Rushing Past

NYC subway

After every single electronic health record update I am left feeling betrayed. Is it the EHR company’s fault? Is it the healthcare system’s fault? I don’t know and I no longer care. I am just so tired of feeling ambushed. It never feels anything gets better or more useful. 

Just different and harder. 

They took away my layout colors, the nice neutrals. Instead there is garish pink and mint green and even deep blue sea creatures. An octopus in an electronic health record? Really? Do you know how disconcerting that is? 

Yesterday the patient summaries would not print until hours later, after the patient left. Used to be that referral information printed out with contact numbers for the specialists we were sending patients to so they could call instead of waiting to hear from an office that may or may not call them. That information is not on the summary anymore. Do you know how disruptive that is when you have a full day of patients scheduled back to back? 

And then there is all of the minutia… buttons changed, orders switched, WTF?

Mayhem. 

Insanity. 

There is a grieving process that accompanies every update. It starts with hope, shock, disappointment. Then the classic five stages of grief: denial, anger, bargaining, depression, and finally there is acceptance. I am a small fish in a big, big ocean and what I or my patients need means nothing. Someone else decides for me, for them. Maybe that is the meaning of those blue fishes on the background? Swim with the group or get eaten by the octopus…

The “updates” rush past whether I want them to or not. I can do nothing to stop them. 

Adapt and accept or die.

This morning I want to hide in my bed and not go to work. I am exhausted already. But I can’t. People depend on me to put on a brave face and muddle through. 

So endure I will, secretly seething inside.

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Owed

Refurbished part of the Ellis Island hospital

The VA medical system in the US is a shameful mess, not worthy of our veterans.

If we expect someone to lay their life on the line to protect our freedom and the freedom of others all over the world, we have a responsibility to provide for their medical care and that of their families even after their service in a way that is on par with the quality of care received elsewhere in the country. 

Instead there is corruption, waste, deception. Veterans die waiting for help. I have seen the effects of poor care.

Let’s stop ignoring it and do something about it. You want to do something meaningful for Veterans Day? Write to your elected officials and demand change.

As Long as You have Your health…

Alrighty, here is another reblog for the week just so you know I am not alone in my grumbling and paranoia. Enjoy!!!!

No Facilities

The perfect place and beverage to share some casual conversation.

If we were having a beer, you’d seem concerned about my health.

“Are you in a wellness program?”

“Why, is that a requirement for drinking here?”

“No, of course not. I was just wondering. My company just started one and it looks interesting.”

“I have access to a wellness program, but it’s not direct with our company.”

“Through your health insurer?”

“No, through the organization that provides the health insurance to our company.”

“Hey guys. Just so you know, it’s not like I’m not concerned about your health, but I am here to sell you adult beverages, barbequed chicken wings, pizza or pasta smothered in cream sauce.”

“Hi Cheryl. I’m not sure where this conversation is going, but before he condemns my poor choices, I’ll have a Yuengling.”

“And I’ll have a glass of Meiomi. So, what’s the scoop on…

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Going Places

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“Ok, I’m going to call it. Any objections?” 

Silence from the room. 

All motion stopped. No more CPR. No more rummaging for the next medication in the crash cart. The nurse on the phone calling for another two units of pack red blood cells simply stopped mid sentence and hung up.

I dropped the empty syringe that had spent the past hour and a half clutched in my right hand into the pocket of my white coat. The fingers were stiff and achy as I stretched them out. “Time of death….” I cranned my neck around the greying head of the house supervisor so that I could see the wall clock by the door. “…. 0325.”

“Good job, everyone. Let’s clean up so we can let the family back.”

Syringes were counted and recorded by the clerk to make sure the amount of each med given was accurately reflected in the log. Debris was swept up. Hands gently covered the emaciated body with a gown and pulled up the sheet, the eyelids were closed. A nurse took out the IV and another pulled the tubes from his nose and mouth, wiping the blood and mucous from the now lifeless lips. 

He looked so peaceful.

Cancer of the stomach. He had certainly suffered. He was not willing to die peacefully, refusing hospice and refusing to sign a “do not resuscitate” order. He fought even at the end. 

My wrist still hurt. 

I liked being around death. It was hard to explain to people. They would stare at me with a puzzled and slightly horrified look on their faces, lost for words so I stopped talking about it altogether. I always wanted to ask the dying to put in a good word for me when they got to where they were going, but I never did.

One by one everyone left the room.

In a minute I would go out to his wife and children and explain that we had done everything we possibly could but I needed a minute before facing the onslaught of grief.

I put a hand on his chest and said a silent prayer for his soul, then one for mine. I looked back up at his face. Strangely, his eyes were open. They were a bright blue. The bluest blue I think I had ever seen.

Then they blinked.

A hand grabbed my shoulder and pulled me closer. 

His hand. 

My heart skipped a beat as fear rushed through my body and into my fingers and toes. 

Then the hand let go and fell back to the bed with a flop, as if there was no more energy left. It must have been some sort of cadaveric spasm…

“She knows.” 

The rasping sound came from his lips but how could that be? He was still attached to the heart monitor, someone had forgotten that detail, and there was no heartbeat. I checked for a carotid pulse. Nothing. No breathing.

“What do you mean? Who is she?”

The eyes bore into me. 

His lips moved. “She knows…” I touched the lips. They were cold.

“Who is she?!?!??” I asked again.

No response.

My voice rose as I asked again and again but the blue eyes just stared back at me never wavering. I grabbed the shoulders and shook him but he still provided no answers.

Anger and terror rose up into my throat, swelling into a tight lump that lodged there. My brain raced from irrational thought to irrational thought. I could not breathe. 

Someone knew what I was doing? But how? I’d been so careful!

My hand touched the pocket with the empty syringe.

Rage. 

I grabbed his shoulders and shook him. Hard. I punched the chest. I yelled at the blue eyes, tore at his lips…

Someone pulled me away.

“Doc! What the hell is wrong with you?”

“She knows. She knows. She knows. She knows. She knows. She knows. She knows. She knows. She knows. She knows….”

Thursday Thoughts From the Throne 

Weight of the world

I dressed for the meeting carefully.

Sexy lingerie? Check.

Slimming black skirt? Yes!

High heeled black leather power boots? In place on my feet.

Hair perfect? Oh, yeah… definitely.

Make up perfect? Absolutely. Double check that no lipstick made its way onto my teeth and no bits of blueberry from my breakfast smoothie are lodged at my gum line? Done!

In my head, I am IT. I am a bad ass lady doctor, strong and capable. I feel the part. 

I make it through the meeting. I see a full day of patients. I joke around with my staff. I drive home.

When I get home I pause downstairs to admire my profile in the mirror one last time before heading up to change into shorts and a t-shirt.

What the heck?

My cheeks flush. All confidence sails out of my body. I feel weak in the knees. Suddenly, I am no longer strong enough to carry the weight of the world on my shoulders. 

Instead, I am crushed by it.

One little tiny button off on my vest and all of the rest were buttoned up cattywampus. THIS is how the universe conspires to keep us humble….

Perhaps it is time to invest in a full length mirror in my bedroom.

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

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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 #6

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.