New Outlook

Lookout at Rockefeller Center in NYC

The beeps. 

I know those beeps.

From where? 

I don’t have the energy to find out. My head hurts something fierce. I slip away, choosing to remain in the darkness for now.

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

The pain at my sternum is excruciating. 

Make it stop!

Except that I don’t have a voice. There is a tube down my throat and I cannot speak. I try to grab the hand at my chest by my arms do not respond.

“Dr. Slaughter? Wake up. Can you hear me?” The voice is much too loud and the words are spoken slowly as if the man enunciating them were speaking to an imbecile.

The pain stops. Then I realize…

A sternal rub!

My eyes are open. He moves his face close enough to mine that I can smell his aftershave. 

“Dr. Slaughter? My name is Dr. Holcomb.” He was too young to be a doctor. Too young to be competent. “Wake up!” he shouts into my ear. 

The pain again. Stop with the damn sternal rubs you f***er! I AM awake.

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

“The patient is a 45 year old male who happens to be a local physician. A neurologist. He suffered a brain stem hemorrhage two weeks ago and is currently in a persistent vegetative state. He has no family we have been able to locate.”

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

I take inventory. What can I move? Arms? No. Legs? No. I try to tense my abdominal muscles. Nothing. A shift or a scoot to take pressure off of my hips. Not even a millimeter. Smile? No. Wrinkle the nose? No. Tongue? Not that either. Blink? Ok. Yes. A blink. I try to move my eyes. Left. No. Right. No. Up? Yes. Down? Yes. 

Not much to work with but it’s something.

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

My dog! Who is feeding my dog?

He was probably dead by now.

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

“Well, his catheter caught on the IV pole so when they were wheeling him down for the MRI, it got rippped right out. We have to place a new one.”

“Should we use the lidocaine jelly?”

“Nah. He can’t feel anything anyway.”

I felt it, bitch. I felt that catheter rip right through my urethra. Use the goddamn lidocaine jelly. Come on. Look at my EYES. See me moving them? Blinking? 

Please? Just LOOK at me. Really look look at me. Someone?

I can make tears.

The night nurses here suck. 
*****************************************

The woman is smiling at me. 

Who is she?

She’s gorgeous. Dark hair. Blue eyes. Long lashes. I have this strange feeling. I think I should know her. 

“Remember me?” She whispers. 

No. No, I don’t.

“I was the intern you came on to ten years ago. A newbie. You told me to go get some gauze and then followed me into the supply room, locking the door and forcing yourself on me. I made it seem I was flattered.” She fixed her gaze onto my eyes and leaned in closer. “But I wasn’t.” 

Her hand was under the sheet, stroking my genitals. An erection. Horror and pleasure washed over me.

Oh, God.

The heart monitor registered the increase in heart rate. A nurse stuck her head in. The hand was withdrawn.

“Oh! Dr. Rutherford. I didn’t realize you were in here.” 

“Dr. Holcomb asked me to see the patient.”

The nurse nodded then stepped out, drawing the curtain closed behind her.

“I hate you.”

Suddenly, fingers wrapped themselves around my scrotum and squeezed tight. Painfully tight. I closed my eyes, fighting the excruciating pain.

“You have locked in syndrome, don’t you, Dr. Slaughter?” She laughed. “You can feel everything but you cannot move. Well….” she chuckled again. “You can move your eyeballs up and down and blink but they haven’t figured that out yet, have they? You taught me well about so many things…”

Another squeeze. More pain.

“You probably know better than anyone that you likely won’t recover.” She smiles sweetly. “But I’ll be back to check on you. Every single day…”

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Broken Windows

Broken window at Ellis Island hospital

It irks me beyond measure that my eyes are aging to the point that to read posts from the WordPress app on my phone I now require glasses, that to look at certain skin lesions in clinic I need to run grab the red framed readers that I *affectionately* call my old-lady glasses. Adjusting to this new reality is taking some time. I still find myself stubbornly squinting at the screen as if denial will make it all go away… 

Friday the 13th

Ellis Island building detail

Every Friday the 13th I tell myself I am NOT going to work. I am so over the bad luck. 

Is it really that much worse than other days? Are people sicker? Is it maybe that everyone is walking around irritable and more afraid than usual and it boils over into how they interact with others? Am I just hypersensitive? Is it a self fulfilling prophecy? 

I dunno. 

All I know is that I don’t want to do it anymore.

Then it sneaks up on me. Every single dang time.

BAM! 

There is nothing to do but just get through it. Buckle down and get it done. 

Survive. 

And we do. 

We always do.

This Friday the 13th it was different, though.

“She looks yellow…” the medical assistant whispered as I pulled up the chart. 

I scanned her info. I’d never seen her before. Hypertension. Diabetes. Cholesterol. Nothing else remarkable.

Knocking authoritatively on the exam room door, I entered.

“Hi! I’m Dr. Denisof. Tell me what’s been going on?” I shook her hand, taking in her appearance. She was quite jaundiced. 

“I don’t know. I woke up this morning and pretty much freaked out when I looked in the mirror.”

“Any other symptoms?”

She shook her head. “Nothing.”

“No fevers? Abdominal pain? Nausea? Diarrhea?” She shook head no each time. 

“Hmmmmm.”

I started examining, working my way from her head down. Eyes, ears, nose, throat all fine. Lungs clear. Heart regular rate and rhythm, no murmurs. 

“Let’s have you lie down.”

She complied.

Her abdomen sounded normal. I pulled off the stethoscope and palpated her abdomen. No masses. Liver felt maybe a bit enlarged. No pain. 

I helped her sit up.

A strange look came over her face and she doubled over, gagging. Blood poured out of her mouth and into her hands, dripping onto her lap.

“Call the ambulance!” I yelled out the door then grabbed an emesis bag, thrusting it under her mouth. She gasped and the vomit stopped for a moment before another retch wracked her body, bringing up more. The room filled with the scent of rust and iron. 

“Need help?” An MA stuck her head in:

“You called 911?”

“Yes ma’am.”

“Can you print a chart summary and her last set of labs for the EMS?”

“Sure thing!”

“And let the other patients know I am going to be running late while we deal with an emergency.”

“No problem.” 

Sirens were audible in the background, growing louder. Having a clinic so near the fire station definitely had its benefits.

Another retch, more blood. 

I put my hand on the patient’s back and looked into her frightened eyes. “You are going to be OK.” She nodded but did not look convinced.

My mind was running through the differential diagnosis. Causes of rapid liver failure, fulminant hepatitis…. infection? Some sort of aggressive cancer? Drugs? A closet alcoholic? 

The sound of a stretcher came from outside the door and two hunky firefighters in dark blue uniforms stepped in. 

“What do we have here?” the tall one asked.

I gave the run down of what I knew, pointing at the bloody emesis bag. 

As I spoke four sets of eyes grew bigger and the firefighters suddenly backed out of the room. 

What the hell?

“Hang on, I’ll be right back,” I told the patient. I left the door cracked so I could hear any more vomiting or any sounds of distress.

One of the men muttered into a radio receiver on his shoulder. The other took a step toward me, his hands raised.

“Doc, we need for you to step back into the room.”

“Why? What’s going on.”

“You are quarantined.”

What?” More sirens. Through the windows I could see police cars racing into the parking lot, surrounding the building.

“Look, no one can leave this clinic. No one. The CDC will be here shortly and they’ll explain everything.”

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

The above was a bit of fictional doctor horror brought to you by the month of October…

Taking It

Looking up at the Statue of Liberty

“He just hit on me again…” She shook her head in disbelief as she sat down the phone receiver. “The man comes in with an STD and then wants my phone number so we can hook up after he finishes the medication.”

“Again? Did he hit on you when he was here?”

“Yep. Twice.”

“Was he disrespectful?” I caught myself. What constitutes disrespect? He didn’t call her a cunt or force himself on her but then isn’t continuing to ignore her refusal as sign of disrespect? Particularly given the context.

“I don’t guess so…”

“I can fire him or have the office manager call him up and tell him to stop.”

“No. That will affect our survey results… likelihood to recommend practice and friendliness of the medical assistant….” Her pay raises and evaluations were linked by the healthcare system to those patient satisfaction measures much like 5% of my income depends on meeting certain thresholds for patient satisfaction.

“Well, you already told him no. That’ll affect it, too.”

“True.”

I think back on all of the times I have laughed off unwelcome advances over the years, people who really and truly crossed the line, and I said nothing. I stood tall and laughed it off, not showing my displeasure.

What will he think if I tell him to back off?

“It doesn’t happen often does it?” people ask. 

Depends on if you meet their definition of “pretty” or not. Then there is the question how often is too often? How far is too far?

Admittedly, “Doc, you sure look nice today,” is a far cry from “I’d like to fuck you.” 

Complements are nice. 

Harassment is not.

It isn’t like my medical assistant wears short skirts and low cut blouses. She wears baggy scrubs. I wear professional attire. Pants. A skirt to at least my knees. A blazer. Maybe jeans on a Friday. We don’t flirt with patients. We aren’t asking for it.

In the past, I have considered these sorts of encounters a part of the job. Now I want to tell this man that what he is doing is crosssing a line but is that going too far?Maybe no one ever said anything to him before. Maybe no one ever will. Maybe he will become the president of the United States or a powerful media mogul in Hollywood. Maybe I am just being overly sensitive. 

Dollars and Senseless

IMG_3774

People in the US are used to this sort of thing but I wanted give everyone a peek into the way healthcare is billed:

The price charged to insurance for OR use and three days of babysitting for a ruptured appendix was $42,500.  No ICU. This does not include the surgeon’s fee or the anesthesiologist’s bill or the pathologist’s examinationof the removed offending organ.

The amount actually paid by insurance was $8,950 with an additional $680 of patient responsibility (what the patient has to pay). 

The other over $30,000 was “adjustment”, money that will never be paid by anyone. 

The games we play. 

After the birth of my child, I received a bill from the hospital for my care… over $2,000. There were also bills for the OB, anesthesia, pediatrician, the NICU stay, etc. 

I expected the bills to be high. My baby was worth any price but I still wanted to know what my money was paying for. Being on the physician side of medicine, I don’t often get to see the $ side from the standpoint of a patient so I decided to dig.

What I found most annoying was that the bill was not broken down into anything meaningful, so I requested an itemized bill so I could see the details.

When I reviewed the several pages of information that came a few weeks later, I found several charges for questionable lab tests as well as medications that I was fairly certain I had never received. Propofol, a sedation medication commonly used in ICU… the one that killed Micheal Jackson. Dopamine, a vasopressor that is used in the ICU to keep your blood pressure up. There were a couple of obscure infectious disease tests that there was no reason for me to be tested for. I called the billing number and listed my concerns to the woman who answered.

“So are you requesting a review of the charges?” She sounded astonished.

“Yes. Yes, I am.”

A week or two passed and I received a call that said that over $700 of the charges had been removed but there were still two items that I was disputing, the lab tests that should have never been done, that they were not going to budge on.

“Well, I would like to see proof that they were done and I would like to know why because they do not make any kind of sense.”

“I cannot provide that.”

“Then I would like to request a copy of my records.”

“Ma’am you are more than welcome to request a copy of your medical record. The charge is $4 per page.”

“How big is my record?” 

“I don’t know but I expect probably over 40 pages.”

(Was it really $4/page? Maybe it was less. Were there only 40 pages to the record? Probably there was more. Much more. It was a few years ago, and I don’t remember the details exactly but suffice it to say, the cost was going to be quite high.)

“Can I come by and just review my record?”

“Absolutely not.”

I did some quick math and figured that the disputed charges were less than the cost of the copy of my medical records and I ended up just paying the dang bill as it was.

Fun, huh?

Thursday Thoughts From The Throne

Interior chandelier Grand Central Terminal

I spent a few free hours this morning doing some CME (Continuing Medical Education). Part of the requirement was listening to real physicians have “difficult” simulated conversations with “difficult” simulated patients. 

It was awful.

The only redeeming factor is that at least I get to claim two hours of CME credit. Otherwise I would feel I had utterly wasted my time. 

Seriously.

Real life “difficult” patients are not that calm and polite when you are telling them you will no longer give them prescriptions for their controlled substances….

Biometrified

Stubborn
The tall, slim receptionist took my information and motioned for me to have a seat. “He’ll be with you in a moment,” she murmured sweetly. 

I settled myself into a nearby chair and pulled out my smart phone. Time to catch up on some blog reading. 

At one point I looked up from a post and saw the woman take a bite of a candy bar. She turned to a coworker standing next to her and whispered loudly, “My biometric screening appointment is in two weeks. I have to start my liquid diet tomorrow. I need that discount!” Her coworker mumbled something inaudibe in commiseration as she munched a largish chocolate chip cookie* then said, “There is no way I will ever have the right waist circumference. I just don’t even bother to try anymore.”

Is a liquid diet healthy when the rest of the year you eat like crap and don’t exercise? Apparently her employer thinks so. 

Many employers appear to think so.

I have serious issues with companies who discount insurance plans based on whether or not an employee falls within an assigned range on their blood sugar, cholesterol, BMI, and blood pressure. Does it really improve health? I am skeptical. 

High cholesterol effects, blood pressure issues, diabetes complications… generally are not going to cause an increase in health expenditures until much later, presumably when patients are retired or no longer employed. So why would their employer care now? Between the two of us, it smacks of a way to force employees to pay for more of their own insurance costs. I wonder how much that saves corporate America? 

So sorry, that’ll be an extra $600 in our pocket. Better luck next time!

It isn’t just that I hate taking the time to fill out the forms for patients, though they are tedious. It feels like a terrible invasion of privacy. Why does an employer need to know if your blood sugar is under 100? What difference does a 102 make to whether or not you can do your job? What does a 102 mean for absenteeism, productivity, customer satisfaction, or anything else they want to measure?

“My employer seems to really care about my health. They gave me a free pedometer!”

“Has that made you walk more?”

“Well, no…”

Each program, it seems, has its own unique set of thresholds… some want a blood pressure under 140/90. Some want a blood pressure of 130/70 or less. Some want a BMI of 25 or less. Others want a BMI of under 30 or even 35. Some don’t care about where you fall, they just want you to submit the numbers. Others want you to enroll in an online health class or two. I have never had a patient come in, however, and tell me that they saw the light after one of those classes and have decided to change their ways.

Many companies require employees to go to a screening at HR rather than heading to their own physician. They have a lay person interpreting those results and giving suspect advice to my patients that can take several office visits to undo. Worse, many patients then believe they then don’t need to do a physical with their primary care physician. I lose my one opportunity each year to catch patients up on their PAPs and mammos and colonoscopies, my one opportunity to screen for depression and to talk about healthy lifestyle.

Here’s another thing, though. There are people who have “high” cholesterol who are in great physical condition otherwise and yet, because their LDL is above a certain point, have to pay considerably more for their health insurance. What difference does an LDL of 148 make when the HDL is terrific and there are no other risk factors for cardiovascular disease? I wouldn’t be putting a healthy 24 year old patient on a statin drug because their LDL is 130 simply to get them below 120 for a better insurance rate. And then there is the issue of diabetes. It is a false perception that diabetes is only about diet and lifestyle. It is a genetic predisposition. Is it fair to punish you because your diabetic parents decided to have children? Ultimately it is a form of genetic profiling and I am surprised no one has made a bigger issue of this. 

We have a version of this for employees of the healthcare system I work for. There are tons of invasive questions about my daily habits and diet and exercise routines that I am required to answer and then I have to submit my screening numbers and measurements electronically to HR in order to receive the discount. We don’t have to meet certain criteria on those numbers… yet. I choose to opt out. I have the financial luxury of being able to do that, paying more for my health insurance. Many people, though, don’t have that ability.

So what are your thoughts?

*Please note, I am not saying here that chocolate OR cookies are inherently evil. In fact, they can be part of a healthy diet.

Concierge 

Gerber Daisies

“The letter said I had to pay $2400 each year to remain a patient because from now on he was going to be running a concierge practice. I would still have to use my insurance and pay deductibles and such. He’s a good doctor but I just don’t have that kind of money!” She said it in a way that made it clear the she hoped he would not hold it against her that she would have to find a new doctor. It wasn’t his fault. It was hers…

Trust me, honey, I know him. He doesn’t give a rat’s ass.

I get told all the time that I ought to go into concierge practice. 

But I won’t. 

Not ever. 

The fact is, I would feel like such a sellout, I wouldn’t be able to live with myself.

Why do I hate concierge medicine so much? 

I want to believe that it is because I think healthcare should be equally good for everyone, not better for those who can pay more. Concierge medicine smacks of elitism. Maybe, though, it is because I don’t understand people that have that kind of money, that kind of entitlement. Yes, I have assigned an unfair stereotype, haven’t I? 

Maybe I am simply jealous of them?

And then I wonder at what point do I actually become one of those rich, entitled people? Is it when I become willing to pay the retainer fee? Or some point before? 

Do I have to have gobs of money to be one of them?

Is wearing a large chunk of fake diamond on my finger selling out, too, in a way? I have had it for just over a year now. People treat me very differently when they notice the “rock” on my finger and I have to admit that I like it, I like the deference and I feel dirty because I like it. And then I ask myself WHY does that make me feel dirty and not any number of other things from my checkered past? 

And so I come back to some level of jealousy. 

I am not noble. I am eaten up with jealousy and having to face that every day would be painfully difficult.

That is why I cannot do concierge medicine. 

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…