Needled 

Door of St. Patrick's Cathedral in New York City

“Your mammogram shows an area the radiologist is recommending that we biopsy. I am going to put in a referral for you to see a breast specialist to get that done.”

“Um. I already have the biopsy scheduled. The radiologist said they could do it. It has been approved by my insurance and everything.”

I glanced at the time stamp on the mammogram report. She’d had the mammogram done just that morning. The report summary said “suspicious calcifications concerning for malignancy….”

“I would really rather we get you hooked up with a breast specialist to do this.” 

Silence.

Who do they think they are, scheduling my patients for procedures that I have not even authorized yet?

“I’d rather just get it done. It’s already scheduled for next week.”

“Look, I can get you in with the specialist in just a few days. This is not going to delay care in any way.”

Suspicion began to creep into her voice. “I really don’t want to,” she said firmly. What exactly had they said to her? 

How do you say, “I think you might have cancer,” without causing panic? How do you remain professional when you are seething inside?

If it were me, if it were my mother, I would want to have the biopsy done by a breast specialist, not a radiologist. They have surgical training but more importantly, they know what to do if god-forbid-it-turns-out-to-be-cancer. Instead of waiting to see someone that can take the next step, I would be already plugged in. I have seen it too often. The panic, fear… the rage… 

My patients deserve the same care I would get, the same care I would demand for my loved ones.

I knew how it was going to go, though:

“If you don’t stop doing this, I am going to stop sending my patients there for mammograms.”

The manager laughed at me through the phone. “You have to send patients to our facilities. We are in the same system. You know they track that sort of thing.” 

And she’s right….

The suit squinted at me from across the table.

“So, in analyzing the data from your mammogram referrals we see that you are sending about 52% of your patients to outside facilities. Care to elaborate on why that is?”

“Is it required that I send patients to only system facilities?”

“Oh, no. No. It’s not required.” 

That would be illegal.

“So why are you here talking to me about this again?” I could feel the pricks of anger rising under my skin.

“We can’t require you to do that but in the interest of managing costs for patients…” He trailed off. 

In the interest of keeping more money in the system…

I held back a laugh. 

It was an interesting thing, how much more frequently my patients getting mammos at system facilities seemed to end up getting biopsies compared to those facilities outside the system that did not do biopsies as part of their services. Did they track that, I wondered? Was my perception about this correct or merely a projection, tainted by the animosity I felt? I resolved to start keeping a tally.

“While we are on the subject, your referrals to system specialists is below the system average for primary care. Why?”

“The why depends on the patient. Some prefer to stay in the area. Driving downtown is a hardship for a lot of them, not to mention the cost of parking. Some need a physician with a certain set of skills or a certain personality. Some have experience with a physician through a family member or have been seeing this specialist for years and need a referral each year because of their insurance.” 

Why am I justifying this to you?

A month ago they added a button on external referral orders that requires me to provide an excuse so they can better track such things. If there was a “bite me” option on the choice list, I would use that. 

Previously they had only loaded the contact info for physicians within the system. If they were not a system specialist they had to be loaded manually by filling out a form that went to the practice manager then to a practice administrator and then to a VP and then to someone to add them in. It took weeks.

Provide us with a list of the specialists you would like to use and we will contact them to try to get them to join the system.”

“I’m not doing that. I’m not letting you use my name to convince them to join anything. If they want to join, they can look you up. Meanwhile, I will continue to refer in a way that keeps the best interests of my patients as a priority.”

Technically they could pull those names from electronic health record. Maybe they already had.

“Oh, we always want you to keep the interests of your patients as a priority. We would never ask you to do otherwise.”

Except that is not how it feels…

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Wavering

Boy making ripples in water of pond with a stick

Last week a physician shadowed me to see if there is anything I or my staff can do differently with my work flow with this new EHR. I was looking forward to having a forum to vent my complaints with the system and hopefully to have a way to fix it but nervous at the same time, not knowing what to expect, worried that they would have suggestions that would make me look a fool.

The physician who happened to come was one that had a hand in writing some of the new EHR templates. I was so disappointed in those templates that between you and me I actually cried in frustration in the first few weeks of our changeover. How could we be expected to do what we needed to do when these were the tools we were given to do it with? I told him that I did not like the templates, that I thought they S-U-C-K-E-D. 

Yes, I used the word sucked and I cringe even now at the recollection. With that one word I dismissed all of the considerable time and effort he had poured into those templates. 

Have you ever been so frustrated and nervous that unreasonable things just flow out of your mouth? 

Of course you have. 

Ever been on the receiving end of someone else’s frustration, as they vented like that? 

Sure you have…

At times, when I feel passionately about something, my filter just ups and disappears. After listening to him tell me that I should hire a staff member to approve or reject all of my refills instead of doing it myself, after having him say that my desire to take and enter my own past medical and surgical histories was a waste of time, after being lectured that writing a narrative history of present illness was silly that I should be clicking buttons instead… I was no longer really hearing his words to me or my own responses back to him. 

But I LIKE doing those things! Interacting with my patients is what makes medicine fun and rewarding for me.

It was not until days later that a realization hit me. He believes this stuff just as passionately as I believe that he is wrong. My response was not just unprofessional, it was mean. I try to have compassion and respect for all of my patients, even the difficult ones, but where was my compassion for him?

You need to be flexible. Medicine isn’t what it used to be. You have to adapt.

I don’t want him to be right. 

I hate that he might be right. 

And so I have spent this past week after reading his write up of our interaction licking my wounds, pondering the next step. What do I do from here?

The first thing, I believe, is to apologize. I don’t know that it will matter to him, but I need to apologize for me. I don’t want to be *that* person, the one who believes their rude behavior is justified.

And then? What then?

There is the question. 

Seeing Through

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“Remember, that meeting is at noon today,” the IM from my office manager read. 

“Meeting?” I typed back. I flipped to my Outlook calendar. 

It wasn’t there.

Damn.

“Yes, THE meeting…,” the window popped up on my screen again.

The patient on the exam table was telling me a long story about the death of his childhood dog. I nodded and made a sympathetic sound as he got to the really sad part. I had heard it a few times before…

“The one where they don’t want us to be working on our computers, the one where we are supposed to provide our undivided attention?” There were fifty-two items on my EHR’s virtual desktop right now with a full schedule the rest of the morning and a lunch appointment with a friend.

A bright spot appeared suddenly in my field of vision. Like I had stared at the sun for far too long. But it was not going away, the sun was not visible, and I had not been around any flash bulbs or used the ophthalmoscope on the wall.

I blinked a few times.

Still there. I sighed. 

Not again.

“That’s the one. And have you RSVP’d for the Saturday meeting?” he responded.

“I’m not going.”

“You know that it is strongly encouraged and if you don’t go you have to email an adequate excuse to the system president.”

The scintillating pattern started to develop further and wind its way across my field of vision. It was a struggle to type without errors.

“I am not going.” I typed again and hit send.

“Are you serious?” he responded. I shifted my eyes around and moved my head a bit to see his words around the growing hole in my vision.

“Yes,” I typed back then realized the patient was quiet, waiting expectantly. 

Story over.

I thanked the gentleman for telling me the story and quickly entered orders on his chart in case the ocular migraine was going to get worse before it got better. 

An IM flashed from the front desk flashed up to say that my 9:30 patient was 20 minutes late for their physical exam appointment and could I still see them? The rule is 15 minutes late you reschedule unless there are extenuating circumstances. They shouldn’t even be asking.

“Please have them reschedule.” I was already running behind because my 8AM had arrived ten minutes late.

“I see you are needing a tetanus booster. Can I give that to you today?”

He nodded.

I sent an IM to my medical assistant to alert her to give him the immunization.

Once that was addressed I did a quick exam. 

Luckily, you don’t have to see well to be able to listen to someone’s heart and lungs.

“We are going to change your blood pressure medication, increasing the dose. Schedule a follow up for one month but if you can call me with some home blood pressure readings in a week or two I can adjust the meds further if needed and get this controlled faster, saving you an extra visit down the road. Got it?”

“Sure thing, Doc!” He grinned.

I almost missed his hand when he reached out to shake mine, then I dashed out of the room.

My office manager was standing outside at the nurses’ station waiting for me, arms folded across his chest.

“They rescheduled the meeting to next week.”

“What?!?!??!”

“So mark your calendar right now…”

It isn’t enough that I touch an average of 110-170 documents in the electronic health record per day. Or that I get from 20-50 emails per day (half of those are about various EHR systems that are not working properly that day or about our numbers for this measure or that measure). Or that I address countless IMs from various staff members throughout the day. I have the attention span of a flea nowadays and THEY made me this way. Now I have sit through hours and hours of meetings “paying attention”to stuff I really don’t care about anyway? I am not sure I can do that without being medicated.

I really, really don’t want to do that.

If brains on video games are remodeled, what happens to brains on EHRs, I wonder?

Is all of this why my ocular migraines are back?

Lifted

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“Doc, something weird just happened.” 

I stopped with my hand on the door handle and turned around, heading back to the rolling stool in the corner by the sink.

Dang. I had almost made it.

“Oh, yeah?” I tried to smile and waited expectantly for him to say he had experienced a run of palpitations as he was sitting there or that he just had a spell of crushing substernal chest pain. If something like that is going to happen it will always be at the very end of the visit when I have already run overtime. 

Still. It must be dealt with.

Always.

“Your hands. They weren’t cold!” He had a funny look on his face as he knit his eyebrows. “Why weren’t they cold, Doc?”

“Oh.” I shrugged, relieved. “Probably because today I am very, very angry at the IT people.”

“Got your blood pressure up?”

“You betcha.” I gave a brief explanation of the printer error which left 3/4 of the staff unable to print documents for patients. It had mysteriously surfaced on a Monday morning and supposedly, no one could fix it. 

I paused in front of the full length mirror in my office before seeing the next patient and realize that I really looked angry, even through the smile plastered on my face. 

If looks could kill those IT people would be dead ten times over.

Bastards.

I closed my eyes and took a deep breath. Exhaled. Again. And then again.

You cannot fix this, either. Getting angry about it won’t make things work faster.

Part of me said, “But I want to be angry! I have every right to be angry!” Another side said, “No, it does NOT feel good! Give it up. Be grateful that you have a job.”

I closed my eyes and made the tension wash away. I willed the arguing voices to shut up.

And then I had an epiphany. This may sound kooky not getting to it until I am almost 42, but here it is:

There will never be a perfect world.

That’s what free will gets ya. Turmoil and drama and instability are the only constant. I keep holding out for when things get better but they won’t ever be better. There simply will never be a day when I don’t have staff errors and patient drama and IT failures and I need to accept that. Humans are by nature unpredictable and unreliable and unstable. The more I try to control the less control I have and the unhappier I become.

I have known this intuitively but it is a far cry from knowing to understanding and an even father leap to acceptance.

So, I squared my shoulders and picked up the computer. I knocked three times on the door of the next exam room. This time, I smiled from the inside as I entered.

We will see how long this lasts…

The Doohickey 

 Ocean at sunset 

There is a little device at the end of my kitchen faucet. I have wondered why. All it seems to do is get debris lodged in it from the road construction in the area. It has been explained to me that the pounding from breaking up old road stirs up sediment and such within the water mains. Who knew that happened? Makes one wonder how much dirt and debris actually gets ingested…

But I digress. 

From time to time enough debris accumulates that I cannot get enough water flow to turn on the tankless water heater. So that doohicky has to be removed, cleaned out, then reinserted. This has been managed successfully a few times since the road construction started over a year ago (they move slow). Well, that is UNTIL last week. 

Part of it broke.

Turns out, that little piece of plastic regulates flow and keeps water from spraying all over the place. Who knew that having your forearms soaked while doing dishes would be so annoying?!?!!?

The kicker? The piece cannot be replaced. I have to purchase another gosh darn faucet. I happen to love the astheticism of this faucet. We have been together for over twelve years, longer than a lot of people’s marriages. None of the other faucet options speak to me. So it is spray down the kitchen every time I turn on the hot water or spend money on an ugly and expensive faucet (those silly things are not cheap folks).

GAH!!!!!!

Curse you, public works department!!!! Curse you people who want driveable roads!

Altered

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Yesterday at 11AM our EHR died. System wide. Hundreds of physicians and thousands of patients were affected. 

What made it so especially infuriating was the fact that I was powerless to change it. I had sixty items on my virtual desktop that still needed addressing but I could do nothing about it. They were untouchable.

If I had known, I would have brought some knitting.

Anger and frustration compounded and multiplied as the promise that it would be fixed in 15 minutes became thirty minutes became hours. We had to reschedule patients because it was not safe: I had no idea what meds they were taking. Allergies? What other medical issues did they have? What kind of lab results did we get on their last check? When was their last check? 

I wanted to hurt something. 

Badly. 

I had a screw driver handy. I could drive it through the keyboard and screen over and over again until it was smoking and sparking but then I remembered that it was not going to do anything to those at fault for the whole debacle. What I really wanted was the hand of the individual responsible on the desk before me so I could drive my screwdriver through it into the wood below. It would cause significant pain but no permanent disability, right?

DAMN IT!

So instead, I bought my staff pizza. I blogged. And I paced back and forth.

At 5 PM, the EHR was back up. Just in time…..

……for going home.

Then the conspiracy theorist in me started to wonder. Was this all because of a cyber attack? Did our system go down because of an attempt to steal sensitive information? Who knows. Healthcare is vulnerable. Want to kill someone? Change their meds. Change their lab results. Change their allergy list.

At any rate, my eye is still twitching and the jaw clenching is causing my TMJ to flare up. Too bad drinking on the job is frowned upon…..

Crabby 

 Pier stretching into the ocean at sunrise. 
October 1st, 2015 

The diagnostic codes for doctors, the way we communicate with insurance companies about what the hell is wrong with you, changed yesterday. After decades of using what is called ICD-9 all physicians in the US were required to change to ICD-10. 

ICD-9 worked just fine, it seemed. Now it is this confusing jumble of letters and numbers and designations arranged into “chapters” that have left me wondering what was wrong with the old way anyway? Still, I am sure there was a good reason. The government always has a good reason….

Hospitals and some outpatient practices have been so terrified about the disruption that they have taken out loans in the millions, expecting insurance companies will be delaying or refusing payments for months as we all sort this out.

Staff still needs to get paid, you know?

So, there is the change itself. Change is always hard. It is magnified 2,000 times, however, when your electronic health record does not have a clue what it is doing: tons of errors, system crashes, and three times the work to get the correct code. Seriously. You would not believe the stupidity we have to go through for each patient and each problem on the list. Colossal waste of time. 

I was lucky that yesterday was my half day. Today? Not so much.

The thing that really gets to me, though, is that it was not like this was a surprise. It has been looming ahead for years. So why can’t they/we be adequately prepared for it? 

Sooooooo….. If you are in the US and you are visiting your doctor in the next few weeks or months, give them a few words of encouragement. We are terribly sorry if you have to wait longer for your appointment or if you get incorrect bills or if everyone in the office seems crabby and disconnected. 

Pardon me…. my left eye is twitching…

The Sick Child vs Modern Medicine

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To a parent, there is nothing worse than having a sick child. The normal colds and childhood diseases are stressful enough, but a chronically ill child is more than many people can handle.

In hindsight, I can explain all the little incidences that cropped up during Cordelia’s childhood. But at the time, I depended on modern medicine to tell me what was wrong, and modern medicine failed. Let’s see if you can figure it out before you get to the end of our story:

I think Cordelia was about 4 when the first notable incident occurred. Hubby and I were both working that day, and Cordelia was cared for by her grandparents. When I arrived that evening, Grandma greeted me by saying, “Let me tell you what we did.” I assumed she was going to tell me they went to the movies, or shopping, or some such – imagine how shocked I was when told that Grandpa had realized his heart medication was running low and needed a refill, so he emptied the bottle into an ordinary drinking glass, which he then put into the kitchen cupboard. Cordelia asked Grandma for some milk. Grandma grabbed the first available glass. Yes, you guessed it – Cordelia ingested Grandpa’s heart medication.

Fortunately, this happened not too long before my arrival, because no one had thought to call a doctor. I called Poison Control, which resulted in Grandpa driving around to several local pharmacies looking for ipecac – wouldn’t you think that would be kept in stock? The ipecac was administered, and the vomiting began. All normal thus far – except that Cordelia could not stop vomiting. We sat her in the tub with a bowl. I called Poison Control, who advised to just give it time. It took hours, but eventually the vomiting stopped.

I don’t know if that incident was the cause of all that followed, or whether it was merely an indication that there was an underlying condition that should have been attended to.

When Cordelia was 8, she got the flu. She could not stop vomiting. Being a stupid young mother, I let it go on for days and finally realized she was sleeping a lot. I thought that was good – she wasn’t vomiting while sleeping, right? I was too inexperienced to know that excessive sleeping after a bout of sickness could mean severe dehydration. When she slept through the evening and into the next morning and then woke up vomiting AGAIN, I called the doctor. This resulted in Cordelia’s first hospitalization. She was put on IV fluids and kept overnight.

After that, every time she became ill, she would experience uncontrolled vomiting, and each time she had to be admitted to the hospital. A normal case of chicken pox resulted in her being quarantined in a hospital room for several days. I’ll never forget the poor father who saw me step out of the doorway marked “QUARANTINE” and grabbed his child away from me for fear she would contract some horrible incurable disease. I tried to explain it was just chickenpox but he didn’t believe me.

The hospitalizations became more frequent and lasted longer. She was getting sick every couple of weeks. I kept an overnight bag packed at all times. At one point, Cordelia got sick and I called the doctor, apologizing. I said I didn’t want him to think I was an overly protective mother who called every time her kid got a little bug. His response was, “In her case, I think you should call.”

It was so bad that when Cordelia started vomiting, her younger sister started crying – because she knew Mom would be going away with Cordelia for a couple of days.
And the absolute worst was the day I had Cordelia in the tub, washing her prior to taking her to the hospital. She looked like a starving child from Biafra, and her skin was so hot that when I touched her, I felt repelled – immediately followed by “This is my child, my baby – how could I feel that way? What kind of mother am I?”

As the course of Cordelia’s illness continued, I began to doubt my abilities as a mother. How could a child become ill so often? What was I doing wrong? It didn’t help that one of the pediatric nurses accused me of Munchhausen by Proxy Syndrome. I had to look it up, at which point I began to doubt my own sanity. Was it possible that I was somehow deliberately making my own child sick just to get attention from medical personnel? Could I be doing something so horrible without knowing it?

Tests were done – xrays, ultrasounds, MRIs and an EEG (I insisted on being in the room for the EEG – Cordelia slept through it, but the strobe lights nearly made me throw up). A psych consult was ordered (for Cordelia, not me, and it came out normal.)

Cordelia’s vomit began to show flecks of blood. The doctors said not to worry.
During her 11th hospitalization (Cordelia was 10), she suddenly started vomiting fresh blood. The floor resident had to lavage her – twice (pump water into her stomach and wait for it to come back up clear – I can’t imagine what that must have felt like).

The next morning, our regular pediatrician arrived for rounds, and I totally lost it. The poor man stood silently for at least 10 minutes while I ranted about the inadequacy of Cordelia’s care, ending with, “That blood has to be coming from somewhere!” The pediatrician put his head down, and then responded, “You’re right, and we’re going to get to the bottom of this.”

Finally, a GI consult was ordered. The GI doctor arrived with an attitude – he couldn’t believe he had been called in simply because a kid was throwing up. As he entered the room, Cordelia held up both hands, with the fingers flexed backwards. I sighed and said, “She swears she’s not doing that.” The GI doctor’s attitude did a 360 degree turn, as he replied, “She’s not, she’s throwing potassium.”

An endoscopy was performed, and afterwards, the GI doctor had me escorted right into the procedure room, where Cordelia was still lying unconscious on the table. The doctor was at a computer, and had pictures to show me. Cordelia had several ulcers in her esophagus, which in the doctor’s opinion were “very, very bad.” Aggressive treatment was to start immediately, consisting of Zantac, Reglan and Prilosec.

Later that evening, Cordelia began to hallucinate, and I called the nurse in. It turned out that the floor resident had miscalculated the dosage of one of Cordelia’s medications, and had prescribed 10 times the amount she was supposed to get! Fortunately, there was no apparent damage caused by the error.

Cordelia began to heal, and that GI doctor became my favorite person in the whole world.

Was the ordeal over? Not quite yet. There were a couple of subsequent hospitalizations, but essentially she continued to improve. The school nurse was a saint who managed to keep the medication schedule (each drug was to be given at a different time).

So, what was the final diagnosis? Have you guessed it?

Gastroesophageal reflux disease (GERD)

These days, we all know what it is, if only from all those TV ads for Zantac and Prilosec. Back then, I’m not sure that Prilosec was even recommended for pediatric use.

Why did I not see the signs? Too many of Cordelia’s vomiting episodes seemed to start after her favorite meal of spaghetti, juice and chocolate cake. Or, did it all start way back when she accidentally drank Grandpa’s heart medicine? We’ll never know for sure.

I’m just glad that the nightmare ended. God bless those parents with an ill child for whom the nightmare never ends. No one should have to go through that.
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This was a guest post by Cordelia’s Mom. If you have not checked out her bog at Cordelia’s Mom, Still please do! She is one of the bloggers I have looked up to since I started blogging. I am honored she took the time to share this post over here.

Crossing Over

  
This new electronic health record?

It has been “optimized for a 24 inch screen”. You have to have a screen this size or you will waste 25 minutes per day doing extra scrolling and clicking. 

Or so they say…

A screen that size is not portable. We will have to have a computer in each room. Of course. Plus each physician will need a docking station in their office for their laptop.

This clinic that we are trapped in until 2018 has tiny rooms. It works carrying a laptop. I balance it on my lap while sitting on my wheelie stool facing the patient so I can maintain as much eye contact as possible. I try to type while we talk to maximize charting time and to ensure accuracy.

To have a computer in each room, given the room size and layouts, will require mounting it to an arm and using it with my back to the patient. That set up will cost about $3,000 per room. Each physician uses three rooms.

Paying for this will require seeing seven more patients per physician per month for three years at which time the computer equipment is obsolete and will have to be replaced.

Which begs the question, how do you do that with an already full schedule?!?!!!? 

Furthermore, why couldn’t this EHR have been “optimized” for a screen size that is more practical and portable? If this is the top of the line program, why wouldn’t they want portability? Who gets a cut of the equipment sales?

Impatient Patient

 building facade in Philadelphia 

“Doc, she says that time isn’t going to work for her. She wants today, 10:30 only.”

I looked at the clock. It was 9:30 and I was already running thirty minutes behind.

“I don’t have anything else to offer. We are double booked as it is because of the other doctor being out on vacation. I don’t know what else to do to accommodate her. We are doing our best.”

“She’s yelling at me.” My front desk person looked on the verge of tears.

“I’m sorry. She is welcome to come whenever she likes but she will have to wait until we can see her. Or she can come at 1:30 and we will see her then.”

I can’t really call the patient at 10:30 and tell them not to bother coming in so she can be seen in that slot. 

“She says she will just go somewhere else.”

I sighed. 

10:30 rolled around and the physical that was scheduled at that slot didn’t bother to show. Neither did the work in that was also scheduled at that time.

Two days later I saw the belligerent patient for her head cold. She didn’t go elsewhere. She was very nice during the visit.

I don’t know what was going on their lives, what extenuating circumstances were involved, but this is what was going on in mine.