Category Archives: Health Care

Health care system discussions

The Harder They Fall

Doctors make lousy patients.

I spent half the summer extolling the virtues of adequate hydration to pregnant woman whose urine specimens were as dark as Granny’s sweet tea, but then ignored my own advice.

Every August our church holds an outdoor mass at a local farm and family activity center owned by one of our parishioners. Several of us arrived early to move picnic tables and set up stands for hot dogs, drinks and dessert. The guys hauled out the four rusty barbecue grills made from steel drum halves and filled them with charcoal. The farm donated several dozen ears of corn which we soaked in Rubbermaid garbage cans half full of water.

We soaked the charcoal with lighter fluid and lit the grills about a half hour before Mass. If the coals didn’t seem hot enough, someone would squirt more fluid onto them, creating a fireball.

“Hey, I heard you’re not supposed to do that.” *wink wink, nudge nudge* Another shot of fluid and another fireball.

We loaded the grills with corn just as Mass started, turning the ears with gloved fingers as they roasted. I had my trusty grill tongs, one in each hand, and my heat-resistant gloves, which last year I discovered don’t work when wet. The heat became so intense none of us could stand close for very long.

The sun was hot and the sweat slithered down my neck. My arms started feeling heavy after about forty-five minutes and I knew I should probably drink some water. I trudged over to the table our family had commandeered and sucked down the rest of my McDonald’s iced tea from a large Styrofoam cup.

Now, I travel a lot for my work and often miss church functions. I didn’t want to seem like a slacker so I refilled my cup with water and headed back to the grills. Everyone else congregated around the covered wooden corn stand, sucking down bottled water. One would have thought that was an obvious sign from God: “Get out of the sun, dummy!”

I was staring at the grills, watching the corn husks charring, the heat blasting my face, when the world faded to black, and I felt the ground sneak up behind me. I imagined the cup was a stationary pole and grabbed for it as I went down, crushing it in my fingers. I thought This is going to hurt…and you’re going to look really stupid.

I grazed my shoulder on the antique plow surrounded by flowers, hit the grass and decided this was as good a time as any for a nap…

I heard voices which sounded far away.

“Hey, are you OK? What happened?”

“I think Jimmy must have pushed him.” There were a few chuckles but their concern was evident.

“He’s pretty warm. Someone get some water and pour it on his head and cool him off.”

“Do you think we should call 911?”

A small crowd had gathered. I still had my eyes closed when someone doused me with a couple of bottles of cold water. It felt good but I was still pretty toasty and asked for another bottle which I poured on my chest. A woman’s voice above my head asked, “Does anyone here know his medical history?”

By this time Peg had arrived and said, “I’m his wife.”

The other voice persisted, “Does anyone know if he has a heart condition?”

“I’M HIS WIFE!”

Lady if you don’t back off Peg is going to hurt you. Don’t poke the bear!

I opened my eyes and was looking up The Voice’s blouse. She was leaning over me, holding a tablecloth for shade. I said, “I’m still pretty hot.”

Someone handed me an open bottle which I poured onto my chest. I reached out for another one and lowered it to my mouth, I took a few deep gulps but then, momentarily forgetting I was flat on my back, lifted the bottle straight up and waterboarded myself. I struggled to turn on my side to drain my nose.

“What’s happening? Is he having a seizure?” The Voice again.

No, you idiot. I’m drowning.

I rolled to my side, snorted a few times and lay back. The Voice said, “His breathing is labored.”

“No, I’m not in labor.” This got a chuckle from everyone who knew me, but she didn’t and said, “He’s delirious.”

“Do you think we should call 911? Do you have insurance?”

Peg said, “Yeah, we have crappy church insurance,” which is true. Every year the premiums go up along with the deductibles and co-pays while the coverage gets more stingy.

“No, I’m fine. I’m just hot and a little dehydrated. Let me sit up for a few minutes and I’ll be OK.” I mentally imagined the cost of an ambulance ride and an emergency room visit; the dial in my head was running faster than a gas pump set for five bucks a gallon.

I heard a familiar voice at my feet. “I’m a personal trainer and my sister is a lab tech! We need to get his legs above his head.” She grabbed my feet and started lifting.

Oh God, no. That is the LAST thing I need.

Peg said, “Don’t do that; he has a bad back and you’ll hurt him.”

Listen to the lady and get your hands off me.

She persisted despite my wife’s objections and I foresaw another rumble.

Peg said, “Put something under his knees if you want but don’t lift his legs up.” One of the guys grabbed a couple of empty charcoal bags and chucked them under me. The personal trainer dropped my legs but tried another well-meaning but ridiculous intervention.

“I’m going to put a couple of bottles of water inside your groin. That will help cool you off.”

You gonna do WHAT??? Jesus, just leave me the fuck alone!

“We really should call 911.”

I knew I wasn’t going to win, but I didn’t want to give in and muttered, “Let Peg decide.”

She gave the OK and later told me, “I did it because if I said no they would have thought, ‘Gee, what a heartless bitch; she won’t call an ambulance for her poor husband.’ You’re a physician and I play one on TV but they aren’t going to listen to either one of us.”

So the call went out and about five minutes later the local ambulance and fire truck pull into the grounds. I’ve never understood why a fire truck always comes along since there’s nothing burning.

One of the paramedics asks how I’m feeling and The Voice says, “He’s cold and clammy.”

No shit. I’ve had four bottles of ice water poured on me.

Peg intervened, gave them a brief history, and I crawled onto the gurney. I’ve ridden in the back of an ambulance with a patient but I’ve never been the one being transported. Once inside they started asking me the usual questions: name; medical illnesses; allergies and any medications.

“Ranitidine; enalapril; aspirin; antihistamine and something for my prostate. It’s…uh…that blue one.” I couldn’t remember the name; maybe this was more serious than I thought.

“Ok, we’re going to start an IV, put some pads on you and do an EKG and check your blood sugar.”

They took their time, for which I was grateful because there’s nothing worse than trying to start an IV on someone with collapsed veins in a moving ambulance that rides like a 4X4 over railroad ties. We finally started moving and I watched the picnic grounds recede out the back window which reminded me of riding in the rear-facing third row seat of a 1960s-era station wagon.

The firemen,  having nothing better to do on a Sunday afternoon,  stayed around for another hour, feasting on roasted corn, sampling the desserts and socializing with the crowd. There’s much to be said for small-town life.

Peg arrived at the hospital long before the ambulance left and asked about me at the emergency room reception desk.

“We don’t have anyone here by that name.”

“Are you sure? I watched the paramedics put him in the ambulance.”

“Oh, wait. We had a call about a man who collapsed at a picnic. The ambulance should be here shortly.”

While she was waiting a man dressed in pajamas and carrying an old-time doctor’s bag walked up to the desk and said, “I’m Doctor Moore and I’m here to check into the hotel.” A woman behind him said, “No, I’m his sister and he’s here to see the psychiatrist.”

Just another day in the emergency department.

The ambulance pulled into the bay about ten minutes later. They pulled the gurney out and I shook hands with the paramedics before they wheeled me into an ER room. The nurse gave me a gown, asked me the same questions and said, “The doctor will be in shortly.” She hung a new IV bag before she left.

Someone brought Peg to my room; her sister showed up a few minutes later. They caught up on what happened after I left; I wondered where my barbecue tongs and gloves were.

The ER doc, a Denis Leary clone, came in a few minutes later and cut his spiel short when he found out I was a fellow physician. He ordered blood work and a 12-lead EKG, even though the one in the ambulance was normal, because there are protocols to follow and asses to cover. I’ve done the same even though I often think it’s a colossal waste of money.

Lab and EKG techs came and went. I dozed; they talked.

Then the woman who gets the insurance information entered. She may seem a humble employee, but she is the Most Important Person in the hospital since the hospital doesn’t get paid without her efforts. One would think the administrative suite would treat her like royalty, but to them she’s just another FTE, an interchangeable cog in the machinery.

My sister-in-law looked at the woman, paused for several seconds and said, “You look familiar.”

“So do you.”

“Do you go to Our Lady of Perpetual Trepidation?”

“Yes, I do.”

Suddenly it was Old Home Week and they chatted while I snoozed on the cart.

I was ignored for the next two hours.  The nurse was staring at the computer screen when Peg went to tell her my IV bag was almost out. About 30 minutes later I needed to go the bathroom. Peg went back to the desk, found the nurse reading a book and the doctor futzing on the computer.

“My husband needs to use the bathroom. Do you have his labs back so we can get out of here?”

The ER doc came in after my potty break. My labs and EKG were normal – big surprise. He asked if I had a primary physician and I just snorted. (I told you doctors made lousy patients). We talked about ER patients and how he had to work another 20 years before he could retire. We finally left with instructions to make a follow up appointment with the primary care physician on call that day, something I had no intention of doing.

It’s probably just as well. Peg did some online research and discovered he was a Family Practice doc with three judgments and a state reprimand in only 11 years of practice. But that’s a story for another blog post.

A woman called the church office on Monday.

“I heard Peg talking about taking her husband to the emergency room and she seemed really worried about the cost. Do you think we should start a GoFundMe page for them?” Our insurance may not be the best, but it is far better than being uninsured

I got the tab a week later:

Ambulance ride: $1047
ER visit:    $5681
ER Physician charge: $651
Humiliating yourself in front of a crowd: Priceless!

Coming of age

I started medical school in 1975, around the time the image of physician as a kind, wise, helpful, infallible, and exclusively white male—mythologized by James Kildare, Marcus Welby, and the brooding Ben Casey—was becoming tarnished, replaced by a far more realistic but much less comforting version. In subsequent years, disappointment would turn to anger and cynicism, expressed in mutual distrust and an explosion of malpractice litigation.

My attending physicians in medical school and residency reflected that reality, varying widely in age, temperament and clinical competence. Some of them still embodied those traits patients held dear—compassion and genuine concern—but others had become short-tempered, sarcastic and condescending towards their patients, their colleagues, and those of us in training.

Those physicians reserved a special scorn for the latter-day Inquisition known as the Morbidity and Mortality Conference, during which the care of a physician whose patient suffered a bad outcome was scrutinized. The Grand Inquisitor presented the case piecemeal, pausing to offer up tidbits from the chart—lab results, x-rays, nurses notes—while sometimes occasionally professing amazement that the offending physician had missed something intuitively obvious to the most casual observer. Some of this may have been defensive; the fear of being in the hot seat one day. “There but for the grace of God go I.”

New physicians are invariably young, naïve and idealistic and I was no exception. I’d witnessed bad behavior first hand and swore I would be different. I would listen to my patients and wouldn’t rush them. I wouldn’t become an arrogant asshole. I wouldn’t be afraid to admit, “I don’t know.” Above all, I would make fixing all their problems my personal mission, instead of blithely dismissing their complaints as psychosomatic.

This delusion is comparable to your teenager telling you he or she will be a MUCH better parent than you were, with a similar rude awakening. It’s not as simple when your own butt is on the line and you’re the one making difficult decisions.

My most liberating experience was learning what I could NOT do. I couldn’t solve everyone’s problems, because many of them were rooted in psychosocial and economic realities that were beyond anyone’s power to affect, including mine. I could be empathetic and listen; I could offer suggestions. I could lead the horse to water but not force it to drink.

Some of my contemporaries drifted to the dark side, seduced by the golden handcuffs. The price one pays for the illusion of financial security includes exhaustion, substance abuse, divorce, and alienated children. Others later denounced their early altruism as “liberal naiveté,” wondering how they ever could have believed health care was a right and not a privilege. Two of them refuse to speak to me anymore because I thought our current health care system needed an overhaul.

I’m more comfortable treating the middle class and poor folk than with Yuppies, and I prefer small-town hospitals to the large and often predatory health care systems. My loyalties lie with the nurses and staff who make doing my job much easier, not with other physicians.

I lost a few battles but I think I ultimately won the war. I just did my best.

Clip Art: CanStock Photo

 

Good Bye, Old Paint

He was the medical director of an Ob/Gyn clinic for the indigent in a southwestern town near the Mexican border. In its heyday, eight midwives and three physicians—including a near-deaf Catholic nun whose car sported an “Ordain Women!” bumper sticker—handled thousands of patient visits a year and delivered more than 130 babies each month.

Poor folk are never a priority for the health care system, even less so if they are black, Hispanic or worse a border-jumper. Many of the patients gave the same rural mailbox number for an address, having paid the “coyotes” thousands of dollars to be smuggled into the US. I can’t say I blame them, because I’d had to deal with the consequences of poor obstetrical care some of them had gotten across the border.

I first met him in 2000 when I worked as a locum tenens physician at the clinic for seven months. At that time he was in his late 50’s, a slight man with thick brown hair and glasses whose quiet demeanor sometimes produced a wry joke that both surprised and amused. I thought he was a kind and decent man, even after I found out he was a staunch Republican and had his picture taken with George W. Bush at an inaugural ball. I’m not sure he ever acknowledged the irony of devoting his life’s work to people the Republican Party despised.

But a sadness always surrounded him as if he recognized the futility of the task while refusing to give in. The hospital expected the clinic to be profitable but funding was always a problem. Private physicians in other specialties never wanted to see the patients in consultation. Some of the hospital staff treated them as vermin. He did his best but most of the time, unlike Sisyphus, the stone never got anywhere near the top of the mountain before falling back.

As often happens, he was pushed out in favor of younger (and less expensive) physicians. He retired a little farther north where he lived before taking his own life the day after Christmas, 2012. His ashes were buried on a ranch in the western state where he’d first practiced—a fitting repose for an old hand.

“Why?” will forever remain unanswered. Was it being discarded like an old pair of shoes? Was being a physician his entire identity and, lacking that, his raison d’être had evaporated? Or had he just reached the end of his trail, tired and dispirited?

He may never have realized to how many people’s lives he brought comfort and healing, but those of us who bore witness will never forget.

Photo credit: CanStock Photo

Talking to the Wall

Physicians don’t listen for shit, even when the patient is another physician.

I spent two hours in my own ER after doing a Cesarean section in a hot operating room. I was sweating like a pig and starting to get shaky, even though I’d had breakfast a few hours earlier. Thinking my blood sugar was plummeting, I wandered out to the nurse’s station and asked for a sugared pop (which tastes like pure syrup when one is used to diet).

Joy, a nurse with a very kind soul, thought I looked like crap and took my blood pressure. She got a panicked look in her eyes because my diastolic was 108. I’ve been on medication for about 12 years and my pressures are usually fairly normal at home. She took it again suggested I go down to the Emergency Room.

I said, “I feel fine. How about I go lay down for a few minutes?”

“So we can find you dead in the call room? How about the ER?”

I objected again so she grabbed the guy who’d done anesthesia for my Cesarean. He listened to my heart, looked at my blood pressure readings and said, “You really should go to the ER. I know the doc down there and I’ll give him a call.”

I relented. “OK, I’ll just mosey on down there.”

The nurses all said, “NO! We’ll get you a wheelchair and take you down. And if you don’t behave, we’ll call Denise to do a one-on-one with you.” Denise is another nurse and doesn’t take crap from anyone! I thought I’d be safer in the ER.

They wheeled me out of the unit, into the elevator and down a very long hallway to an ER bed. The ER nurse had me change into one of those idiotic gowns, then hooked me up to a monitor and a blood pressure cuff. She asked me the usual questions: Did I have any chest pain? Was I taking any medicine? Did I have a history of hypertension? Heart disease?

The ER doctor came and I repeated the same information, adding I was taking medication for my blood pressure; that I couldn’t take it at night with the drug that helped me pee because my blood pressure would plummet and I’d fall on my face; that I wasn’t diabetic but that I’d had a can of sugared pop shortly before coming down.

He listened to my heart and lungs, ordered an EKG, a chest X-ray, and blood work and told me he’d return when all the results were back. Standard ER protocol. I figured all the results would be normal.

The nurse started an IV and drew a few tubes of blood. Then someone from Imaging (the X-ray Department to anyone my age) snapped a chest x-ray. She apologized for the cassette being cold, but it felt really good on my back. I thought about the good old days when x-ray departments had 55 gallon drums of discarded films. Now everything is digital and viewed on a computer screen.

A Cardiopulmonary tech did an EKG, which read normal sinus rhythm—big surprise. Yes, the EKG machine reads the strip and makes comments. After that Dave from Respiratory Therapy came by with an albuterol solution because my lungs were a little tight.

“Have you ever done a nebulizer treatment,” he asked.

“Yeah. I have Symbicort—“

“That’s not a nebulizer med.”

Dammit, let me finish my sentence. “—albuterol inhaler and albuterol solution for my nebulizer.”

“So, you know how to use it?”

Yeah, it’s like taking hits off a bong but I’m not about to tell YOU that.

I laid on the gurney, pondering what my wife would say when I told her I’d been in the ER as a patient. I’d left my personal cell phone upstairs in my locker so I couldn’t call her, which was probably just as well.

The ER physician came in about 90 minutes later. All the results were normal, except for my non-fasting blood sugar of 174, which was not a big surprise after ingesting 39 grams of pure sugar. My blood pressure had returned to more normal levels. He told me to take it easy the rest of the day.

All was fine until I got the discharge paperwork which the following diagnoses:

  • Acute generalized weakness
  • Near syncope (fainting)
  • Chronic diabetes
  • Uncontrolled hypertension

WTF??? I didn’t have “generalized weakness” and I didn’t come anywhere near fainting. I’m not a chronic diabetic. I’ve checked my glucose levels frequently at home and if anything I’m prone to hypoglycemia if I don’t eat for several hours. (My record low was 54). My blood pressure came down to normal after lounging on the gurney for two hours. One makes a diagnosis of hypertension with several blood pressure readings over several days, not a couple of hours. If I had to guess, I think he assumed “fat Hispanic guy; must be diabetic, hypertensive, non-compliant and a walking heart attack waiting to happen.”

The next day I had the nurses at the office check my blood pressures, which were normal every day. I bought a glucometer and poked my fingers five to eight times a day, dutifully recording what I’d eaten and when along with my blood sugars, all in a nice Excel spreadsheet. My fasting blood sugars were just a bit high (101-103), but they normalized when I had a protein snack before bedtime.

Patients have complained to me that their doctors didn’t listen to them. Well, they are probably right more often than not, and for that I am truly sorry.  And now I understand.

Photo Credit: Canstock Photo

What Does The CBO Say?

Last week the Congressional Budget Office released “The Budget and Economic Outlook: 2014-2024.” Conservatives and the right-wing media got an instant woody over Appendix C – Labor Market Effects of the Affordable Care Act: Updated Estimates. The ACA would kill 2.5 million jobs, take away the incentive to work and put millions more on the dole.

The White House, predictably, embraced the report as a victory of sorts for the beleaguered American wage slaves who have been worried they will die chained to their desks.  Meanwhile, Politico accuses both sides of “cherry-picking” the data in the report.

(C) Can Stock Photo

(C) Can Stock Photo

So what to make of all this?  Here’s my take.

First, CBO’s projections are educated guesses about the future based on current data and realities that are likely to change, requiring further analysis and adjustments.  Indeed, the CBO admitted:

“…estimate(s) of the ACA’s impact on labor markets (are) subject to substantial uncertainty, which arises in part because many of the ACA’s provisions have never been implemented on such a broad scale and in part because available estimates of many key responses vary considerably. CBO seeks to provide estimates that lie in the middle of the distribution of potential outcomes, but the actual effects could differ notably from those estimates…”

The claim that there will be 2.5 million fewer jobs by 2024 can be blamed on conservative animosity towards the ACA, aided by the CBO’s authors’ poor choice of words.  The report forecast workers voluntarily reducing their labor by 2.5 million full-time equivalent hours. That will likely happen mostly among low wage workers, amounting to 1.5 percent to 2.0 percent of total hours worked.

“…The estimated reduction stems almost entirely from a net decline in the amount of labor that workers choose to supply, rather than from a net drop in businesses’ demand for labor, so it will appear almost entirely as a reduction in labor force participation and in hours worked relative to what would have occurred otherwise rather than as an increase in unemployment (that is, more workers seeking but not finding jobs) or underemployment (such as part-time workers who would prefer to work more hours per week)…”

Those workers are NOT quitting altogether to go on the dole. Some may go to part-time jobs; others may retire early. There are 10,000 Baby Boomers retiring every day through 2031; their exit from the workplace could potentially create job openings for younger, qualified currently unemployed workers.

However, any potential job changes come with trade-offs.

Full-time employees whose income is more than 400% of the Federal Poverty Level (FPL) or whose employers offer health insurance are not eligible for subsidies for health insurance purchased through the exchanges. So they will either continue to work full-time, switch to a different full-time job, or go to part-time jobs and purchase their own insurance, especially if the net result is working fewer hours while maintaining their desired standard of living.

Employees whose income is less than 400% FLP or whose employer does not offer insurance can obtain insurance through the exchange, and they are eligible for tax credits and subsidies, which decrease as income increases. They might work less to avoid crossing the FLP threshold which means losing their subsidies and credits while effectively hiking their taxes. But then again, they might decide the extra income is worth the tax bite

People living in states that agreed to expand Medicaid are now eligible for Medicaid benefits if their income is less than 138% FLP. If they earn more, they’ll be eligible for insurance subsidies, ensuring they won’t lose coverage. People living in states that did not expand Medicaid, however, can only get insurance subsidies, not Medicaid.

I think the real issue is: conservatives and their corporate overlords hate losing the leverage that health insurance once gave them over workers.  How many people have endured “job lock,” staying in a thankless job, working more hours for less pay, working for condescending employers who’ve made it abundantly clear employees are unimportant, easily replaced, but a necessary evil?  Have you ever been told, “Bend over and like it because there are ten other people out there waiting for your job?”

Employers might be a little more considerate now that health insurance isn’t always tied to the job. I’m not holding my breath.