The Overseers

Through a window at the American Museum of Natural History in NYC

I see your drones flying overhead,
Your truck driving by.
I know you are watching me,
Following my every move… 
Silently waiting 
For the proper time to strike. 
You know my internet searches,
The names of my kids. 
You know my habits 
And my darkest faults. 
Some days you know my secret wishes 
Before I can even get the chance 
To wish them. 
Always there, behind the scenes 
Your satellites measuring my level 
Of devotion. 
Well placed hints, strategic glimpses, 
All forms of intimidation
Meant to remind me that I am yours 
Entirely,
Forever subject
To your every whim.

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

If you want to see something fun, zoom in on the bottom left of the photo.

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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…

Impact: Chapter Six

Chicago elevated train.

I awoke to sunlight streaming in through the windows. I stretched lazily. There was nothing more blissful than waking up to bright, warm light on your face after a long shift. This was why I always opened the curtains before crawling under the covers. That, and there was something reassuring about waking up in the night to see the lights of the city outside. It helped with the loneliness.

My shift! OMG.

My heart leapt into my throat and I sat bolt upright in bed. I had picked up an extra shift. I was supposed to work today.

Why hadn’t the alarm gone off?!?!!?!?

I distinctly remembered setting the alarm. Did I do something wrong? The new phone lay on the empty pillow next to me. I snatched it up and after hitting the button over and over again found that it was dead. 

How? 

I checked the power chord. It was plugged into the phone and the wall properly. Last night should have been a clue when email wasn’t working, I realized. I picked up the land line phone beside my bed. I needed to call in but there was no dial tone. I punched a few numbers and clicked the receiver a several times. Nothing. I slammed the receiver down in frustration. 

Skidding to the bathroom, I flipped the light switch but no light. I tried every damn light switch in the apartment but none worked. The clock on the microwave was a black, empty space. The TV would not turn on. Soon it was clear that the power was off completely. 

There hadn’t been a storm, had there? 

I checked out the window. The streets looked dry.

The clock on the wall in the kitchen read 9:18. I wondered if it was right or not but remembered it was battery operated. I was so miserably late and this time I did not have a Good Samaritan excuse. They probably wouldn’t believe me about the power.

I threw on some clothes. I had a habit of sleeping naked. It felt good to strip off all vestiges of the day and lie beneath clean sheets but now I felt terribly vulnerable. 

Exposed.

What was going on?

I would have to sort out everything later. The first order of business was getting to the hospital. 

Brushing my teeth helped. So did splashing water on my face. Quickly, I pulled my hair back into a ponytail. There was no time for make up. I shoved my make-up bag into the satchel next to my computer and headed out the door. Maybe I would have time later to apply something. I didn’t want to scare the patients…

Without my phone, I could not summon Uber. I was going to have to use the train. I zipped around other people as I ran two blocks to the nearest station. I flashed my card at the till but the light did not turn green. I tried again. 

Still red. I was getting frustrated and contemplated just hopping over.

“Hey, lady, do you think you could maybe go through or get out of the way?” The voice behind me was irritated. I turned to see a blond twenty-something in a light gray suit wielding his briefcase with an air of self importance. He glared at me. He was probably running late, too. So was the middle aged woman behind him and the older woman behind her.

“It’s broken.”

He rolled his eyes and reached around me with his card. The light turned green and he pushed past muttering obscenities under his breath.

The woman behind him did the same. I tried my card again but still got a red light. 

Fine.

The bodies behind me were pressing forward. I backed up from the turnstile pushing past the line that had accumulated behind me and did a quick visual search for a kiosk. 

Something was wrong with my card. Maybe I had lost track of how much was on it? I found one of the vending machines and attempted to load more money onto it but the message flashed that the card was invalid. I tried to purchase a regular ticket using my bank card but it said that card was invalid. Then I tried my credit card but received the same message.

Damn it!

Precious minutes were wasting! I fished out some cash and purchased a ticket that way, then made my way to the platform. 

I found a seat in the corner of the train and stewed. How could it be possible that all of my cards were dead? I watched the faces of the other commuters, wondering if any of them was experiencing something similar. No. They all seemed calm.

I decided to distract myself by putting on some mascara and lipstick.

At the next stop a woman settled into the seat next to me. She looked like a talker. I scooted closer to the wall and crossed my arms across my chest, hoping the body language would send the clear message to leave me alone. I couldn’t bury my head in my phone since it wasn’t working. I felt exposed again.

“Good morning!” 

Clearly, she had not gotten the message.

“Morning,” I muttered.

“You look like you are having a bad day.” 

I glanced over at her and raised an eyebrow. 

“My daughter, Cordelia, does the same thing.”

“What?” I was puzzled.

“Wrinkles her forehead like you do.”

“Oh.” I hoped the clipped response would shut down the conversation. 

It didn’t.

“I work in real estate as a paralegal. It is the most dreary office ever, so small you would think it had once been a closet. I feel the life sucked out of me a little bit each day.” My brain flashed to the scene in The Dark Crystal where the Skeksis drain essence from the Podlings, leaving them dessicated, mindless zombies. “Where do you work?”

“In healthcare,” I said carefully. Admitting that I was a physician always opened me up to awkward questions.

“Oh how nice! What exactly do you do in healthcare?” She smiled.

“I’m in housekeeping at the hospital.” It was sort of true.

She squinted at me, then laughed. “That’s funny! I would have put you in management. You just never know about people.”

I shrugged.

“I get off up here,” she said, digging her purse. She handed me a business card. “If you ever need to buy some property…” She winked as the train stopped, then was gone.

I tucked the card into my bag next to the accident victim’s card, shaking my head. What a 24 hours this had been. 

The rest of the trip passed in blessed silence. 

At the correct stop, I exited and ran the remaining few blocks to the ER at Northwestern. I stoppped at the nurses’ station to catch my breath and survey the lay of land. I could see they were fully staffed. There was Dr. Prick, I mean Dr. Waters, back again to make everyone miserable. There were three other physicians seeing patients but they and the rest of the staff pointedly avoided making eye contact. I checked the board. I was not on the list for today. Then I realized my name had been erased from the rest of the week, replaced with Dr. Waters’ name. A sense of foreboding came over me.

“Dr. Benton!” It was the ER director, Dr. Boyack. Someone must have alerted him to my presence. “Why don’t you step into my office?”

Oh, god.

I followed him into the tiny office around the corner. He settled himself behind the desk, motioning to the chair across from him. The room was sparsely decorated except for an ivy plant by a window that looked out onto a brick wall and a framed illustration of a busty female robot stood on the corner of the desk. Eccentric was the word for him. He studied me for a moment, probably for dramatic effect, then leaned forward, steepling his fingers in front of his long beard. 

“We have decided to let you go, effective immediately.”

I let out the breath I hadn’t realized I was holding. A million panicked thoughts were racing through my brain. When I didn’t respond, he continued.

“You have excellent patient satisfaction scores. The staff loves you. But we need someone more reliable.”

Wait! I wanted to scream at him. This isn’t fair! But in his defense, I had a habit of running late. Getting used to the unpredictability of Chicago transportation had been difficult. If I had not already established a pattern of behavior, we would not be having this conversation. So instead I just nodded. 

I was not sure this day could get any worse but at least now I had time to figure out what was going on with my bank and credit cards and to try to get the power back on at my apartment. Oh, and the phone. That goddamn stupid phone that I had been forced to get after the men in suits had stolen my original. I fingered the cold screen in my pocket. I wanted to take the cursed thing out and stomp it to pieces right then and there. 

But I didn’t.

He pushed a long, white envelope across the desk. “Your last paycheck. I’ll need your badge and keys.” He smiled sympathetically.

I dug the items out of my bag and dropped them onto his desk, giving a satisfying clang as the metal and plastic hit the fake mahogany surface. I opened my mouth to speak but thought better of it, choosing instead to leave the office without a word. As I reached the door he called out to me.

“Hey, Dr. Benton?” I paused, looking over my shoulder. “Good luck. I have a feeling you are going to need it.”

Chapter One

Chapter Two 

Chapter Three

Chapter Four

Chapter Five

Impact: Chapter Five

The Bean in Chicago
I lay there wondering if I would ever be able to breathe again. 

We moved faster and faster.

Faster…

Then suddenly everything stopped.

There was a look of horror on the man’s face right before I connected with him, knocking the air out of my chest. The seconds of weightlessness just beforehand seemed like an out of place dream sequence in slow motion, especially with the startled screams going on in the background. 

I looked down at the man I had landed upon. His nose was broken, blood pouring from it. He wasn’t breathing. It wasn’t my fault, this whole thing, but I felt guilty nonetheless. I saw an arm beside me, impossibly bent with shards of bone protruding from it. At first I thought it was his arm, then realized that it was my own.

Whimpers. Cries for help. 

I could not move. 

What to do next?

I shrugged it off and stood up from the plastic seat, slung my bag over a shoulder, and exited the train.

On the platform people stood waiting to board, avoiding eye contact with everyone else around them… I wondered how many others were having these same images?

The truth was that death followed me. These intrusive scenes popped into my brain at the strangest times. 

What if that taxi cab hops the curb and takes me out?

I used to wonder what was wrong with me. It wasn’t that I wanted to die. One day I realized that maybe it was the opposite. That I wanted to live so much my brain was preparing me for survival by throwing scenarios at me to work through. So I stopped being afraid of it.

I walked the remaining few blocks to my apartment. It was dark and only few people were on the street. Some people were afraid to walk at night in Chicago… the most violent city in the United States. 

My apartment was lonely and I tried to avoid it as much as possible, instead lingering at the hospital for hours after my shift so I could stay around people. 

The key turned in the lock and I moved around flipping on lights. While heating up some ramen with cheese and frozen mixed veggies I paused to check email on the new phone I had picked up on the way home. An alert popped up to say that my password was incorrect. I reentered it and the message popped up again. 

Well. That was weird.

Probably just a bug since the phone was new. It would probably sort itself out in the morning.

I flipped open my laptop and tried to log in that way. No dice. 

Maybe hotmail was down for some reason?

The microwave dinged.

I tried to pull up a movie on Netflix, only it said my account didn’t exist. Hulu and Amazon were the same. I tried to call the hospital, but my phone said no service.

I decided to eat and get some sleep. Tomorrow was another day. I would have to sort it out then. 

Chapter One

Chapter Two

Chapter Three

Chapter Four

Embellished

img_3987

I used to be an author.

Every day I wrote two dozen or more short stories. 

Some were comedies:

“The pain in the right knee started after a snowboarding accident in Aspen two months ago during a spring break trip with friends. He swears that a tree suddenly jumped into his path and evasive maneuvers failed.”

Some were tragedies:

“The patient states that she learned last night that her husband has had a two year long affair with a coworker. She would like STD testing and something to help her sleep for a few days.”

Now I am supposed to point and click predetermined text to generate my note. It comes out something like this:

“The episode started two months ago. Pain is in the right knee. It is worse with movement. It is better with nothing.”

Where is the patient in that? Gone.

Then it is followed by a long list of smart text that generates an office note so full of crap that it is impossible to get to the meat of things quickly. I routinely get 4 page notes from specialists. I read the first paragraph and then the last page to hopefully figure out what is going on. The rest is meaningless drivel that is tacked on for billing purposes. I scan through hundreds of pages of documents every day. You know how I can read so many blog posts so quickly? Years of practice…

We are losing our humanity. 

Change the human body from a person to a machine.

Change the healthcare providers into automatons.

It is inevitable, isn’t it? Dehumanize the patient. Dehumanize the doctor. Dehumanize the nurses and medical assistants and other providers. Do it little bit by little bit. If you do it in one fell swoop, there will be rebellion. Whittle away at it in small bites so it is easy to swallow and then one day we will all look up in horror at what we have become but by then it will be too late.

Once you have done it to healthcare, do it to every other aspect of our lives. 

Little bit by little bit. 

I think, perhaps, it is already too late.

Homework assignment! Ask to read what your doctor writes about you next time you go in…. 

Impact: Chapter Three


I glared at the group of men until the laughter died down. 

Finally, the one who had led me to the van spoke up. “Happy Halloween!”

“What?” Now I was really confused. Halloween was Monday. Last Monday. Seemed a bit late for a Halloween prank.

“The whole thing was fake.” He gestured down the street. The ambulances and police cars were gone. No more flashing lights. “It was part of a TV show pilot…”  He shrugged. “You weren’t supposed to be there.”

“Bullshit. His injuries were real.”

Another man spoke up. “They can do amazing things with make up and special effects nowadays.”

I wasn’t stupid. I nodded slowly and smiled. “Sure.” I chuckled a bit for good measure. “Wow. Completely had me fooled.” 

“Here.” I was handed a damp towel. The rust color of dried blood stained the white fabric as I cleaned up. It sure smelled like real blood. 

My hands appeared clean but I still felt contaminated. I would for a long while…

I handed back the towel and was passed my bag.

“Thanks.” I slung the strap over my shoulder. “Am I free to go?”

“Absolutely.”

I started walking quickly, back the way I had come. I wanted to put as much distance as possible between us. As I neared the place where the body had been, I turned back. The van was gone. There should have been blood on the ground, but it had been cleaned up, somehow, as if the man had never existed. The whole thing had been so surreal…

Then I remembered the business card I had shoved into my pocket.

I fingered the corners to make sure it was still there. No way was I going to pull it out in case someone was watching.

Work!

I picked up my pace. They said I wasn’t supposed to go to work. Like they could be trusted. I reached for my phone but realized it was still in their possession. I spun around, then remembered they were gone. 

Damn it!

Fine. Maybe I could use the “find my phone” function to locate the bastards. I walked even faster toward the hospital.

Then, again, did I really want to know? 

I wondered if it would be a HIPAA violation to look up his name in the electronic health record at the hospital. Probably. But still, I had “treated” him. We had established a physician/patient relationship, right?

Wait. How did they know MY name?

An idea struck me. I watched for traffic as I carefully crossed the street, using a hand to pat just above my left breast. 

Bingo.

My fingers connected with a cold piece of plastic. My ID was clipped to my shirt collar. I kept it on a retractable clip so I could pull it out to unlock doors. It would zip back up when I let go.

Well there you go…

———————————

Chapter Two

Chapter One

Virtual Perfection

img_2856

My new electronic health record (EHR) likes to be helpful. Very helpful. It is full of all sorts of suggestions to ensure that my care is better than best.

For instance:

When I prescribe a birth control pill, a warning flashes up in the form of a red and yellow pop-up to remind me that it is contraindicated in pregnancy. Um. Duh? The patient isn’t pregnant. Not yet anyway. 

Similarly it wants me to know that metoprolol, a medication used for blood pressure and the heart, is contraindicated in chest pain. Well, Ok…

Dozens of commonly used medications have absurd warnings. What I am most afraid of is getting to the point where my brain blocks out all warning pop-ups because at some point I am going to get alerted about an allergy that I forgot about. I don’t want to automatically click through that alert. It would help if the medication allergies were listed on the same screen as the order entry screen. Wishful thinking, I guess.

The EHR wants me to add “Morbid Obesity” to everyone with a BMI over 30 and “Overweight” to everyone with a BMI over 25. For many of my patients, rubbing their noses in their weight is counter productive AND the bigger question would be is being overweight by BMI standards really a medical condition? I don’t think so. THEN it wants to suggest that I send the patient for nutrition guidance. That would be all well and good but when was that ever covered by a patient’s insurance company? Almost never. Even for diabetics, thank you very much. I have yet to have a patient volunteer to pay $1,500 for nutritional guidance with a dietician. I sure as hell wouldn’t.

Are you coming in for strep? Well, the computer wants to remind me that you also need your tetanus booster. Except that I already gave you a tetanus booster two years ago. You are good for another eight years, technically. In fact, the computer has that immunization in the shot record, it just isn’t giving you credit for it. Or me credit for it, apparently. I have to go through a complicated series of maneuvers to “properly” record that you had the vaccination. It cannot be easy. Oh, no.

Oh! I have patients that are finding their records merged with old records from when they saw an unrelated doctor in another part of the state over fifteen years ago. Kinda fun, except that their name is now reverting back to their maiden name or some other nonsense and I have to delete those ancient meds off of their current med list before anyone gets confused.

Speaking of the magical appearance of meds, do you have something you don’t want your PCP to find out about? TOO BAD! If you fill an antibiotic or any other medication at a pharmacy from another provider, I’m gonna find out. That has made for some awkward conversations with patients about their over utilization of teledoc services… I hate it when they cheat on me with another physician!

The EHR fills in quantity and refills on many of the meds I order automatically, except it often isn’t correct. For instance, a Z-pack (azithromycin) that it says to take two pills on the first day and then one pill every day thereafter, auto fills a quantity of two rather than six. Or amoxicillin three times a day for ten days sometimes auto fills a quantity of 20 rather than 30.

It is still early. We will see how this continues to shape up as I get more proficient.

Dark Days

pond before a rainstorm

So how was it? The first day of the new EHR?

If you really want to know… It was a cluster F**K with a capital “F”.

I don’t want to bore you with all of the gory details but suffice it to say some clinics had staff so frustrated they were just walking out, quitting on the spot. 

My staff is all coming back tomorrow. I think. I’d like to believe that pizza and slushies and chocolate helped but I am not sure there was anything that really could have made it better short of an electrical fire. A devastating electrical fire….

Hmmmm.

There’s always tomorrow.

The End and The Beginning

Yesterday was the last day I had to use our old electronic health record. I hate that thing. Loathe it. In fact, I am not quite sure there is a word in the English language that would adequately convey the depth of my negative feelings about that thing. If I could physically place that EHR behind the wheel of my truck and roll over it back and forth until it was pulverized, it would be very gratifying.

However, as I closed it out for the last time, my virtual desktop completely empty, I felt an odd sadness that I had not expected. I spent nine years learning how to play that game. I knew how to navigate the system, work around its weaknesses. It was familiar to me. I was comfortable because I knew what to expect. I knew how many clicks X, Y, and Z required. If I couldn’t print, I knew I needed to log out and try to get hooked up to a new server. I knew how to phenangle clicks to get credit for preventive care, even if it was laborious. I knew lab orders and imaging orders could get lost, how we needed to utilize a back up plan. I knew that no matter how much I complained about the screen blanking out periodically, or the eprescribe function sometimes not working, the help desk would always say that it was a “known problem” and there was no ETA on when it would be fixed, if ever.

On Monday, I will log into a completely different system. A better system. As I drove home yesterday I realized that I now felt more professional, more grown up, more like a “real” doctor. I felt taller in my seat, somehow.

Now I have a grown up EHR. 

Then a black cat sauntered across the street in front of me at a stop sign, mocking with his bright green eyes….

Seriously. It was eerie.

The reality is that I don’t know what the hell I am doing in the new system. The training sucked as all EHR training does. I don’t know what to expect. I don’t know where the holes are or how the work arounds need to function. I don’t know how to get credit for preventive care. Heck, I’m not even sure I can construct a coherent office note and we will be taking a hit financially due to the switch since the new system is more expensive and we have had to operate at reduced capacity due training requirements.

What is the future going to be like in my virtual world going forward? 

Hmmm…

Black cats aren’t really bad luck, are they?

Advisory

Taylor, a high school student thinking about medical school, asked some questions on my It’s All An Act post about six weeks ago. I had been saving these because I wanted to think about them for a bit.

How did you choose your specialty?

I chose family medicine so that I would not get bored. I get to see patients diaper to diaper and everything in between. In truth, I had it narrowed down to surgery, psychiatry, and family medicine. Surgery was a lifestyle I was not sure I could cope with in the end, despite how much I loved it. Psychiatry… that deserves its own post, but after doing a few extra rotations I was disheartened by what I saw. That left family medicine. I still think I picked the right one, despite my grumblings about the various frustrations of primary care.

If you had the chance to change anything about your career, what would it be?

The EHR. I will rant more about this later. I don’t understand why we cannot have a simple, straightforward system that is intuitive. This is 2016, for crying out loud. We put man on the moon decades ago! This is not rocket science.

Is medicine worth the 20 years of education/sacrifice in your twenties?

Yes. I have a placard that hangs over the door in my office, so I can see it every time I step out to see a patient. “One shoe can change your life. -Cinderella” That may seem cheesy and trite but I have done more, see more, accomplished more than I ever thought possible. Medicine is my shoe. It is an honor and privilege to get to practice medicine every day.

Do you have any advice for aspiring physicians?

There is no substitute for hard work. This sounds simplistic but there it is. You have to be smart, sure, but without hard work, smart is meaningless.