Thursday, September 20, 2012


     Some weeks are worse than others.  This one was not good--my poor, forbearing staff can attest to this.  Every day I felt like throwing in the towel.  It seemed to me that one patient after another could have been sent as a spy by the government--trying to trip me up, checking to see if I really did what my clinic billed, if we really spend that much time with patients..  The mindset which assumes there are threats all around belongs to the conditions of warfare, not the world of doctoring, mothering, gardening or business management.
     One angry patient called and threatened to go to another doctor if I wouldn't write off his co-pay.  He said he'd been promised he could be seen "for free" at hist last visit, way back in March.  There was no indication of such a promise in the computer nor in our handwritten notes, nor was there a waiver in his chart, nor any good reason to waive his copay--so I figured he was a manipulator--or an undercover agent.  Prior to last year's government raid such a thought wouldn't have occurred to me.
      Many of my real patients have been interviewed by FBI agents, and tell me that one line of questioning has focused on my willingness to allow patients to be seen without a copay if their symptoms amount to an emergency and they don't have money, or if they sign an affidavit attesting to the fact that they are in a period of severe financial hardship.  Although this is perfectly legal, and my office is the only one to bear the cost, the FBI agents would like to show that I have a "pattern of writing off copays"--and turn this small act of benevolence into a crime.  The government and insurance company rationale is that if I'm willing to write off the copay for a patient, I should also be willing to write off the entire charge for the insurance company.  (Charity should be distributed evenly, they seem to think, to rich and poor.)  But Blue Cross posts yearly profits in the hundreds of millions--in 2011 it reported reserves of $1.15 billion--whereas some of my patients tell me their annual income is less than $5,000.  I can hardly justify writing off a bill  for "someone,"  i.e., a corporation, with huge profits every year, nor can I consider a reckless, spendthrift government a charity case. 
     The FBI agents can't find wrongdoing in my life or my clinic--because I haven't done anything wrong.  Therefore, they can't justify the federal charges they've imputed by the fact of the raid, so the next step in saving face is for them to trump up civil charges. 
     Another patient insisted that he had lost his prescription for prednisone--for the third time--and needed a new one.  I no longer trusted the story of this otherwise intelligent, well-heeled, ingratiating man who has spent a lot of time insisting that his gout pain is terrible, and also asked for pain medication in amounts that could cause harm. 
     "I don't see signs of gout," I told him.  "Your toe isn't swollen, red, or tender."
     "Yeah, but I really need pain medicine," he said.  "You can't see what's in-side."
     I thought I saw a smirk of contempt flash from the corners of his mouth, and his right shoulder was rolled forward--two of the telltale signs that indicate someone is lying.
     "Let's talk about your diet, because that's the real treatment for the problem of gout.  Can you reduce the amount of beer you're drinking?  Beer-drinking in hot weather can trigger gout."
     The patient feigned irritation.  "Are you going to give me what I need or not?  Cuz I need to get back to work."
     A third patient pressured my staff for "nerve medicine."  The only one that worked, she said, was Xanax--the most addictive prescription medicine in the world.  When I entered the exam room to treat her, she asked me in six different ways for the prescription.
     "Just a few," she said finally, as though we were forging a compromise.  "I can't sleep."
     "But you have THC in your urine, and our prescription policy states that we cannot give controlled substances to patients who use street drugs."
     "I can't survive without weed," she told me, her voice escalating.
     "I think you can," I said.
     "Obviously, you have no understanding of anxiety," she said.
     "There are other ways to manage anxiety, but it will take time.  I can help you."
     "If you won't give it to me, I'll just have to get it somewhere else," she warned.
     "That's your choice," I answered.  "But don't pretend I'm your partner in crime.  I'm still willing to help you in a medically sound way."
     Was this patient prompted by the feds, or am I just getting paranoid?
     When I leave work and arrive home each evening, I put on my muck boots and hurry down to the pond behind the house, flashlight in hand--because it's always dark.  This is where I recover from the day.
      As I approach the water I hear the plop-plop-plop of frogs, their sensitive nervous systems registering my footsteps, clambering from their mudpads into the cold, clear depths.  I squat down low and stare into the water, where spiders dart across the surface before taking nosedives.  Black beetles tool around like miniature submarines.  There are schools of baby minnows--I'm the one who got them started with a breeding kit.  I wasn't sure the pH of the water, at 6.0, would be alkaline enough for them to multiply, but it looks as though they're going to make it.  When the lead minnow swims to the right, they all follow suit.  This synchrony of movement provides a glimpse into the choreography of nature, which underlies everything--it must be directed toward a goal.  The pond offers insights about how the whole universe works, and it restores my faith.  I walk away the pond and its little creatures with the same sense of having been restored that taking communion from a priest bestows.
     I look for the alligators, whose eyes sometimes reflect the shine of my flashlight.  I haven't seen them for a month, nor have the snapping turtles bobbed their heads above the surface.  They gave the pond its aura of power, and danger, which I transferred to my situation with the government.  Don't mess with me, I've got weapons in reserve.  What are the weapons to use against sinister forces?
     Last week I saw at the east side of the pond a floating mass of gelatinous globules--hundreds of them--with black polka-dots at the center.  It undulated like an enormous jellyfish when the dogs took a swim a few yards down.  These are toad eggs which take seven days to hatch.  I looked very at one, using a magnifying glass, and the black dot was revealed as a tadpole-in-the-works, complete with a knobby head and tiny eyes.  The tadpoles will eat algae and dead insects over the next three to four months, as they undergo the phenomenal transformation to toads.
     I usually stare into the water until the mosquitoes claim a victory over my meditiation, then I trudge back to the house under the moonlight.  The feds, the office, the billing, the coding, my suspicions, the incompetencies of our methods of governing ourselves as a race, the sadness of the human condition, unfairness, illness, grief, longing, death--all of these are relativized, for me, by the fact of this pond.  

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