Boreal B[l]og

I apologize to those waiting at Wal-Mart on Wetmore for their prescriptions, while I was on the phone tying up one of the pharmacists.  I know I was inconveniencing you, because she eventually said she had a long line of people waiting, so I got off the phone, in order to give her time.

What happened?  Bad system.

Why?  Good question, and easy to answer, because in large part, nobody in Tucson listened to me when as medical director of a hospital, I said we had to fix bad systems, not punish bad people.  Since then, bad systems helped speed the demise of both my parents and affect every other member of my small family’s medical care. I’ve been through all of that in prior posts: I will stick only to the current problem.

I am on Medicare and needed to sign up for Part D drug benefits. I went online and decided to do it through Humana, which meant Wal-Mart and not CVS.  OK, no problem.  I can drive, rather than walk, to get my medications.

On the Web site where I went, it asked for what year.  I checked 2014, since I wasn’t interested in 2013.  I MADE A MISTAKE.  Or did I?  I was born in December, so I went on Medicare on 1 December.  I needed to sign up for a 2013 plan (December), then sign up for a 2014 plan.  I am quite certain this was not made clear.  The broker whom I used for my supplemental did not make this clear at all.  I am certain of that.  I was told it would be “easy to do”.  What I was not told was, “You have to take care of 2013 before you do 2014.”

Watch what happened.

I signed up for 2014, and I got a lot of paper with an ID card for my 2014 plan.  In the paper, which I try to read,  I learned my drug plan began 1/1/2014, so I said, “Uh oh.  I need coverage for December.”  I could have just paid for it on my own, since I take very few prescription medicines, but that assumes I stay healthy in December and not need a lot of high powered drugs for a ruptured bowel, a traffic accident when I drive to Oregon, or a host of other possibilities.

I called Humana.  I was transferred four times, the fourth back to the original person.  I finally had to explain to them clearly that I was a first time user and not changing my plan.  This is a problem I find far too often in this country.  There is an implicit assumption made, whether it is your car getting fixed or having major surgery, that each person innately understands the key vocabulary.  I did not say the right words, which were, “I am NEW to Medicare.”  That cost me about 20 of the 66 minutes I would spend on the phone.  I explained diagnoses to people.  I explained treatments.  Whether people listened was another matter.  Back then, there were a lot of complaints about how long doctors let patients talk (18 seconds) before interrupting.  I never heard how long patients let ME talk, before interrupting (5-10 seconds).

The next 25 minutes were spent giving out all my personal information, which at least was easy to do.  That led to the last 21 minutes, which was a “phone signature,” which I had never done before.  I have seen 14 total solar eclipses, traveled to 48 countries, published 60 articles, and am well on my way to being bilingual, but I do not know what a phone signature is.  Eventually, that was explained, and I hoped that the telephone system would not crash the whole time I heard a lot of words and had to remember to say “yes” after the prompt.  Starting over was not an option.  I then was accepted, and got the 2013 paperwork, which I added to the 2014 paperwork.

Later, I got another call, this time from Cincinnati, Humana’s headquarters.  Because I had signed up for 2013, now my 2014 plan was invalid, so I had to reapply for 2014.  That was easy, since I had done it before.  The one good thing was that I had a telephone number to call if I had trouble.  I had no trouble.  Why I kept the phone number, I don’t know, but I often save things, although I have trouble finding them later.  Again, I will be sent the same volume of 2014 paper coming, because I originally signed up for it.  This country runs on paper.

On the first of December, I took to the pharmacy the letter that later arrived from Humana, which explicitly stated I had coverage.  The pharmacist at Wal-Mart was efficient, and I inconvenienced virtually nobody.  I was set to get my first Medicare prescription on the sixth.

On the third, I got a call from Wal-Mart, saying my prescription was not ready, for I was not in the system.

I didn’t get incensed.  I was mostly disappointed in that I couldn’t find all the necessary pieces of paper. I thought computerization was going to do away with paper; it has increased it vastly, until recently, when with great fanfare companies send electronic prospectuses and tout how many trees they are saving. I think a prospectus ought to be limited to the following: “we can take all your money, and there is nothing you can do about it.”  But back to Wal-Mart, where I’m keeping people waiting.

I gave all the numbers I needed to, but there was still a problem.  As I saw it, once I cancelled 2014, somewhere in the system 2013 was cancelled, too.  At that point, the pharmacist begged off to serve other people.  I didn’t blame her.  Had I been waiting, I would have been annoyed, too.  Sorry, folks.

Somewhere, in the pile of paper, I got lucky and \found the number in Cincinnati.  I called the woman, told her my problem, and she said I was in the system.  So, I can only think that Wal-Mart hadn’t called.  I can’t think of another reason.  I called Wal-Mart back and gave them the number in Cincinnati.  This at least will save the pharmacist time, since the person (1) will know about me and (2) will assure her that I am in the system.

I have to hope the two of them don’t comment on what a bastard I was to deal with over the phone, a retired physician, whom nobody listened to when he discussed broken systems, a bitter old man, but one who WAS ultimately right, who ONCE again had to find the short term fix.

Welcome to American medicine.  Part D, by the way, is not Mr. Obama’s fault.

When I was medical director of a hospital, I dealt with a Dr. Noneg, a prominent member of the medical staff.  Noneg entered practice near the time as I was changing my role to hospital medical director from neurologist.  Because of personality clashes, he soon left the practice that hired him.  He wouldn’t budge on his demands, but he was new to the practice, so there were choices, but not very good ones.  He could lessen his demands, or he could leave.  He left and began his own practice.  He was against insurance companies, as many were, and for some time got a great deal of press because of his outspokenness.

Noneg occasionally practiced outside his field.  When we were both in practice, he handled carotid artery disease cases, something I believed then and now only a neurologist should do.  Since 1984, I had tracked outcomes and referred my patients to only one surgeon, whose outcomes were slightly better than untreated disease.  I made my data available, but the local surgical community slammed me for my data and approach.  I was the only one to deal with this issue using outcomes at my local hospital.  Dr. Noneg did not.  He handled MS cases, which an internist can, but really a neurologist should.  For me, it was a matter of doing what is best for the patient; I wasn’t protecting my turf. Indeed, I wanted less work, not more.

Noneg and I clashed when it came to coverage of the emergency department at night.  Many patients who come to the emergency department don’t have physicians.  If it were a particular specialty, that patient would be assigned to the physician on call for that speciality.  Each physician was on call in a rotation that lasted a month, and several of us had several months a year we had to take new patients.  When one was building a practice, this was a way to do it, unless, of course, the patient couldn’t pay for the services.  I wrote off $30,000 a year in unpaid bills for over a decade.  It was considered normal, but I made good money in spite of it.

Noneg didn’t like this coverage arrangement, and he convinced many of his colleagues that the hospital should pay for such, $500 a night per specialty.  Needless to say, this would have been a great expense for the hospital, since there were at least ten specialties a night that would need payment.  Noneg wouldn’t negotiate.  Not a bit.  In many ways, he reminded me of the Republican Party.  There was no give or take.  If you did what he wanted, he was a nice guy.  If you didn’t, he was an enemy.  Had the hospital capitulated, I certainly would have been laid off, which I could have dealt with, but then the physicians would have had to deal with their issues (yelling at nurses, turf wars) themselves, which physicians, for all their power, are loath to do.  By the way, physician behavioral issues were the single biggest problem I faced as medical director.  I counted.  “Administration is the problem,” was said, until there was a thorny issue, and then “administration needs to fix it.”  Substitute “government” for administration, and you have a common national refrain.   We hate government, until a Cat 5 or an EF4 devastates our town, and then we can’t have enough of it.

Back then, we had nurses from managed care companies review patient charts to see if continued care was necessary in the hospital.  On the one hand, it was a physician’s decision whether or not to discharge a patient, not an insurance company’s.  On the other hand, many physicians would write “Doing well” for days, without any indication of why if the patient were doing so well why they needed hospitalization.  Hospital resources were consumed, not the physician’s worry.  But if somebody is paying the bills, that somebody usually wants to have some control over the costs involved.

An additional issue with utilization occurred in winter, because the city had an influx of visitors, and hospital beds were in short supply.  Getting patients discharged was necessary to allow new admissions, otherwise having to go on “divert,” which was not good for the city.  It was not uncommon for patients to stay in the Emergency Department 24 hours, no bed being available.  This was not good care.  When we didn’t have a bed, because a physician hadn’t visited that day, the physician said the patient wasn’t ready to go, without any documentation in the chart, or because the person covering for a physician refused to make a decision, we had one less bed we could fill.  Dr. Noneg responded to the notes from managed care nurses, polite as they were, with a simple “Drop Dead.”

In a hospital, that is not particularly funny.  Nor was it helpful.

Dr. Noneg persuaded his colleagues that the care of emergency department patients was the hospital’s problem, and the physicians stopped accepting them.  Accordingly, the hospital hired people willing to practice in the hospital full-time, called hospitalists.  They took care of these patients, and during their stay, found a physician willing to care for them after discharge.  I would have liked that job: regular hours, taking care of sick patients, then not having to manage their problems in the office afterwards.

Soon, hospitalists started caring for more and more inpatients.  For some physicians, who were very busy in their office, this was a good idea.  For others, who found that they were no longer going to be able to take care of their patients in the hospital, this was resisted.  The state medical association tried to intervene, but when physicians give up control of taking care of emergency patients, sometimes there are consequences.

Not negotiating has consequences outside of medicine.  It has tied Congress in knots over a host of issues, all of which could be dealt with given some creative thinking and a little willingness to let the other side have something.  But if you are Dr. Noneg, or a member of the Tea Party, you simply don’t negotiate.  Maybe the other guy caves, maybe not.  I learned early in life that the world isn’t going to do what I demand it do.  I had a lot of temper tantrums.  Some apparently do not learn that.

Eventually, Dr. Noneg set up a boutique practice, where he would be available 24/7 for his patients, each of whom paid him $1500 a year.  It wasn’t for the money that Dr. No did this, of course, except whenever somebody says it isn’t for the money, it is always for the money.  Dr. Noneg tried to have his patients jump the queue in Emergency Departments, but one soon learns in medicine that ED physicians and nurses are extremely strong-willed individuals who work in a high stress environment and deal with it well.  They don’t negotiate, either.  Dr. Noneg lost, and his patients had to wait.  The $1500 didn’t cover hospital or consultant costs, although I suspect–but cannot prove–many patients thought it would.

A while back, I got a call at home from Noneg’s office, wanting “my staff” to pull a chart of a patient I had once treated.  I haven’t practiced in over 20 years, and my charts, if still intact, would have remained with my group.  I was surprised that Noneg didn’t know that.

I was also surprised he didn’t demand I produce the charts. That would have been an interesting negotiation.  I would have enjoyed it.  But the world doesn’t always work the way I want it to.

My wife read a CT Scan of the heart recently, done to check coronary artery calcification, and told the referring physician the patient had breast cancer.

Whoa!  What does that have to do with heart disease?  The answer: nothing, and that is the point: we need radiologists to read films formally and not clinicians, and I say that as a former clinician who read CT head scans really well.  It’s fine for a medical group to have its own X-Ray facility and for clinicians to read the images.  But every image must have a formal reading by a radiologist, for that individual is both unbiased and trained to look at everything on the image, every corner, every part.  There is no law in nature that says a person will have one thing wrong.  It is entirely possible for a neurologist to look at an MRI of the spine and miss a large abdominal aortic aneurysm.  We see what we expect to see.  Seeing isn’t believing.  Believing is seeing.  We believe something, and we tend to look for it.

On a CT scan, there is a side view, which shows the skin.  This isn’t a mammogram, but it certainly is capable of showing a breast cancer.  In addition to the breast cancer, there was a “ground glass” area in the lung suggesting there might be an early lung cancer, too.  Wow. A CT scan of the heart is done for coronary disease, and two other systems have primary cancers.  Maybe the cardiologist would have found those, but I doubt it.  I doubt when I read CT scans of the head that I would have found a throat cancer, even though the throat was scanned and on the film.

In my defense, I was once sent a patient with leg pain, with a concern that this was due to pinched nerve in the back.  The lady had pain near the knee, but it was point tender, and I obtained a bone scan, looking for a fracture.  I found a hairline fracture of the proximal  tibia.  I got a lot of pleasure diagnosing something correctly out of my field.  Most specialists do.  There is a cardiologist in town, whom I met 31 years ago when he was new here.  I had seen a man in the emergency department who had driven 2500 km to Arizona and presented with sudden, brief unconsciousness.  I saw him and noted he seemed to be breathing a little faster than normal.  I obtained an arterial blood gas and found pronounced hypoxia.  Thinking that a cardiac arrhythmia would cause unconsciousness (strokes seldom do), and thinking of pulmonary emboli as a cause of both that and hypoxia, I did a lung scan, since that is what we did back then, and there were pulmonary emboli, because of leg clots that occurred during prolonged sitting on his drive to Arizona from Minnesota.  The cardiologist happened to be present, and I referred the patient to him.

Several years later, one of that cardiologist’s partners referred a patient to me on whom he had diagnosed an occipital lobe infarct.  For a neurologist, that is not difficult, but I was impressed the cardiologist had picked it up.  Most non-neurologists miss it.

So when the MRI of my neck was unchanged from 9 years ago, that was good news, I was a bit chagrined, however, when the radiologist told me that I had a significant thyroid nodule.  It never occurred to me look for thyroid disease on my MRI.  It is sort of like people’s being surprised when I tell them the Moon is visible in broad daylight.  “It is?” they say.

“It’s there, isn’t it?”  I reply.  The thyroid nodule was quite present.  Once I looked, there it was, plain as can be, like the first quarter Moon in the southeastern sky in the afternoon.  Try finding the Moon in daylight, sometime, if you haven’t seen it.  You will discover a whole new world–literally., and wonder why you never noticed it before.  That’s the problem.  We notice only what we are willing to notice.  Once we are willing to notice many things, a brand new world opens up to us.  Like the Moon, or even Venus, which you can often see in broad daylight, if you know where to look.

Look around you.  See, smell, touch, hear, and taste the world.  Notice things.  Life becomes very interesting when you do.

Even when you have an “interesting” thyroid nodule.  By the way, it was benign.

A 90 year-old man presents in an emergency department with abdominal pain and is found to have an abdominal mass.  It is likely he has colonic cancer with impending perforation.  He refuses colonoscopy, and he refuses surgery. “I am ready to die,” the man says, who is competent.  The surgeons think they can help him.  The man refuses again.  The surgeons say that without surgery, this will be a painful way to die.

This scenario is being played out as I write in a nearby city.  I was asked, as a former member of a hospital ethics committee, what I would do.

It’s difficult to say, without really talking to the patient and whatever family members are available.  I don’t know whether the man has a living will or a health care power of attorney.  If you don’t have either, I would do so at the earliest possible opportunity.  Don’t think because you are in your 20s, this isn’t an issue.  Accidents can leave people in permanent coma; Terri Schiavo, Nancy Cruzan, and Karen Ann Quinlan were all young, when a catastrophic event left each of them vegetative.

If the man is truly competent, he has the right to his decision.  Patients have the right to refuse things that we physicians think they ought to have.  This doesn’t hold for children, and more than one physician has given blood to a Jehovah’s Witness.  But one is on shaky ground to treat a competent patient who has refused such treatment.

That doesn’t mean we have to take care of that patient for that particular illness.  I had people refuse to take anti-convulsants for epilepsy.  I said that I would provide a list of physicians to whom they could go, and they had 30 days to do so.  I could not, in good conscience, have a patient whom I thought was a danger to himself and others be under my care, yet refuse my recommendations.  But, I also would not, as some did, fire the patient and dump the case on the hospital medical director, which more than one time happened to me.

The “painful death” part disturbed me.  Yes, peritonitis is painful.  So is colonic surgery, with a colostomy likely, and the possibility of further surgery, poor healing, infection, or pulmonary complications, for major surgery on a 90 year-old will be complicated by definition.

We can control pain.  We have palliative medicine physicians, and we have hospice.  There is no reason for somebody to die in horrible pain.  There are those who worry about addiction to morphine, which would be laughable in a dying patient, if the problem weren’t laughable and people really didn’t say that.  But they do.  We have a conflicting dichotomy in this country:  hospitalized patients are asked constantly about how much pain they are having.  Once you are an outpatient, then narcotics are bad things.  Oh, it isn’t quite that simple; however, the truth is not all that distant, either.  This dichotomy is grist for another mill.

There are others who worry that we will kill somebody by giving them so much morphine that they will stop breathing.  Morphine depresses respiration, but if a patient dies by receiving too much morphine, isn’t that in fact what was going to happen anyway?  What in the world are we so afraid of?

Death.

Not passing away, not going on to a “better place,” not “expiring”.  Death.  Dying.  Ceasing to exist as a human being.  I always used the term “death” in talking to families.  I wasn’t always popular, but I was far more often respected by people I cared about than I was despised by those whom I did not respect.

Yes, I do worry about contracting certain conditions.  I know medicine, and I know what can befall the human body.  But I am also worried about being kept alive when I would not want to be.  If I am vegetative, I wouldn’t be aware of it by definition, but it would be hell on my wife, and I would not want her to go through that.

I worry a great deal that I might end up in an ICU with a bunch of “keep him alive at all costs” folks working on me, long after it is obvious that the result will be poor and counter to my living will.  I worry that somebody will point out a “miraculous cure after 20 years in coma,” when in fact the person was vegetative and happened to smile, which vegetative people do.  I do not want my name associated with a court case, like the three women I mentioned above.  Nor do I want to hear “you never really know what will happen,” when we do know with extremely high probability what will happen. The best thing I did in medicine was not curing people, for I did little of that.  The best thing I did was allow people to die when it was time.  I knew when it was time, not to “give up,” but to accept reality.

The next day, both hospice and palliative care people talked to the man and his family.  He died soon afterwards.  For me, he no longer exists.  For others, he has gone to a better place, and they have memories of a long, happy life.  For all of us, he is no longer suffering.