The oncologist shook his head as he walked out of the room. He still held a paper towel in his hand which he used to wipe the last remnants of soap and water. He tossed it into the trash, and looked in my direction. We talked for a few moments. The cancer was more widespread than originally thought. The surgery exposed a belly full of metastases. The options for chemotherapy were thin.
I entered the room with a heavy heart. I sat next to the bed, and listened before beginning with a litany of questions. The post operative pain was well controlled. The patient had been informed of the diagnosis but still felt lost. Her family watched hopefully, and measured each word as it left my mouth. Their chins moved up and down frantically when I was hopeful, and back and forth soberly when I was not.
Before long, the conversation turned to prognosis. The patient bowed her head and prepared for the answer. Every ounce of my soul longed to tell her that everything would be okay. If only human will were the issue, I would explain how we could eradicate each cancer cell one by one.
And in that moment, I chocked on the truth. I wished to give her the gift of hope, even though I knew it was false. It was not because it was easier, not because I wanted to intentionally deceive. In reality, I couldn't face my own frailty as a physician. So many times we ultimately lose to diseases that are far too advanced or ingenious for our rudimentary knowledge.
I discussed the prognosis truthfully. After answering their queries, I left quietly.
But I understand why physicians lie, why they embellish.
Even harder than telling someone they are going to die,
is seeing oneself without distortion in the reflection of the mirror.
Friday, August 9, 2013
Monday, August 5, 2013
Sacred Ritual And Twitter, Some Thoughts On @nprscottsimon Live Tweeting His Mother's Death
It was another perfect Los Angeles day. My family and I sat on the veranda of the hotel as the midafternoon sun cascased gently onto the shoulders of the onlookers. We collected in rows of chairs that were covered in white linen. The music marched forward, and the wedding party assembled cleanly in pairs of twos. We all knew what was coming next. Of course there would be some variation, but most have been through enough weddings to be familiar with the routine.
We use rituals to mark our sacred events: beginnings and endings, birth and death, and even marriage. We gather our loved ones, our communities, to celebrate or mourn with us. But as the bride and groom waltzed down the aisle at the end of ceremony with smiles on their faces, I scanned the reaction of the spectators. A number of them were hunched over their mobile phones. No doubt facebooking and tweeting. And I couldn't help but think for a moment about Scott Simon.
Many know that Scott recently made a splash in the social media world by live tweeing the death of his mother. At first, being a physician involved in hospice and palliative care, I wasn't thrilled with the idea. His tweets were authentic and brilliant, but while reading them my first inclination was to wish that he would put down his phone and just be with his family.
This wedding reminded me how profoundly we have been altered by social media. It has become crystal clear that our digital communities are just as important as our traditional, filial, and geographic ones.
Scott turned to twitter to share this sacred moment with his friends, family, and yes, followers. The outpouring of love, respect, and well wishing he received is exactly what one would expect at a traditional funeral but was more consistant with his digital reality.
Scott, I'm sorry that I originally doubted you. I have a profoundly different understanding of community after reading your eloquent tweets.
My deepest and most heart felt condolences to you and your family.
We use rituals to mark our sacred events: beginnings and endings, birth and death, and even marriage. We gather our loved ones, our communities, to celebrate or mourn with us. But as the bride and groom waltzed down the aisle at the end of ceremony with smiles on their faces, I scanned the reaction of the spectators. A number of them were hunched over their mobile phones. No doubt facebooking and tweeting. And I couldn't help but think for a moment about Scott Simon.
Many know that Scott recently made a splash in the social media world by live tweeing the death of his mother. At first, being a physician involved in hospice and palliative care, I wasn't thrilled with the idea. His tweets were authentic and brilliant, but while reading them my first inclination was to wish that he would put down his phone and just be with his family.
This wedding reminded me how profoundly we have been altered by social media. It has become crystal clear that our digital communities are just as important as our traditional, filial, and geographic ones.
Scott turned to twitter to share this sacred moment with his friends, family, and yes, followers. The outpouring of love, respect, and well wishing he received is exactly what one would expect at a traditional funeral but was more consistant with his digital reality.
Scott, I'm sorry that I originally doubted you. I have a profoundly different understanding of community after reading your eloquent tweets.
My deepest and most heart felt condolences to you and your family.
Thursday, August 1, 2013
Regression To The Menial
I was far ahead of my time.
The cachectic middle aged man had been admitted to the hospital fifty times in the last calender year. The other residents and I joked that new graduates only truly became interns after they had Leon on their service. He suffered a range of chronic illnesses, mostly respiratory, that were overwhelming to his mentally challenged mind. He often would walk off the floor with discharge instructions only to appear in the emergency room minutes later complaining of shortness of breath.
I liked Leon. He was soft and gentle. His lack of mental capabilities only made his kindness more endearing. He was anxious about the outside world and preferred the safety of the hospital confines. And I couldn't blame him, to a homeless man on the St. Louis streets, our institution must have looked quite welcoming.
After his third hospitalization in as many days, I decided to take action. I gathered the patient's pulmonologist, primary care doc, and a bevy of clinic nurses together in a room to hash out this difficult case.
The pulmonologist retrieved his cat scan, and outlined the nodules and signs of emphysema. The primary care physician reviewed his compliance record. The clinic social worker and nurses attested to his housing issues. We worked together as a team. The group consensus was that his lungs were benign, and the best plan of care relied heavily on social intervention.
I left the room feeling like, for once, Leon had a concrete plan of action. I discharged him the next day confident that we could stem the tide of hospitalizations. From time to time, over the next few months, I patted myself on the back in recognition of the fact that Leon seemed to be nowhere in sight.
While strolling through the halls of the clinic during my third year outpatient rotation, I bumped into Leon, and almost didn't recognize him. He had gained fifty pounds. His emaciated figure filled out into more normal proportions. He smiled as he walked by and waved. Moments later, Leon's primary physician filled me in on his progress.
It turns out that Leon left the hospital the day I discharged him, and walked across the city to the emergency room of a competing hospital. He was admitted, and the attending physician called our institution. This physician listened to the details of our work ups, and was informed about our team discussion. He then decided it was all bunk, sent Leon for a biopsy of his lung nodule, and diagnosed him with tuberculosis. Leon was sent to a state facility for six months for monitored medication administration.
Leon thrived. He gained weight, his breathing improved, and he had been living out in the community for six months without a single readmission.
Now I know what you are thinking. Another case of a doctor warning about the diagnostic traps of not taking a frequent flyer seriously. But my point of contention is actually more about team based care. Ahead of my contemporaries, I used the group model, now lauded by healthcare reformers, to try to "hot spot" Leon.
The problem with team based care, however, is there is often a regression to the menial. Ideas and diagnostic possibilities on the periphery are inevitably homogenized or coerced to the center by other members of the team. Extremes are reasoned out, and often those who think out of the box are marginalized.
Specialty groups have an altogether different issue. Tumor boards and such often make extreme options more palatable. Last ditch and low probability chemo is bolstered by like minded individuals with well meaning intentions but often little clinical evidence.
It turns out that what Leon needed was not a team at all. His savior was a lone internist, weighing the clinical evidence carefully, measuring the pros and cons, and not being clouded by the faint murmurings of ineffectual group think.
The cachectic middle aged man had been admitted to the hospital fifty times in the last calender year. The other residents and I joked that new graduates only truly became interns after they had Leon on their service. He suffered a range of chronic illnesses, mostly respiratory, that were overwhelming to his mentally challenged mind. He often would walk off the floor with discharge instructions only to appear in the emergency room minutes later complaining of shortness of breath.
I liked Leon. He was soft and gentle. His lack of mental capabilities only made his kindness more endearing. He was anxious about the outside world and preferred the safety of the hospital confines. And I couldn't blame him, to a homeless man on the St. Louis streets, our institution must have looked quite welcoming.
After his third hospitalization in as many days, I decided to take action. I gathered the patient's pulmonologist, primary care doc, and a bevy of clinic nurses together in a room to hash out this difficult case.
The pulmonologist retrieved his cat scan, and outlined the nodules and signs of emphysema. The primary care physician reviewed his compliance record. The clinic social worker and nurses attested to his housing issues. We worked together as a team. The group consensus was that his lungs were benign, and the best plan of care relied heavily on social intervention.
I left the room feeling like, for once, Leon had a concrete plan of action. I discharged him the next day confident that we could stem the tide of hospitalizations. From time to time, over the next few months, I patted myself on the back in recognition of the fact that Leon seemed to be nowhere in sight.
While strolling through the halls of the clinic during my third year outpatient rotation, I bumped into Leon, and almost didn't recognize him. He had gained fifty pounds. His emaciated figure filled out into more normal proportions. He smiled as he walked by and waved. Moments later, Leon's primary physician filled me in on his progress.
It turns out that Leon left the hospital the day I discharged him, and walked across the city to the emergency room of a competing hospital. He was admitted, and the attending physician called our institution. This physician listened to the details of our work ups, and was informed about our team discussion. He then decided it was all bunk, sent Leon for a biopsy of his lung nodule, and diagnosed him with tuberculosis. Leon was sent to a state facility for six months for monitored medication administration.
Leon thrived. He gained weight, his breathing improved, and he had been living out in the community for six months without a single readmission.
Now I know what you are thinking. Another case of a doctor warning about the diagnostic traps of not taking a frequent flyer seriously. But my point of contention is actually more about team based care. Ahead of my contemporaries, I used the group model, now lauded by healthcare reformers, to try to "hot spot" Leon.
The problem with team based care, however, is there is often a regression to the menial. Ideas and diagnostic possibilities on the periphery are inevitably homogenized or coerced to the center by other members of the team. Extremes are reasoned out, and often those who think out of the box are marginalized.
Specialty groups have an altogether different issue. Tumor boards and such often make extreme options more palatable. Last ditch and low probability chemo is bolstered by like minded individuals with well meaning intentions but often little clinical evidence.
It turns out that what Leon needed was not a team at all. His savior was a lone internist, weighing the clinical evidence carefully, measuring the pros and cons, and not being clouded by the faint murmurings of ineffectual group think.
Thursday, July 25, 2013
Mental Calculus
He would describe himself as sensitive. Not as in a lack of confidence, but more like able to tune into the feelings of the people around him. It is probably why he became a physician. A lover of math, he tripped on the mental calculus. How many wins were needed to make up for each loss? How many lives would transform a death. Even Michael Jordan missed a shot occasionally. You can't tell me that Babe Ruth didn't strike out from time to time.
He liked to daydream about powerlessness. It would be so much easier if medical science were impotent. He then could measure his worth in the warmth of a smile or the weight of a hand resting on a tired shoulder. These were things he could offer without risk, without opening himself up to heartbreaking failure.
He often pictured his own death. Others fantasized about being met at the pearly gates by people they knew who had passed on: parents, friends, or lost lovers. But who would meet him? He had known hundreds, if not thousands who died. He touched the acrid flesh, over and over again, uncovering physical and emotional pain.
He wondered if there would be a calamity. His supporters would surely welcome with open arms and kind heart. But what about those who were not ready to die? They may shake their fists and scowl because he had not been enough. A sort of scuffle would break out and opposing forces would clash. Who would win?
But this was all just a dream, a confused, paranoid dream. In reality there was no battle of judgement, no balancing scale. And this was his burden. This was the thing he carried on his shoulders from day to day, week to week.
This was the thing that pulled him back, that propelled him forward.
He liked to daydream about powerlessness. It would be so much easier if medical science were impotent. He then could measure his worth in the warmth of a smile or the weight of a hand resting on a tired shoulder. These were things he could offer without risk, without opening himself up to heartbreaking failure.
He often pictured his own death. Others fantasized about being met at the pearly gates by people they knew who had passed on: parents, friends, or lost lovers. But who would meet him? He had known hundreds, if not thousands who died. He touched the acrid flesh, over and over again, uncovering physical and emotional pain.
He wondered if there would be a calamity. His supporters would surely welcome with open arms and kind heart. But what about those who were not ready to die? They may shake their fists and scowl because he had not been enough. A sort of scuffle would break out and opposing forces would clash. Who would win?
But this was all just a dream, a confused, paranoid dream. In reality there was no battle of judgement, no balancing scale. And this was his burden. This was the thing he carried on his shoulders from day to day, week to week.
This was the thing that pulled him back, that propelled him forward.
Wednesday, July 24, 2013
Does Ezekiel Emanuel Think We Are Weenies?
Tilburt et al published a study in JAMA this week suggesting that physicians feel that other players (lawyers, insurance companies, hospitals, etc) are more responsible than doctors for reducing healthcare costs. Furthermore, they are hesitant to promote reforms that eliminate the current fee for service payment system.
Although I would bet the no one would be surprised by these findings, a scathing editorial by Ezekiel Emanuel and Andrew Steinmetz caught my eye. Before I get to the particulars, I would like to make a few (hopefully mostly uncontested) observations.
1)Physicians are some of the most educated, hard working individuals in American society. Very few professions require a four year doctorate, plus a minimum of a 3 year apprenticeship. After finishing our training, we have long hours, take phone calls over night, and work many weekends.
2)People, by in large, don't go to medical school to make a fortune. There are many other professions that are more economically worthwhile with less debt incurred. Based on the GPA requirements, these applicants could likely choose almost any profession. Medicine is a passion and calling. Those who do not feel so drop clinical practice fairly quickly.
3)The daily job of physicians is to investigate, consider, and choose between incredibly complex and different avenues, and then take action. We are trained to see the subtleties in both the written word as well as during patient presentations. This is a thinking man's sport.
So when a large majority of educated, capable, and thoughtful people proclaim an opinion, one would think it would be wise to pause, consider, and evaluate before wholeheartedly dismissing the group as a bunch of weenies. Unfortunately, Emanuel and Steinmetz think differently. They proclaim:
The findings of Tilburt et al. confirm this ingrained human behavior by showing that physicians are hesitant, if not unequivocally opposed, to taking bold steps to re-engineer incentives in the system -- steps that may well have the most meaningful effects on controlling costs...
I couldn't agree more. Yes, thoughtful physicians who have been led astray before, are not jumping into the arms of governmental change. Let us ponder a few questions.
1)Have any of the finished medicare demonstration projects ever had positive results?
2)Has pay for performance in the past, on balance, shown a financial or quality of care improvement?
3)Is there any proof that ACOs or PCMHs will improve the quality or cost of care?
4)How is the government doing so far at balancing the budget in general?
As physicians we learn to use scientific evidence to support our theories. We have been burned time and again in medicine by using logic above data. After careful consideration, moving forward "boldly" but foolishly may do more harm then good. Ezekiel's fantasies about healthcare are unsubstantiated. Show us the data, and we will follow willingly.
The editorial continues:
This is a denial of responsibility...Of course, physicians do not want to be blamed for the country's major problem. But can they really be both the captain of the healthcare ship and cede responsibility for cost control to almost everyone else? Ultimately, what this survey tells us is that physicians acknowledge that health care costs are an issue, but they are not yet willing to accept primary responsibility and take definitive action to lead change. The rejection of transformative, bold solutions to address the seriousness of the cost problem is indicative of much bigger problems ahead of we don’t start seeing more leadership from the physician community.
It's simple. If you want us to be captain of the ship and take on all the responsibility, then you have to actually listen to our opinions. Rehospitalization policies, pay for performance, and meaningful use are all untested ideas that have made both our and our patients lives miserable. EHRs have never been shown to improve quality or cost of care. Study after study is starting to show that rehospitalization rates are extremely difficult to modify.
Most importantly, our lives as primary care physicians have deteriorated greatly in the last two years. The amazing amount of paperwork, the denials, and the computers are sucking our attention away from real life, difficult, patient problems. Ask any patient, they will tell you that the office environment has deteriorated.
Finally, Emanuel and Steinmetz warn:
Unless physicians want to be marginalized -- unless they are willing to become just another deckhand -- they must accept and affirm that they are responsible for controlling healthcare costs.
I guess he doesn't realize that we feel as if we have already been marginalized. But "deckhands" we are not. If we decide decide to jump ship, whose going to steer the boat?
Maybe Ezekial Emanuel will.
Although I would bet the no one would be surprised by these findings, a scathing editorial by Ezekiel Emanuel and Andrew Steinmetz caught my eye. Before I get to the particulars, I would like to make a few (hopefully mostly uncontested) observations.
1)Physicians are some of the most educated, hard working individuals in American society. Very few professions require a four year doctorate, plus a minimum of a 3 year apprenticeship. After finishing our training, we have long hours, take phone calls over night, and work many weekends.
2)People, by in large, don't go to medical school to make a fortune. There are many other professions that are more economically worthwhile with less debt incurred. Based on the GPA requirements, these applicants could likely choose almost any profession. Medicine is a passion and calling. Those who do not feel so drop clinical practice fairly quickly.
3)The daily job of physicians is to investigate, consider, and choose between incredibly complex and different avenues, and then take action. We are trained to see the subtleties in both the written word as well as during patient presentations. This is a thinking man's sport.
So when a large majority of educated, capable, and thoughtful people proclaim an opinion, one would think it would be wise to pause, consider, and evaluate before wholeheartedly dismissing the group as a bunch of weenies. Unfortunately, Emanuel and Steinmetz think differently. They proclaim:
The findings of Tilburt et al. confirm this ingrained human behavior by showing that physicians are hesitant, if not unequivocally opposed, to taking bold steps to re-engineer incentives in the system -- steps that may well have the most meaningful effects on controlling costs...
I couldn't agree more. Yes, thoughtful physicians who have been led astray before, are not jumping into the arms of governmental change. Let us ponder a few questions.
1)Have any of the finished medicare demonstration projects ever had positive results?
2)Has pay for performance in the past, on balance, shown a financial or quality of care improvement?
3)Is there any proof that ACOs or PCMHs will improve the quality or cost of care?
4)How is the government doing so far at balancing the budget in general?
As physicians we learn to use scientific evidence to support our theories. We have been burned time and again in medicine by using logic above data. After careful consideration, moving forward "boldly" but foolishly may do more harm then good. Ezekiel's fantasies about healthcare are unsubstantiated. Show us the data, and we will follow willingly.
The editorial continues:
This is a denial of responsibility...Of course, physicians do not want to be blamed for the country's major problem. But can they really be both the captain of the healthcare ship and cede responsibility for cost control to almost everyone else? Ultimately, what this survey tells us is that physicians acknowledge that health care costs are an issue, but they are not yet willing to accept primary responsibility and take definitive action to lead change. The rejection of transformative, bold solutions to address the seriousness of the cost problem is indicative of much bigger problems ahead of we don’t start seeing more leadership from the physician community.
It's simple. If you want us to be captain of the ship and take on all the responsibility, then you have to actually listen to our opinions. Rehospitalization policies, pay for performance, and meaningful use are all untested ideas that have made both our and our patients lives miserable. EHRs have never been shown to improve quality or cost of care. Study after study is starting to show that rehospitalization rates are extremely difficult to modify.
Most importantly, our lives as primary care physicians have deteriorated greatly in the last two years. The amazing amount of paperwork, the denials, and the computers are sucking our attention away from real life, difficult, patient problems. Ask any patient, they will tell you that the office environment has deteriorated.
Finally, Emanuel and Steinmetz warn:
Unless physicians want to be marginalized -- unless they are willing to become just another deckhand -- they must accept and affirm that they are responsible for controlling healthcare costs.
I guess he doesn't realize that we feel as if we have already been marginalized. But "deckhands" we are not. If we decide decide to jump ship, whose going to steer the boat?
Maybe Ezekial Emanuel will.
Saturday, July 20, 2013
Unlikely Miracles
We were pretty damn lucky that she was young and healthy.
The surgery had been technically successful. I watched as the resident finished with the last sutures. Although the attending had already left the room, I looked on with the eagerness of a third year student. Orders were written, and the patient was transferred to recovery.
It was a routine hysterectomy. None of the pizazz and flare of a gyne onc surgery, but at such an early stage in my career, I thought I was witnessing rocket science. We left the OR and rounded for the rest of the afternoon. As I hunkered in for a long evening in the hospital, I got a page from the resident.
Our hysterectomy dropped her blood pressure, meet me in her room!
The seen was serene. Our patients blood pressure was low indeed, but she was none the worse for it. Her belly was tender, but not alarmingly so given her recent surgery. We checked the numbers again manually, adjusted the fluids, and sent stat labs. We had no idea how long of a night we were in for.
As the hours passed the blood pressure continued to drop after each bolus of fluid. Serial blood counts showed that the hemoglobin was dropping disturbingly. I ordered a few units of packed red blood cells and listened to the resident arguing with the attending.
She's bleeding out. We need to go back to the OR now!
The attending, however, was unconvinced. In a strange haze of denial, she came up with any and every reason not to take the patient to the operating table. And so the resident and I sat at the bedside all night adjusting IV's, ordering more transfusions, and praying.
The miracle came around five o'clock the next morning. The hypotension resolved. The counts stabilized. Large purplish bruises outlined the patients abdomen and back, a reminder of the huge amounts of blood that had been lost. The resident and I figured that the fussy bleeder must have finally tamponaded.
The attending rounded in her usual fashion. She entered the patients room with an air of confidence. She turned to the resident smugly and barked off a few orders. It was clear that she was patting herself on the back for what she believed had been the right decision.
Years later, I still find it surprising that our patient survived the night. I have no doubt that the right thing to do would have been to return to the OR immediately and address the hemorrhage surgically.
And this seems to be the problem with difficult, involved decisions. Sometimes the decision makers are vested emotionally and otherwise. Often our vision is clouded, even when the correct path of action is undeniably staring us in the face.
As the drumbeat of healthcare reform marches on, there are those physicians and policymakers who call for greater regulation and more reporting.
Physicians like myself, working in the trenches, find ourselves backed into a familiar corner.
Our patient lies in the bed hemorrhaging, and we stand close by with both hands tied behind our backs hoping upon hope,
for another unlikely miracle.
The surgery had been technically successful. I watched as the resident finished with the last sutures. Although the attending had already left the room, I looked on with the eagerness of a third year student. Orders were written, and the patient was transferred to recovery.
It was a routine hysterectomy. None of the pizazz and flare of a gyne onc surgery, but at such an early stage in my career, I thought I was witnessing rocket science. We left the OR and rounded for the rest of the afternoon. As I hunkered in for a long evening in the hospital, I got a page from the resident.
Our hysterectomy dropped her blood pressure, meet me in her room!
The seen was serene. Our patients blood pressure was low indeed, but she was none the worse for it. Her belly was tender, but not alarmingly so given her recent surgery. We checked the numbers again manually, adjusted the fluids, and sent stat labs. We had no idea how long of a night we were in for.
As the hours passed the blood pressure continued to drop after each bolus of fluid. Serial blood counts showed that the hemoglobin was dropping disturbingly. I ordered a few units of packed red blood cells and listened to the resident arguing with the attending.
She's bleeding out. We need to go back to the OR now!
The attending, however, was unconvinced. In a strange haze of denial, she came up with any and every reason not to take the patient to the operating table. And so the resident and I sat at the bedside all night adjusting IV's, ordering more transfusions, and praying.
The miracle came around five o'clock the next morning. The hypotension resolved. The counts stabilized. Large purplish bruises outlined the patients abdomen and back, a reminder of the huge amounts of blood that had been lost. The resident and I figured that the fussy bleeder must have finally tamponaded.
The attending rounded in her usual fashion. She entered the patients room with an air of confidence. She turned to the resident smugly and barked off a few orders. It was clear that she was patting herself on the back for what she believed had been the right decision.
Years later, I still find it surprising that our patient survived the night. I have no doubt that the right thing to do would have been to return to the OR immediately and address the hemorrhage surgically.
And this seems to be the problem with difficult, involved decisions. Sometimes the decision makers are vested emotionally and otherwise. Often our vision is clouded, even when the correct path of action is undeniably staring us in the face.
As the drumbeat of healthcare reform marches on, there are those physicians and policymakers who call for greater regulation and more reporting.
Physicians like myself, working in the trenches, find ourselves backed into a familiar corner.
Our patient lies in the bed hemorrhaging, and we stand close by with both hands tied behind our backs hoping upon hope,
for another unlikely miracle.
Wednesday, July 17, 2013
Should Lawyers Be The New Doctors?
Dear patients,
It has been a hard week. I wanted to take a moment to personally apologize for all that you have endured. As one who has witnessed your pains and struggles, I can only wince with each new passing hurdle you are forced to leap over. This business of disease and illness is not for the weak of heart (metaphorically, that is).
To the man stranded in the hospital with a pelvic fracture, I wanted to say I'm sorry. Contrary to what you have been told, it was not I who gave the order to make your admission an observation. In fact, I did just the opposite. I had clicked the full admission order while doing the requisite computer work after seeing you that first night in the hospital. But the next day, I received a call from a physician in a distant city who has been paid by the medical center to review such cases. Although he reluctantly admitted that he is a pediatrician who doesn't even take care of adults, he has been given the power to interpret medicare rules and has decided that you don't qualify for inpatient status. Unfortunately it is of little interest to medicare, or this physician, that you are non ambulatory and that your wife is to frail to lift you. If you want to go to a skilled facility to strengthen before returning home, you'll have to pay for it yourself.
I'm sorry for the young woman I saw in the office crippled by pain caused by gastroesophageal reflux. I cannot explain why your insurance company has decided to deny my prescription for twice a day prilosec. I am aware that they have always filled it in the past. I am also aware that you have now been out of medication for a week, and are in severe discomfort. It baffles the human mind to understand the foibles of prescription coverage. It would be impossible for the insurance company to know, as I do, that you had been hospitalized with these symptoms and only by using the medicine twice a day have you found relief. This is a secret that only you and I share.
I'm sorry to the middle aged man who unexpectedly suffered a life altering stroke. Unable to walk, I had great hope that a motorized wheel chair would give you the mobility and Independence that had been cruelly taken from you. I filled out the paperwork as carefully as I knew how, but the request was denied. I know that the world is full of fraud and misuse, but surely even the most uneducated could see that you are a perfect candidate for such technology.
I guess I can only imagine the unendurable suffering to all of you caused by such indiscriminate shows of brute force by our medical system. I too suffer. Not, of course, like you. I ache from the depths of my being when the product of my life's work is sour and impotent. I spent all those years learning how to become a healer, a secretary and insurance negotiator I am not.
My skill set no longer matches your needs.
Perhaps a lawyer would get you farther.
It has been a hard week. I wanted to take a moment to personally apologize for all that you have endured. As one who has witnessed your pains and struggles, I can only wince with each new passing hurdle you are forced to leap over. This business of disease and illness is not for the weak of heart (metaphorically, that is).
To the man stranded in the hospital with a pelvic fracture, I wanted to say I'm sorry. Contrary to what you have been told, it was not I who gave the order to make your admission an observation. In fact, I did just the opposite. I had clicked the full admission order while doing the requisite computer work after seeing you that first night in the hospital. But the next day, I received a call from a physician in a distant city who has been paid by the medical center to review such cases. Although he reluctantly admitted that he is a pediatrician who doesn't even take care of adults, he has been given the power to interpret medicare rules and has decided that you don't qualify for inpatient status. Unfortunately it is of little interest to medicare, or this physician, that you are non ambulatory and that your wife is to frail to lift you. If you want to go to a skilled facility to strengthen before returning home, you'll have to pay for it yourself.
I'm sorry for the young woman I saw in the office crippled by pain caused by gastroesophageal reflux. I cannot explain why your insurance company has decided to deny my prescription for twice a day prilosec. I am aware that they have always filled it in the past. I am also aware that you have now been out of medication for a week, and are in severe discomfort. It baffles the human mind to understand the foibles of prescription coverage. It would be impossible for the insurance company to know, as I do, that you had been hospitalized with these symptoms and only by using the medicine twice a day have you found relief. This is a secret that only you and I share.
I'm sorry to the middle aged man who unexpectedly suffered a life altering stroke. Unable to walk, I had great hope that a motorized wheel chair would give you the mobility and Independence that had been cruelly taken from you. I filled out the paperwork as carefully as I knew how, but the request was denied. I know that the world is full of fraud and misuse, but surely even the most uneducated could see that you are a perfect candidate for such technology.
I guess I can only imagine the unendurable suffering to all of you caused by such indiscriminate shows of brute force by our medical system. I too suffer. Not, of course, like you. I ache from the depths of my being when the product of my life's work is sour and impotent. I spent all those years learning how to become a healer, a secretary and insurance negotiator I am not.
My skill set no longer matches your needs.
Perhaps a lawyer would get you farther.
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