“You work hard all your life and when it comes time when you need help, you get tossed aside like an old rag” That’s what the patient’s wife said to me when I told them I had to discharge them tomorrow. My patient is dying of a terminal cancer, all his wife wants is an extra two days in the hospital. She needs to work; they have nobody else. It would be more convenient if he could be discharge two days later. She could have the house cleaned and be there when he arrived from the hospital. Sounds reasonable. I said he couldn’t stay the extra two days. He was medically stable for discharge. I explained that his vitals and labs had all returned to normal. The electrolyte disturbance he was admitted with had been corrected. He was eating and walking more. The therapists have all cleared him for discharge. Hospice would be there to set up services and provide equipment for him when he got home. All of this felt like yelling into the wind. I could see the disappointment in her face. The wife said, “Getting old is bad. You work hard all your life and when your health fails, no one is there to help you.” She felt abandoned, hurt. She asked again if they could stay longer. I had already done my homework. I scoured the chart for every possible reason to keep the patient longer in the hospital. Again, I said “no.” I sat there in silence with both of them. I contemplated whether to explain my position further. I wanted to say, “Look, we’ve set up all these services for him. We haven’t abandoned him.” Most of all I wanted to say, “I’m sorry for failing you.” Instead, I asked if they had any further questions. Sensing defeat, they said “no” I excused myself and left the room.
Oftentimes doctors and patients disagree on when they should be discharge. Most patients want to leave ASAP but others want to stay longer. The problem is Medicare or private insurance won’t pay for hospital days when patients are medically stable. The patient can refuse to leave but they’ll end up paying for those extra days. Charges will likely be in the tens of thousands of dollars. Most families can’t afford to pay this. The responsibility of determining medical stability is up to the physician. I’d like to think that most docs provide compassionate care but they also can’t make up things up to keep their patients hospitalized longer. Medicare fraud carries fines and jail time. None of this matters to the dying patient and his wife. He just asking for understanding and a little more time. I have lots of the former but none of the latter for him. What bothers me a great deal is that my patient doesn’t think I have either for him.
I have a good job. Decent pay, good schedule, and I get to help people. Why did I travel to another state for a job interview? The biggest reason is professional dissatisfaction. I work for ‘The Man’. Which is to say I am an employee of a large health system. I am a cog in a massive health care company. I feel more like a screw than a cog though. Goals, deadlines, and required participation are sent down to us from administrative leadership. Thou shall see this many patients in a year or your pay will be deducted. Thou shall achieve high scores on patient satisfaction survey. Thou shall attend meetings where you will be taught to be a more compassionate doctor. As a person who spent 8 years in school, 4 years of residency training, and accumulated $200,000 in debt from schooling, I find being treated in such ways demeaning, and insulting. My co-workers and I find being sent to learn to be more compassionate and empathetic degrading. We have trained for years to take care of people. Being told by a trainer who has not taken care of real patients to sit down, lean in, nod our heads while listening to a patient talk is maddening. I’d like to say my company truly cares what patients thinks about our service, but instead it’s all about money. Let me explain. Part of the Affordable Care Act stipulates that health care organizations, hospitals, and doctors need to be held more accountable for the care they provide. So Medicare payments will be linked to patient satisfaction results obtained through surveys. I agree that patient satisfaction is important but why the sudden interest now when previous years the company had focused on decreasing length of stay (average number of days a patient is hospitalized), increasing case mix index (doing more expensive procedures, having sicker patients), and improving payer mix. I find it hypocritical that the company is using patient satisfaction as a guise when their real motivation is improving reimbursements from Medicare. It’s about improving the bottom line. So I’ll trudge to training, and learn to listen more attentively so that maybe patients will give me good marks on the after hospitalization survey. Quietly though, I’ll work to provide good care for my patients, survey or no survey.
I ordered a new toy for myself. A Jawbone Icon Bluetooth headset. I justified the purchase by telling myself that it will make my commute safer when I had to return pages while driving. I found the model and price I wanted from walmart.com. Order came in 2 days. Everything was great until my order shipped. Headset shipped with only bubble wrap. No fancy box, no extra earpiece for better fit, no warranty info and only part of the instructions. The headset itself was chipped, scuffed, and had something that looked like earwax on it. Ya, I know, gross. I cleaned the earpiece off until it was pristine. I even contemplated using an alcohol swab on it but didn’t want to use chemicals on it if I might return it. When I tried the earpiece, it didn’t fit. Without extra earpieces for better fit, I was screwed. Drove to my local Walmart while cussing about such poor customer service. Thankfully, brick and mortar Walmart was more responsible than walmart.com. They let me return the order and even paid my shipping! Kudos to brick and mortar Walmart, boo to walmart.com. Expect an angry letter from me soon.
Toronto has an extraordinary clean city. There some panhandler but not much compared to the size of the city. The city is beautiful; the people are pleasant. There are a lot of variety of food. Food is fair to very good. I did not encounter any excellent food though. Maybe I just didn’t go to the right place. Everything was expensive though. From bottle water to baseball caps. The conversion rate from USD to Canadian didn’t help either. Like San Francisco, Toronto is a good place to visit but I’m not sure I’d want to live there.
Where is more less? Health care, that’s where. For the average consumer, less is best. The US model of health care is more is better, has been for decades. This has led to our bloated, expensive but ineffective health care system where the major players work to keep the status quo. Think about how expensive health care is in the US. Does it really make sense that insurance and pharmaceutical companies make more money than hospitals, clinics, and health care providers? There has been a lot of debate on health care reform this year. And while both sides have legitimate points, I would go further by saying health care reforms has to start at home. We have to think carefully about how we want to consume health care. If your child has a fever, do they always need antibiotics and chest x-ray? Do you think about the risk associated with them? Antibiotic resistant MRSA (methicillin resistant staph aureus) or Clostrium Difficile colitis from antibiotic overuse, and leukemias and skin cancer with radiation exposure. Now the cancer risk is very low, but radiation doses are cumulative.
Look to examples overseas like in Norway where they achieved dramatic reduction in MRSA infections http://bit.ly/4M0qfu. Another study published in JAMA (Journal of the American Medical Association) in 2006 http://bit.ly/63gwIV showed that Wait and See Prescription method was equally effective in treating ear infections in children with substantially less antibiotic use. The point to all of this is more is not necessarily better. We need to embrace this paradigm one person at a time and realize that health care reform starts with us.
New Years is a time for making resolutions. I’ve read some resolutions that seems overly ambitious. Maybe it’s good to be ambitious but I feel it’s important to accomplish goals, even small ones. To that end, my resolutions are to drink more water, eat smaller meals, and take more time for myself, family and friends. If I can consistently do those things in 2010, I would consider myself a better man for taking care of myself, and being there for others. What are your resolutions and why?