Proximity

Pizza shop in New York City

“I need to do a six month physician supervised weight loss program before I can get the gastric sleeve covered by my insurance.” She wasn’t even that heavy to start off with, her BMI was 32. She wasn’t diabetic and did not have high blood pressure. 

“You are going to be married to a fistful of vitamin supplements for the rest of your life.”

“I don’t care. I am tired of being fat, of having people judge me.” I understood. People can be so cruel. “My friends have all had it done and they look great,” she said hopefully. “But I can’t loose too much weight right now or I won’t qualify anymore…”

We both knew she had no intention of really trying. 

Sure enough she demonstrated a nice weight gain at each visit and steadfastly refused to count her calories or exercise or do anything except to say, “I’m cutting back, Doc. Really I am. I don’t know why I keep gaining this weight!” 

I don’t know why that sort of thing qualifies someone for surgery. A barbaric surgery with lifelong consequences. Sometimes I wonder about the ethics of the surgeons doing these things and why there isn’t better after care for people undergoing the knife. Cut them up and then cut them off seems to be the plan across the board. 

She had her surgery. 

Three years later her weight was back where it started from and then some and she wanted a referral for a surgery revision. 

I wanted to say, “I told you so.” And then I wanted to call her surgeon up and give him a piece of my mind.

But I didn’t….

A few weeks ago I was at one of those giant outdoor malls. There were easily 20-30 restaurants clustered around. Right there in the midst of it all there was a weight loss clinic. 

Having just eaten at the Melting Pot myself I was so stuffed it was hard to breathe. Way too much food to be healthy but then why didn’t I just stop eating? I was too focused on not wasting anything. Getting my money’s worth. I blame my upbringing. I blame past poverty. I blame portion sizes. 

I blame myself.

Where does that come from, anyway?

At first I was offended that this clinic placed itself where it did. Then I realized it was a brilliant marketing strategy. This is what we have become, isn’t it?

Binge. Purge. Binge. Purge.

Binge.

“How’s your daughter?”

He smiled and pulled out his smart phone, flipping through pictures of a grinning, curly haired toddler. They’d had so much trouble having a baby. 

“Oh, she’s beautiful!” 

He nodded, beaming.

“How is your wife?”

His face changed in a instant. He looked stricken. “You knew she had the gastric sleeve done?”

“Yes, I had heard.”

“Well, she developed Korsakoff Syndrome.” Oh. Wow. “She got confused, couldn’t remember things. Couldn’t walk straight.”

Thiamine deficiency.

“When she said she wanted to get the surgery, I didn’t say anything. I just wanted her to be happy. She suffered so much emotional turmoil over her weight. We had no idea something like this could happen, though. If I could go back in time I would tell her she didn’t need to do it. That I loved her just the way she was. Now she is not the same person. She has to carry a book with her to write everything down since she has so much trouble remembering things and she uses a cane to get around.” 

“Mommy, I’m thirsty!”

It was swelteringly hot. I stood in line to get our fifth soda refill of the day in the $15 red amusement park drinking bottle I had purchased earlier that morning.

*Free* refills on Coca-Cola products all day!

I don’t need Coke products. My kids don’t need Coke products. Water would do just fine to keep us hydrated. But STILL…. I paid $15 for that stupid cup since I could not bring anything into the amusement park. I want to get my money’s worth, dang it. A small bottle of water costs $4.50 a pop multiplied by at least five times per person per day… but soda pop in the big red drinking bottle? Yeah. What is anyone going to pick?

So here we are.

Making money by making people fat. Making money to make people skinny again. Making money getting them fat again. Making money to get them skinny again.

And so on.

It does not ever stop.

How do we make it stop?

Emergencies 

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

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

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

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

Honestly, it has been a rough week. 

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

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

It is like this every year. 

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

Shopping Around

Macy's in New York City

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

I’ve seen this a lot lately.

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

So she came in….

Crying.

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

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

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

Tall and Skinny, No Whip

The Empire State Building

“Your patient is on social media Tweeting about it.”

“Tweeting about what?”

“The weight thing that prints out on the after visit summary for the patients.”

Come to find out she had also called and spoken to my office manager and my practice administrator. 

Good for her.

When we first moved to this electronic health record last fall one of the most annoying things was that on everyone that the program deemed “overweight” or “obese” got a large bright yellow box on the screen that alerted to me to the fact that I needed to add weight loss to their goals. 

I always hit the ignore button but it annoyed me that now I had to click an extra button because it stood between me and each patient’s active problem list. Not everyone needs to have “obesity” on their problem list and I would argue that NO ONE should have “overweight” as an official diagnosis. People who are “overweight” and  “obese” know good and well where they fall. They certainly do not need a computer “diagnosing” them with it, too.

I growled inside each time I saw that yellow box.

Then sometime in March I noticed that all of my “overweight” and “obese” patients were getting detailed weight loss instructions printed on their end of visit paperwork. It was going so far as to tell them exactly how much weight they needed to lose to reach a BMI of 25.

WHAT? I didn’t tell it to do that!

It was autopropagating. Someone flipped a switch somewhere which meant a good many other someones approved the change.

What were they thinking?

Shouldn’t I have control over that? Shouldn’t I be the one to decide? I am the doctor. I know the patient. 

I complained.

Nothing happened.

I mentioned it again.

Still nothing happened.

Some of my patients have eating disorders. A number of my patients have serious emotional issues wrapped up in their obesity. These people for sure should not end up with that kind of stuff on their handouts.

I messed around with the program for a while and discovered that I could manually remove it from the print outs if I clicked an obscure “X” box on the wrap up page at the end of the visit. I have to scroll down to the bottom of the screen to find it. That meant that on every patient I see every day I would have to scroll down to that area and click a box to remove weight from their goals.

I should not have to do that. There are literally 30 million other clicks I have to remember on each patient at each visit. Give me a busy day and things will slip through the cracks. This is something where the cost of human error is too great in my opinion.

For this patient, I was running 30 minutes behind. On hers I forgot to click the button. The print out told her she needed to loose over 30 pounds and detailed the diet and exercise changes she needed to make to get that accomplished. So she went to social media with it.

Suddenly, everyone downtown started scrambling. There will be a meeting now to discuss this.

And I am so very angry.

But not at her.

What does it say about a system that responds to social media pressure before it listens to its own physicians? And why would you ever pick a BMI of 25 and set it as the automatic weight loss goal for every single patient? What about the studies that show that people who are in “normal” BMI range do not live as long as those in the overweight range? That a decrease in life expectancy does not occur in obesity except for the extreme morbid obesity range?

Obesity isn’t killing people. Diabetes is. Cardiovascular disease is. We have put such a focus on weight that we have sabotaged the patients who are most vulnerable and as far as I am concerned we are killing them.

“I can’t lose weight so what’s the point of exercising and eating healthy?” 

I hear this every day.

Weight is not the point. It should not be the point. Healthy lifestyle is. But rather than use those things as the goals they made weight loss THE goal.

Fine.

Maybe I cannot change their mind. Maybe I cannot change yours. But do NOT force me to participate in a game that I do not want to play.

Next time I see that woman I am going to give her a great big hug and a high five.

Depressions

New York Public Library entrance

“I see from the medical assistant administered PHQ-2 that you have been feeling down lately. Tell me about that.”

“Uh, I am here for my knee. Why was she asking me about depression?”

“Well, we want to put a focus on mental health, you see…”

“What about my knee?”

“We’ll get to that at your next visit. Right now all we have time for is delving into this positive two question depression screen.”

“You guys never did this before.”

“I know. But here we are. Better late than never. So are you thinking about killing yourself?”

“NO!”

“Should we put you on medication?”

“I don’t like drugs.”

“Counseling then! Good choice. I’ve got a list of counselors in the area…”

“I am not paying for counseling and I haven’t got time for it in the first place. My knee is what is getting me down.”

“Yes, well. Come back in two week’s time and we can talk about the knee.”

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

That wasn’t real. But it could be….

The healthcare organization I work for is now measuring my quality based on my medical assistant asking patients questions about depression once a year right before they check the blood pressure. 

I have yet to have a patient say this was a good addition to their rooming procedure but that is beside the point. Why are we focusing on this in the first place?

To save lives.

Personally, I hate questionnaires. They are an attempt to oversimplify a very complex problem. Can we really put depression into a box? Should we?

If the PHQ-2 is positive it should be expanded into the PHQ-9. The PHQ-9 should be used to monitor response to treatment. 

I much prefer a conversation with a patient to reviewing a questionare. I can tell, usually, when a patient is having a hard time but even if I can’t I still ask once a year at the physical as part of my review of systems. And if they say they are having problems I pry, by golly. Are we talking about a chemical imbalance or did their mom just die? Is it affecting their ability to hold a job? To take care of their family? My medical assistant shouldn’t be the one asking the questions. It should be ME. That is my job. Which then brings me to documentation. Make it easy for me. Don’t hide it on a different screen. My review of systems documentation should be sufficient shouldn’t it?

It frees the physicians up to do other more important things.

What is more important than mental health? But then, I wonder, are we perhaps overemphasizing it on some level, too?

When we made pain into the “fifth vital sign” we created a whole population who became focused on feeling no pain, a pharmaceutical industry happy to create addictive drugs that prevented anyone from feeling pain, and physicians caught in the middle. Ultimately, the prescription narcotic addiction crisis was the unintended consequence.

So I worry that we will over diagnose depression. I am not sure that assigning labels like that is all that helpful for most people. I worry that those who are truly ill, who need the most help, will be pushed out of an already failing system that becomes glutted with everyone else. I am already seeing this trend. Making my very ill patients wait three to six months for an appointment with a reputable psychiatrist is unacceptable but it is par for the course nowadays.

The mental health system in the US sucks and that’s the truth. It especially sucks around here. There is a dirth of good psychiatrists in my area. Same with counselors and psychologists. What are we supposed to do? Should we as primary care just push drugs on everyone? Drugs that have side effects and risks and which are not appropriate for all patients? Who then will manage those drugs? Me? With very minimal training? And if we push drugs but cannot effectively pair it with counseling support, what have we accomplished? We are supposed to help, to make people better aren’t we?

I’d really like to know YOUR thoughts…

A Supporting Role

Bridge in NYC

“She just won’t eat healthy stuff! If I give her a cupcake and some broccoli she always eats the cupcake.”

“Think back to when you were eleven. If you have a cupcake and some broccoli in front of you, what do you pick?”

He shrugged. “The cupcake.”

“Right? Me, too. We’re not idiots. We pick what tastes best to us. As kids that’s the sugar. So you cannot put them both in front of her and expect her to pick the broccoli. That’s just cruel. She’s eleven. YOU have to make that decision for her until she is able to make it on her own and that is not going to be for a great many years. Get the cupcakes and junk out of the house. She is beautiful no matter what size she is but you and mom both have diabetes so she is at higher risk herself. Be the parent. Don’t sabotage her. Help her learn healthy habits that will last the rest of her life.”

We had this conversation every summer for five years running. Each year the same thing, like it was her fault. But this time? This time, somehow, was different….

This time he listened.

What made the difference? I don’t know.

It gets discouraging, saying the same things over and over again. There are days when I open my mouth to say, “Stop smoking!” for the millionth time and wonder if there really is any point. You never know, though, when the seeds you sow will fall on fertile ground and take hold. 

A Mistaken Identity 

Hudson Bay clouds

My heart sank into the floor.

“You did what?”

“I gave the wrong immunization! I didn’t look close enough at the orders.”

The baby ended up getting a double dose of one of the routine childhood vaccinations because my medical assistant gave the wrong combination vaccination and overlapped. It was not a terrible error, as far as medical errors go, and would not cause harm but try to convince a parent who has gone through multiple miscarriages and IVF to get this one beautiful baby boy. It was not a phone call I looked forward to making.

I could ignore that it happened, sweep it under the rug so to speak. Make it disappear. They would never know….

Still it had to be done. They had the right to know. So I did it. I called and explained and reassured. They seemed to take it very well at the time, or so it seemed.

I see FOUR generations of this family. 

Four.

Or rather, saw. 

They left my practice. 

To be honest, if it were my own kid I would have probably not been nearly so nice about it and I would have also taken my kids elsewhere. I am not upset at this family at all. It hurts but I totally get it. 

Trust is gone.

This was the first time an incorrect pediatric vaccination was given by a staff member to my knowledge in my practice. Fourteen years. That means nothing when it’s your kid. One mistake. Made by one of the best medical assistants we have, the absolute last person I would have expected to make an error. She will carry that one around for a very long time. 

So will I.

We can learn from every mistake, can’t we? 

If I told you I had never made a bad call or made a mistake myself I would be lying to you. There is no perfect doctor. Sometimes we lie to ourselves. Sometimes we lie to other people. That is how we keep going each day. We are not perfect. I know each and every mistake I have made over the years and they play in my mind over and over again, their faces pop out at me usually when I am already upset about something else that is unrelated. 

See? You suck, you suck, you suck! 

Why does our brain do that to us? Kick us when we are down?

Sometimes it is hard in the aftermath of a “mistake” to clear the mind and keep focused. There are other patients to see, my family to take care of. Still, I also need time to grieve and process. To forgive myself. To forgive others. I need people around me, my family, to let me do that without trying to “fix” me. Eventually my mind will settle down and move on.

Because life goes on.

It always does.

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.