Can We Calculate The Price Of Human Dignity?

I never claimed I was brilliant.  I never bragged that MENSA representatives were knocking on my door and pleading for me to join.  But I am smart enough.  Smart enough to matriculate medical school and residency.  Savy enough to own and operate a business.  Lucky enough to be married and have kids. Most difficult projects in life require hard work and a certain amount of stubbornness.  And I rejoice in that I have been given the mental faculties and vast opportunities to succeed.

I reluctantly admit, that I have always found a way around most of the hurdles in my path.  I either jumped over, ducked under, or swerved to the left or right.  Occasionally, I turned and ran the other way.  Nothing extraordinary here.

Recently, however, everything has changed.  I've met my nemesis.

It takes the form of a colossus of metal, rubber, and a little bit of padding.  One can see it hocked on the Internet, and in infomercial like segments with elderly people cheerily scooting around with smiles on their faces.

Yes, I'm talking about power wheelchairs.

Now, in general, I'm not a fan.  Of the thousands of geriatric patients I take care of, I may have ordered twenty in ten years of practice.  Occasionally, no matter how much I don't like them, some patients are so disabled that there is no choice.  As their doctor, I want to help these patients.  I want to protect them from falls and increase their mobility.  I want to restore a modicum of dignity through the wonders of lost agility.  I want to be a Doctor. 

But no matter how I try, every order I have written in the last 6 months has been denied by Medicare. 

It's not that I don't understand.  Fraud happens, and these machines are expensive.  So I get that in order to have this kind of service covered, a face to face evaluation of the patient must occur documenting the disability and the reason for the need.  I get it!

Unfortunately, I can longer traverse this process without messing it up.  Either I document too thoroughly...or not thoroughly enough.  My review of systems is inadequate or my review of systems is too adequate.  One patients note did not describe to enough detail the weakness requiring a power chair.  When I addended my note and clarified, I got a denial message saying that the patient was to weak to maneuver the chair.

Huh?  So this poor, frail, elderly person who has been tripping over her walker because of inadequate strength will not be able to move her hands enough to operate a joystick? Really?

We often use the word draconian to describe the clunky nature of governmental regulation.  The collateral damage of dealing with small amounts of fraud is often greater that the cost savings from such measures.

My unstable octogenarian will not get her power wheelchair.  Instead she'll trip over her walker and land in the hospital with a broken hip.  Instead of a five thousand dollar piece of medical equipment, the bill will likely be over fifty grand.

Let's not forget the cost of a hundred covered days in a nursing home.

And can we calculate the price of human dignity?

The Mice Keep Running

It had all been so easy when Jim was still around.  Lisa's ex husband had many shortcomings, but being a critical care specialist sure came in handy.  Any time her mom or dad had a health crisis, he was right there in the middle of it: advocating, interpreting, breaking down the complexities into easily digestible morsels of information.  But then Lisa's father died, and the emotional and physical stress brought the unstable union to a breaking point.

Years later, she sat in the ICU holding her mother's hand and longing for the man that she had grown to despise.  She felt a slight tenderness stir in her heart that was suddenly extinguished by picturing her previous husband with his new, almost teenage love interest.

Damn!

Lisa's mother suffered another stroke.  The ventilator had been removed but her mental state was dubious at best.  She was not eating.  And the hospitalist was suggesting a feeding tube.  Lisa recoiled.  Her memories of her agitated grandmother socked away in a nursing home pulling on the plastic protruding from her abdomen was too much a burden to be replayed a generation later. 

If only Dr. Phillips would come to the hospital.  As her mom's primary care physician, Lisa trusted him.  But he abandoned his privileges years ago.  He once confided that he no longer knew how to take care of such sick patients.  Lisa missed his optimism and his gentle hand on her shoulder resting tenderly.  He understood her struggles.  The hospitalist was nice enough, but young.  He seemed overly concerned with protocol and rarely spent more than a minute in the room without leaving to answer a page.  He certainly had no advanced knowledge of the woman lying in the bed in front of him.

The family meeting was pathetic.  Instead of the hospitalist, a palliative care nurse joined the social worker and other supportive staff.  Thirty minutes later, Lisa walked out more confused than ever.  Most of the conversation resolved around disposition: nursing home, home with hospice, or rehabilitation center. Each member had their own checklist of salient decisions that often seemed far removed from her mother's wants or needs.  There was no question who each participant worked for.  The hospital, the government, anyone except for the poor helpless struggling patient. 

Lisa thought of Jim again.  If only she had an advocate.  Someone who answered to her and her mother instead of the litany of outside interested parties.  If only her doctors would lift their heads from the computer screen for just a few moments.  If only someone with medical knowledge took a moment to see the forest from the trees.  

The mice keep running through the maze trying to find the elusive cheese.

Damn!

What the hell has happened to our medical system?

The Gift That Keeps Giving

An Imaginary conversation spoken softly in a plush office behind closed doors.

CEO: We really took a hit fourth quarter. Why were the numbers so bad?

CFO: Well, acquiring SER (small EMR company) tightened our cash flow, and we have yet to convert those customers. 

CEO: Convert? When's that press release going out?

CFO: By next week.  It will take a few months for the clinicians to realize that their platform is being discontinued.  Our upgrade, which will cost roughly thirty thousand a physician, will be ready by March.  I figure we'll convert ninety percent given it would cost double to implement a new system.  We can also sneak in some upgraded hardware.  That could increase profits by ten percent. 

CEO: Ha!  They have no idea what's about to hit them.  What about that big account we just lost?

CFO: Government regulators shut them down.  Something about inadequate documentation.  Really a tragedy.  It kills our customer base a bit, but all those patient records need to go somewhere.  I think we may be able to package up the platform to their competitors.  That should make it easier for them to gobble up all that new business.

CEO: And of course, there's meaningful use?

CFO: Yep!  Now that the new rules are being finalized, we can role out a bunch of upgrades.  Money in the bank.

CEO: Meaningful use.  Huh.  The gift that keeps giving.

CFO: And giving, and giving, and giving.

Transience

I'm flawed.  Deeply flawed.

Sometimes it's hard to remember that in the la la land of blogging where everything is clean and tidy.  I'm a representation of myself.  It's much more pleasing to turn towards the unsplintered side when the camera is on.  Best to avoids the cracks.

Patient care can also be like this.  The surly octogenarian squints at me through beady eyes as she shifts in her seat.  The remnants of chewing tobacco spit out around her over sized cheeks while talking. She is gruff.  Her belly hangs over her waist supported by small spindly legs.  Her language is thick and colorful.  Only the most superficial would mistake her for a dolt.  Her wealth, gained and lost many times, the symbol of a savvy forward thinker.  She unloads into a cup and smiles in my direction.

You're my mentor.

I get her meaning.  She is thankful that I made the diagnosis that the emergency room physician missed.  A few days of steroids and her lungs are better than ever.  It wasn't the first time the aged, beaten body had unexpectedly bounced back.  In a short few years there had been hospital stays and nursing homes, emergency visits and family meetings. I had been there every time.

And I wonder what she will do after I leave.  Not exactly uncomfortable, I am unable to stay too long in a position that I know is unjust.  I will sacrifice my gift to stand up for a principal.  Whether my intention or not, I will live and die for an ideal.  That, I think, is my path.  My awkward, flawed path.

But there are times that transcend the humanness: the seconds where the exhaustion of exercise gives way to one more burst of activity, the illuminesence of my children's eyes as they start dancing when my wife clicks the radio on our IPAD, or the rush I get when making a difficult diagnosis. 

For moments the wrinkles and frown lines disappear.  And I am perfect. Fleeting. Broken.  Full of myself.

But perfect.

Perspective And Empathy

I could see through the two window shields into her car.  Her forehead creased into a petulant frown and she mouthed the words over dramatically.

Asssssshooole

Five minutes earlier, I was packing up my papers at the nursing home when my pager went off.  I fumbled for the desk phone, my arms constrained by the bulky winter jacket I had just climbed into.  I tapped my feet and waited impatiently for someone to pick up the line.

Hello, hello Dr. Grumet?  I think she's dying.  Can you come now?

The ICU nurse sounded panicky.  It was early in the morning and the critical care specialist wasn't in the building.  I jumped out of my seat and sprinted toward the car.  The trip was less than a mile.  I turned onto the expressway and then made a right onto to the nearest exit.  I stealthily navigated a series of small streets punctuated by a stop sign.  As I came to the intersection another car pulled up facing me.  Seeing her right turn signal and knowing I was going straight, I made a superficial attempt at stopping and then rolled through.

While passing, I could see the anger seethe from her lips for my failing to abide by the most basic rules of the road.  She was furious.  I felt like laughing.  If she only knew that I was racing to the hospital in the most dire of circumstances. 

It was a matter of perspective.  But I couldn't be too angry.

Hadn't I been just as guilty?   How many times had I shook my head disapprovingly as an elderly patient hobbled into my office thirty minutes late?  Had I fumbled with the icy certainty of arthritic joints or the Himalayan distances crossed in the parking lot, maybe I would understand differently. 

It is shockingly easy to regret the futile decisions of  a panicking family when it's not your loved one lying in the hospital bed.

Perspective and empathy.  Different sides of the same coin.

The women in the car was right. 

I had been everything she hauntingly accused me of.

At times. 

The Five Stages of #hcsm

It all started with denial. 

I mean, I'm a doctor.  Who has time to be clicking away on a mobile phone when there are patients to see?  There are only so many minutes in the day.  And what is there to gain anyway?  I don't need more friends, I need to be reading journals.  I need to be studying for boards.  I need to be building my practice and meeting colleagues. 

Yet I have a voice, a viewpoint.  Certain things need to be said.  How can I be heard?

But then anger set in.

Everyday I bang away at the computer and bust out content, blogs and tweets abound.  Yet post after post no comments, no followers.  All I do is give, give, give and get nothing in return.  I want to be notable, a superstar.  At this rate all I'll be is a foot note.  My writing, my words will be lost in the diaspora.  So why do I keep going?

The bargaining phase was inevitable.

If you follow me, I'll follow you.  I retweeted you...how about some love back?  Your writing is amazing, I blogged about the same topic the other day. 

Then, of course, depression.  Desperately curt, poignant depression. 

Why bother anyway?  No one cares.

Somewhere in the darkness: sweet acceptance.    

I write because I have to.  The connections I've made are lasting.  I learn, I grow, I'm lifted by the brilliance that surrounds me.

And then denial creeps back around the corner.

Maybe I should go back to concentrating on being a doctor and not waste my time on such things.

Eviction

The sweat coalesced on my forehead.  I leaned forward to push the weight of my body into the wheel chair.  I was terrified.  Behind me strode the baffled parents with their arms full of coats and scarves.  The young boy shrunk into the chair and balanced his IVed arm on the rest, trying not to disrupt the tubing that had been so painfully inserted. 

I was lost.

A week into my rotation as a volunteer in the pediatric emergency room, I was a child myself.  I spent the first few days running labs and sitting with the desk person filing forms.  But now a little one was being admitted.  And I, fumbling between IV pole and wheel chair, was asked to transport the precious cargo to the medical floor. 

I hadn't yet ventured into the hospital.  Now, not only was I horrified to be responsible for a living breathing child, but also had no idea how to wend my way through the confusing maze of elevators and corridors to the appropriate dropping off place.

It was the beginning of a lifetime.  I could feel the breeze of the scrubbed technicians as they raced by, and whisked away down the hall.  I took in the sites and sounds: the faded linoleum, aseptic breath of alcohol, and the murky lighting hiding the sacred altar of patient care.  People lived and died here.  It was a place of mercy and despair, faith and disappointment, a place for bodies to heal.

I'm not sure if I can track the evolution.  When the fear of the volunteer became the anticipation of the student or the wonder of the resident.  Things happened to me in hospitals.  Whether the dreary VA or the high tech multi lighted academic Mecca, I grew and changed.

A nonreligious man, I prayed there.  I cried there. I questioned everything I knew about myself, and came out on the other side different.  Alive, scarred, and half the empathy pulled out of my bosom and stomped on.

Yet I was competent and able.  I had a new understanding of life.  For better or worse, I had become a doctor.

I can't explain the affinity I have for hospitals.  Like an old friend, I always feel something when walking through the electronic glass doors.  Even the first time I enter a facility,  I'm home.

The idea of practicing Internal Medicine and not seeing my own patients in the hospital is like agreeing to sever my own limb.  It's not compatible with my view of the profession.

So why does it feel like the winds of change are blowing us out of the hospital?

If you don't like it, just use the hospitalists!

It's like being evicted from my childhood home.

We Hold These Truths To Be Self Evident

This past week my email account exploded.  Friends, blog followers, and the twitterverse have reached out, all with one question on their mind. 

Is everything alright?  Are you OK?

My answer is a resounding yes.  As I mentioned in a recent post, revolutions come in all sizes, large and small.  They also come in all speeds.  Some coups occur overnight, others are years in the making.  My decisions broadcasted over the web in the last week were nothing if not measured.  I've spent years building a foundation for change.  I've kept my ear to the ground and one finger to the air testing the winds of change.  And change is coming. 

This is as much the end of as journey as the beginning of one.  Years ago, I set the motions in process to develop other revenue streams outside of my office practice.  As those streams have become brooks and eventually gushing rivers, I have felt the pull from deep down inside.

We hold these truths to be self evident...

The dictates of dignity hold that we must believe in a certain innate value in ourselves.  We craft this sense of self in our relationships, in our families, and in our life's work.  The value proposition is not only based on our skills and abilities, but also on our identity. 

At times we give this value to others without monetary compensation.  We invest in a  spouse, children, and friends.  These connections reap the reward of human kindness, love, and companionship and are thus (if one is lucky) paid back in spades. 

We also trade our value for material wealth.  That value may be a skill, or possibly a unit of work.  Long held theories have based the worth of this value on the markets want or need for such a product.  These theories, while much respected in college courses in economics, often forget to take into account the provider of such skills or services.  In other words, only the individual can decide how much he will or will not accept for the value he brings to the world.  In this way these theories are flawed. I can always decide to withdraw from the market. 

To accept a paltry sum for your value is to denigrate your worth, to minimize your individuality. 

The primary care physician of today is accepting less for more and more .  The administrative duties expand: face to face forms, computerized order entry, preauthoriztion, med reconciliation, and the list goes on.

I have reached a tipping point.  I believe my value is worth more than the current system is willing to give.  I can grin and bear it like my fellow physicians, or I can make my stand.

I will not give myself willingly to a system that does not believe in the worth of my abilities.  To do so is to harm my patients as well as myself.  The treadmill of clinical care is currently serving no master particularly well.  

I will not abandon clinical care. 

But I also will not accept what is being proffered me.

Grief And Loss

It was really rather predictable.  Our nanny, after four years, was leaving.  It was the right time.  Things change, kids grow older, and our families needs evolved.  My daughter danced around the room nonchalantly refusing to pose for pictures.  The night before she had carefully lettered a thank you card, but all trace of tenderness was now gone.  Like so many of us, she had already become an expert at erecting barriers. 

Thirty minutes after an emotionless goodbye, my daughter struggled with her jacket.  Her boots were dangling haphazardly off her feet and her hat lay untouched on the counter.  The rest of us dressed and ready to go, looked back with annoyance.

That's when the damn broke.  She sat down on the floor and began to cry.  Her face contorted as the tears ran down her cheeks.  I was stunned by the strength and volume coming from her mouth, and the heavy heaving of her chest. 

Grief.  Pure unadulterated grief, she carried on free of the constraints and self awareness of maturity.  And as I watched, I couldn't help but ponder the loss I bear witness to in my everyday life. 

Walking in and out of hospital rooms stains ones soul with the harshness of human reality.  Unlike my daughter, I am always struck by the silence.  Heads turn down and tears are quietly wiped away before being allowed to traverse down the cheeks and fall petulantly to the ground. 

Sometimes I long for the loud, overwhelming, embarrassing grief of the child.  That way, I could steal close and put my around shoulders and coo gently into their ears.

And promise them with great confidence,

that everything would eventually be OK.

She's Just Not That Into You

Have you ever been in love?

I'm not talking about that sorta, maybe kind of love.  I'm referring to the heart burning, stomach reeling, can't sleep at night because you're so infatuated love.  The kind we all hope for.  Maybe the kind you've had before.  And if you were lucky enough, you coaxed the object of your affection into a relationship.

You spent months or even years building the connection.  At first, everything was quite smooth.  Walks in the park, holdings hands at the movies, and those things you do when you feel that way. 

But maybe the tide turns.  Your calls are answered less frequently.  The response to your texts take hours.  The subtle shift makes your heart ache.  So you become a tad desperate, and up the ante.  A romantic getaway or unexpected gift becomes the patch for the hole in your relationship. 

Despite your efforts, your best intentions, the divide grows.  Eventually you realize that no matter how hard you try, you aren't receiving all that you hoped for.  You still call each other significant others, but your feeling more other than significant.

You've come to a crossroads.  You can either continue to sublimate yourself in an effort to fulfill your partners wants and needs, or you can step back and look at things in a different way. 

Your heart, the most valuable part of yourself that you give willingly, is no longer being accepted.  Sadly, she's just not that into you.  At some point you realize that any confident, self fulfilled person, must not offer themselves to such a partner.

To continue in this relationship is to denigrate your value.  You're better than that.

And so it goes with me and our current health care system.

I guess, for better or worse,

we're breaking up.

If You Don't Like It, Use The Hospitalists

It happened, of all times, when I was in the car driving the kids to violin practice.  My pager buzzed with a message from one of the medical floors.  I waited till the car was parked, and dutifully pecked the numbers on my cell phone.

Hello doctor, we have your patient, can you please put admitting orders into EPIC?

I, of course, like most doctors, wasn't sitting by my phone waiting at a computer terminal.  I explained that I would have to give orders over the phone.  There was a pause.

I'm sorry Doctor, new hospital policy, all orders must be placed by a physician.

I already knew that there was no use fighting it.  This was just another onerous policy piling the work on the primary care physician's back.  The last time I faced this situation the nursing supervisor couldn't have been more clear...If you don't like it, use the hospitalists!

I explained that I wouldn't be able to sign on to EPIC for a couple of hours, and told her I would call back.  When violin practice was over and the kids were tucked sleepily in bed, I signed on to the EMR to admit the patient.  Browsing the med list in the computer, I quickly realized that the ER staff hadn't reconciled the medicines correctly.  The list on record was outdated by years, a remnant from the last admission.  But since that time the patient had stayed at a nursing home and had several changes.  Sitting in my office at the house, I had no way of knowing the right doses. 

So now I had to call back to the medical floor, have the nurse rustle through the paper chart and find the medicine list from the nursing home.  Then, because she was not allowed to enter the orders herself, she had to read off all twenty medications and wait while I entered them one by one into the computer.  It took forty five minutes in all.  Forty five minutes in which neither the floor nurse nor I were actually taking care of patients.

Now it's safe to say, we wouldn't have had this problem if the nurse or physician had reconciled the meds correctly in the ER (like they were supposed to).  I could have just pointed and clicked. But they don't have enough time either!  They can barely appropriately accomplish their jobs.

As the parade of health care reform travels on and the electronic revolution continues, our most valuable and scarce resources are asked to carry the largest load.  And we all know that there isn't going to be a physician uprising.  This is my new reality.

How can I, a physician responsible for twenty five hundred people, spend an extra hour on nonclinical administrative work for each admission?  Maybe I could handle that kind of workload if I was taking care of a patient population a tenth of the size.

Hey, wait. 

There's an idea. 

Steppin' Out

Revolutions come in all sizes: large and small. 

For years I have written about the travesties of the American medical system.  So many posts have focused on the atrocities of healthcare reform.  Yet year after year, I follow the lead of my fellow physicians.  I put my head down and work.  I deliver the best I have to offer even as the paperwork, frustrations, and threats rise.

Physicians are a tired and humble group.  We are meek.  We have been slayed by our own oaths to a population of patients who in reality we harm.  We harm them as we speed up the treadmill to cover overhead.  We harm them as we watch our hospitals bend to the slavery imposed by clunky and dangerous electronic medical records.  We shake our heads in disgust because we feel powerless to effect change.  We break the contract we signed in blood as we blindly follow the herd over the cliff

We are not powerless.

Somehow we were hoodwinked into believing that administrators, technologists, and governments deliver healthcare.  They do not...we do.  There is a knowledge gap.  Those who have the skills have allowed themselves to be cowed by those who don't.  We are disorganized, our representative bodies are impotent, and we have been painted as criminals to a society that suffers under the current economic realities. 

I have made the decision that enough is enough.  I must think globally, yet act locally.  The only thing I have left is my unique ability to care for patients.  The art of caring for the elderly is quickly fading.  Medical residents become hospitalists or specialists.  Hospice and palliative care physicians are being trained at a glacial pace.

There will no longer be anyone to manage our most fragile, at risk patients.

And beginning one year from now, the great exodus will include me.  I've given notice to my practice.

I'm steppin' out of this broken system. 

Want to know what happens next?

Stay tuned.