Ken and Barbie

Influence. Is that a negative or positive word? I guess it depends on who is influencing whom, huh? But when it comes to the relationship between Doctors and Pharma reps I’m watching a huge pendulum swing and it is not a good time in to be a Pharma rep.

So for background on the history of this relationship we need to visit LifeAfterDx University (LADU) for Under the Influence 101.

Once upon a time, not so long ago, but before I was in the industry (damnit), the reps showered the medicine decision makers with box seats, first class junkets to tropical destinations, gold-plated golf tees, and call-girls. Things got so out of hand the Feds stepped in a now any Pharma “gift” must be usable in the office. Thus the ubiquitous Pharma pen. And sticky notes. Sometimes clocks, business card holders, and anatomical models (my personal favorite, now that there are no call-girls). It’s fun to watch them try to think outside the box but inside the law. The first place award goes to Novo for their NovoLog “cheetah” computer wrist rest. It’s an orange cheetah-shaped gel-filled critter with little miniature flex pens floating around inside of it.

But a new trend is sweeping the industry. Pharma-free. Many practices are closing their doors to the Ken and Bardies.

I actually had a rep break down in tears in my office as she told me how rudely, no…cruelly, she had been treated up in Taos—our state’s epicenter for the anti-pharma movement. Signs in the lobby proudly proclaimed the practice to be free of all influence. The receptionist threatened to call the cops on the rep. But please drop off some samples while the door hits you in the ass.

Ban or don’t ban. But it seems unfair to try to play it both ways.

I’ll admit to having a conflicted relationship with the reps. If we take Time Tunnel back to my pre-dx days (not that long ago in dog years, but it seems like five lifetimes ago to me with the 24-7-365 nature of Type-1 diabetes) I can remember waiting in my primary care doc’s office. And waiting. And waiting. And waiting. And…

My appointment was at 9am. It is now 11:44. Boy am I pissed. Then click, click, click, click, click on her high-heals comes Barbie. Blonde, busty, blue-eyed, beautiful MBA Barbie with her little rolling suitcase of samples and woooooooooosh, in the door she goes to meet with my doctor while I’m cooling my heals in the waiting room.

I really hate her guts.

At first.

Then, surprise! I got diabetes. WFT?

And I was given a glucometer. A free glucometer. A sexy, small, cool meter. And a bunch of strips. And some free pills (oops, well, I was miss-dx’d as a T-2 for a very short while). All “gifts” from Barbie’s visit.

Then I spent almost a year not paying for insulin as assorted doctors, specialists, and educators loaded me up with “samples.”

Well, now, this is benefiting me.

Then I end up on the receiving end of Barbie’s visit. I admit, I’m a sucker for all the cool little gadgets they bring. And I love having samples for my patient’s. There is no retail pharmacy in our town. We’ve got a small one at the clinic—cash pay for uninsured, but we don’t take insurance there (as a side note, many “insured” patients are now required to make such obscene co-pays that it is cheaper to pay out-of-pocket at our non-profit pharmacy).

So my patient’s with insurance sometimes only get to a pharmacy once a month when they load up three generations in the truck for the Sam’s Club run. Samples keep them going from med-start to monthly Sam’s run. For my really poor patients, samples keep them alive while the patient assistance paperwork crawls through the system.

And having a pretty girl flirt with me doesn’t damage my ego too much either.

But do the sticky notes, samples, pens and flirting affect my decision making?

Absolutely not. Well…..that’s not true, come to think of it.

Back before the BIG SCARE, when I recommended that we start a patient on a TZD I always selected Avandia over Actos. They both reportedly work much the same. Actos should have been a better clinical choice as it has a mild lipid-lowering side effect. But we always started Avandia instead. Why? Because we had samples in-house. The Actos rep couldn’t be bothered to call on us. We had two similar drugs to choose from and samples for one of the two. So that became our default.

For what it is worth after the BIG SCARE we dropped Avandia and switched patients wholesale to Actos which isn’t worth a shit (compared to Avandia) for lowering BGLs. Sigh………..

But will wineing and dining and bribing medicine decision makers really effect their decision for what’s best for the patient? I hope not. But clearly the big pharma companies think so.

So it was both the possibility and the appearance of influence that started the Pharma-Free movement.

Now you have to meet K. She’s young, bright, pretty. She looks like a pharma rep, but not in this lifetime. She’s a baby doctor. No, not a doctor who delivers babies, a doctor in training and if she wasn’t so dedicated to medicine you’d probably want to strangle her for just being so perky and perfect. She’s doing “locums” with us—basically exposure to the real world. She’s my shadow one day per week to learn about diabetes, diabetes meds, diabetes gear, diabetes treatments, diabetes care. I enjoyed her company immensely. And not because she is pretty and perky. I love her for her mind.

OK, we’re going to start this patient on Glucophage.

K: what’s it’s chemical name?

Metformin.

K: what does it do?

It holds back nocturnal hepatic release of glucose.

K: what’s its method of action? What’s the pharmacology? What’s….

She peals back every layer of my knowledge non-stop like she’s pealing an onion. Until finally, like a parent saying “because I said so” I have reached the limit of my knowledge, and her thirst unquenched, I have to resort to Just Google it.

Anyway, being young and idealistic, she questioned my relationship with the pharma reps. And told me her teaching hospital was Pharma-free. They even have stickers they put over the pharma pens to cover the logos.

Wow.

I love my pens. Especially the one with the laser pointer, flash light, tablet stylus and two colors of ink.

So I laid out my self-justifying why-we-need-Ken-and-Barbie arguments.

Which she shot down like Robin Hood at the archery tournament. I first allowed as how I did think the “ask you Doctor about…” TV ads should be banned. No, no, no. You don’t ask your doctor if an Rx is right for you. You tell your doctor where it hurts and its his (her) job to figure out what’s wrong.

But I wasn’t ready to close the door in Barbie’s face. Not yet.

K fenced with me off and on throughout the day and the next day on my drive to work her arguments finally worked their way through my thick skull and into my tangled, miserable, overworked brain.

Damn. You know she’s right, Wil. We really shouldn’t be taking samples and goodies from the makers of meds. We should be sitting in medical school libraries carefully comparing the scientific data and balancing the actions, side effects, and interactions of competing medications using evidence-based data.

At least in the perfect world. The world we don’t live in.

I arrive at my office, blow my nose on a Byetta kleenex, sanitize my hands with Zetia alcohol gel, glance at the time on my NovoLog clock, sit down and move my Merck paperweight out of the way, pick up my Lipitor pen and jot my self a note an a Lantus sticky note pad. Nope. No influence in my world.

So like so many other things in medicine I find myself splashing around in grey water.
At least in rural health we find ourselves in a symbiotic relationship with the pharma reps. I’m not sure who is the parasite and who is the host. But they need us and, for now, we need them. They need sales. We need samples. Ultimately the patient wins.

I hear some groans from the audience. So meet Jose, age 57. He is a plasterer—a tradesman who hangs wire on the outside of a New Mexico house, then coats it with a cement-like substance. His employment is seasonal. He’s Type-2 on basal insulin and orals. He’s also on a statin for lipids and today his blood pressure is 167/98. Hypertension generally takes more than one med to control properly. Oh, did I mention his average monthly income is $728? He has no insurance.

Jose will almost certainly qualify for Patient Assistance from the drug makers. But it will take 6 to 8 weeks by which time there is a good chance he will have had a stroke. With samples he can be medicated today, right now, while we sort it all out and get him the help he needs.

When K came in that morning with her stethoscope and Starbucks I challenged her: how do you choose the best medicine for your patient?

And she gave me the text book answer, to which I told her: Wrong. You give the patient NOT the medicine that is best for their condition, you give the patient the medication they can afford. The one you can get. The one that WILL DO today.

And so, the door is unlocked and click, click, click, click, click on her high-heals comes Barbie. Welcome home. Did you bring me a pen?

Bones

Debbie, Rio, and I have a pet skeleton. That sounds kinda weird, doesn’t it?

Well, here is how it happened. Once upon a time my clinic had an award winning school-based clinic at the local high school. This worked great for everyone until a bunch of conservative religious nut-cases took over the school board.

Now remember, we in health care tend to be liberal. I don’t want to insult anyone who feels otherwise, and I personally respect all view points. But when it comes to children’s health I strongly believe we need to do what is necessary to protect it.

And that means if a 13-year-old girl asks a school nurse for condoms, I think we should give them to her and be grateful she asked.

Others disagree. Others believe that if you give out condoms, kids will run out and have sex. These others believe we should only council abstinence. To keep our federal funding our nurses are actually required to council the “A-B-Cs” to any one who comes in on any kind of heath visit that involves anything remotely connected to sex. “A” is for Abstinence, “B” is for Be faithful, and “C” is actually (surprisingly) for Condoms. It has to be done in that order. I hear nurses saying, the federal government requires me to tell you…So the message from the Feds is: don’t have sex, and don’t have sex with only your wife/husband, and be sure to wear a condom when you aren’t having sex with only your wife or husband.

I need a drink.

Actually I have no problem with counseling abstinence. But I still think you should provide condoms, and make young people aware of them. They are cheaper than teen pregnancies. Cheaper than STDs. Condoms save lives, in more ways than one.

Anyway, we got kicked out of the school shortly before I started at the clinic. Then I walked past my bosses’ door at just the wrong time. You see, we had a couple of thousand dollars of grant money that had to be spent or returned. “How would you spend a couple grand on diabetes and children in the school?” she asked me. And without thinking too much I blithefully said I’d finger stick every kid in the school system.

“Do it.”

I had no idea what a can of worms I had just opened. A finger stick, which we all take for granted as a simple daily part of life is technically an invasive medical test.

What followed was months and months of attending school board meetings, PTA meetings, meeting with parents. It actually took me nine months to give birth to this little project, which is kinda ironic when you think about the genesis of the funds for it.

But in the Spring of 2007, right before the end of school, we did finger sticks on all kids from the fifth grade through the 12th. We also did BMIs and blood pressures. And the results scared the hell out of everyone and were far worse than I had ever imagined in my wildest nightmares.

I won’t even depress you with the numbers, but the assistant superintendent of the schools came to me and asked, “what can we do?”

And I replied, Change society as we know it. To which she said:

“Do it.”

I really gotta learn to keep my mouth shut. So over this last year we’ve put together a health education program that will be taught in the schools by clinic staff. At first it was just going to be healthy eating and exercise and the like. Soon, however, it became apparent that this information in a vacuum was worthless and it evolved into a broader based understand-your-body-understand-your-health program that would cover life, the universe inside of us, and everything.

As we had significantly elevated blood sugars and pressures in 5th graders we decided we had to go to the source of the Nile. We’d start with the pre-K kids. Next, looking at our resources we decided it was “too late” to change the older kids. Coldly, cruelly, we’d write them off and try to save the next generation. Our program rolls out pre-K through 5th grade only.

I hope to add one grade per year. I child in pre-K this year will see clinic staff a couple times a month through high-school graduation and we’ll have no idea if this worked until… oh… after I’m dead.

Next I knew we had to make learning fun. So I went on a quest for cool visual aids to make health and the human body fun, which it is. And I had to make it age appropriate. One of the things I bought (on eBay, of course) was a pygmy skeleton. Don’t freak out. It isn’t a real pygmy. Or even a real skeleton. It is a “Mr. Thrifty” skeleton made by Anatomical Chart Company. Very real, very detailed, about a yard tall. Same size as most pre-K kiddos.

I bought it used from some guy who was also selling a leaf blower, a Dallas Cowboys sweat shirt, and a set of unused dishes that probably came from his mother for Christmas and were detested by his wife. The skeleton was labeled as used, excellent condition, with original box. I love ACC, but this would cost me less than half of what a new one would set me back, and that would give me more money for other stuff. I hit the Buy It Now button and paid for it from my PayPal account. I planned to submit the receipt for reimbursement later. That, as it turned out, would never happen.

The skeleton arrived the next week. In great shape, in the original box, as advertised. I pulled him out, annoying little bits of Styrofoam floating everywhere. I attached his legs and set him on one of the library chairs while I put the stand together.

His head flopped to one side. On inspection something wasn’t…..right….about his neck. I got the sneaking suspicion that my new educational, scientific, highly accurate pygmy skeleton was hung by the neck until dead as a Halloween decoration.

After several failed experiments, Dr. Lee fixed the patient’s neck by stuffing some of the aforementioned foam peanuts between the mandible and the cervical vertebrae (think throat). He looked kind cute on the chair, so I crossed one foot over the other and put his hands behind his head.

He was a big hit with Debbie and Rio; who has an unusual interest in, and an extraordinary knowledge of, human anatomy—no doubt a legacy of having a father with a chronic illness. In discussing visual aids for the kindergarten my boss said, “You know Rio’s not a normal kindergartener, are you sure that normal children will be interested in this?” Granted, probably most kindergartners don’t know where there liver is and what it does; much less be able to properly identify all the major organ systems in the body, but I think all kids are interested in what’s under the skin.

The next day I found the skeleton calmly smoking a “cigarette” in the form of a kitchen match, one knee up, one hand on his hip, the other arm resting on the chair’s arm rest.

Last night, when straightening out the house I set him up like this:

I wouldn’t be surprised to find him watching TV in the living room sometime next week.

“What’d this little guy set you back?” asked Deb.

Oh…I don’t remember exactly, twenty or twenty-five bucks. About half what Anatomical wants for them new.

“Don’t submit the receipt for a little while,” she said.

About two weeks later I said to her, the pygmy skeleton is never going to see the light of day at my office, is it?

“I don’t think so,” she said.

Well, then we’d better name it.

Now I don’t know if it is male or female. Physical anthropologists and skeletonologists and probably even my medical director could take one look at the pelvis and tell me; but it is hardly worth the effort. Depending on the pose it can look quite feminine or quite masculine. We needed a gender neutral name.

After considering Addison, Devon, Jaime, Logan, Riley, and Tyler, we settled on the obvious: with apologies to Gene Roddenberry and DeForest Kelly we named our pet skeleton Bones.

Scoping out addiction

I creep quietly out of my bedroom. The moon has set, it is pitch dark outside. The wife is fast asleep. I slip through the living room, cocking one ear to hear Rio’s rhythmic breathing from the couch. Yeah, the punk thinks the living room is his bedroom. Some battles with a stubborn six-year-old will just never be won. As I tip-toe into the library, even the cat is sleeping. No one will catch me, that’s for sure.

I stealthily close the library doors. And lock them. Then I boot up the computer. The light from the giant flat screen the only illumination. The flickering light like a campfire for the cranium. I enter the URL from memory, no shortcuts to give me away. My heart pounding in my chest, I type in my user name (TRULY) and my password (ADICTED).

My hands quivering, I begin to search through the images, all but drooling.

Oh yeah! Oh-my-God she’s beautiful! Look at those lines, those curves. That’s pure art! Oh baby, I really want to you.

But I need a 1945 Bausch & Lomb microscope like I need a hole in my head.

What? Ohhhhhh.......you thought I was surfing for porn, didn’t you? Nope, I’m not making a nocturnal visit to Naughty-Nurses; I’m on eBay. My fiercest addiction.

I drink a little red wine.

I smoke a pipe.

I like expensive coffee.

I swear.

But I don’t cheat on my wife, do recreational drugs, or even speed on the interstate. I’m pretty square, actually. But God help me if I spend time on eBay.

I’ve bought pipes. That’s semi-justifiable as it is one of my few vices and I actually use them. But I’ve got, like, forty of them. But I’ve also bought:

A piece of a meteorite (But babe, this thing was in space! Never mind the whole planet is…). A brass sextant (I don’t even use GPS). A statue of a busty mermaid (It matches the sailing ship bookends my assistant gave me for my birthday). A leather map of the world made by an artist in Argentina (It’ll help Rio learn the continents and countries of the world). A real Pit Viper skeleton (It….well, OK I have no justification for the snake skeleton, but having been banned from the house by you-know-who, it is actually the second most popular attraction in my office. The first most popular is every glucose meter made, plus a bunch of “antiques,” attached to my door with industrial-strength Velcro.)

I guess I was sort of aware of the fact I had a problem. I just didn’t want to face it. I used to check the AP news headlines on Yahoo over morning coffee and yogurt. Then I found myself checking eBay instead. I wonder if anyone listed an Orvis Ranger Jacket on eBay today? I used to read D-blogs at lunchtime; but you know there is always a chance that someone listed an antique telephone. When I came home from work I used to double check personal email but I really need a pancreas coffee cup. Got it all, except the jacket. So if you got one in green, either medium or large, that needs a good home…..

Like I said, I was sort of aware I had a problem, but I didn’t really quite accept the fact that I’m a sick man. Not until the microscope. I was looking for a antique brass microscope. Why? Beats the hell out of me. I’m real good about divining what drives others, but clueless when it comes to understanding my own erratic behavior. I’m guessing that on my genome the gene that controls shopping restraint (GGATCAA) mutated in me to (EBAYSEX). Go figure.

So microscopes. I guess I had decided I needed a microscope in my office for decoration. I’m not really that into microbiology. But it would look right in my mad-scientist lair, and like wearing a stethoscope when you don’t really need to, it might make me look smarter than I really am. (Look dear, he has a microscope, we’d better listen to him.)

Well, as it turns out, brass microscopes go for a lot of money and I’m chronically broke because I have a chronic illness, a chronic 120 mile daily commute, and I work for a non-profit. Oh, yeah, and that whole eBay thing might possibly have some detrimental effect on the family budget, but I doubt it.

But then, because I didn’t have $450 or more to spend on a brass microscope, and because on further thought my office really isn’t Victorian in flavor, it occurred to me to search for vintage microscopes. In eBay speak, vintage generally means not old enough to be antique but too old to be useful. Just like me! Maybe I should get a T-shirt that says “Vintage Diabetic.”

I digress.

You would not fucking believe how many microscopes there are on eBay. I’d go check right now and get you the exact number but I’m on this cold-turkey quitting thing…more on that later. You’ll have to check for yourself. I never knew there were so many brands and models. And the shear volume is impressive given that most people never look into one after high school.

So here is what I learned about the aesthetic history of the microscope: in the late 1800s they are made of brass, are tall and lean. Sexy in a primeval way. Sometime between 1900 and 1920 they evolve into the object we all picture when some one says “microscope.” Then, like Neanderthals, their evolution stops. Oh, sure, later we get microscopes that have two eye pieces. And some have multi-lens turrets. But if it’s not an electron microscope, the one in the Gilbert Chemistry set looks pretty much like the one at Harvard Med School.

Except, that is, the 1945 Bausch & Lomb that I stumbled onto. Actually the seller didn’t know it was from ’45. The seller didn’t know for sure, but thought 1910-1930. Looking at it, that would have been a good guess. It is post-modern-art-deco-what-we-thought-the-futre-would-look-like-back-then. She was black and satin-chrome. Lots of satin-chrome. I’d never seen a microscope with so many wonderful knobs. The head was a graceful rounded-edge rectangle rather than a tube. The curves were elegant. The piece de resistance was the azimuth. On the base were the slides go is a rotating silver disc, precisely machined with 360 degrees of numbers.

Excuse me for a minute while I wipe the drool off the key board.

I had never seen anything like it. I spent hours searching both eBay and the world-wide web and found nothing else like it, even at websites dedicated to the history of Bausch & Lomb. I tracked down the 1945 date from an obscure PDF that detailed how to interpret B&L serial numbers. The rotating base suggests it may have been a geology microscope, but I’m not sure.

All I knew was that I had to have it, and I even had the perfect spot for it in my office.


It was around $150 when I found it. Then followed the longest six days of my life. I placed a “snipe” at a level I figured would be high enough to secure it for me. And then to auction began to escalate. And I increased my snipe. Again. And again. And again.

I was a nervous wreck. I was grinding my teeth at night. I wasn’t sleeping well. I wanted it, but I knew it was getting beyond my ability to pay for. Logic and desire, the fire and water of the soul, collided.

On the last day of the auction I checked on it every hour between patients. The price stood steady until the last three hours. Then the battle began in earnest. Two hours to go. It is a dark and stormy evening. Rain is pounding on the roof of my modular office as the last patient leaves and dashes for safety. The window next to my office leaks and water is splashing drip-drip-drip into the three coffee cups I keep on the widow sill to catch rain water coming in. And I have a moral dilemma on my hands.

The damn thing is already at $358 dollars. Waaaaaaay more than I can afford. But it is only money. But the phone bill is overdue again. But you’ll regret it forever if you don’t get it. But the cars need tune ups. But you can’t even find another picture on Google Images of this model. But….

I do the responsible adult thing and cancel my eSnipe. Then I reinstate it. Then I cancel it. Then I put in a lot larger number. Then I collapse into a pile of Jell-O. This auction will end on my way home from work. While I’m on the road. I need to make my final decision before I head out, and then leave it in the hands of the gods. About to have a stroke, or an aneurism, or both, I do what any sensible man does: I called my wife.

Who went through the roof.

After the are-you-out-of-your-fucking-mind rant, and the list of bills unpaid and upcoming, and all the stuff-she-wants-and-doesn’t-have speech; she relented. With conditions. OK, says my most responsible mate, if that’s what you really want I will stand with you on it. But….(there’s always a ‘but,’ right?)…if you win you need to sell some of this other crap you’ve won on eBay until you replace the money you spend to win it.

Like any good heroin addict, I know a good deal when I see one. We agree on $430.99 as the max, I place the snipe, shut down my computer, lock my office, and dash through the rain to my car.

I drive home with my cell phone on my knee, radio turned off to make sure I can hear it ring. Deb will check the auction after it ends and call me.

I’m tempted to call her and have her cancel the snipe. I’m tempted to call her and have her increase it to a thousand dollars. How rare is this thing, anyway? Does rare also mean collectable? I’m suffering from proactive buyer’s remorse and losers regret simultaneously and it isn’t even over yet. I hope I win. I hope I lose. But, damn-it, I hope I don’t lose by a buck. If I’m going to lose I hope that fucker goes for $5,000 bucks.

I really hope I win….

I’m a nervous wreck. And all the sudden I realize I have a real problem. Driving home in the rain, with the radio off, and my cell phone on my knee, I start trying to understand myself. With no luck. What drives this unquenchable desire to own stuff? I start thinking about my patients. I got one guy who is addicted to the home shopping channel. He’ll buy synthetic gem stones (it’s an investment…the lady on the phone said I’d double my money before the package arrives) instead of firewood. I’ve got others who don’t “have money” for their blood pressure pills but have money for a case of Budweiser every weekend. I’ve got crack-heads, alcoholics, heroin addicts, shop-a-holics, sex addicts…

Is there something about chronic illness that triggers addictive behavior? Is it in our genes? Or are we trying to patch the holes in our souls that being a living zombie creates? Are we compensating for our mortality or escaping our reality?

I don’t know. What about you? What’s your poison? Check in by comments.

And what happened with my most beautiful, make me look smart, decorate my office, microscope? I lost. Not by five thousand, not by ten bucks. I lost by $24.01. Crap. To someone who had only bought one item on eBay before.


While I was totally bummed that I did not get my microscope, I realized at the same time that I was totally out of control. It was time to stop. I had to get a hold of myself. I swore to myself I would not go to eBay for at least six months.

But the microscope loss was only the start of a really bad week. The next day I got more bad news (too long a story for now). I fell into a deep depression and to my shock discovered that surfing eBay was my depression-coping mechanism. When I get depressed I snoop around and distract my self. Oh look, a Roman coin with Claudius on it. So that’s what he looked like. For some reason I expected him to look like Derrick Jacobi. Go figure. Oh look, some one is selling a jet fighter plane. I wonder if he’ll get his $400,000 asking price?

Which is all good and fine, but I was looking and buying. So there I was on my lunch hour, depressed to the point of suicide, with no strategy to deal with it. But I was strong and did not go to eBay.

So no carbs. No spending. I’m trying to be happy with what I have. It’s not working yet, but I’m staying strong and I’m glad to free (for now) of my addiction.

But damn, I really wanted that microscope.

Robin Hood’s Evil Twin

Yes, I know it is pathetic. I’m a personal friend of Robin Hood’s evil twin, Robert Hood. He steals from the indigent and gives to the poor. How sad is that? Let me tell you the tale. Spoiler alert: no tights, no swords or bows and arrows, and most definitely no merry men.

To set the stage for our drama you need to understand that except when it comes to your BGLs; you really don’t want to be in the middle.

If you are truly, pathetically, abjectly poor—what we call indigent in the medical world—then you will actually get damn good health care. You’ll probably get Medicaid, which is arguably superior to the Medicare we give senior citizens who worked hard all their lives. Plus you’ll also qualify for Patient Assistant Programs, called PAP, from all the major Pharma companies. Because we got lots of poor people, hundreds of thousands of dollars of top tier name-brand drugs arrive via UPS at our little clinic every month.

If you are truly rich, well, then health care really isn’t an issue is it? You can afford the best insurance. And being rich you’ll probably have fewer health issues. Sad truth: the rich are healthy. They can afford to take care of things right away, they can afford proactive, preventive care.

Anywhere in the middle, you are probably screwed. No, not probably: definitely. Anywhere in the middle you are definitely screwed.

The worst spot to be in is working poor. You make $38 dollars per month (half tank of gas) too much to qualify for PAP, you don’t have insurance at all, and you can’t afford the drugs that would really make you healthy. We send you to Wal-Mart for $4 generics, but….

The next worst spot to be in is working poor with insurance. In theory you are covered, but deductibles, high co-pays, and tiered drug benefit plans literally make chronically ill patients choose between their health and keeping the lights on. I can’t tell you how many times I’ve have this conversation:

Me: OK, let me just review your meds with you real quick to make sure our records are up-to-date.

Working Poor Patient: OK.

Me: So we’ve got you on 45 units twice a day of Lantus, right?

WPP: Yep.

Me: Great, and you take Lipitor 40mg for your cholesterol, right?

WPP: Looooooooong silence. Patient is looking at his hands. Well………Um……..I haven’t been taking that for a while now.

Me: What?! Why the hell not? Of course, I know the answer that is coming.

WPP: I can’t afford it.

The first drugs the WPP’s drop are the ones with silent effect. In most cases, but not all, they’ll take their diabetes meds because even if they only check their BGLs every-once-and-while it doesn’t take long to see the effect that skipping your D-meds has on your body. But most folks, especially WPPs who can’t afford to pay for lab tests out-of-pocket, don’t check their lipids as often as they need to. The WPPs are also quick to drop their high blood pressure pills. It is easy to rationalize a high blood pressure: I just had a cup of coffee, my kid’s in jail, my wife left me for my brother (all real things real patients have told me).

Trivia question: what kills diabetics? If you said diabetes you are wrong and must now go sit in the back of the class. Unless you were sitting in the back to start with, in which case you must now sit in the front row. The correct answer is: heart attack. And the best way to keep that pale horse at bay is to keep your cholesterol and blood pressure down. I’ll bet you worry about what high blood sugar does to your kidneys, huh? Did you know that high blood pressure can actually be more damaging?

Let’s face it, the cards are stacked against us D-folk to start with, anything we can do to keep the rest of the body healthy in money in the bank. But life with out electricity and heat at 7,000 above sea level in the New Mexico mountains sucks too.

So back to Robert Hood (the evil twin). He’s my counter-part at a neighboring community health center. We are a lot a like, except that I’m older and a lot more handsome. Over coffee and idea trading recently he told me he was getting comfortable living in ethical gray areas. It started with an honest mistake. In filling out some insulin PAP paperwork for a patient that would need nine pens for a three month period he checked off nine boxes of pens. The UPS driver dutifully brought forty-five insulin pens: 36 more than the patient needed.

Robert hesitated about 1.6 seconds and dove into the grey water. He re-distributed the extra pens to his WPP folks. I’m guessing he’ll check the wrong box when he renews. And maybe on a few other patients too.

I haven’t gone that far. Not yet. Not ever. Damn this moral compass! But my boss once threatened to create “fake” patients to get the meds to real ones that need it but can’t get them. Of course, he was just venting. If he did that he’d lose his license and be publicly executed by hanging, no doubt.

Now I have to take a detour here and tell you about the pinto beans. My mother-in-law gets “commodities,” a food program for low income seniors. They get a variety of food stuffs each month, including one pound bags of pinto beans. Pinto beans in New Mexico are the same a rice in China: a ubiquitous staple. Quality pintos are pale tan. One of my jobs as spouse-of-Hispanic is to “clean” the pintos; a kitchen table sorting process whereby I scoop the good ones into the pressure cooker and discard the rocks, broken beans, and dark ones.

The commodities program was giving out bags of dark beans. My mother-in-law would not use them. Each month she put them in her pantry. The pile grew until there were 14 bags of these dark beans. She was afraid to throw them out because the local rumor had it that the authorities were keeping an eye on the dumpsters and that if people were throwing items away the government would stop giving stuff out. Hmmmmmmmm…one hopes the government has better things to do, but one never knows.

One day, after hearing her discuss various schemes to rid herself of the beans, I loaded them up and took them to my office to see if anyone would want them. Sure enough, we had folks who were hungry enough not to care that the pintos were technically sub-standard. By end of day one the beans were gone. Well one thing lead to another, word gets around a small town, and pretty soon my office was doubling as a unofficial, unapproved, uncertified, and probably illegal commodity re-distribution center.

Amongst our glucometers we now have cans of juice, bags of creamed wheat, boxes of pasta. Patients bring what they don’t want or use and take what they need. The needy helping the needier.

So Robert and I both work in an impossible world. Diabetes and obesity costs our state a million dollars a day but we failed to get a crappy one million dollars from the state legislature to run the state’s diabetes control and prevention program for an entire year. Don’t you think that investing 1/365 of the cost of a problem in preventing it is a good investment? Our national lepers….err….leaders…. espouse a “culture of life” while they let large corporations rape and pillage the populace. Greed rules the health care system, patients simply don’t count. We are at the edge of the tsunami that is the diabetes epidemic and not only do we not have any oars; the life boat is full of holes.

So I understand what Robert is doing. I applaud him, even admire him and I secretly wish I had the balls to do what he’s doing… but I’m too much of a boy scout to join the Hood brothers. As well as being a chicken and a sissy.

I stress out every day. I worry about my patients. It pains me to know what meds they need but to know I can not get the right meds for them. I actually use to be happy that I was diabetic. I know that sounds crazy. But I felt it was some sort of calling, the hand of God if you will, and that now my life had purpose. Some days I still feel that way. But some days I don’t feel that way anymore. So much misery has worn me down. I long to put my head into the sand, hide my face behind a camera and pretend that I’d never heard the word diabetes. I live it 24-7. I read about it on the internet. I write about it. I talk to schools, parents, and lawmakers about it. I work it full time. I go to trainings in the evenings and my days off. There is no escape.

But after talking to Robert I began to wonder if what worked for pinto beans would work for insulin. As meds changed, and dosages changed, folks sometimes had left-overs. So long as it hasn’t been opened we can give it to someone else. I put the word on the street: bring me your unopened bottles, your sealed vials, your extra needles and lancets.

Then I got an email from a reader. Her T-1 kiddo had gotten a pump and they had some left-over Lantus and some supplies. Could I use them or could my patients? Absolutely. I don’t use it myself, but plenty of my patients do. I emailed her our address. I was expecting a vial or two. Wrong. I got a huge box with 16 vials of fresh insulin (already half now in the hands of those who need it) and a second carton of boxes of pen needles, lancets, and other goodies. Surplus from the insured helping the uninsured. Awesome.

Rather than add life of crime to my Maalox moments and general insomnia, another idea came to me, thanks to the pinto beans and my reader. What diabetic doesn’t have three boxes of D-stuff they don’t need anymore? So, dear readers, to keep me and all those like me from resorting to joining the Hood gang, if you’ve got extra D-goodies of any kind cluttering up your closets, call your local non-profit community health centers, they’ll get your goodies into the hands of those that need them the most.

I drink coffee with Hoods, but I guess I’m more at home working with the Peace Corps, the Red Cross, and all those other folks that find a way to spread resources around. Still, when my head hits the pillow at night I briefly fantasize that I am a highwayman, stopping Pfizer, Merck, and Amylin trucks with an Uzi, loading up their supplies and slipping back into the night…..