Emergencies 

Sunset reflected in a road puddle
“I want a wart removed this Friday”

“The doctor does not have any openings for a procedure this week. We are short staffed and she is completely booked. We can get you in on Monday if you like.”

“I am going on vacation next week. The doctor always accomodates me! You tell her I want to have this removed on Friday.”

I do try hard to get people in when they need it. But sometimes…

Honestly, it has been a rough week. 

With one of my partners out, our nurse practitioner out, AND it being the week before school starts back for many kids in the area… the clinic has been crazy. Finding time to blog/breathe/pee has been hard to come by.

“Fine! You tell her I am finding another doctor.”

It is like this every year. 

Next week it will be a ghost town around here but for now those emergency wart removals are killing us. 

Shopping Around

Macy's in New York City

“She doesn’t have physical exam coverage and her insurance only allows three office visits per year. No lab coverage. No preventive care coverage. She needs her blood pressure and diabetes meds refilled but she cannot come in for a physical.”

I’ve seen this a lot lately.

“No problem. Tell her to come in for a regular office visit so we can at least check her blood pressure. I will code a 99214 and she may get a 30% discount off that as a cash pay patient. I can send her to a discount laboratory for labs that will save her hundreds of dollars. In October she can get a $99 mammogram at one of the local imaging centers. Her flu vaccination she can get cheap at the health department. We will just have to postpone her PAP another year.”

So she came in….

Crying.

“I pay over $700 a month for this insurance.  I work for myself and with my diabetes no one will cover me otherwise. I can’t afford anything else. They told me that all of my doctors were covered and my meds were covered. They lied.”

She did not read the fine print. Not that she really had any other options available to her… 

It used to be like this ten years ago. People with expensive but essentially useless policies. Here we go again. Now, at least, I have access to a discount laboratory. 

Ruined

Ruins of hospital on Ellis Island

He came with her to all of her doctor’s appointments, more than an observer he was involved, concerned, present. He came off as her protector. I thought we were on the same team.

The alcohol was getting worse, though. So was her liver failure.

“Who buys all of the beer she drinks?”

“I do,” she spoke up. “And he does.” 

I glanced over at him.

“Sometimes she makes me.”

“Makes you how exactly?”

“She can get really ugly.” He looked away sheepishly, unable to meet my eye.

“You mean to tell me that all of this time that she has been going to her liver specialist appointments, all of this time that we have been talking about how she needs a complete and immediate cessation of alcohol, all of this time that you have sat in that chair and nodded your head in agreement, you have actually been providing her with the substance that is killing her?”

I wanted to scream at him. What the hell are you doing? Sabotaging her? Murdering her? WTH?

But I don’t know what their life together has been like. Is he the equivalent to a battered woman in an abusive relationship? 

I just don’t know.

So I suggest counseling, giving them contact information for treatment centers, and usher them out the door wondering all the while if I have somehow failed them both.

Dread 

Morgue at Ellis Island hospital

I dread going back to work after being off for a vacation, even if it was only for a few days. 

I know, I know. I’m not alone, am I? 

The thing is, I never know what my in basket is going to look like. After a regular weekend I can walk in to find 50-70 items on my virtual EHR (electronic health record) desktop. After a week of vacation it may be 150 or more. 

Please God, let it be manageable!!!!

When one of my partners is off, it is a full on life/death struggle to keep my head above water and I am certain they have experienced the same frantic craziness trying to keep up with my stuff while I’m out. 

Patients get crabby when their physician is gone and there will invariably be several fires to put out. Did the clinic roof leak again? Did my office manager actually reschedule the patients that I saw were on my schedule last Monday? Did that woman’s MRI get done? What did it show? 

It was not enough that I worried about everything all week. Oh, no. Now I have to face up to it in the morning.

Gah.

I won’t be sleeping well tonight.

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The photo above is what is left of the morgue inside the ruins of the hospital on Ellis Island. It was a teaching hospital so autopsies were done in this theater. On the left is where the bodies where stored. I took the hard hat tour and got some really great images. I wish I could have gotten to see some of the upper floors, like where the ORs were. Maybe someday…. 

Recognizing Patterns

“I did an internet search for my symptoms and after doing a bunch of reading, this is what I think I have….” She pulled a sheaf of papers from her large purse and passed them over to me. 

Erythromelalgia.

I scanned through it quickly.

It wasn’t anything I had ever heard of before, but then her symptoms were not something that I recognized either. Hands that turned red and burned like they were on fire. They got better when she raised them up overhead or ran them under cold water. It had been going on for years. The pain was excruciating and now occurred at a more frenzied rate to the point she was afraid to leave her house.

“I think you might be right,” I told her. 

Now, if I were honest with you and with myself, I would admit that my pride didn’t want her to be right. I wanted to be the hero. I wanted to be the one with the answers, not her and certainly not Dr. Google, but here we were anyway. 

We did bloodwork to make sure it was not caused by something more serious and she started aspirin. Like magic, the pain was gone. Somehow, she still considered me her hero even after I told her I probably never would have figured it out on my own…

Several months later, a new patient showed up in my clinic telling me of the pain she was experiencing in her hands and feet. The pain came and went with no rhyme or reason. It burned terribly, kept her for doing things for fear it would appear.

“Do your hands and feet change colors?”

 “YES! They turn red and I have to elevate them or run them under cold water to get them to stop.” Over the years she saw half a dozen specialists and was diagnosed with all manner of things: Fibromyalgia. Anxiety disorder. Neuropathy. Malingering. 

She cried. She had clearly suffered and I suspect the implication that she was crazy was just as excruciating as the physical pain itself. 

This time I got to be the full on hero. “You are NOT crazy. What you are experiencing has a name and a treatment!”

And by golly, she got better.

I have patients who come in all of the time and say sheepishly, “I know I shouldn’t be reading online but…” 

But what if that first woman had not? 

Maybe I would have referred her to someone who could eventually figure it out. Maybe she would have ended up like the second patient spending years suffering, passed from one specialist to the the next, always told it was all in her head. Then when that second patient showed up, I wouldn’t have had an answer for her, either. 

Patients teach me new things every day, sometimes it is something simple… like keeping my pride in check so I can actually hear what patients are saying.

Fulfilling

“When was the last time you saw a doctor?”

“Three years ago.” 

I looked at his blood pressure reading and cringed.

“How long have you been out of your blood pressure medication, then?”

“Out? I haven’t been out. My old doctor just kept refilling it.”

Our clinic recently instituted a protocol for allowing staff to authorize patient medication refills. It is a system wide thing, across our healthcare organization, so it is being utilized in every practice. Supposedly it is to free physicians up for more important things, like seeing patients, generating revenue. Isn’t that nice.

I hate it, though. 

I hate the whole idea.

Sure, I have trust issues. That is the first problem: Trusting that staff is always doing the right thing is hard for me in this case because these are drugs. Drugs can kill people if used wrong. Doing my own refills gives me oversight. Then, there is the self importance issue. If a medical assistant can refill meds, then what does my degree really mean? Less then it did before. And most importantly, if I don’t have time to handle simple refills for my patients, then am I too busy? 

I enjoy keeping tabs on my patients, doing their refills. Maybe I am crazy? I really do enjoy it. Taking refills away from me makes me feel less useful, less fulfilled. But I am going to try it. I’ll give it a go for a bit and see…. I don’t want to be labeled an old fogey. Yet. 

Doctor’s Day

Cute butterfly on a blossom

Doctor’s Day was yesterday. Did you know that?

Caught me completely by surprise.

It used to be a big thing ten years ago. The hospital hung banners up and handed out logo emblazoned umbrellas, bags, pens, and whatnot. My staff signed a big card the office manager picked up and a new potted plant would now sit on my desk. Drug reps dropped off cards and swag. There would be emails celebrating doctors sent from the suits. Well not really from the suits. From their secretaries. The point was, though, you just could not escape what day it was. 

To be honest, all of the hoopla back then made me feel very uncomfortable. 

This is not why I am doing this. I am not here for the accolades or the potted plants and I resent the insinuation that these things matter to me. Please leave me alone.

Each year it is less and less of a big deal. This year? Silence. Not a single frickin word from anyone. In fact, my only clue was a post from someone else on WordPress. 

Yesterday I told a woman she has metastatic ovarian cancer. I told a man that he now has diabetes and we developed a treatment plan together. I did a newborn visit on a precious two week old baby. I cried with a woman over her divorce and saw a man whose mother just died from the same disease he now has. Then I watched the last few minutes of my son’s karate class and picked up cupcakes for my daughter’s class party. 

This is life. My life. Every day. 

And you know what? Despite any bitching and complaining that I do here, I really, really love my job. It is such an honor and a privilege to care for people, to be there when they need help. THAT is what keeps us going… keeps me going.

In truth, I’d do this job for free. Just don’t tell the suits that I said that. ūüėČ

Cash Flow

Fountain at the Alamo in San Antonio

“You tell that doctor to write me a prescription for something affordable!”

*Click*

My medical assistant glanced up at me with a shocked look on her face. There was no need to repeat the conversation. I had heard every word.

“That does not make any kind of sense. It is a generic medication. It should only cost $40. Max. Call his pharmacy and find out what that med is going to cost him there.”

Later in the day I read the computer message that said it was going to cost $340 for a one month supply. Hell. I wouldn’t even pay that. 

I typed out a quick message and routed it back, asking why it was going to cost that much.

It is the brand name. If you want them to fill the generic you have to write for the generic. 

Except that I HAD written for the generic. I always write for generic. 

I sent back a stongly worded message pointing this out and telling them to fill the frickin’ generic. 

This was followed by a string of other patients with similar complaints all from the same pharmacy chain. Insurance companies refusing to cover prescriptions that patients had been getting without issue because the pharmacy chain was filling brand name instead of the generic option. It makes them more money. I would have never known this was occurring if the insurance companies had not denied coverage. 

From a drug coverage standpoint we love to hate on insurance companies but pharmaceutical company and pharmacy shenanigans are one of the reasons healthcare costs in the US are skyrocketing out of control. 

So I tell patients to be aware of what they and their insurance companies are paying for. If there are significant changes, please ask questions. Shop around to other pharmacies. The variability of cost from one pharmacy chain to the other is astonishing. AND, talk to your doctor. The only way I find out about these kinds of things is from patient complaints.

Just maybe don’t yell at my staff… 

Behind Your Back

Detail of building in San Antonio

So. 

One of the biggest time drains in my life is sorting through paperwork from insurance companies telling me that Mr. or Ms. So-and so is not filling their medication and therefore “likely noncompliant”. 

My question to you good people is this:

Do you want your doctor calling you to say your insurance company sent us this message and you need to take your meds, or else? Or do you prefer that we pretend that never came across our desk?

Power Lines

Power lines

“Hey, Doc. Remember me?”

I quickly glanced again at the name on the chart. He was a new patient. His name did not ring a bell. I squinted at his face. Dark beard and hair with some gray in it, a bit shaggy, but fairly well groomed. Lips. No. Then his eyes. I remembered the eyes from somewhere….

My heart caught and my fingertips went numb.

“How do I know you?” I asked, playing dumb. 

I knew good and well who he was. 

He smiled at me. “February 14th, 2016.” He paused a second to let it sink in. “That was the day you found me guilty of aggravated sexual assault and sentenced me to 10 years in jail.”

I quickly tapped a help message on IM to my office manager. 

“I don’t remember…”

“Sure you do, Doc.” He leaned forward close, too close, and spoke again in barely a whisper. “They made a big deal about who you were during jury selection. Got out a bit early. I had very, very good behavior. Not a day went by, though, that I did not think about what I was going to do to you when I got out. I have a very good memory.”

He sat up straight. There was a knock on the door and my office manager popped his head in. 

“This visit is over. Leave,” I rasped, embarrassed that my voice caught in my throat like a frightened fool instead of conveying strength and force. 

Damn.

A look of mock hurt crossed his face and he laughed. “Fine. See you around, Doc.” 

He sauntered out, slowly, pausing before rounding the corner to look over his shoulder and wink.

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In case it needs clarifying, this IS a work of fiction.