medical problems seemed to disappear after 24-48 hours never to reappear. Do not put off the frequent attender based only upon your observation that "he's just been seen." He needs to be seen in order to satisfy Estelle v. Gamble. You must demonstrate an ongoing attention to his complaints. Here is a medical suit brought against me and everybody else while in Maryland.

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 989 F.2d 491

NOTICE: Fourth Circuit I.O.P. 36.6 states that citation of unpublished dispositions is disfavored except for establishing res judicata, estoppel, or the law of the case and requires service of copies of cited unpublished dispositions of the Fourth Circuit.
Robert Leon BUCKNER, Plaintiff-Appellant,
v.
WARDEN, EASTERN CORRECTIONAL INSTITUTION; Commissioner of
Correction; William Donald Schaeffer Governor; Lloyd
Gatherum, Medical Department Supervisor; Correctional
Medical Systems, Incorporated, Defendants-Appellees.

No. 92-6228.

United States Court of Appeals,
Fourth Circuit.

Argued: December 4, 1992
Decided: March 9, 1993

Appeal from the United States District Court for the District of Maryland, at Baltimore. Norman P. Ramsey, District Judge. (CA-91-2362-R)

Julie Uebler, Student Counsel, Appellate Litigation Clinical Program, GEORGETOWN UNIVERSITY LAW CENTER, Washington, D.C., for Appellant.

Aron Uri Raskas, KRAMON & GRAHAM, P.A., Baltimore, Maryland, for Medical Appellees.

Audrey J.S. Carrion, Assistant Attorney General, OFFICE OF THE ATTORNEY GENERAL, Baltimore, Maryland, for State Appellees.

Steven H. Goldblatt, Director, David B. Goodhand, Supervising Attorney, Heidi A. Sorensen, Student Counsel, Appellate Litigation Clinical Program, GEORGETOWN UNIVERSITY LAW CENTER, Washington, D.C., for Appellant.

Philip M. Andrews, KRAMON & GRAHAM, P.A., Baltimore, Maryland, for Medical Appellees.

J. Joseph Curran, Jr., Attorney General of Maryland, OFFICE OF THE ATTORNEY GENERAL, Baltimore, Maryland, for State Appellees.

D.Md.

AFFIRMED.

Before WIDENER, HALL, and NIEMEYER, Circuit Judges.

PER CURIAM:

OPINION

Robert Leon Buckner, an inmate at Eastern Correctional Institution (ECI) in Somerset County, Maryland, sued various state officials under 42 U.S.C. § 1983, alleging they had been deliberately indifferent to his medical needs, denying him medical care in violation of the Eighth Amendment. See Estelle v. Gamble, 429 U.S. 97 (1976). In particular he alleged, "I need corrective surgery on my lower lip very bad. The M.D. (Dr. Sohr) here at ECI has said that this [is] 'elective' surgery and that I only want it for cosmetic reasons. On the contrary, the greater portion of my lower lip is missing because of an [automobile] accident in July 1991 and when I eat food falls back out of my mouth and it is hard for me to speak and/or articulate." He seeks injunctive relief to require reconstructive surgery and damages.

On the defendants' motion for summary judgment, the district court entered judgment for them, concluding that Buckner failed to show deliberate indifference to his medical needs. The court pointed out that the record establishes a "high level of involvement" by health care providers and that the action taken by the health care providers was "neither grossly incompetent [n]or inadequate, nor was the treatment provided shocking to the conscience or intolerable to fundamental fairness."

Having reviewed the record carefully, de novo, we conclude that, while Buckner has established satisfactorily a continued need for treatment of a medical condition that existed before he entered prison, he has not demonstrated that the defendants' response was in any sense deliberately indifferent. The record establishes quite the contrary.

As the result of an automobile accident on July 11, 1990, Buckner sustained extensive facial injuries for which he was admitted to Prince George's Hospital Center. When he was discharged two weeks later, he had undergone plastic surgery to repair substantial facial lacerations, including lacerations extending into his lip. No evidence was presented that he sought any further medical treatment, however, until late December after he had been convicted of theft and committed to ECI-a period of some five months.

After he entered into the custody of the Maryland Division of Corrections on December 7, Buckner submitted a sick-call request, on December 11, complaining of back problems and a bad tooth. On sick-call requests of December 13 and December 17, he continued to complain of his back problems. On the December 17 request, however, he also indicated he was having trouble with solid foods because of his facial surgery in July. On each of these sick-call requests, as well as all of the 30 or more that followed in connection with a diversity of complaints, the response by medical authorities was immediate, and in each case they provided some form of treatment.

Buckner complained about pain in connection with his facial injuries for the first time on December 19, 1990. He was provided with pain medication and advised to engage in facial exercises. A few days later Buckner was examined, in connection with his facial injury, by Dr. Eric Sohr, who referred him to an oral surgeon, Dr. D. B. Rae. Dr. Rae suggested a mandible labial frenectomy to give Buckner better flexibility with his lower lip. The operation was actually performed on March 13, 1991, and a week later, when Buckner was seen during his post-operative examination, Dr. Rae noted that the surgery "looked great." Buckner apparently agreed, reporting having been "very pleased with the result." Thereafter, on numerous occasions Buckner complained about facial pain and on each occasion was provided with a prescription for pain medicine. To assist Buckner in eating at a slower pace, he was offered a "feed in option," which he refused.

Approximately two months later Buckner insisted that he needed a further operation, leading to an administrative complaint and the complaint filed in the district court. In response to his request for further surgery, both Dr. Sohr and Dr. Rae, who are not shown to have had any bias or ill will toward Buckner, gave their opinion that Buckner's facial condition "should not interfere with eating and speaking" and that further "surgery for this problem [was] unnecessary and purely for cosmetic reasons." They nevertheless continued to treat Buckner's pain with medicine and to see him on a regular basis. Buckner's administrative appeal was denied by the Maryland Commissioner of Correction based on the opinion that no"corrective lip surgery is required."

Buckner makes no assertion that he was not given prompt treatment, but only that he was denied a further operation on his lip. He disagrees with the opinion of two doctors that further corrective surgery would be only for cosmetic reasons. Regardless of whether there might be another doctor who might agree with Buckner on this point, this is not a record on which a claim for deliberate indifference by the state officials is shown to any degree. While it is indeed unfortunate that Buckner continues to suffer pain and defacement from his automobile accident injuries, under the circumstances presented, we believe that the defendants met their constitutionally-established obligations to Buckner. See Russell v. Sheffer, 528 F.2d 318, 319 (4th Cir. 1975). We therefore affirm the judgment of the district court.

AFFIRMED

This is reasonably standard type of inmate suit. There was no evidence of any medical care for this problem in the five months prior to his incarceration. Once incarcerated he becomes focused on getting plastic surgery to his mouth, although his first sick call slips are for back and dental pain. (In fairness to the inmate, he may have experienced increased scarring and skin contractures during the first few months after surgery. So the appearance of complaints at 5 months would not be particularly unusual.) He was seen by the Physician Assistant in sick call and by me a few days later. Our prison was fortunate in having a contract with an oral surgeon who was able to see Buckner within the facility and to perform a frenulectomy. Even more importantly, the surgeon's experience and comfort with his findings allowed him to stand up to the inmates' continued complaints and lawsuits.

Notice also that Georgetown University has used the inmate's lawsuit as an opportunity to give their students experience suing the neighboring government officials in Maryland.

Although he claimed he couldn't eat in the short amount of time provided at the dining hall, he refused an opportunity to take meals at a slower pace and there was no evidence that he lost weight. In the free world, the inmate would be warmly received by a plastic surgeon provided the patient was willing to accept the need to pay. I'm not sure whether Medical Assistance (Medicaid) would have paid for this surgery had the patient qualified. Facial scars are relatively common in prison. This patient was the squeaky wheel. His complaints were never ignored. He was seen promptly. However, we could not have provided this inmate with his surgery without, in all fairness, being willing to provide cosmetic surgery to any other inmate who desired it.

From the above, case we can determine what the judge needed to see in order for us to have met our constitutional mandate. 

• he has not demonstrated that the defendants' response was in any sense deliberately indifferent. The record establishes quite the contrary.
• On each of these sick-call requests, as well as all of the 30 or more that followed in connection with a diversity of complaints, the response by medical authorities was immediate, and in each case they provided some form of treatment.
• Thereafter, on numerous occasions Buckner complained about facial pain and on each occasion was provided with a prescription for pain medicine. To assist Buckner in eating at a slower pace, he was offered a "feed in option," which he refused.
• While it is indeed unfortunate that Buckner continues to suffer pain and defacement from his automobile accident injuries, under the circumstances presented, we believe that the defendants met their constitutionally-established obligations to Buckner

6. Establish Formal Clinics for Frequent Attenders and Difficult Patients
Some of the more difficult patients are those who manage to "split staff" into the good guys and the bad guys. The more needy the staff, the more likely you will find staff who enjoy being the good guy. They are likely to go easier on the patient, to provide more medication, more likely to give lay-ins, and to petition other staff for special accommodations for the patient in question.
The "splitting" inmate can identify those fault lines that exist between staff members and wiggle into them and increase the distance in the split. The more extreme examples of such patients are likely to be so-called "borderline personality disorders." It is hard to imagine more miserable people. They do not have a firmly founded sense of self. Their emotions can bounce around wildly and they often show self-destructive behaviors including cutting on themselves and head-banging. They may attach tightly to a staff member and will hurt themselves if they perceive the care-giver as abandoning him.
Borderline patients thrive on cracks between staff--divide and conquer I think it is. While staff is divided it will be hard to establish boundaries for the patient because the staff is unable to bring themselves to a place as a group where the boundaries can be defined. When viewing a staff that has recently become more dysfunctional, look for a borderline personality disorder patient. In the most severe cases,  the pathology cannot be readily "contained" or "held" by a single person. It will definitely take a village. In order to defeat treatment, the borderline patient will be working to destroy the cohesion necessary for the group to enforce the "no fly zone."
When you identify a difficult patient in the medical department, you are likely to find that the same individual is having problems dealing with custody staff and with his boss at work or his teacher at school. When such a patient is complaining about the inadequacy of care, it is often useful to assemble everyone involved in care, including mental health and custody when appropriate, physicians, nurses, and administration for medical. With all the disciplines there, the inmate is asked to explain the nature of his complaint and his proposal for solving the problem. Following that presentation, a free ranging discussion can follow. The medical department can provide information that has been culled from the previous visits and explain the current status quo and treatment plan.
A group approach provides multiple witnesses who can refute the borderline patient's own perception of the sequence of events and the boundaries of the treatment plan. Everyone is on the same page. It is less possible for the patient to make unchallenged claims about the treatment plan.

7. If you do your job correctly you will be sued. While it is hard for inmates to get much traction in malpractice suits, it is very easy for them to file lawsuits complaining about a violation of their constitutional rights against cruel and unusual punishment. In seven years in Maryland, I believe that I was sued more than 10 times. In four years in Nevada I was sued twice, both times by patients with severe mental illnesses. If you have practiced reasonable medical care, you will win your lawsuits if you can demonstrate consistent and reasonable responses to the inmate's complaints. One of the problems with being sued, is that you will be carrying this history around for the rest of your life. You will be notifying every state board and hospital where you apply for licensing or privileges in the future. This is one of the down sides of prison medicine.

8. Be quick to admit mistakes.  Inmates are probably better at detecting deception than any other population. The medical department will make mistakes. Look at the high medication error rates in free world hospitals and nursing homes. There will be frequent errors in prison as well. Most of them will be Medication Errors. Few will be of serious consequence--but they must be admitted and documented. As a part of the documentation, there should be a chronology that indicates that the information about the error has been passed back up the chain of command. 


As a medical director in Maryland, I took it upon myself to have a visit with inmates who had experienced a medication error. I handled it in a formal manner. "Mr. Smith I called you up here today to let you know that we are aware that an error occurred in your medical care. (dialog with patient about the nature of the error and the possible effect and what you are doing to try to make sure that it doesn't happen again.) "
Then I would continue. "Mr. Smith, I wish to apologize on behalf of the medical department. Would you like me to put it in writing and send it to you, or can I just give it to you directly? "
Mostly they would accept an immediate verbal apology.
"Mr. Smith, on behalf of the entire medical department, I want to apologize for the error that we made. We will do everything in our power to make sure that it does not happen again."


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