I was reminded of this last night, as I sat with some friends discussing the topic of miracles.
A few weeks ago, I had the privilege of being a missionary, of working on a new mission. Maybe I didn't look it, as I seemed to be doing my usual work. You see, I was able to cover the inpatient service of one of my colleagues from the community, so that he would be freed up and be able to join two of his children on a mission trip to Africa. I've heard it said that there are two kinds of missionaries - those who go, and those who stay home. I had the chance to be the latter. Several of my practice partners helped out in this service as well.
And, another doc from the community had taken a good deal of this work as well. After his days of work, he "handed off" over a dozen patients to me, so that I could continue to care for them in the hospital. One of those patients was an older woman, who was now on "comfort care".
One of the tenets of the ethics of medicine is that each of us has the right to direct our own medical care. In this situation, the patient, through the designation of a healthcare proxy, had declared that she didn't want any "heroic" measures if it appeared that she was terminal. She had been admitted with kidney failure and pneumonia, and after a few days, the decision had been made that, indeed, it appeared as though she would not leave the hospital, she would die from these problems. So, the plan of care switched from curing her to offering her comfort while she died.
When I met her, she was unresponsive, essentially in a coma. She was not eating or drinking; she was not responsive to pain, and did not communicate with staff.
Well, after I had watched over her for three days, I got a call from the nursing staff. On that morning, she had sat up in bed and asked, "What's for breakfast?"
I need to be reminded that miracles do happen. It is a privilege to witness, and sometimes participate in these miracles...
Monday, April 28, 2008
Wednesday, April 23, 2008
"And then I saw my church..."
I haven't posted for a few weeks, and feel the need to get back "on my soapbox". I thank those of you who've noted by abscence, and encouraged me to pick up the conversation again...
I guess I'll start with some stories. I feel compelled to document these sorts of things because I am constantly encountering stories which I find unbelievable, and in fact, I'm convinced no one thinks that these sorts of things could be happening in our community.
I was on call last week, caring for our patients in the local community hospital. And, it was a tough week. I took care of as many as 24 patients per day - seven days x 24 hours per day. One night, I got a call from the nurse on the psychiatric unit. The psychiatrist had accepted a "voluntary admission" for a young woman who was suicidal. She had, in fact, been thrown out of her home by her mother that night, who said to her "You're worthless; why don't you go kill yourself." So, she walked to the nearest bridge.
As she was standing on the bridge, she happened to look over the city of Bremerton, and see her church in the distance. And, rather than kill herself, she chose to call a church member, who came to her aid and brought her to the safest place she knew - the local hospital's Emergency Department.
So, the call I got from the psychiatric unit was that the patient had experienced an apparent seizure, and therefore needed a medical, rather than psychiatric, provider to take over her care. I did so.
The next day, I found that she was medically stable. However, the psychiatrists who had accepted her initially would not take her back to the psychiatric unit, despite her desire to have treatment. The stated reason was that "she was not a good candidate" for care, since she was "argumentative". They came to write in her chart, but didn't even prescribe any medications for her. As a primary care physician, it was now my burden to treat this actively suicidal patient.
So, was she still suicidal? Well, about 24 hours after her admission, again in the night, she in fact wrote out her "will". She stated that she was going to kill herself, and she outlined who should get her few possessions, her iPod, her favorite clothes. Within twelve hours, "the system" had decided that she was safe to go home. Even though she came to the hospital seeking care, she wasn't welcome to stay in the psychiatric unit. Even though she was suicidal, she wasn't offered any medications for this acute exacerbation of a chronic underlying psychiatric disorder.
She saw her church. And, her faith brought her to the hospital for care. And, "the system" turned her away.
That's the way it happened. Believe it. Or, refuse to believe that, in the wealthiest nation on earth, we have created a system in which this patient is turned away, left to herself. There are times when I am ashamed to be a part of it.
I've gotten some comments of support and encouragement from some of you, and from friends. Thank you. Even if it seems I'm surrounded by a world without compassion, or maybe because I'm surrounded by that world, I'll keep at it. I couldn't see doing anything else.
Friday, February 15, 2008
Busy days...
Things have been busy for us lately. I guess they're always busy! And, likely to remain so....
I just thought I'd take a few minutes to tell some stories. It's always so moving to me to be allowed to take part in the stories of people's lives. And, I consider it a privilege.
I want to tell you about a man I have known for a few years. He's a little younger than me; in his mid-thirties. He and his family are out patients. I recall how, a few years ago, he had told me about his concern that his neighborhood wasn't safe for his family. He was worried about having young children in a home where drug deals and prostitution sometimes took place just outside his front door. He was very happy to be able to sell that home, and move into a nicer suburban neighborhood. He and his wife have both been working hard to provide this for their children.
Well, I saw him a couple of weeks ago. His wife has had to have surgery, and is now unable to work, at least for several weeks. He tells me that he's on the verge of bankruptcy, will be losing his house, his car, and doesn't know where he's going to take his family.
In this time of political debate, I'm hearing some of my friends talk about "personal responsibility". But, I can't help but think that my patient has nothing to be ashamed of with regard to his decisions. He has kept his family's well-being as his priority. He and his wife have worked hard to provide a safe home and neighborhood for his children. And, it certainly wasn't a "moral failure" or "lack of responsibility" that led his wife to surgery. In fact, he tells me that it was his wife's work that led to the injury which required surgical care - somewhat ironic, I'd say.
Now, to talk more about that concept of "personal responsibility", I still wonder what "they" would say that my patient should do now. I get that question stuck in my head when I hear that a doctor or a medical practice has decided that they will no longer be seeing patients with (fill in the blank: no insurance/Medicaid/Medicare/Tricare...). So, if they were sitting across the exam table from that patient, what would they say the patient should do now? Okay, if you can't see them, who will? If I can't refer the man with the broken hand to the hand surgeon, what would you suggest I say to him, when I sit with him?
My wife used to take those phone calls, in her work as a medical assistant. And, she would tell patients, "I'm sorry; we're not taking your insurance." She now says that she had no idea that it meant that the patient might not get care - she assumed "someone else" was going to take care of the patient.
Well, that's my job - to take care of the patient that can't find care elsewhere. But, there just aren't enough parnters in my practice to take on all that burden...
I just thought I'd take a few minutes to tell some stories. It's always so moving to me to be allowed to take part in the stories of people's lives. And, I consider it a privilege.
I want to tell you about a man I have known for a few years. He's a little younger than me; in his mid-thirties. He and his family are out patients. I recall how, a few years ago, he had told me about his concern that his neighborhood wasn't safe for his family. He was worried about having young children in a home where drug deals and prostitution sometimes took place just outside his front door. He was very happy to be able to sell that home, and move into a nicer suburban neighborhood. He and his wife have both been working hard to provide this for their children.
Well, I saw him a couple of weeks ago. His wife has had to have surgery, and is now unable to work, at least for several weeks. He tells me that he's on the verge of bankruptcy, will be losing his house, his car, and doesn't know where he's going to take his family.
In this time of political debate, I'm hearing some of my friends talk about "personal responsibility". But, I can't help but think that my patient has nothing to be ashamed of with regard to his decisions. He has kept his family's well-being as his priority. He and his wife have worked hard to provide a safe home and neighborhood for his children. And, it certainly wasn't a "moral failure" or "lack of responsibility" that led his wife to surgery. In fact, he tells me that it was his wife's work that led to the injury which required surgical care - somewhat ironic, I'd say.
Now, to talk more about that concept of "personal responsibility", I still wonder what "they" would say that my patient should do now. I get that question stuck in my head when I hear that a doctor or a medical practice has decided that they will no longer be seeing patients with (fill in the blank: no insurance/Medicaid/Medicare/Tricare...). So, if they were sitting across the exam table from that patient, what would they say the patient should do now? Okay, if you can't see them, who will? If I can't refer the man with the broken hand to the hand surgeon, what would you suggest I say to him, when I sit with him?
My wife used to take those phone calls, in her work as a medical assistant. And, she would tell patients, "I'm sorry; we're not taking your insurance." She now says that she had no idea that it meant that the patient might not get care - she assumed "someone else" was going to take care of the patient.
Well, that's my job - to take care of the patient that can't find care elsewhere. But, there just aren't enough parnters in my practice to take on all that burden...
Tuesday, January 22, 2008
Hope!...
Just thought I'd add a note of hope to the downer I just posted.
Senator Karen Keiser, representing the 33rd Legislative District in the Washington Senate, and Chair of the Health & Long-term Care Committee, has introduced SB 6221, available for review here, which would create a system for universal healthcare insurance coverage in our state. There's a nice review of the issue, and the history of healthcare reform in Washington, in this Puget Sound Business Journal article.
One of the interesting points in the preamble to the bill is the statement: "In 2007, the average annual premium for family coverage was twelve thousand dollars, of which over three thousand dollars are paid by the worker." There are a number of similar interesting statistics noted.
So, thank you Senator Keiser, for your work. And thanks for providing me with some hope...
Senator Karen Keiser, representing the 33rd Legislative District in the Washington Senate, and Chair of the Health & Long-term Care Committee, has introduced SB 6221, available for review here, which would create a system for universal healthcare insurance coverage in our state. There's a nice review of the issue, and the history of healthcare reform in Washington, in this Puget Sound Business Journal article.
One of the interesting points in the preamble to the bill is the statement: "In 2007, the average annual premium for family coverage was twelve thousand dollars, of which over three thousand dollars are paid by the worker." There are a number of similar interesting statistics noted.
So, thank you Senator Keiser, for your work. And thanks for providing me with some hope...
HealthCare Meltdown 101: The Emergency Room...
As we lingered after dinner with our dearest friends this weekend, we started talking about politics and health care. And, one of the first things spoken round the kitchen table was "We have great healthcare in America." And so began a converation about just some of the myths that Dr. LeBow debunks in his book: Health Care Meltdown: Confronting the Myths and Fixing our Failing System.
In the first chapter of the book, Dr. LeBow starts with these two quotes:
"America has the best health care system in the world." - Many American politicians
and
"The moon is made of green cheese." - Anonymous, 16th century, likely a dairyman
The first myth that Dr. LeBow tackles is one that I've heard even recently: "Everybody has access to care through the emergency room".
This myth was recently stated as fact by our own President, George W. Bush, a man whose home state ranks #1 in the number and percentage of uninsured, as noted by many sources including this review of US Census Bureau statistics. In a speech last July, the president made this bonehead statement:
“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”
There's a great commentary on this statement here.
This was the topic of a recent article in the Puget Sound Business Journal. In the article, one of my old partners in practice, Dr. Brian Wicks, appears to bemoan the fact that our government put in place laws that make it illegal for hospitals to turn away patients in the case of an emergency life-threatening condition or active labor, the EMTALA act. To quote Dr. Wicks:
"Anybody who walks into an emergency room will get taken care of, (and) that's part of the problem, because people use the emergency room instead of going to a primary care doctor."
So, what's wrong with this position? Well, there are a number of issues. The one that strikes me most squarely in the face is that (some) patients are not getting care when they present to the emergency department. They are, in fact, being turned away. Oh, not so that it would violate EMTALA. But, let me tell you a story, a true story.
A young man, while working at his construction job, injures his hand. His right hand; he's right-handed. He presents to the emergency department for care. (We'd all do the same thing, wouldn't we? Surely, this isn't the inappropriate access to which Dr. Wicks referred...) He is seen by the emergency department physician, and xrays are obtained. He has a comminuted fracture of the hand, a fracture that is thought to be beyond the scope of practice for a family physician, and would most commonly be treated with orthopedic surgery. Good thing we have a hand surgeon in our community, one might think. But, unfortuately, the hand surgeon is not on call today. So, the emergency department physician makes a referral to the orthopedic surgeon on call. (Our community hospital in fact keeps orthopedic surgeons "on retainer" by paying them to be available to take these sorts of cases. But, that's another topic.) The patient is given instructions to call their office the following day to schedule an appointment. So far, so good.
Well, when the patient calls the next day, he is told by the office staff that he cannot schedule an appointment. He sees one of my partners in our current practice, who hears the story and has our staff call on the patient's behalf. The answer remains the same, "Our practice doesn't take his insurance." (Oh, but I thought the hospital was paying you to be on call for the emergency department?...)
In this situation, which is not unique in our experience, the patient certainly runs the risk of deformity, chronic pain, and disability, because he didn't have the right "credentials" when he presented to the emergency room. He is not alone; the Kaiser Family Foundation reviews similar risk in the report entitled "Sicker and Poorer: The Consequences of Being Uninsured." And, the Institue of Medicine estimates that 18,000 adults die each year because of lack of insurance, in this report, despite this safety net of emergency department care.
So, while the emergency department didn't literally turn this patient away, the result was the same - the patient went without the care he needed. And, clearly this care is outside the scope of primary care. So, Mr. Bush, what would you have him do? So, Dr. Wicks, which of your partners in the community will see this man? And, if it were your brother, your father, your neighbor, what would you want for him?
I enjoy the benefit of close and caring friends. And, I think we came to the right conclusion at the end of our brief talk - the world has a hard heart toward others.
In the first chapter of the book, Dr. LeBow starts with these two quotes:
"America has the best health care system in the world." - Many American politicians
and
"The moon is made of green cheese." - Anonymous, 16th century, likely a dairyman
The first myth that Dr. LeBow tackles is one that I've heard even recently: "Everybody has access to care through the emergency room".
This myth was recently stated as fact by our own President, George W. Bush, a man whose home state ranks #1 in the number and percentage of uninsured, as noted by many sources including this review of US Census Bureau statistics. In a speech last July, the president made this bonehead statement:
“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”
There's a great commentary on this statement here.
This was the topic of a recent article in the Puget Sound Business Journal. In the article, one of my old partners in practice, Dr. Brian Wicks, appears to bemoan the fact that our government put in place laws that make it illegal for hospitals to turn away patients in the case of an emergency life-threatening condition or active labor, the EMTALA act. To quote Dr. Wicks:
"Anybody who walks into an emergency room will get taken care of, (and) that's part of the problem, because people use the emergency room instead of going to a primary care doctor."
So, what's wrong with this position? Well, there are a number of issues. The one that strikes me most squarely in the face is that (some) patients are not getting care when they present to the emergency department. They are, in fact, being turned away. Oh, not so that it would violate EMTALA. But, let me tell you a story, a true story.
A young man, while working at his construction job, injures his hand. His right hand; he's right-handed. He presents to the emergency department for care. (We'd all do the same thing, wouldn't we? Surely, this isn't the inappropriate access to which Dr. Wicks referred...) He is seen by the emergency department physician, and xrays are obtained. He has a comminuted fracture of the hand, a fracture that is thought to be beyond the scope of practice for a family physician, and would most commonly be treated with orthopedic surgery. Good thing we have a hand surgeon in our community, one might think. But, unfortuately, the hand surgeon is not on call today. So, the emergency department physician makes a referral to the orthopedic surgeon on call. (Our community hospital in fact keeps orthopedic surgeons "on retainer" by paying them to be available to take these sorts of cases. But, that's another topic.) The patient is given instructions to call their office the following day to schedule an appointment. So far, so good.
Well, when the patient calls the next day, he is told by the office staff that he cannot schedule an appointment. He sees one of my partners in our current practice, who hears the story and has our staff call on the patient's behalf. The answer remains the same, "Our practice doesn't take his insurance." (Oh, but I thought the hospital was paying you to be on call for the emergency department?...)
In this situation, which is not unique in our experience, the patient certainly runs the risk of deformity, chronic pain, and disability, because he didn't have the right "credentials" when he presented to the emergency room. He is not alone; the Kaiser Family Foundation reviews similar risk in the report entitled "Sicker and Poorer: The Consequences of Being Uninsured." And, the Institue of Medicine estimates that 18,000 adults die each year because of lack of insurance, in this report, despite this safety net of emergency department care.
So, while the emergency department didn't literally turn this patient away, the result was the same - the patient went without the care he needed. And, clearly this care is outside the scope of primary care. So, Mr. Bush, what would you have him do? So, Dr. Wicks, which of your partners in the community will see this man? And, if it were your brother, your father, your neighbor, what would you want for him?
I enjoy the benefit of close and caring friends. And, I think we came to the right conclusion at the end of our brief talk - the world has a hard heart toward others.
Friday, January 18, 2008
Long week...
It's been a long week. I've been on call for our practice, which means that I'm responsible for all the adults and children requiring hospital care from our practice. And it's been, unfortunately, a typical week - busy, with some very ill patients, many of whom are uninsured or "underinsured".
I am caring for a middle-aged woman who presents with chest pain, so she gets admitted to me to be sure that she hasn't had a heart attack. (yeah, there are cardiologists in our hospital, but they don't do this kind of work...) And, oh by the way, she is actively suicidal. (yeah, there are psychiatrists in our hospital, but they don't do this kind of work... sensing a theme here?) I was able to have her seen by one of our psychiatrists, who started her on therapy. She has no evidence of heart disease, and so now she sits on the medical unit due to her depression and suicidality. (We do have a psychiatric unit in our hospital, but... you know what I'm gonna say! - When I inquired about her being cared for on the psychiatric unit, the immediate response was, "Well, she's uninsured, so...".)
I'm seeing a young man, a man who works hard in a physically-demanding job. He's been ill for more than a month. He went to the Emergency Room when he got sick, and they treated him for pneumonia. He was asked to follow up with one of my partners in our office, but he couldn't afford it. (We are not a free clinic, but we charge people based upon their ability to pay, so the fee for the office visit may be as low as $20.) Since he couldn't afford to see us in the office, he had to go back to the emergency department a few days ago, having gotten more and more sick. He has been in the hospital all week with a severe pneumonia. He's worried about how long he might be off work, since if he doesn't work, he doesn't get paid. He'll need a month of antibiotics, which would cost him only about $350 at a local pharmacy. "That's almost what I pay for rent," he says. The owner of the small business for which he works doesn't offer him health insurance; he's been on a waiting list for Washington Basic Health Plan for two years. Let's see, two emergency department visits, two CT scans, four or five chest xrays, inpatient care for ~ a week, with antibiotics and oxygen.... that's likely to be, I would guess, $20,000. How many of us can cough that up? How long will he be paying for this? Oh, and he doesn't smoke. This clearly isn't a case of an error in judgment, "personal accountability" - it could have been any of us with this course.
You know, you can find some information now on the web showing the costs of care for various diagnoses at your local hospital. At this site, I see that the average cost for my local non-profit community hospital. Uncomplicated pneumonia: $8,100-11,400 - "33% lower than national average." This young man surely has costs higher than this average, given the severity of his disease and the extra tests and time he's had to have. I'm also interested to see that the website indicates the services available at the hospital, starting with Behavioral Health / Mental Health / Substance Abuse Services. It looks like they forgot to add the asterisk, which points to the fine print: "...some services only available if you have desireable insurance status, and not available at all to the uninsured in our community."
Let me add this comment here. The words here are my own ramblings, and do not necessarily reflect the opinion of my employer or those with whom I work.
Well, back to work. I have to see some more patients after my lunch break.
I am caring for a middle-aged woman who presents with chest pain, so she gets admitted to me to be sure that she hasn't had a heart attack. (yeah, there are cardiologists in our hospital, but they don't do this kind of work...) And, oh by the way, she is actively suicidal. (yeah, there are psychiatrists in our hospital, but they don't do this kind of work... sensing a theme here?) I was able to have her seen by one of our psychiatrists, who started her on therapy. She has no evidence of heart disease, and so now she sits on the medical unit due to her depression and suicidality. (We do have a psychiatric unit in our hospital, but... you know what I'm gonna say! - When I inquired about her being cared for on the psychiatric unit, the immediate response was, "Well, she's uninsured, so...".)
I'm seeing a young man, a man who works hard in a physically-demanding job. He's been ill for more than a month. He went to the Emergency Room when he got sick, and they treated him for pneumonia. He was asked to follow up with one of my partners in our office, but he couldn't afford it. (We are not a free clinic, but we charge people based upon their ability to pay, so the fee for the office visit may be as low as $20.) Since he couldn't afford to see us in the office, he had to go back to the emergency department a few days ago, having gotten more and more sick. He has been in the hospital all week with a severe pneumonia. He's worried about how long he might be off work, since if he doesn't work, he doesn't get paid. He'll need a month of antibiotics, which would cost him only about $350 at a local pharmacy. "That's almost what I pay for rent," he says. The owner of the small business for which he works doesn't offer him health insurance; he's been on a waiting list for Washington Basic Health Plan for two years. Let's see, two emergency department visits, two CT scans, four or five chest xrays, inpatient care for ~ a week, with antibiotics and oxygen.... that's likely to be, I would guess, $20,000. How many of us can cough that up? How long will he be paying for this? Oh, and he doesn't smoke. This clearly isn't a case of an error in judgment, "personal accountability" - it could have been any of us with this course.
You know, you can find some information now on the web showing the costs of care for various diagnoses at your local hospital. At this site, I see that the average cost for my local non-profit community hospital. Uncomplicated pneumonia: $8,100-11,400 - "33% lower than national average." This young man surely has costs higher than this average, given the severity of his disease and the extra tests and time he's had to have. I'm also interested to see that the website indicates the services available at the hospital, starting with Behavioral Health / Mental Health / Substance Abuse Services. It looks like they forgot to add the asterisk, which points to the fine print: "...some services only available if you have desireable insurance status, and not available at all to the uninsured in our community."
Let me add this comment here. The words here are my own ramblings, and do not necessarily reflect the opinion of my employer or those with whom I work.
Well, back to work. I have to see some more patients after my lunch break.
Friday, January 11, 2008
Advocacy 101 Workshop
An "elevator speech" is a short list of "talking points" that you can use to tell your story in the short time of an elevator ride. Mine goes something like:
"I'm a family physician.I work at a Health Center, which is a private not-for-profit medical and dental practice owned by the community and run by a volunteer Board of Directors, the majority of which are patients we serve. The community started our Center twenty years ago, with the mission of seeing patients who can't find care elsewhere. I work there because I think that access to health care is a right of every human being."
What's your "elevator speech"? Why do you do what you do?
Advocacy 101 Workshop
Originally uploaded by Doug Felts
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