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.

Fertility vs. Virility

Gerber Daisy in a pot

“I need help,” she pleaded. “I don’t know where else to turn.” 

“Sure. What do you need?”

“I’m pregnant.”

She was newly married. They were recent college grads, just starting their first jobs and their lives together.

“Congratulations! How exciting!”

Her face crumpled and she began to cry great body wracking sobs. I braced myself. Had he left her? Was she being abused? Was there something wrong with the pregnancy? Had she lost her job somehow?

“My health insurance excludes coverage for birth control. The pills make me so nauseated and the depo provera shot just made me bleed and bleed. I couldn’t afford to pay out of pocket for other forms of birth control. So we used condoms. We tried to be careful.” She whispered hoarsely, “I don’t know what to do.” There was terror in her eyes. “My insurance policy excludes coverage for pregnancy. We made calls. All of the OB’s in the area want at least $10,000 up front in cash. We don’t have that kind of money. We have student loans and a mortgage!”

Could health insurance DO that? Exclude coverage for both pregnancy AND birth control? Oh, yes. Yes they could. And it was always hidden in the fine print. It was the young women starting out in life that didn’t know what to look for, the ones most likely to end up pregnant. 

It made me angry for her. What kind of misogynistic world did we live in where this was allowed? Where women are punished for possessing a functional uterus? The United States of America. The bastion of freedom and democracy.

We talked about her applying for Medicaid. 

It felt wrong, though. A woman… married, employed, insured (sort of, apparently) having to apply for Medicaid. That was not what Medicaid was intended for, was it? Once her dates were calculated, the pregnancy predated her employment contract and would have been considered a preexisting condition anyway, even if she did have pregnancy coverage. No matter what kind of policy she had, she was screwed. Literally and figuratively.

The other thing, which no one talked about out loud, was that the OBs who took Medicaid in the area were typically so awful no one with real health insurance would ever willingly use them. There was a huge stigma attached to it all.

So what happened to her, you ask?

She had an abortion.

Despite what you want to believe, hers was not an isolated story.

What a relief it was when the Affordable Care Act worked to changed that. No matter whatever else you felt about the ACA, it was a powerful step forward for women but even it did not go far enough. We all deserve comprehensive medical care that takes care of our entire bodies, not just the parts that correspond to our male counterparts.

But here we are with some people thinking it would be great to go back to that alternate kind of reality.

Well…

Be careful what you wish for.

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. 😉

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… 

Veracity


He chuckled to himself. Potassium level?

Let’s make this one 6.5….

He hit enter then scanned down the list. 

Ahhh… a 90 year old woman. Perfect!

This time he picked the sodium level. 

126

In thirty minutes he had changed the results on over three dozen patients. Just one or two per provider, not enough to cause much of a stir…. Since none of the docs at the various system clinics spoke to each other.

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

Potassium level 6.5? No eveidence of hemolysis noted. Damn.

She sighed and dialed the patient’s number, hoping he would pick up.

“Hello?” a male voice said

“Mr. James?”

“That’s me…”

“This is Dr. Stephens. I was calling to discuss your lab results. Do you have a second?”

“Sure, Doc!”

“Your potassium is showing as rather elevated. Most of the time this ends up being an error but at this level, if it is true, it can kill you. We need to get it rechecked. The best place to do that is the ER. They will recheck the levels and do an EKG and if it is really elevated they can bring it down.”

“Are you sure?”

“Yes, sir. I know going to the ER is not a cheap proposition but I don’t feel like at this level we have much of a choice.”

He sighed audibly. “Ok, Doc. If you say so. Should I go right now?”

“Yes. I’ll call ahead and let them know you are coming and why.”

She had alerted the lab to these abnormal results several times. Each and every time it seemed they were proven false. It had been occurring since the mandate that all providers had to use the system laboratory instead of sending their samples to an outside place. Invariably she was told it must be a problem with the way staff was drawing the blood. 

Only it wasn’t… She knew that was not possible.

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

The board gave a standing ovation. Revenue for the system had reached an all time high. It had been a banner quarter. Things had been looking grim for so long….

A nondescript figure in a dark suit with a light blue silk tie sat silently in the corner, arms crossed, smiling to himself. 

The Cost of Protection

Carved flowers on a Victorian tombstone.
There have been several times over my career that I have had to step in to protect a patient from their family. Each and every time it gets nasty. It takes a certain kind of person to abuse their child or to molest a mentally challenged adult or neglect an elderly person to the point they have maggots in their wounds. Those kinds of people fight and they fight dirty.

I marvel at how some attorneys can look at the facts of a situation and defend it by attacking and terrorizing the physician who had to make the call. It is exhausting and terrifying and can leave you questioning yourself and your judgement throughout the process:

Surprise subpoenas summoning you to appear in court in 60 minutes, requiring you to cancel all of your afternoon clinic appointments at the last minute.

Threats of lawsuits.

Antagonist depositions. 

Lies and accusations made publically.  

Nothing in medical school prepares you for this sort of thing. Physicians have malpractice insurance but this is not malpractice. There is no one to walk you through it unless you hire your own expensive attorney.

Eventually you are vindicated but not before your life is made a holy living hell. It takes a toll on your family and friends as well, as you cannot discuss it with anyone else. The process can drag on for months or even years.

You are isolated and alone.

Fortunately, all of my experiences have been before social media. I have seen, of late, some unbelievably ugly online attacks made on physicians who are only doing their duty and trying to protect the vulnerable. It appalls me how quick the rest of the world is to jump onto the hate the doctor bandwagon when they do not know the whole story. Physicians are not allowed to defend themselves due to privacy laws. The rest of the world will never know the whole story.

What some people seem to forget is that our role as physicians is to assess the situation and make a recommendation. We are required by law to report suspected abuse. We are not omniscient super humans and maybe we don’t always get it right. All we can do is our best. In the end is up to the courts to decide guilt or innocence. 

The price we pay to do so is often very, very high….

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.

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. 

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.