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. 😉

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.

*********************************

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

Games Played

Pelican on the water

“The staff doesn’t like you. They are all scared of you.” She sat across from me, feigning concern.

“Why?” I felt my face redden and struggled to keep the emotion under control.

“They just think you are too demanding. You should stop talking to them. Let me handle it for you so they can be mad at me.” 

Too demanding? I was not being ugly. I just asked the front desk to check on a patient’s insurance coverage. How could that be construed as anything but an honest and necessary question so I could take better care of a patient? 

“If you have a problem, come to me and I will take it to them.” 

And with that I was not supposed to communicate directly with my staff anymore. Because they feared and disliked me. The practice administrator over her and HR supported this she said. 

Whatever. 

My head reeled. She left. I closed the door and had myself a good cry.

Unbeknownst to me, that office manager was telling the staff that she was the boss, not the physicians, that they should stop taking their concerns to us. If there was an unpopular decision the staff was told that it came from the docs even if it didn’t really. If it was something good, she told them that she had done everything in her power get us to reluctantly agree. She lied and lied and lied to the staff about everything.

If you have been reading my blog posts for a few years you may recall the angst of this period of time. How could I be doing the same thing I always did but now all of a sudden everyone thinks I am the bitch from hell? Is it really that I am so evil? Or is it that I am woman and as such people are taking everything I say and do and twisting it into something I am not? If so, why now? 

What was going on?!?!!??!!

I had this niggling suspicion, as my staff continued to leave the clinic one by one, that my office manager was not supporting the physicians or the staff, that there was something else going on to which I was not privy. I reached out to upper management and they listened for a change. Within a couple of months she was gone. It was startling how quickly that occurred. Typically there is a huge HR process and blah, blah, blah. At the time I felt guilty, terribly guilty, blindsiding her with it when HR showed up to escort her out of the building. I worried that I had destroyed her career. 

Yesterday I found out that there was an investigation going on, that each employee who had left the clinic during that period of time was approached by a contracted firm for statements as to why they left. The investigation supported what I was saying which was why upper management moved so quickly. But no one ever told me this occurred. I found this out from one of the employees that we rehired. 

In fact, virtually everyone who has left this clinic has asked to come back at one time or another. On some level I knew it was not really me but how to rationalize that with what I was being told by an office manager that I trusted?

That whole period of time really messed with my head.

Friends and family started to doubt me. Hell, I doubted myself. I questioned my judgement. I questioned everything. In the end I realized that I had to let it go. All I could do was what I thought was right and I found my peace with that. While the maelstrom swirls around me, I can stand upright knowing I am doing right. In that respect the whole experience has been invaluable. I care so much less what people think about me. 

Just do what is right.

I have been back to communicating directly to my staff again for over a year. The practice administrator last week complimented me on my “level of engagement with the staff,” saying that everyone always had positive things to say about me.  

Ok. 

But I am doing the same thing I have always done. Maybe it is just the tequila I keep in my office?

Elongated Shadows

Carved wood totem

Suddenly, the exam room was plunged into darkness.

Thinking that the energy saving motion sensor had somehow felt the room was empty, I was placing the sutures with my back to the door and the patient was lying very still since I was stitching up his face, I raised my hand and waved.

Nothing.

“Well, that’s a first…”

The patient made a nervous laugh. 

I stood and using the glow of the light visible from the battery powered laptop that was perched on the countertop, I made my way to the door. Sticking my head out, it was clear the entire clinic was without power. Other patients and staff stood in the hallway, waiting expectantly. 

But the power never came back on.

For the next hour we saw the remaining patients by the light of our cell phones, doing the best we could. I was not able to look inside ears or do EKGs. I could not order any tests or X-rays. Our clinic phones did not work. We had to *gasp* handwrite our prescriptions. The centrifuge could not spin our blood vials before transport to the lab.

In fact, almost the entire city was without power thanks to an accidental severed line somewhere… according to reports from the power company.

Tens of thousands of dollars worth of vaccines in our fridge/freezer could potentially go bad as the ETA on the power coming back on was maybe 12 hours away. Some of the staff graciously packed up the vials boxes and drove them to another clinic with power for safe keeping.

The movie theater cleared out next door. None of the traffic lights worked and the backed up intersections were utter mayhem. My kids’ school was pitch black and they had runners bringing to the front kids for pick up since the intercom system did not work.

You know what, though? It was fun! A dry run for the zombie apocalypse… We’ve got this! 

It was a glorious feeling.

And then? 

I spent the entire evening when I got home trying to catch up on the charting and patient calls that I could not get to from the office. Why is it that ONE hour without power turns into THREE frickin’ hours of work? How is that even possible?

Grrrrrrrr…..

Founders Keepers

There is a term in population genetics called the founder’s effect and I have caught myself thinking about it a lot lately.

Basically, in a founder’s effect a small subset of a population is isolated from the larger population. For instance, maybe seven people went on a three hour boat tour but instead ended up stranded on a deserted island. The Professor and Mary Ann mate and reproduce, as people are wont to do, and several generations later the resulting population on that island looks very different from the larger population that it originated from. There is a loss of genetic variation and certain traits get reproduced at a greater rate than you would find elsewhere. Sometimes this is benign, like with a greater proportion of blue eyes or brown hair. Sometimes it is bad, like when you have a higher predisposition to develop colon cancer or maybe a higher rate of growing an extra leg out of your backside…

EPIC is one of the largest electronic health record in the US. It is highly customizable. Therein lies its power AND its weakness.

Keep in mind that I have only a small part of the picture and I am making certain assumptions, but here is what I have gathered:

When a healthcare system decides to go with EPIC there is a build out, or personalization, that occurs. The EHR that I see is very different from the one used by a physician in another healthcare system across town or in one across the country even though they are all called EPIC. 

From that initial build out, there are changes made as the product is tweaked. For instance, when we went live, we had to enter our password to log in but then had to enter it again with each and every note we signed, every single order we placed. Hundreds of times a day I was typing in my password. Now? I only type it in to log on. Good thing, too, as I was at risk of destroying expensive equipment.

I have staff in my clinic who have worked for three other major hospital systems in the area who also use EPIC. What they describe is much, much easier to use than what we have currently. In fact, they regularly threaten to leave and go back to those other organizations so they can feel at peace again.

How does that happen? 

How do they have such different products? 

Because they are all starting with a basic product. It is thrown out onto a deserted island with a few people making decisions and then everyone waits to see what you get down the road. 

The founder’s effect.

No one from the other hospital systems is sharing what works for them from what I can tell. There is no collaboration. So each one has parts that work well and other areas not so much. Why can’t we help each other?

THEN you have smaller islands. We are a small clinic in a huge system. We did not get support staff who came out to help us after going live until the following week and then only for two days. The bigger clinics? They had trainers there on day one. Some clinics never got anyone. Training classes done before had very little to do with the reality of the EPIC we were presented with on day one. So we have muddled through figuring out our own work arounds. Some good. Some bad. We need an infusion of fresh genetic material to correct our problems. 

That only works well when you have someone visiting your island to add to your gene pool and that only works if that person is genetically diverse themselves. Getting people to leave their islands is difficult. Distance to travel, time constraints, don’t know how to swim, etc… 

So we get this perpetuation of problems and errors… fractured systems. It has been really interesting to watch from my vantage point at the bottom, looking up. I wonder what this will look like in six months.

Menorrhagia

Light in Boston art museum

She was new to me.

She was mentally challenged although I will admit that I don’t even know what the right PC word is anymore. Clinically I have tons of appropriate labels but speaking to all of you, I don’t know what term to use that will guarantee that I do not offend someone. 

On top of that, she had developed dementia. 

Her sister spent her entire life as her personal caretaker… never married, never had children. Out of her several siblings, she was the one who stepped up to the plate. She genuinely cared. She had watched countless times as the medical community wrote off her sister. She had watched the untold emotional and physical suffering and she felt the unfairness acutely. 

One of the toughest things to deal with in this population is menstrual problems. Periods by themselves are bad enough when you understand them. Imagine trying to deal with your period when #1 you don’t know why you are bleeding from between your legs and #2 that bleeding is irregular and excessive. 

As a physician, working up menstrual problems is especially hard when you have a grown person who is willing to slug you, who screams and cries and is so terribly, awfully afraid of what you are going to do to her. I don’t believe tying someone down, forcing myself upon them, should be necessary. That sort of thing only exacerbates and perpetuates fear but it took us 45 minutes just to draw her blood. I held her hand. Her sister held her other hand. Two other staff members worked together to do the draw. No one got hurt, most especially the patient, but it took us 45 minutes to get her calm enough to endure four sticks to find a good vein.

In fact, it had been years since anyone had even tried to draw her blood because of how much of a challenge it was. Still, it had to be done. And we did it. But for the rest of the day I was running 45 minutes late. I could not catch up to save my life. 

I cannot go in to each patient afterwards and explain what happened. Patient privacy. Takes too long. Etc. etc. etc. But to all of those patients who graciously accepted my ambiguous apology, thank you. Thank you for not slamming me on patient satisfaction scores. Thank you for giving me the freedom to take care of this one person who really needed me.

You made a difference. 

You helped save a life. 

You are all my heroes and I am lucky to have you as patients.

Outcomes

eileandoonancastle3cropped

His voice shook.

“She’s in ICU. I thought you should know.”

I felt my body grow cold. She and her family had been patients of mine for almost ten years. She was so young. Younger than me, in fact….

“They aren’t sure if she is going to make it.”

“What happened?” It was supposed to be a simple cyst removal.

“Her small intestine was perforated. They have her belly open, said they couldn’t close it yet.”

I had used a new surgeon, someone I had never used before, because the mass was blocking the tube from her kidney to her bladder, causing quite a bit of pain and endangering the kidney itself. She needed surgery quickly and no one that I typically used was available to work her in. 

“That’s just awful. Keep me posted on how she’s doing. I’ll be saying a prayer for her and for you.”

“Thanks, Doc.”

As I hung up, the guilt welled up. I felt personally responsible for the bad outcome, even though my hands weren’t the ones actually in her belly. MY hands had hit the referral button, signed the order. 

She trusted me. 

She ended up making it, but it took a huge toll on her both physically and emotionally and financially. It affected her relationship with her husband. It affected her kids. They had almost lost their mother and it left them all shaken and ungrounded for almost a year. Things are only now starting to look up.

I feel guilty when patients don’t like someone I refer them to. I feel that I have let them down. I feel guilty when I find a cancer, as if somehow it was my fault. I should have prevented it. Maybe I could have found it sooner somehow? And, yes, I feel responsible for surgical errors and outcomes.

So when I tell patients they need to see a different specialist than the one they picked out, I worry how far to push it when they aren’t agreeable. When I know a back surgeon is bad, how much do I tell a patient who is not listening to my gentle suggestions to seek a second opinion elsewhere? Where is the line professionally and legally? 

These are my thoughts on this Monday morning….. 

Shooting Stars

img_4013

“The per patient expenditure for your assigned patient panel the last quarter was up by $XYZ, so we will be dropping your rating on our website from five to four stars. Your patient satisfaction and preventive care scores remain outstanding. We will re-evaluate your rating at next quarter.” A letter from one of the big insurance companies a few weeks ago.

You know what? Bite me. To my knowledge I am not wasting money. I take appropriate care of my patients.

But then it occurred to me, do patients even know that this is what those stars mean? How much money they and their physician cost the insurance company….