Derelict 

My community opened a new hospital a while back. 

I live a few blocks from the old one. I chose this house for its proximity. For years I would crawl out of bed in the wee hours of the morning to go see a critical patient. I listened in the night for the helicopters and ambulance sirens, waiting for my pager to go off when I was on call. I remember the gentle sloping of the back hallway on the second floor, all of the nooks and crannies, smells, sounds. 

They are all ghosts now, as the building stands silent and empty.

I have a photography fetish. I love looking at photos of derelict, rotting buildings, imagining all of the lives that have passed through them, and I wish I were brave enough to trespass and take my own pictures. I imagine what this place will look like in a few years….

Birth. Death. Sickness and health. Love. Hate.

This building.

My son was born here. My mother got her new knees here. Who remembers these things but me? The walls do.

Those memories fade along with the building and it makes me sad. Or am I mistaking sadness for something else?

Nostalgia perhaps? 

A few decades from now there will be mold on the walls and ivy in the halls, and the place will crumble away just like me, becoming someone else’s fetish.

The Lost Dollars

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So there is this thing in the US that you may not have heard about. ACO’s, Accountable Care Organizations, are groups of physicians that have “joined together to provide high quality care” for Medicare patients. So says the CMS (Medicare) website.

What does this mean for patients?

Hell if I know. I don’t practice medicine any differently than I always have except that I find myself spending more and more of my time clicking the requisite buttons in the EHR (electronic health record) so patients get less of me. Quality care is quality care and should be given across the board to all patients no matter what bonus structure happens to be in place. I do have suits that come out and flash PowerPoint slides at me that tell how many of my patients ended up in the ER over the past quarter but I don’t pay attention. Frankly, I should not be making a decision whether or not a patient needs to go the ER based on what my “numbers” may or may not look like. 

What does that mean for physicians?

Supposedly, I get money every year that I can demonstrate that I provided savings to Medicare. If Medicare does not spend as much money but patients still get their colonoscopies and whatever else done (I have no idea how that is supposed to work), then I get a share of the “savings.”

How big is that check?

It is not like winning the lottery, that is for sure. I resent the insinuation that I need to be paid extra to do the right thing, but that is beside the point.

The healthcare corporation I work for requires me to complete some…. tasks… before I get this check.

For instance, I have to attend quarterly regional meetings and log onto two separate websites each and every month. To be honest, none of the physicians I know look at anything on those websites. They log on and log off to get the credit. (Of note, I have asked why it has to be two websites. Why can’t it just be one? No one gives me an answer.)

All of this, if it actually improved patient care, would be fine. But it doesn’t. Not one bit. It turns physicians into cute puppies doing silly tricks for their next treat and I refuse to participate. 

By not participating, however, the corporation gets to keep that check. I might not care about that if I knew it was going to go to helping indigent patients get access to care or some other noble cause but I don’t have the foggiest idea what they plan to do with it…

Personally, I think it should go back to Medicare.

Drippy

pink flower with raindrops

This part of the country has endured oppressive humidity and temperatures in the mid to high 90’s for months. Even last week running was miserable, despite doing it in the dark of night. It took me an hour in the air conditioning to stop sweating. 

Then BOOM! 

Rain. A cool front. 

This morning the air has a bit of a nip to it. 

No matter what kind of awfulness is going on around us, this kind of weather is like a healing salve. The Earth has a way of going on without us, in spite of us. In the grand scheme of the universe we are tiny specks who have no sway over the orbits of the planets or the brightness of the stars. The seasons will change whether we want them to or not.

Life will go on.

How’s that for a sappy, drippy post-debate post? 😊

Pushing Buttons

“This is none of your business!”

“Ma’am, I am trying to explain your benefits to you so you understand why you have the balance of $32…”

“Shut the F* up! I’m not paying anything. And you, little man, what the hell is your problem?” She turned from the front desk woman she had been yelling at to the office manager who had come to address the commotion.

Admittedly, he is a bit on the short side but who belittles someone to their face because of their height?

He identified himself. “You sounded upset and I thought I would see if I could help.”

“F* off!” She grew redder in the face and threw a clipboard at the check in window. “I am going to report you, you bitch!” Her voice rose, full of venom. “I am going to report the whole lot of you!”

Everyone stared, silent. Shocked. Finally, she turned and stormed out.

Later that day, she called the complaint line and raised holy hell. My staff and office manager were left to defend themselves to the higher ups, as if they were the ones on trial.

We have had a rash of verbally abusive patients over the past couple of months. I am not there to witness the interactions, but I do get to hear about them later in great detail. It is over silly stuff, like having to have a copy of the driver’s license of the person picking up a controlled substance prescription. 

Bullying. Almost daily. From new patients but also from people we have been seeing for years.

I realize that I talk about this sort of thing a lot. Healthcare is a tough field. You’ve got to have a thick skin or it will destroy you. Here’s the thing, though: I am used to these sorts of things happening from time to time, people are scared after all and there is nothing more frustrating than navigating the healthcare system, but I have never, in over twelve years of practicing medicine, ever witnessed the amount of abuse laid down over the past couple of months. I wonder why my staff even comes back every morning for another day of it. I am not sure we can ever pay them enough. The attacks are incredibly mean and ugly, more over the top than I am used to witnessing in past years. People are becoming more abusive, more hateful with each interaction and I don’t know where it is coming from.

If you work in healthcare, you are expected to maintain a perky and yet calm and meek facade at all times. We are to be patient, kind, respectful and never let our emotions show even in the midst of a brutal onslaught. If we crack, even just a little bit, suddenly the whole event becomes our fault. Let me tell you, that it is extremely difficult to maintain calm when you are getting beaten down every single day. I feel for my staff who absorb the brunt of it.

Why is this behavior even necessary? 

Is it a symptom of the political climate right now?

Verdun

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He fell to his knees, gasping for air.

A strange sensation at his fingers brought confusion and he glanced down at his hands. They were clutching a knife, his knife, sticky with blood. 

A dark crumpled form lay a few feet away, its face buried in the damp ground of the forest floor, deathly still. 

He tried to take longer breaths. He needed more air.

Shadows played tricks with his eyes in the twilight, making every tree seem a menace. Were they moving closer? 

Yes. Yes, they were.

He struggled to stand but found it was impossible as he still could not breathe. His chest felt as if it would explode. At the same time, all of his senses seemed to come alive. He could see things for what they really were. He could hear things he had never heard before. His hands and feet felt alive, somehow stronger. 

And yet, he still could not stand…

She had not really loved him. He knew that now.

A hike with his fiancé had seemed so romantic. A picnic lunch in the forest, in France. 

They had gotten lost.

She had belittled him. Told him he was stupid for getting them lost. She had taken the ring, his ring, and flung it into the trees. Then, the monster was there. It had devoured her. He had to save himself, didn’t he?

Oxygen. Where was the oxygen?!?!??!

His vision narrowed even as he could hear the leaves rustling in the trees overhead. The ground came up to meet him. He tried to claw his way forward before everything went black.

He woke in a room. Beeping. Something in his throat, pushing air into his lungs. A hospital? He tried to sit up only to find his wrists restrained. Panic set in. 

He had to get free!

There was a uniformed guard posted at the doorway, “for his own safety” he was told by the nurse who spoke remarkably good English. She tried to calm him down.

There would be an inquest, she said as she fiddled with an IV drip of cloudy white liquid that hung at his bedside.

He struggled to stay focused, alert, but drifted back into blackness anyway.

Days later, he awoke again. The ventilator was gone and the stream of visitors began. Gendarmes with heavy accents demanded to know why he was in the red zone. 

What red zone?

THE RED ZONE. Restricted because of the left over unexploded munitions left from World War I. He was lucky to be alive. Or so they said. Phosgene gas escapes from time to time from corroded shells. You can’t smell it. Not until you are already dead, they said.

Then they asked why he had killed his girlfriend. Stabbed dozens of times with his knife, the knife they had found in his hand. 

The crumpled body. The monster? 

It was her….?

He wished he actually were dead. A few days later he was able to get his hands on something sharp. They found him in a pool of his own blood, a crumpled body on the floor. 

Another casually of the war to end all wars, a hundred years later.

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This post was brought to you by this article thanks to C. S. Boyack’s Idea Mill

Unkempt

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“Um, Doc, I can’t do that.” A look of horror crossed her face.

“You are here for your physical, right?” I checked the schedule again to make sure I was not hallucinating. Then, I double checked her preventive care, just in case. She was indeed due.

“Well. I wasn’t expecting to have to do… that.

“Technically, I can’t force you to do anything. It IS your body, after all.” I shrugged, trying to use my body language to convey that I was not trying to pressure her. 

“It’s just,” she leaned forward and whispered, “I didn’t shave my legs.”

“Look, I haven’t shaved my legs in ages, either, so you have nothing to worry about.” I lifted a pants leg to show off a bit of scruffy ankle. “See? No judgement here!”

We both laughed.

She got her PAP done.

Torpedo

 “I thought you were engaged?” I had caught sight of her bare finger.

“Yeah. Well. Not anymore.” She gave a noncommittal shrug. 

“Oh, no! I am so sorry.” I searched her face looking for clues as to whether this was a good thing or a bad thing. 

She smiled. 

I felt relieved.

“Honestly, I feel like I dodged a bullet, Doc.” She stared at me for a second gauging wether or not she should share the rest of the story, then shrugged again. “One day he tells me that he has sworn off carbs. No more bread, rice, pasta, potatoes. He gets mad if I cook anything with carbs.” She laughed. “I have always made bread. From scratch. Fresh homemade pesto for my pasta. Roasted herbed potatoes. I love carbs, for crying out loud! So I wait, thinking this is just a phase. Months pass. He makes comments about how much weight I will lose if I just give up those carbs.” She laughed again. “Then I realize, this isn’t about the carbs. It isn’t about him. It’s about me. He thinks I’m too fat!” 

“Ouch.” I could feel the sting of that realization. 

A torpedo to the heart. 

She nodded. “After I sat down and thought about it for a bit, I could not imagine giving up carbs. Not for him, anyway. I would rather be a bit more… voluptuous… and happy with my carbs, than skinny and starved for love with him.”

Amen.

Leaning to the Left

Chicago skyline from a boat in Lake Michigan

“They denied it again.”

“WHAT?”

I had, no joke, completed various permutations of that paperwork half a dozen times and I was done. DONE, I tell you. The faxed rejection notice included two pages of suggested changes to be completed before resubmission, all things I had already taken care of.

Four months of this back and forth. I was trying to get diapers, pads, wipes, and barrier skin cream for a patient with cerebral palsy via Medicaid.

Initially, I had completed the form just as I had for years. However, I found through subsequent denials that I could not use just cerebral palsy as the diagnosis code. Nor could I just use the code for incontenance or neurogenic bladder. I had to use ALL of them together. But that was still denied.

Then I wrote a letter of medical necessity, as Medicaid said the paperwork forms were not enough. The letter I wrote said, “This patient has cerebral palsy and incontenance and needs diapers, pads, wipes, and skin cream.” Seriously, it was exactly the same thing the forms themselves conveyed, only I wrote it in sentence format on a letterhead.

After the letter, they said they would cover everything except the skin cream. 

Take a guess why.

Because I had to say the skin cream was to be used as a barrier.

I rewrote the letter, adding the phrase “for barrier to prevent skin breakdown” after the skin cream mention.

Finally, it was approved. 

Two months later everything had expired. So I meticulously rewrote the forms and the letter with the exact same codes and phraseology. I even placed the periods and signature flourishes in exactly the same places.

It was denied.

You know what? I will play whatever damn game they want me to play but I need to know the rules. Changing the rules randomly without warning and without explanation is absurd. Sure, it wastes my time, but the real issue here is the patient needs the covered supplies and the state is doing its darndest to make sure that doesn’t happen. Not on their dime, at least.

These are the games we play.

Meanwhile, skin breakdown and ulcerations….

Kerfe at Method Two Madness asked, “Do you have a solution for remaking the way medicine is practiced in the United States? I know our politicians don’t consult either doctors or patients when they write their laws. But let’s pretend they will listen and do the right thing…what would you suggest?”

My list of biggest desires is this:

1. A simple EHR and an end to the litany of stupid ways that I have to prove to the government that I am using it *wisely* or demonstrating that I am providing a “patient centered medical home” or any other inane acronym/phrase they come up with.

2. No more silly game changes like the paperwork situation above. There would be a simple rule book that does not change on someone’s whim without notice.

3. Controls on the costs of medications.

4. Universal healthcare coverage that is shared by all politicians. This scares me because I have seen the government muck up almost everything it gets its hands on and healthcare is too important to screw up any more than it already is, but I don’t know how else to do it. I have watched as even people with insurance cannot afford needed care with the high deductible plans now provided by employers. It is a sad state of affairs.

5. A salary cap for healthcare, insurance, and pharmaceutical company CEOs.

6. Better security for the IT part of healthcare. I have read that stealing healthcare data is much more valuable than stealing a credit card number. I don’t doubt it. We have rushed into the technology without adequate safeguards. 

To be honest, though, I am probably the last person who should be fixing things. I have very little knowledge in the areas of politics, policy, and government finance. If you relied on me to take care of things, we would probably have a collapse of our economy…