Punishing sun and relentless regulations

Google_blue_skyThe sun in Mountain View can be relentless. Although there were several overcast hours, the vast majority of the time the sky was a cloudless azure blue. The air was so dry I could feel the UV rays burning my skin.

I have a college reunion coming up in ten days. One of my classmates is a U.S. Senator. He has asked me (more likely, everyone in the class) to come to an election fundraiser at the end of our reunion weekend. He has promised to send the details by email on two separate occasions but they have yet to arrive. Are missives from the U.S. Senate rejected as spam?

From the U.S. Senate to Hospital Regulations

The fact that his staff has failed to contact me after either conversation is of no real consequence. I will get the details eventually and the Senator has been good enough to return my calls. What gets in my craw is HCAHPS. The first call from the Senator preceded a meeting I chaired at my hospital about patient satisfaction. The call back from the Senator followed that meeting. Both calls ended with the promise of an email with details. HCAHPS reared its ugly head.

HCAHPS (Hospital Consumer Assessment of Health Plans Survey) is a nationally standardized survey developed by CMS (Center for Medicare and Medicaid Services, the current name for the organization administering Medicare and Medicaid) that is used to rank hospitals against one another based on patient (“hospital consumer”) satisfaction.

The hospitals have a third party administer a survey on patient satisfaction and report these results to CMS. CMS then ranks the hospitals on a confusingly relative sliding scale and bases a small percentage of Medicare reimbursement on the hospitals’ relative ranking and its improvement, or deterioration, in the rankings as other hospitals rise or fall.

All hospitals are crowded into a small band based on absolute value of the results and then that band is expanded to place all hospitals within that band in a relative display. For example, if 100 similar community hospitals are being compared it is likely that all the hospitals will score between 75 and 89 on the absolute value satisfaction reports. Within that 14-point spread each hospital will be re-ranked relative to the others. So a hospital scoring 79 might have a ranking in the 25th percentile while one scoring 85 might be in the 75th percentile. To move between percentiles becomes increasingly difficult as all hospitals cluster toward the top of the absolute score.

CMS then uses the final percentile to either withhold one or two percent of the previously scheduled annual reimbursement for “poor” performance or to pay a similar bonus if the hospital moves up in the relative rankings.

Author’s disclaimer: If I have misrepresented the system it is either because the government has changed it since my last review of Sibley Hospital’s performance or I have oversimplified the process because only CMS troglodytes can understand it. No Defense Waived. – SPH

As you, good reader, can see, eventually all hospitals will be crowded into the 90-99 absolute satisfaction score range and then most of them will be punished for falling below some relative satisfaction scale.

Gaming the system and getting cheated in return

Curiously, I do not have a deep emotional reaction to the CMS program. I have developed a deep cynicism toward all aspects of the medical care financing process. I believe that most providers have been gaming the system too long and deserve to be cheated in return. What really causes me to have a visceral reaction to this process is the way that hospital administrators have embraced it.

In an ideal world, you might expect a coordinated response by the AMA and the AHA (American Hospital Association) to reject this law and, in an act of civil disobedience, to refuse to see any more Medicare patients. Instead, hospital administrators have turned to the medical, nursing and administrative staffs and told them: “Move us up in the rankings.” This madness has spawned whole new administrative offices that are devoted to patient satisfaction. At some institutions a new division has been added to the administrative flow chart, topped by a VP of Patient Experience.

Discussions about “teaching to the test” are everywhere and the whole process reduces physicians and nurses to the level of car salesmen and service representatives asking to be ranked 5 or “Always” on every question.

Of course patient satisfaction depends on multiple factors, many of them well beyond the immediate control of health care providers. The most important factors are environmental. Private rooms will always trump “semi-private” which means two patients to a room and no privacy whatsoever. The engineering of a hospital (nursing station locations, rugs, sound baffles, etc.) will either reduce noise or not and little can be done about that in a timely manner.

Other aspects of patient satisfaction are self-evident and should not require the governmental carrot and stick to implement. Administrators, if your staff (nursing, technical or janitorial) is impolite or surly, retrain them or dismiss them. Medical Staff President, if your physicians are uncooperative, disruptive or self-important, re-educate them or sanction them. But do not reduce your nurses to customer service satisfaction representatives. Or, in hospital jargon, “service recovery agents.”

The correct variables of patient satisfaction: safety and education

Patient satisfaction efforts should be focused on two things, patient safety and patient education. The common factor here is patient expectations. Teach patients about their disease, their medications, their treatments and what they can expect to happen and you will have improved the quality of their care and their satisfaction simultaneously.

There is no limit to what a physician can and should teach their patients and if your doctors will not embrace this concept get a new medical staff. Do not let your physicians be reduced to car salesmen, however. Medical care may be the most important service industry but its devoted health care providers should not be reduced to PR agents.

Back to the U.S. Senate

So what does this have to do with the United States Senate? If a doctor tells a patient that they will send an email or make a call with clinical information and if they do not follow through, that is a cause for dissatisfaction. It leads to anxiety for the patient and should result in a negative evaluation. Therefore I find it ironic that the institution that makes laws governing patient satisfaction will not govern itself with laws regarding electorate satisfaction.

The Northern California sun is relentless but no more punishing than the endless regulations applied to the health care system.

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A fellow retiring physician: what are the odds?

BarbieIt was one in a million. Debbie and I were furling the sail on my son-in-law’s 22-foot sailboat after a short sunset cruise in Stonington harbor. The fishermen were in for the day. The wind was dying down. The water was calm.

We were exulting in a flawless trip. The outboard worked as designed. The knots held. No halyards snarled. We took the mooring in a single try. As sailors we are not adventurous. We take pride in the small victories over the wind and waves. We do not heel.

I noticed a sharp-looking Avon skiff approach with a pair of well-dressed travelers. Matching aviator sunglasses, clean fleece tops and pressed blue jeans. Not locals, yet most summer folk are gone and there is only the occasional yacht passing through.

I was wearing my full AARP; a Tilley hat, Cocoon sunglasses and Keen boat shoes. I looked like a pervert. Debbie was also dressed for the elements and, therefore, unrecognizable but her female presence legitimized my appearance enough to allow a stranger to approach. The female of the couple called out, “Which is the town dock? Please.”

I responded, “Barbie…..? Barbie!!”

It was Barbara. Barbie was my college classmate as well as an occasional college roommate of Debbie’s. We had not seen her for years. My instant recognition was based on her voice, her movement and her silhouette. It was not based on a true visual identification.

We reconnoitered on shore and after sharing a brief overview of our recent past we learned that she and her husband, both physicians, had retired and had been living on their 44-foot sailboat for 15 months. Their travels to and from the Caribbean made our sailing excursions seem small but the shared excitement of the moment overwhelmed this self-deflating perception.

Stunned at Barbie’s retirement

Barbie expressed no surprise at my Gap Year announcement. She seemed completely understanding. I, however, was stunned that she had retired. She was the most energetic and committed physician that I can conjure up. She had an academic/research/clinical career as a hematologist and during past meetings was bubbling about her students, her fellows and her patients.

Although her retirement decision was clearly multifactorial I did pick up on comments that resonated with me. “I just got tired of documenting every 15-minute patient interaction for their insurance companies,” she said, off handedly. I could sympathize with that.

She also noted that her career was not going to become more rewarding. I know she had established a great reputation, she had contributed to the literature in her field, she had saved patients and she had done lots of good.

What I heard her telling me was that the rewarding aspects of her distinguished career were being squeezed out by the unrewarding requirements of more documentation, more metrics to observe, less face-to-face time with patients and less appreciation as measured by salary or patient gratitude.

Finally we also shared the philosophical perspective that many physicians, and others, acquire as we observe the deterioration of our patients, friends and family. Disease and disability come to us all. We do not know when it will arrive or what form it will take but it happens with more frequency as we age. If we want to take advantage of our health to do something other than practice medicine we have to make our own calculation and seize the moment.

Great physicians are looking elsewhere for satisfaction

I suppose it seemed like a “One in a million, Doc” moment [Ed note: obscure Seinfeld reference – Debbie] when Barbie’s boat neared ours, but that is not the point of this blog folly.

What I am trying to say is that medicine has changed so much during my generation that the personal sense of pride, accomplishment, appreciation, service, humanity, communication, human interaction and compassion has been so diminished by the institutionalization and dehumanization of metrics, technology, documentation and production pressures that many great physicians look elsewhere for satisfaction. .

If one of my peers had asked me: “What are the chances Barbie will take early retirement?” I would have replied, “One in a million.”

Addendum: gone is the intoxicating pleasure of being in charge

The next generation of physicians was born computer literate and is unaware of the difficulties of the transition from paper to EMR (Electronic Medical Records). They are also unfamiliar with the practice of medicine with fewer third-party overseers, regulators, and a wall of technology between patient and physician. They are members of teams of providers and are not likely to know the intoxicating pleasure of being completely in charge.

The transition from the minimal documentation of the generation before me to the EMR has been quite a struggle. I remember consulting on a terminally ill patient, with constipation versus partial bowel obstruction, 30 years ago.

Doctors don’t get paid for “The last chapter”

The primary care physician spent a long time with the patient and family counseling them on the decline and the expectations they should have for the last few days of her life. I joined in for a bit of edification. His final note for the day read, “The last chapter.”

Woefully inadequate for this day and age, and documenting nothing except his palliative care orders, this physician could not be reimbursed for anything now. Yet he did his duty then; I saw him do it.

I also remember the handwriting police. I was one of them and also the occasional offender. I never understood how some doctors took pride in their illegible notes that could lead to medical errors.

The EMR will solve the documentation issues of “date and time.” It will replace the frustration of multiple signatures with the frustration of multiple log-ins. It will allow the creation of notes that satisfy the regulators and payers and it will do it with reams of information created by pre-population, cut and paste, and endless templates. It will not make the care of patients better.

Do WFMCs (World Famous Medical Centers) offer the best care?

md_anderson_logo_detailI recently learned that a cousin has been diagnosed with brain cancer. He is a few years younger than I am. It was a stunning revelation. My response to all things medical is generally muted. I have given bad news to hundreds of patients and been the first physician to recommend hospice care to dozens. Still, when cancer strikes within the family it reverberates.

I found myself telling family members, “Well, he will be cared for at the World Famous Medical Center (insert the WFMC of your choice: Dana Farber, Sloan-Kettering, MD Anderson) and that is the best we can hope for.”

And then I ask myself, how does one know? How does one know they have the right doctor or facility?

The simple answer is that one doesn’t know, but one can hope. It starts with trust in your primary care physician. It moves on from there.

WFMC and other acronyms

WFMC is an acronym used in the admission notes of interns and residents where, understandably, abbreviations abound. “This is the first WFMCA for this 75yo W LOL in NAD” is the initial line in scores of hand-written notes at tertiary medical centers across the country. Translated it says, “This is the first admission to this hospital for this 75-year-old white Little Old Lady in No Acute Distress.”

It means, with a  tone that is at once self-mocking and disparaging, that this woman has mild symptoms, probably evaluated elsewhere on several occasions and now she has been referred to the “Mecca” (a WFMC) for final assessment.

As an aside, I wonder how these abbreviations fare in the world of Electronic Medical Records. Although free texting exists in EMRs there are also a lot of check boxes, pre-populated phrases, and cut/paste opportunities. I digress.

The point is there is an appropriate suggestion of cynicism in the use of WFMC as well as a little pride.

Keep in mind that WFMCs are giant institutions with giant PR machines that promise hope and brag about their US News & World Report rankings.

What you can expect from a WFMC

I have had plenty of experience with WFMCs. In my opinion the physicians are generally not exceptional and the care is less than extraordinary. The physicians tend to be very intellectually engaged and offer wild diagnostic possibilities. But their diagnoses are no more accurate, nor does their treatment offer better results.

My opinion has been formed over decades, however, and currently the national movements to monitor patient satisfaction, quality and outcomes as mandated by the Joint Commission and the CMS, are making these institutions perform as well as their PR machines have claimed in the past.

I have frequently used WFMCs to supply a third opinion about a patient who has a symptom that is not diagnosable. When a group of MDs at the Mecca fails to find a cause for the complaint, it reinforces to the patient that their care has been adequate to date. Sometimes I have sent the patient with a cynical agenda on my part because I believe he or she is malingering, and sometimes because I am truly worried that I could not find the answer to a real problem.

Even in the hallowed halls of a WFMC you should remain alert and skeptical. There are many stories to tell but here is one that is most informative.

When a WFMC surgeon was wrong

Years ago, one of my favorite elderly relatives called with an intermittent and severe GI symptom. Her primary care physician started standard treatment for diagnosis X. After our phone interview it was clear that simple X was not the diagnosis and Y was quite likely. If the tests I outlined were conclusive and Y was confirmed then surgery would be the treatment.

Y was confirmed and after consulting with several surgeons my relative sought the opinion of the chief of surgery at a WFMC a few hours from home. The surgeon outlined the surgical options and described the risks and benefits of doing it laparoscopically versus by open surgery. He opined that the procedure MUST be done open and that ONLY he could get the promised results.

My relative called to report. It became clear that the surgeon was self-important, older, uncomfortable with the new laparoscopic technology and unable to admit it. His advice was unconscionable and at a minimum he should have brought a laparoscopical surgeon into the room to present their results.

I advised my relative never to see him again. Another surgeon performed the procedure laparoscopically and the results were immediately effective. Long term I have heard no complaints.

Questions to ask a WFMC

This experience highlights some issues with WFMCs. They are institutions with the associated inertia. Here is an older, past-his-prime, physician. He is “revered” by some and his reputation masks his current failings. The other surgeons know that his laparoscopic skills are inadequate and that his recommendations are old-fashioned but they are unable to unseat him.

Inertia can be good or bad. Do not put yourself on the “bleeding” edge of new technology without deep thought. Equally important, do not ignore advances in technology. Finally, examine the ego of the physician and the collective self-importance of the institution. If the physician says, “Only I can do this well,” then you are probably in the wrong office. If the institution’s PR machine makes promises that sound too good, they probably are.

So what about my cousin, his brain cancer, and the WFMC? Most of what I have written pertains but hard-to-treat cancer is a special case. A team of physicians will be involved here so no single ego is likely to pull them off course. The early phases of brain cancer therapy are fairly well regimented across large institutions so “pie in the sky” promises will not be made. Yet, because of the WFMC research, clinical trials will be available to consider at some point in the future.

For my cousin the WFMC is the place to start. My hopes are with him.

[Ed. note: when I chose the MD Anderson logo to illustrate this post, Sam pointed out that “eradicating” cancer is what the WFMCs and their PR machines promise – and it is a promise they cannot keep. That makes him angry. – Debbie]

Bombast, swagger and lobster boats

lobster_boats_racingIt’s 0530h. West Penobscot Bay is throbbing with the sound of diesel motors, thousands of horsepower under the decks of hundreds of lobster boats. The sun has been up for twenty minutes. By now, many of the lobstermen have been hauling traps for two hours.

I have an appointment to take the gasman to the island to fix the stove’s thermostat. [Ed note: it is wildly out of whack, resulting in charred brownies and other disasters. – Debbie] He better bring the right fittings; it’s a long way back to his truck on the mainland. He is taciturn and a man of few words even when pushed into conversation.

Self-absorbed bombastic bloviators

Occasionally I will meet a self-absorbed, bombastic bloviater (SABB) here in Maine. You know the kind of person. It’s usually a guy, very confident and always very opinionated. They control every conversation and always have the last word. If you meet such a person in Maine, they are usually from “away.” Because they are from away they are usually on vacation and if they can afford to be here on vacation they are usually “successful.”

Such behavior is more common in the big cities which, in my experience, means New York or DC. How it leads to success is what I do not understand. Bombast leads to lack of communication and poor communication leads to failure. Yet, SABBs survive.

Defining the SABB syndrome

Let me further define this SABB syndrome. I do not mean an ignoramus. I do not mean someone who is simply verbose and pompous. I mean a person who dominates a conversation, finds themselves on the wrong side of the facts and then is unable to accept that. Finally, by the end of the exchange, they are still trying to convince me they are right; i.e. that black is white. Or, they may use a technicality to change their position while never acknowledging that they were wrong.

They not only survive, they thrive in the world of business and politics. There is an old expression, “Close only counts in horse shoes and hand grenades.” But it must be good enough in a lot of business dealings to make money. “Close” does not count in medicine. In medicine you have to get it right.

SABBs in the operating room

Of course bombastic bluffers do exist in medical practice. They are frequently marginalized, but not always. If I was asked to see a patient by a newly-acquainted physician and I found the doctor overbearing, I would finish my consult and treatment plan and that would be the last elective consult I accepted from them.

More importantly, the SABB personality is frequently associated with or confused with the surgical personality. “Frequently wrong but never in doubt” is an old saw applied to surgeons. In fact, surgeons may never be in doubt but a good surgeon is well trained and rarely wrong. They have to make hundreds of intraoperative decisions that both the patient and the physician must live with forever.

When the SABB-like personality appears in the operating room or on the wards it plays out as a physician dressing down a subordinate physician or a nurse. This used to be considered a part of the natural order of things in a hospital. “The doctor is always right.” Things have to be done their way. But as patient safety studies gained traction in the ‘80s and ‘90s it became apparent that these abusive physicians were, in fact, responsible for treatment errors and because of their poor communication skills were associated with a disproportionate percentage of the malpractice cases.

The euphemism applied to this  kind of behavior is “disruptive physician” and it is equally represented among male and female physicians. Medical staff leaders monitor such behavior at the peer review level and correct it or rescind privileges. The less obvious cases are hard to define and lead to lots of friction among the medical staff. Because of the important association of this disruptive behavior with medical mistakes, it must be eliminated.

Why is SABB behavior tolerated?

Does this happen in the corporate boardroom? I do not know personally but I am confident that it does. The threshold for culling someone from the organization, however, would be quite different. If they produce, if they make money, if they are “successful.” I suspect more SABB behavior is tolerated.

I wonder if health care systems should not require personality profiles before hiring physicians. It is easier to withhold a position than to withdraw it. Most of these disruptive physicians can be identified in advance. Some malpractice insurance companies have started this practice and do not offer policies to the SABB physician.

I am no longer in practice. My peer review responsibilities are shrinking. I have never been corporate. Now I only experience SABB behavior at social events where it is irritating but inconsequential. Maybe that is why I let it get under my skin.

Or maybe I wish I had a little more chutzpa myself, more self-confidence untempered by decades of behavior moderated for a professional medical setting. I admit that achieving a bit more self-expression is a Gap Year goal. Leaving the World Domination Summit I did affect a bit of a swagger.

Or maybe I wish I were out on a lobster boat where the organizational chart consists of one captain and one crewmember.

*Image credit: Guy Biechele / Flickr

Gap Year metrics: how to fit it all in

DEM_RAM_Aug2013Andy*, this one is for you, but you have to read to the end to get the rant.

It has been about two weeks since I returned to Maine from visiting my father in Milwaukee. This is peak summer vacation time and, indeed, that is what I have used it for.

A Gap Year principle that I am passing along is: do not over schedule; you will fail. That’s especially important when your body clock says “Maine! Vacation!”

As I have said before, if I could practice medicine, run the business of a private practice, serve on non-compensating boards and committees, maintain a family life as well as a Washington social life AND… write a book, reform health care and plan exotic trips, then I would not need a Gap Year.

But I cannot do all those things and so I need a break in August.

Reminder: why a Gap Year

Now that I have the time to enjoy an extended family visit in my favorite place on the planet, I still do not have the mental energy or strength to pay my day-to-day bills, play golf, sail, repair motor boats, babysit for two toddlers, prepare fresh seafood for island guests and in-laws AND research health care reform, research French lessons, research exotic travel (safe, yet outside the “tourist bubble”) and think about job opportunities for next year.

Something has got to go.

I have to remind myself that when I first began this year I knew that June would be a month of transition, July would be a combination of events and projects (finish the guest house, go to the World Domination Summit, visit my father) and August would be spent trying to have an extended summer vacation without the time pressure of past visits.

Measuring the perfect eight-hour day

The lesson I have learned is that while I had hoped to plan and research my Gap Year projects simultaneously, that is not going to happen.

My dream of a structured eight-hour day of research reading, personal growth reading, exercise, writing (touchy-feely blog posts, health care rants, personal notes), French exercises, etc. has not worked. I am unsettled over the fact that I cannot do it all and cannot decide what to do first.

Therefore, I am letting my grand plans wait a few more days until my grandbaby toddlers decamp and I can dial down in-law visits. Then, I promise I will get my schedule set and Debbie and I will start and end each day with briefings, progress reports and a review of Gap Year “metrics.” [Ed note: looking forward to this. – Debbie]

And now… a rant about healthcare metrics

Ok, let me rant about metrics for a minute. Does your business have metrics? Is it ruled by metrics? Do they work?

I suppose metrics have a role in terms of dollars and cents, time sensitive production issues and quality control of widgets. They may even have some role in the management of hospital systems and medical care.

I will grant that keeping the “post sternotomy blood sugar below 200 mg/dl” is associated with better outcomes and fewer wound infections (I’ll bet most of you don’t know what that means and never thought it would be measured) and is a laudable goal.

But is it a metric we should pursue? Everything can be turned into a metric. Should we do so?

Our rankings have slipped; what metric shall we improve?

I remember well a quality committee meeting at a WFMC (World Famous Medical Center, to the uninitiated) where the business people outnumbered the health care providers.

Three issues come up over the course of an hour. These were how many patients were dying of septic shock per month; how many patients dying of septic shock should be or were palliative care patients; and how much time elapsed between the first symptoms of septic shock, its diagnosis and the initiation of treatment.

Because of the high mortality of septic shock patients at this WFMC, its standings in the U.S. News and World Report rankings had slipped and the bean counters wanted to improve these metrics.

Conflating improved patient care with improved metrics

Suddenly these issues were conflated into a single management tool. It was proposed that a Septic Shock Rapid Response team could be created and the time from notification to treatment could be monitored.

Recognizing that much of the delay in treatment (and therefore the success of treatment) could be attributed to family discussions about appropriate care in a palliative care situation, it was proposed that diagnosis and treatment be instituted before a definitive family decision.

Well, if you have not seen the initiation of a septic shock work up you do not want to see one now. And, if you have you would not wish it on a family member in or near a palliative care status. It is brutal.

Fortunately, reason prevailed, at least briefly, and the metric managers looked elsewhere for something to monitor.

Patients are not widgets

People are not widgets. ER throughput of patients (another metric) should not be about filling beds to make more money but should be about getting the patient to the appropriate care level in the appropriate time period (a judgment, not a metric).

I am going to play golf, but I am so angry thinking about metrics that I am not going to keep score.

[Ed note: thanks to cousin Andy for being a loyal reader of this blog. As for golf, Sam reported back that he was six over par after six holes. Then he quit. – Debbie]

Real life during a gap year: battling the U.S. Postal Service and Blue Cross Blue Shield

US_POToday and tomorrow are the big pushes to get “stuff” out of the house, where it clutters the floor and the mind, and into our new guesthouse. Hopefully the mind clutter will diminish.

A brief healthcare rant

Recently The New York Times reported that medical insurance premiums will fall by 50 percent in the state of New York with the advent of health insurance exchanges as mandated by the Affordable Care Act (aka Obamacare). [Ed note: there are 893 comments on the healthcare article in The New York Times. – Debbie]

A follow-up article in The New York Times attributes the 50 percent drop to the artificially high premiums people have paid since a 1993 law barring New York insurance companies from denying applicants with pre-existing conditions and mandating equal premiums for all people regardless of age or disease.

This meant that the premiums of young healthy people were inflated to pay for the care of the elderly. But, because the New York law did NOT include the universal mandate, many young people opted out of coverage. This shrunk the base of the pyramid further, elevating the premiums of those who do pay. The universal mandate of the Affordable Care Act will reverse this process and drop those premiums.

The frustration of applying for individual health insurance

Because of my self-unemployment I have been applying for individual coverage for Debbie and myself.  It has been a nightmare of missed phone calls, misplaced applications and denial letters from Blue Cross Blue Shield.

Over three decades my office paid tens of thousands of dollars in premiums to BCBS for my family’s coverage. We used it very little. Now that we seek individual coverage, Debbie has been denied a “premium” product because she had the temerity to actually use her coverage electively for a one-off medical procedure and some counseling.

This denial requires me to follow three applications (mine, her appeal application, and an open enrollment application) in three divisions of BCBS which do not communicate with each other and which refuse to speak to me about her applications based on HIPPA confidentiality issues.

The result is endless frustration and the anxiety that she may be without health coverage for a few months, after years of paying into the BCBS system. We are being punished for redeeming a tiny fraction of what we have paid in. They are cherry picking their applicants, even former “loyal” customers.

[Ed note: thank you, Sam, for dealing with this. – Debbie]

Researching the advantages of a single payer system

In the last week I have been looking into the site for Physicians for a National Health Program (PNHP). It has become clear to me that a single payer system is the only system that makes sense and that enterprises like BCBS exist to perpetuate themselves as a business entity and not to insure people as a service.

New and welcome distractions: the grandchildren

Our new guesthouse is now occupied. A new set of distractions has arrived in the form of family and grandchildren. After struggling with the passive aggressive behavior of the U.S. Postal Service and BCBS for three weeks I am giving up and giving in.

Our mail was lost in central processing; I am going sailing

Bills will be unpaid because three weeks of mail have been left in central processing. I might not be able to get Debbie insured for the next month because BCBS has mailed me an appeal notification rather than describe it over the phone. That mail is held hostage with my bills.

So, if you think a Gap Year is without logistical problems, think again.

Of course, if I had the bandwidth to deal with all these logistics before starting a Gap Year, I would be such an organizational whiz that I wouldn’t need a Gap Year.

I am going sailing with my son-in-law.

From the desk of Dr. Harrington: “The bubble over my head”

bubble-over-my-headOne of the most irritating expressions a patient can use is… “I am supposed to…”

It is usually verbalized just after a diagnosis is made and a treatment plan is being considered.

For example:

“Mr. Smith, your CT scan shows extensive diverticulitis; and, although no abscess is demonstrated your abdomen is very tender; I recommend hospitalization and IV antibiotics.”

“But Doctor Harrington, I am supposed to go to New York for the weekend.”

The bubble over my head wants to ask Mr. Smith, “What are you going to do there… address the United Nations and finalize a plan for permanent world peace?”

Instead I say, “Well, this is inconvenient but in the interest of your health I think hospitalization is best.”

The dictionary defines supposed to to mean (in order of decreasing usage):

– pretended, alleged, held as opinion (believed)

– considered probable (expected)

– understood, made or fashioned by intent, required by authority, and given permission.

When a patient uses the term it is invariably to tell the doctor that they are obliged (required by some unseen authority) to be somewhere or to do something that makes following the medical recommendations simply impossible.

“But Doctor Harrington, I am supposed to go to New York this week, not to address the UN but for something more important: I promised my granddaughter to take her shopping.”

Other variations on such an obligation might be: “I am supposed to go to the beach, it is supposed to be a lovely week end.” Or “I am supposed to go to Nantucket for the summer; my family and I have done it every year for 20 years in a row.”

What makes this response, this quasi-rationalization, most irksome is that it frequently comes from someone who has lived well and has high expectations combined with a sense of entitlement.

Indeed, frequently their illness is caused or compounded by the richness and overindulgence of their lifestyle.

The case in point would be an overweight, former smoker, with diabetes, hypertensive heart disease and degenerative arthritis who develops a bleeding ulcer from alcohol and NSAIDs, while taking a blood thinner for atrial fibrillation.

This is the type of person who will bleed into shock, get resuscitated, have a surgery-sparing endoscopy to clip and cauterize the offending ulcer and then will question the recommendation that travel plans be put on hold pending observation of their clinical status. “But I am supposed to… ”

Compound this scenario with someone who thinks they have some insight into their condition and it makes the responsible physician’s head explode.

[A little wordy but I think he needs to get this rant out of his system. – Debbie]

Take the following vignette:

The phone rings at 2:00 AM on a Sunday. The answering service reports that a Mr. Jones has abdominal pain and needs an immediate call back. The call is put through.

“Hello?”

“Dr. Harrington here, I am covering for your primary physician, Dr. X. How can I help you, Mr. Jones?”

“I have diverticulitis and I need you to call in some antibiotics.”

“How do you know this is diverticulitis?”

“Well, this is just like the last time and my father was a doctor, so I know.”

After a few questions to clarify that the patient is not critically sick, does not take any problematic medications, has no allergies and has been symptomatic for several days, I respond, “Well, it does sound like diverticulitis, but there are other possibilities.”

The patient could indeed have diverticulitis (alternatively, and much less likely, the differential diagnosis would include bowel obstruction, colon cancer, a ureteral stone or early shingles).

I continue, “The best thing to do would be to see your doctor in the morning and clarify the diagnosis. Ideally you should have some blood work, an abdominal exam, and possibly a CT scan to exclude a complication, such as a mass or abscess, before committing to antibiotics.”

“But, doctor, I am supposed to leave for New York on the 9:00 AM shuttle. My doctor treats me over the phone all the time and my father used to do that, too.”

“What are you going to do in New York?”

“I am giving a speech.”

“To the UN?” I wonder, aloud.

“No, to a group of lawyers, colleagues.”

This is where my head threatens to explode.

Here is a well-educated man who has had symptoms for several days but calls for help at the last minute; indeed too late to actually get the proper analysis, and has the expectation that he should get free care because he is supposed to do something “important.”

Yes, under other circumstances his personal physician might be willing to phone in antibiotics because of past experience, but as a lawyer he should know that an on-call physician has a different obligation and in some jurisdictions it is illegal to prescribe without examining the patient.

After giving him a not-so-diplomatic lecture on the meaning of supposed to, the inappropriate timing of his call, and the pathophysiology of diverticulitis, I did phone in the antibiotics and did report off to his primary MD later.

The expectation that all illnesses can be successfully treated and the added expectation that they can always be treated within the patient’s schedule is a real problem in the well-heeled population.

It is encapsulated in the phrase: “I am supposed to…” When I hear that I know I have a lot of patient education to perform, starting with a reality check.

More later on the problems of “expectations.”