Patients: #11, Can We Choose the Way We Die?

     My father died in the front passenger seat of his Cadillac one chilly afternoon on the way to a dinner theater with friends. In his left hand was a cup of coffee, which did not spill when his head slumped forward and his heart stopped.  He had been bragging that the coffee was "free" at the service station where they had just filled the tank with gas.  He loved a bargain.
     Never one to waste a drop, his arm remained suspended in the air with his hand clasping the cup until Betsy, who was at the steering wheel, pulled the car over and gently peeled his fingers from the styrofoam container.  Then, his arm thumped onto his lap like a broken tree limb, and he fell forward.  I'm sure that in his last moments he regretted wasting the coffee--not to mention the four theater tickets, which had been purchased in advance.  Better to have died after the show, when they had gotten their money's worth.
     Nevertheless, my father was given the death he had imagined.  Despite worsening heart failure, he'd insisted to the universe--and to anyone else who would listen--that it would do no good for him to waste away in a hospital, allowing others to watch his vigor draining like gas from a hot air balloon with a slow leak.  No, he would prefer go in the midst of anticipating a good time with friends, wearing an expensive suit and garish shoes (he never quite escaped the Italian immigrant's inclination to flaunt success), in the middle of telling someone else what to do.
     "You could have made it through that intersection!" he snarled at Betsy, for he was an impatient man, always cutting corners.  "The light hadn't turned red yet!"  Those were his last words, meant perhaps for God:  The light's not red yet, you can't take me!  Useless, of course, in the face of eternity.
     Mr. R. was a patient I had grown to love.  He hailed from Lochloosa, population 120, the fishing and frogging village where I live--but he was the one with a native's expertise, not I.
     He had never learned to read or write--forced out of school in the third grade by an abusive father who worked him and his brothers to exhaustion on their farm.
     "What about child-labor laws?" I asked him, and he shrugged his shoulders.
     "That wasn't no matter to him," he answered.
     He was beaten so often he began to think of the world as a cruel and caustic place.  He decided to circumscribe his existence, stay put, be happy with less.
     Mr. R., therefore, feared the outside world, with its hieroglyphic billboards and fancy-talking people.  He never wanted to travel beyond a ten-mile radius of home, preferring instead to tend his wildly fruitful citrus trees and vegetables, or fish from the dock of one or another neighbor's pond.
     Every other weekend in winter I would come home to find, on my doorstep, grocery bags filled with his masterful oranges, eye-popping-big Meyer lemons, or terrific fanning bouquets of collard greens.  He had a kind, generous nature, and was always giving me tips about tending my own anemic-looking citrus grove.  But you can't teach someone how to have a green thumb.
     The central experience of Mr. R.'s life was the loss of his 16-year-old son, his only boy, the core of his being, raised with a degree of tolerance and compassion Mr. R. had never known and therefore was able to experience only through his own child-rearing.  The boy was--as is the case with many a first son, in relation to a father--the exemplar of his life.
     It seemed to me that Mr. R. had never forgiven himself for the boy's death, his drowning in a local pond thirty-eight years ago, his never having learned how to swim, his beautiful boy-body dredged out of the water and buried too soon, far too soon, and causing the kind of grief that frays one's nerves, one's conscience, and one's very being.  He spoke about it with me, but as far as I know, no one else ever brought up the tragic incident, or allowed him to vent his pent-up fury.  He did not go to church. How dare God do this to him?  How dare he steal from him the chance to raise a boy right, and to get something in return?
     I was saddened--though, perhaps, not truly surprised--to learn that Mr. R. himself died two weeks ago, drowned in a local pond, having himself never learned to swim.  A terrible shame, in this land of swamps and lakes and ponds and waterways.
     Instead of fishing off the dock, he had taken, for once, a canoe out to the middle of the water.  Instead of sitting quietly, he may have stood up to scan the water--verboten in a canoe--tipping the the whole shebang upside-down.  Or, maybe he got a really big one on his line--a 20-pound-2-foot bass, for instance, very rare, an astonishing catch--and it dragged him in, tipping the canoe, trapping him underneath.  It pulled him under as though it had been his own very son, longing, at last, to have his father returned to him.
     This is my fate, Mr. R. may have thought.  Now my boy's suffering is redeemed.  Now I can rest in peace. 
     My first reaction, on learning of Mr. R.'s death, came in the form of the oft-quoted T.S. Eliot lines, from "The Hollow Men"--

          This is the way the world ends
          This is the way the world ends
          This is the way the world ends
          Not with a bang but a whimper

     Can we choose the way we die?
     I think, in fact, we can.  Our deaths are not accidental, but pre-configured in our lives, part of the pattern of who we are.  As we live our lives, we are spinning, strand by strand, the web which will catch us in its cradle, finally, when we fall.
     We may not be able to speak of our final fate, or--as in the case of Mr. R.--it may be spoken about indirectly, and only with those who are open and able to hear, and not superstitious, and unafraid of that vast beyond, which exerts its relentless pull from some future venue whether we admit it or not.
     Mr. R. told me, in so many words, that the only expiation for his guilt would be for him to meet his son at the time of his death, joined together in suffering.
     My father, not wanting a forewarning, put his order in with God:  Do not make me waste away slowly.
     Most of my patients who die are given deaths that make sense in the context of their lives.  I am often amazed at how the pattern of life fulfills itself in death, like a great mandala colored with intricacy and detail, in which the last bits of its circumference are closed off with one final stroke--then it's finished, the edifice of a life, complete.  Afterward, it's supposed to be brushed away, Tibetan-style, empty space, making room for something new, the generative miracle of existence constantly renewing itself.
     Our deaths are there, waiting for us. They provide a prospective function to all our endeavors--go here, they say, go there, your destination is far away, in that direction--but not so very far that you can't see.  
     Our deaths are admonishing us to live.  If you listen carefully, you may be able to hear yourself giving hints, in regular conversation, about the details of your final passage--pointing, over there, to where you're headed. 

  
     

My Mother's Baked Custards

Organic milk, local eggs, and nutmeg make this a highly restorative food.  My mother made it whenever one of her children was sick. 

6 slightly beaten eggs
3/4 cup sugar
1/2 tsp salt
1 quart milk, scalded
1 tsp vanilla
Freshly grated nutmeg

Beat eggs.  Add sugar and salt.  Stir in scalded milk, whisking to mix quickly.  Pour in custard cups. Sprinkle with nutmeg.   Set in a  13 x 9 pan that has been filled to 1/3 with hot water.  Bake at 325 F for 30-40 minutes until custards shimmy slightly.  Eat warm or cold.  Makes 6-8 servings.

Some People Don't Want Us To Be Like Canada

     "Some people" = a long list of businesses that profit mightily from the leviathan of American medicine, attaching like barnacles and sea lice to its broad, satiny surface, hitching long, sumptuous rides, and sucking blood from the generous, unsuspecting host year after year.
     These are businesses in the medical insurance and pharmaceutical sectors.  They make ungodly profits off the backs of ordinary working people.   Most of them would be put out of business by a true national healthcare plan, because insurance--subsumed under the federal budget--would no longer be a worry or necessity for plain folks, and drug company profits would be down-regulated by the musculature of federal bargaining power.
     In Canada the insurance industry is regulated by the fact of the national health plan.  There still exist many private insurance carriers, which cover things like elective and cosmetic surgery, but their potency has been diminished by the absence of necessity.  Individuals don't need private insurance, any more than they "need" a new Lexus or a built-in swimming pool, therefore they have the capacity of judgment, not unbalanced by the fear of getting sick and not having basic coverage, to analyze and reject absurd, expensive offerings like insurance coverage with an unaffordable $5,000 or $20,000  deductible.  Such plans almost guarantee that patients will not seek out preventive care, or go to the doctor with early symptomatology, or agree to expensive screening tests like a colonoscopy ($3,000), because the deductible acts as a deterrent.
     In Canada, too, pharmaceutical companies don't have the formidable lobbying heft that it has in America.  The Canadian government acts like a true protector of the people, negotiating the prices of drugs down so that everyone can afford them, rather than like the piss-poor weaklings our congressional representatives have become, succumbing to the slick longiloquence of Armani-suited lobbyists from Merck and Pfizer without cross-examination, and allowing their industry to squeeze by without price-regulation no matter who's at the helm.
     America's failure to force pharmaceutical prices down makes it impossible for doctors like me to choose the best treatment for patients, because if that treatment happens to be a brand-name product, no one can afford it--nor will insurance companies agree to cover the outrageous cost.
    Here we are, then doctors and patients, caught in the middle of the obscene profit-mongering of two megalithic incubuses--the pharmaceutical industry imposing huge prices, and the insurance industry, refusing to pay.  Stranded and suffering are people with cancer, or bipolar disorder, or ulcers, or pain whose understanding of the situation is dampened by distress and forbearance, and who cannot pay out of pocket without postponing mortgage payments or reducing the grocery bill, and who are deprived, in the long run, of the best medical care.
     The answer to the question, "Why can't we be like Canada?" is this:  the insurance and pharmaceutical companies would lose power, and money if we switched to the sensible, Canadian system.  The insurance and pharmaceutical industries would be forced to get off the long sky-ride that has turned them into mega-billion powers with the lobbying clout to indemnify them against losses and ignore the fact that their products aren't serving people very well, as long as our country maintains its private insurance system.
     We are all being milked, year after year, by the insurance and pharmaceutical businesses--so we might as well pay taxes and get the federal and state governments, through adoption of national health insurance, finally, to force these greedy, self-serving corporate monsters into abeyance.
     That is why I am in favor of a national healthcare plan.       

Why Can't We Be Like Canada?

     In 1964 Canadians made the decision to adopt a national healthcare plan.  There wasn't a lot of fanfare--it was a common-sense decision.

     First, Saskatchewan--a far-away province which was suffering from a shortage of physicians--passed, in 1946, a bill giving its citizens free access to medical care;  several years later, Alberta followed suit.  By the early 1960's these programs had proved so successful that a universal healthcare system--wherein half of each province's healthcare costs would be borne by the federal government--and half by the province, was established.  

     A series of modifications to the healthcare act have modified the program over the years, and it isn't  perfect yet--but no one in Canada seems to be looking back.  Several of my Canadian friends shake their heads and laugh at Americans when I bring up our tortured way of making the decision to adopt universal medical coverage.  

     What's our problem?  Everyone knows that civilized countries need to guarantee their citizens access to free healthcare and a free education all the way through college.  We can't run a country without a healthy, educated population.  And people who are nervous about how they're going to pay for surgery, or college, can't give their utmost to their endeavors.  So why is the United States "debating" something so obvious?

     Frankly, I think the debate is a waste of time.  Maybe it makes for good news stories about "battles" in Congress, and presidential candidates who "fight it out" and "differ" about what healthcare should look like in America.   More likely, there are too many interested parties who don't want a universal healthcare plan to cause them to lose their booming businesses and ill-gotten profits.  

     Maybe Americans can't do anything without turning it into an Act of Congress.  

     You and I aren't really the ones debating healthcare issues.  When patients ask me what I think about Obamacare, I simply tell them:  It's about time.  Americans need to stop worrying about how they'll pay for what might happen.  Who disagrees?

     Besides, universal healthcare costs less, and people get more, in Canada.  The cost per capita for medical care in Canada is about half that of the United States.

     For one thing, the government negotiates prices for pharmaceuticals, so people don't have to pay astronomical prices for medicines they need.  For another, primary care and prevention are paramount to an effective healthcare system.  Everyone carries a health card, like a driver's license, and gets the same level of care.  Patients don't need to know anything about how "plans" work, and don't have to make co-pays.  The government doesn't tell doctors how to practice and it doesn't threaten them with intimations of fraud, or raids, or "take-backs," or perpetual warnings that payments are headed south.  Physicians don't need to know how plans work either--they can practice medicine.  Pregnancy, infertility, psychological counseling, drug and alcohol rehabilitation--all these are covered without a lot of noise.  Doctors are able to focus on their patients, and make very good salaries, money isn't wasted on advertising, patients aren't misled about what they're getting, and lawsuits against physicians are uncommon.  To top it off, per capita spending for healthcare in Canada is almost half of what it is in the United States.

     Who among us can't imagine the catastrophic effect of an unforeseen health crisis on a family?  Who would deny medical care, for instance, to someone with a ruptured brain aneurysm, simply because that person was playing the odds and decided to take his family to Disney world instead of buying health insurance?  Are we that punitive?  If I had to choose between a lineup of insurance products with widely differing "coverage" caveats, explained in fat packets of jargon-filled "policies,"and a new roof-- both costing $16,000--I'd probably choose the roof.  Or the family vacation.

    Health problems can come out of the blue.  We should not have a system of healthcare, then, that punishes people for having disease.  Since state and federal governments pick up the cost of health crises anyway, via Medicare and Medicaid, why not simply extend these programs to cover everyone?   

A Fun Thing I Did Today

     Buttermilk was on sale at the grocery store.
     I bought two quarts and poured them into a heavy earthenware platter to take down to the chicken yard.
    Thick, smooth, coddled liquid like scooped-up clouds that might have been gathered with ladles and plopped onto the shiny glazed pottery, the buttermilk glistened in the morning light as I carried the platter very carefully across the yard to the place where the chickens were converging, and dispersing, and speculating according to their private pecking order rituals.
    I heard them trilling and muttering under their breath like old women going about their morning chores, a chorus of contentment that increased in volume once they understood that my muck-boots were headed--not to the clothesline or worm pit or garden or fish pond, but--straight to them.
    "Bawk bawk!  buck-buck, buck-buck, buck-buck, buck-buck" they shouted with great anticipatory commotion.
     They jostled and knocked one another off to the sides in a wing-spanned rush to get to the gate before I opened it, so that I had to block the opening with my clunky boots to keep them from squeezing out the openings at the sides.  I almost tipped over the piece of pottery as I shut the gate with my elbow, and held the platter steady against my sternum so I could free up a hand to drop the latch into a locked position.
     The chickens now gathered in one great mass of feathers around my boots, and some of them were pecking the rubber where tiny dots of splattered mud must have looked as though they could be gnats.  Some of them looked up at me, their pairs of eyes meeting mine like those of my girlhood dolls--bright, close-set, tense, and so mysterious in their blankness that I could imagine they knew me, and cared about me as I did them.
     I don't know if chickens feel love.  Surely it would be an error to count on them as my sole source of love and affection in the world, but I don't see anything wrong with including them among the community of creatures, human and non-human, who fill my universe with a sense of belonging.  Besides, they know nothing of the ignominy of that part of my little life which is playing itself out in a one-sided polemic with the government, and therefore they can't be hiding doubts, or diverting accusatory looks, as I sometimes imagine my colleagues are doing.
     I edged my feet forward into the chicken coop, taking care not to step on chicken toes, to get to a place where I could lower the buttermilk to the ground.  Stooping down, with chickens massed around my legs, I set down the platter.
     All the chickens gathered round and began dipping their beaks into the plump, broad mess of it, raising their gazes to the sky, allowing the pearly smooth liquid to ease into their gullets, and dipping again.  Scooping and swallowing, the chickens seemed to be in a state of ecstasy.  They were no longer exercising their perpetual hierarchical powers, but instead were allowing one another--given this unforeseen abundance--to drink freely.
     Sometimes one or another of the chickens would waddle over to where I was leaning against a pole and watching them, and knocked its beak against my boots repeatedly, one side, then the other, in rapid succession.  I knew the bird must be cleaning wet feathers around its beak, nevertheless it felt to me like lots of small kisses were being delivered to me out of gratitude.
     My chickens have so little fear of me that they stood still as I petted their silky feathers--a gesture they will tolerate even though they can't possibly--as birds--enjoy it.  Today, I examined each one's comb--bright red and firm--and its feathers and feet.  No diseases, no cuts, no peck marks.  I checked their vaults through which, unbelievably, eggs pass every day.  I know the mechanics of chicken anatomy and physiology, but the fact that these lightweight, hyperactive creatures can make eggs out of grits, and dried peas, and--today--buttermilk, remains one of the great mysteries of life.
     When they had their fill, the chickens started a big conversation among themselves, and traveled in a troupe up and down the long, enclosed run, chattering in a way that sounded to me like songs.
     I went into the chicken house and found four perfect eggs.  Two were still slightly warm and had bits of shredded nesting paper adhering to their shells.  I set them down, outside, and pulled some new grass and a bunch of the tender leaves from bidens alba, a weed whose leaves taste like spinach.  I threw them into the coop and saw the chickens converge again, cackling, invigorated, inspecting the plants for bugs.
     Then I walked back to the house under a blue sky to scramble my breakfast.

Our Psychopathic Nation

     I just finished reading The Executioner's Song, Norman Mailer's 1,100-page Pulitzer prize-winning book about the convicted murderer and psychopath, Gary Gilmore, who fought for his right to be executed promptly once his jury had returned a verdict of guilty and the judge ordered the death penalty.
     No one had been executed in this country for ten years prior to Gary Gilmore.  Perhaps our nation was trying to move in the direction of humanism--ushering in an era of thoughtfulness, compassion, and the possibility of incorporating our shared psychopathy into the fabric of American culture without allowing it to do terrible damage to the vulnerable, aesthetic and rational components.
     True, it's very hard to feel compassion for a person who forces his victims to lie stomach-down on the floor with their hands clasped beneath them before being shot in the back of the head at close range.
     But there had been many more gruesome murders prior to Gilmore's--murders that involved terrible suffering and cruelty (e.g., the man who forced his victims to swallow Drano, or those who branded victims, or took their eyes out, or starved or stabbed them fifty times).  The murderers in those cases were not being put to death by a government adhering to the ancient eye-for-an-eye penal code.
     Gary Gilmore said his reason for killing by gunshot in the back of the head was that it was quick and caused the least suffering.  This suggests a straw of fellow-feeling stranded among neurons firing like wild pick-up sticks in his brain.  It's possible that this straw might have offered the possibility of rehabilitation for Gilmore--but not in our deplorable prison system.
     The death penalty had been reinstated in 1976 after a ten-year de facto moratorium following a Supreme Court case, Furman v. Georgia, in which the court forbade inconsistency in the application of capital punishment.  Justice Potter Steward declared the death penalty cruel and unusual punishment, unconstitutional, and wholly arbitrary and capricious, especially since race and the type of crime seemed to serve as deciding factors when it was imposed.
     It was the robbery/murder case, Gregg v. Georgia, which reinstated the death penalty, when the high court decided it was not, in fact, unconstitutional.  But the problem of its being "capriciously applied" remains.   Since the Gilmore case in 1976, 1,280 people have been executed, with three and a half times as many blacks as whites,  and only twelve women.  Until it was banned for individuals with IQ's less than seventy, 44 mentally retarded individuals were executed.  Since 1976, Texas has executed 488 people, more than four times as many as the next highest state, Virginia, at 109.  Florida is the fourth most vindictive state, having executed 68 inmates, with 402 on death row--far more than any other state.
      Despite statistics showing that 61% of Americans favor the death penalty, it is banned in seventeen states--all in the north, where citizens' average IQ's are reportedly higher.  (Is the death penalty endorsed, then, by dumb people?)
     The fact that, as the Supreme Court stated, imposition of the death penalty is marked by "prosecutorial arbitrariness" and "local idiosyncrasies"--i.e., it is unfairly applied--is enough for me to oppose its use.  The possibility, despite the advent of  DNA evidence, that those accused might be wrongly convicted and executed, is grounds for eliminating the death penalty altogether.
     Gary Gilmore waived all his rights to appeal, after being sentenced, because, he said, life in the prison system would be a far worse punishment than execution.  Prisons are grim, gory, abodes of sameness punctuated by rape, drug abuse and psycho-physical persecution inflicted by inmates and guards whose internal hierarchy and rules of operation are invented by them alone, and are outside the law as we understand it.  If execution is preferable to a lifetime in prison, one has to question a country's commitment to humanitarian ideals.
     While there are many pockets of humanitarianism in America, as a nation we tend instead toward barbarism, irrational thinking, Old Testament ethics, and violence.  Our salient values center around acquiring money and spending it--and those who acquire money by any means are treated as stars, even if they happen to be pilloried within the penal system.  Wealth is the great goal, even though it's well-established that great wealth does not give way to great happiness.  Envy and greed on the part of those who are not wealthy, and accusations of wrongdoing and attempts to take back money on the part of those who can't accept that someone else might achieve more than they do, in a vocation, are the occupational hazards of those who succeed.
     Reading Norman Mailer's stupendous chronicle from the time Gilmore was released on parole for armed robbery to his execution for murder eight months later, was probably my attempt to look closely at the inner workings of a psychopathic system--whether it's in the mind of an individual, or in the politics and judiciary of an entire nation.  After all, I feel as though I have become a victim of a psychopathic system.
    Gary Gilmore could not think and feel in synchrony.  It was as though his Neanderthal hippocampus had not been wired to his new-age prefrontal cortex.
     He could feel:  he loved and longed for his girlfriend, Nicole, with enormous vigor and eloquence;  he lusted after a white pick-up truck and staved off his impatience to have it immediately;  he tapped right into the emotions and needs of those around him--when they might be useful to him.
     He could think, too:  he calculated how much cash he needed for that white truck, and how he could obtain it by stealing from cash registers after murdering the attendants;  he managed a complicated matrix of lawyers, media agents, and financiers once the publicity his case received made him rich;  he wrote letters that were like dissertations, with philosophical reflections, literary quotes, and arguments in favor of his execution.
     What Gilmore couldn't do was operate within the two worlds of feeling and thinking at the same time.  Such maneuvering requires a series of internal compromises, which can be experienced as the pain of loss in one dimension or another.  He thought of a viable solution to his financial problems--kill the guardians of the till, and plunder the contents.  But his feeling-apparatus didn't make an appearance to say:  No, wait!--that might hurt someone else, and it's against the law, so you'll suffer guilt.  When he had big feelings, like the desire to be with Nicole all the time--in effect, to own her--his thinking-apparatus didn't make an appearance, to say:  If you try to have her 100% of the time, you'll lose her altogether--so make a deal with yourself and agree to 50%.  He committed murder because he couldn't figure out what else to do--he killed two men, he said, because he didn't want to kill Nicole.
     Had this man's well-developed feeling and thinking capacities been able to talk to one another, Gilmore might have had an ordinary life full of the tensions of wanting and not-having, wild problem-solving ("I could kill that guy!") and feeling restraints ("Oh my god, I could never recover from the remorse!") that many of us experience as our ongoing internal dialogue.
     Here's what's wrong with America's large-scale psychology:  as with psychopaths, our thinking and feeling functions don't talk to one another.  Legislators approve statutes because they make logical sense, but don't feel through the long-term consequences for people who have to suffer the implementation of those statutes.  Americans vote for people like the President of the United States on the basis of feelings:  "Romney reminds me of my grandfather!  He has such a kind voice..." or "I can't acknowledge my racist-driven anger, but I can vote against Obama as though it's based on real issues," or "Those Arabs are all the same, and we need to bust their butts with a two-trillion-dollar bigger military, or we might look weak"--but can't think through the consequences of acting on these feelings any better than Gilmore, in his small-scale way, drew on his intellect to correct the errors in judgment made by his feelings.  Corporations, we know, operate purely out of the profit-motive--using thinking tools to maximize earnings at any expense to their feeling-based clientele.  Even the charitable donations made by corporations are calculated to improve the corporate image.
     Are we going to remain a nation of outlaws and renegades, criminals and outcasts--as we were, in large part, when our feral ancestors sailed to these uncultivated shores centuries ago?  Or can we begin to reflect on our attitudes and judgments, and act as though our brains are wired together--amygdala, hippocampus, frontal cortex, pre-frontal cortex, and corpus-callosum--before we make a bigger mess of things than Gilmore ever did?
     If the prosecutors in my case had advanced brain-wiring, they would not be waiting (as they did in my blogpost commentator Rinker's case) until the very last minute, after tremendous damage has been done (about which, Rinker says, they have no feelings--except, perhaps, antipathy) to close out their empty case, admit their mistakes, and allow me to get on with my vocations and life.
     But federal prosecutors, the FBI, and much of our country's judicial system, operate out of the primitive brain, which feels anger and envy, and exercises violence and retribution.  This is plainly evident in our prison system and among the vast numbers of people (1% of our population) housed there, who are constantly being returned to its sadistic quarters.
     I wonder what can be done about this awful situation, the psychopathy of our judicial system, the psychopathy of those who elect crazy leaders, the psychopathy of mega-corporations--our GDP's dominant enterprise--and all of us who support their inhumanity by buying their mega-products.
    One person at a time, we need to work quietly and diligently on our personal psychology, ferreting out hypocrisy and automatic thinking, questioning our moralism and religiosity, and owning--and rehabilitating--our personal, inner psychopath.
     We all have one, a psychopath within.  Instead of putting it in front of a firing squad, in the visage of criminals like Gary Gilmore (as though we could wipe out all psychopathy by wiping out all criminals!) we would do better to insist on a real connection between thought and feeling in our own psyches.
     One person at a time, we might be able to rehabilitate our poor country, which is suffering in the disconnect between the great poles of thinking and feeling.  

Medical Clinic for Sale!

     Special Offer!
     Hurry!  Limited Time!
     Big Sale!
     Thriving Family Practice medical clinic in busy Gainesville, Florida location with room to expand.
     4,000 square feet of office space.
     Trained personnel.
     Established February 2010.
     3,786 patients, with many new patients calling daily.
     Huge demand in neighborhood, with growth to 7,000 patients anticipated if clinic hours are expanded and if excellent, committed physicians with good communication skills can be hired.
     Turnkey operation, designed to provide one-stop medical care for up to eighty patients per day.
     Equipment includes:  Lunar bone densitometer, Konica digital x-ray unit, 2 Sonosite ultrasound units with four transducers, 2 Burdick Holter monitors, 2 Burdick ambulatory blood pressure monitors, Quinton stress test machine, 2 Schiller spirometers, 2 Burdick EKG machines, 1 Medtronic automated surgical exam table, 8 manual exam tables, 7 Welch-Allen wall ophthalmoscope/otoscope sets, 1 colposcope, 1 videonystagmogram machine, 1 microscope, 2 Hako-Med horizontal electrotherapy units, 1 centrifuge, 1 autoclave, 1 chemistry analyzer, 1 incubator, 5 large and small refrigerators, 12 computers, 5 printers, 1 centrifuge, 1 autoclave, 3 IV poles, 1 Geri chair, 2 overnight oximetry units, 1 Wallach cryosurgery unit, 1 electrocautery unit, 16 workstations with desks, chemistry analyzer, surgical instruments.
     Don't miss this opportunity to own and manage a medical clinic with trained staff and an expanding, appreciative patient base.
     Watch the great transformation of American medicine from a front-row seat!
     Learn from the government how to jump through hoops!
     Price:  Value of appraised equipment, or best offer.
     Reason for sale:
          Current owner feels the need to make room for resilient young doctors who don't know or care about the pleasures of relating to patients, and making decisions, and saving lives, and--
          Current owner has been afflicted with a special form of disheartenment fostered by relentless government scrutiny, and--
          Current owner can no longer resist the childhood urge to open a candy store, and have unlimited varieties of jelly beans available at all times.
  

      

Not Enough Money for Payroll

     My bookkeeper tells me the clinic bank account is short $7,000 for payroll this week.  I'll have to deposit personal funds to make up the difference.  Most weeks we aren't getting enough insurance payments to cover the clinic's operating costs.
     It's not that we aren't busy.  Yesterday, there were so many patients that we had to reschedule five. Several others walked out after waiting two hours.  We can't keep up with demand for our services--the shortage of medical providers is going to get much worse when Obamacare covers millions of currently uninsured people.
     The problem is, insurance companies are not paying.  Specifically, Medicare stopped paying me altogether, after the raid, as though overnight I had turned into a dirty character.  They began paying this year--for services rendered a year ago, picking and choosing items on the claims they felt like paying and items they felt like denying.  The result has been substantial reductions in the overall payments, so that the cost of providing care to Medicare patients is not covered by the payments.
     "What Medicare feels like paying," really does express the arbitrary nature of the "decisions" from on high.  There can be no explanation whatsoever for Medicare's refusal to pay for flu shots, or IV's in patient's with pneumonia, or ultrasounds to measure a pelvic or thyroid mass.
     No business can stay afloat if revenues can't be predicted, and controlled.  Working hard and working smart no longer seem to affect payments.   
     When I opened Colasante Clinic in February 2010, I was correct in predicting that half the practice would consist of Medicare patients.  This is Florida, after all, the retirement state.  And my patients in Hawthorne had been fifty percent retired folks, on Medicare.
     Therefore I purchased equipment geared toward evaluating the health problems of people over sixty-five. Since older patients have more cardiac problems, I bought a stress test unit and echocardiogram apparatus.  Since they report dizziness and have more falls, I installed vestibular testing equipment.  Since people over 65 get osteoporosis, I thought it would be convenient to own my own bone densitometer, saving patients a trip to a radiologist.  X-rays have been invaluable for diagnosing fractures, cancer, arthritic deformities, and pneumonia.  On-site lab equipment gave us instant readings on warfarin levels, potassium, blood counts, and illicit drug use.
     Now this equipment is mostly lying dormant, because I can't afford to do studies for which no payments are likely to be forthcoming.  When I do studies on Medicare patients, I'm able to diagnose and treat them promptly, but Medicare doesn't pay me promptly--if it pays at all.  I don't even know why.  The EOB's are vague, saying, "no medical necessity."  What are they talking about?  Since when is a chest x-ray not necessary for a patient with pneumonia? 
     How many businesses could wait a year or more for payment?  How many could rely on a Medicare billing specialist's decision about whether they deserve to be paid or not?  How many could survive in a system where non-payment is acceptable, and the appeals process essentially nonexistent?
     Why is it okay for the government to steal my patients' charts, take my clinic assets, refuse to say why, and decline to pay for legitimate work for the next year, under the guise of protecting my patients and the American people?  How is it protecting patients to put me out of business in this underhanded way?
     The government can't put me out of business outright, or it would have done so.  Government officials with legitimate suspicions could take my license, close my business, remove me from Medicare's approved provider list.  They could indict me.  They could give me reasons.  But after twenty-eight months of "investigation" they haven't done any of these things.  They don't have legitimate reasons.
     My Medicare patients are, in effect, authorizing the government to use their saved-up Medicare tax money to pay for medical services at my office.  They can't believe the EOB's they get in the mail saying I was not paid.  "Why are they refusing to pay for what you did?" they ask.  I tell them I'm turning the office into a free clinic.
     No one else gets away with stealing and mismanage money in this way--why should Medicare, and other insurance carriers?
     Sooner or later a system that allows such government perfidy will catch up with itself.  Maybe there are plenty of other places for patients to get treatment, if I'm forced to shut down.
     I'm one lonely solo doctor--no big deal.  But my message is not unique.  Living in fear, not getting paid, and having no workable mechanism to appeal unfair treatment doesn't make doctors want to stay in business.
    We doctors can, of course, take refuge in giant organizations, and wait for our Thursday paychecks like factory workers.  We can dispense treatments the way factories dispense toothbrushes and candy bars.  We can let our government-mandated software systems tell us what to do, and when to do it.
     But that's a different version of medical care--one where doctors become bureaucrats, the free market disappears, and the medical system works as well as, for example, our bankrupt U.S. postal service, and all the other government and corporate institutions where we get put on hold, talk to computer answering systems, wait for hours in lines to get medicre service from bored civil servants.
     Small solo medical clinics have been one of the last holdouts--next to friendship--for humanity:   places where one person could actually count on another person to listen and respond in a non-programmed way.  It's sad to watch this holding-place for human connection--with all its healing potential--being forced out of existence.

The U.S. Image Abroad

     I have noticed a fair-sized contingent of Russians reading my blog.  There are also readers in China and South America.  Blogger provides a map of people in the world who are logging onto my site, along with pageview numbers.  It's more than you'd expect.
     I don't know people in any of these places.  Why have they latched onto my blog?  Are they brushing up on their English? 
     I think they're looking for information from average Americans about what life is really like in the United States.
     In my world travels over the decades I have always been impressed by the fascination most foreigners have for Americans.   What's life really like in America?  They want to peel back the make-believe images from TV and magazines and find out how average-Joe citizens experience daily life.
     "Do you really drink ten or twenty cups of coffee a day, over there?" I was asked, in Scotland.
     "Does everyone carry guns?" an Egyptian asked, incredulously, because guns are illegal for all but the police there.
     "Do you guys still execute people?" someone asked, in Italy.
     "You mean, you have the best health technology in the world, but patients have to pay for check-ups?  And can't get medical care if they don't have money?"--from a Canadian.
     "You guys are workaholics!" exclaimed an Englishman.  The Brits' workday starts at 10 am, gets interrupted for leisurely lunches, and stops for tea in the afternoon.
     "Why would you need a doctor to tell you whether you should use birth control pills?" I was asked in a Thai pharmacy, when I remarked to people in the aisle that they had access to the pill (cheap!) over the counter.
     In Guatemala, free condoms were dispensed from containers in the airport, and in most public restrooms.  No visits to Planned Parenthood, no health department shortages.  No $1.25 each Magnum Extras--why do we make people pay to prevent public health hazards, and epidemics?  Why will the American government cover $40,000/year HIV medication--but won't issue free condoms in all public facilities?  I'm sick of having to inform unsuspecting patients that they have HI V, and should sign up with Medicaid for expensive treatments covered by the state.
     What is my experience communicating to people in other countries?  How is it adding to the impressions they form from television, or from what they deduce by our often-reckless foreign policy?
     For one thing, it says the Wild West image is real:  people take the law into their own hands.  The government can come in, hold up a doctor's office, take everything of value from the place, and leave without a word.   We exercise ruthless power.  We "believe in" the death penalty.  We fight for liberal access to guns, despite statistics that prove guns lead to violence--which in turn exacts largesses from our healthcare and penal systems.
      We're acting out of our primitive brains--the hippocampus, the amygdala--and failing to make connections with the modern prefrontal cortex.  We're a sociopathic country, at the corporate and governmental levels.  No one's listening much to the more developed brains out there, the Ph.D.'s, writers, artists, and law professors.
     Therefore, any efforts on my part to "reason" with my prosecutors, or the FBI, or even my lawyers, and tax-supported legislators and governors, are likely to fail.  They all have primitive brains, they want victims, they want blood, they want lurid images of people who broke the law and are forced to suffer horrible sentences.  Guilt and innocence are irrelevant.
     And they want cowboys who get away with murder, and whose idea of "the law" is government agents breaking into peaceful places of business with glinting badges and holsters loaded with weapons, ready for a shoot-out.  They want to take down ordinary-looking citizens, like me, to demonstrate their power.  They're taking me down.  They've put me on the pillory-block.
     They're tearing at the very fabric of our culture, the everyday people who go to work, pay taxes, do some good.  There you have it, my blog-readers in Russia, China, South America.  Why don't you post some comments?  Why are you reading this blog?
       

Why I Should NOT Be Voting for Obama

     I think it goes without saying that most American doctors are Republican.  My father was staunchly, embarrassingly Republican, and my mother followed his lead--fortunately, neither one ever cast a vote.  The party membership was simply a convenient repository for their particular prejudices.
     My mother just told me she plans to vote in this election, and it will be for Romney.  "He reminds me of my grandfather," she said.  "Kind eyes, a calming voice, he'll take care of our country."
     "Good reasons," I told her, and she missed the sarcasm.  There's no convincing an 86-year-old woman who believes in shows of strength, and it's not nice to be sarcastic with one's mother, at least not after the teen years.
      I have never voted Republican.  My teen years were influenced by Nixon, Watergate, Vietnam, jobs like the ones I had in a bedspread factory, steam-cleaning machine company, donut shop and volunteer work in a state hospital.  Later, housecalls to patients who lived on $438/month wiped out any inclincation I might have felt to vote out of self-interest.
     Voting for the public good, rather than out of self-interest, goes against the greatest economic theorist of all times, Adam Smith.  In The Wealth of Nations, Smith outlined an economic system which promulgates the gospel that individuals who act out of self-interest are led by an "invisible hand" to promote the public good.  They don't intend to do this, and don't know how much they advance public interests, because they only seek to protect their own gain, but ultimately society becomes more prosperous when individuals serve themselves.
     Here's Adam Smith:  "By pursuing his own self-interest he frequently promotes that of the society more effectually than when he really intends to promote it. I have never known much good done by those who affected trade for the public good."
     Therefore, I should vote Republican because:

     1) Democrats foster the power of a centralized government, and my life has turned to grub because of big government intervening where it should not.
     2) Democrats favor increasing taxes for people in doctor income brackets.
     3) Obama does not favor caps on non-economic damages, i.e., malpractice lawsuits for pain and suffering.
     4) Obama plans to cut Medicare by >$500 billion, which means reductions im payments to doctors, services for patients, and money available to pay for staff and supplies in offices like mine.
     5) Obama's mandate to the Department of Justice continues to be, "Crack down on Medicare and Medicaid fraud!"--without insisting on truth, accuracy, evidence, cause, or government accountability.  Having experienced firsthand the devastating effects of the DOJ's carte blanche in pillaging offices, I should not be encouraging his administration further, as it re-possesses so-called fraudulently obtained payments by barbaric means.
     6) Running a business when agents come in and tell you retroactively that you've done something wrong (and--in my case--don't tell you what that is), is impossible.  Romney, at least, proposes practice management assistance for doctors.
     7) Adam Smith instructs me to act in my own self-interest.

     It's not out of habit that I will vote Democrat (or even Green party), but because I remember one caveat in Adam Smith's directive.  He warned against the possibility that businesses might form cartels, fixing prices and conspiring against the public good.  Hasn't this already happened? 
     If we're not careful, it won't be long before our real world leaders declare themselves as ExxonMobil, Walmart, Murdoch, the Chinese propaganda machine, and the American government.  The rest of us have already, in a sense, become their peons.
     Farewell, Mr. Smith.  The world has changed in ways you could never imagine.  It's time we voted with all of mankind in mind. 
     Instead of following your advice:  What's good for the individual is good for the world...we need to be saying:  What's good for the whole world is what, in the long run, is going to be best for me.
    

The Government is Two-Timing on Me

     Since there is no other possibility, the FBI raid on my clinic must be centered on fraud.  Fraud in the medical field is one of the following:

     1.  Billing for services not provided.
     2.  Over-billing/over-coding for services provided.
     3.  Providing and billing for unnecessary services.
     4.  A pattern of reckless billing, suspicious because it covers a broad swath of patients.
     5.  Billing under a false provider ID.
     6.  Pretending to have a license to provide services, when one does not.
     7.  Billing for services for which there is inadequate documentation.

However, the government and its relevant agencies assume fraud when:

     1.  A doctor bills more services than the average in his/her category.
     2.  A doctor provides services unusual for his/her category.
     3.  A doctor receives more revenue than the government thinks is right.
     4.  A whistleblower reports a doctor to the government for personal gain and,
     5.  The doctor makes more money than average and,
     6.  The government can use the statutes at hand to take back money to support
          a flagging system and appease a DOJ under presidential orders to rectify a
          national debut using Medicare fraud as the target.

     When the FBI raided my office, took charts, and withdrew $400,000 from my clinic and personal bank accounts, thereby crippling the medical practice and forcing me to downsize (placing numerous employees on the unemployment rolls), their unstated explanation was that I was guilty of Medicare fraud.
     Medicare, in response, placed my office on what's called a "100% review."  This meant that Medicare wouldn't pay my office for patient services until it had reviewed paper copies of every single medical service billed.  Since Medicare is backlogged, it has taken up to a year for its coding specialists to get around to reviewing my clinic's documentation for patient services.  (What happened to the law stating that Medicare must pay within 45 days?)
     Starting in January 2012, payments from Medicare began to trickle in.  The payments are for services from last year.  Each month, the payments get bigger, showing that Medicare coding specialists do not find evidence to support allegations of medical fraud in my clinic.  While it is aggravating that it takes up to a year for me to get paid for services, including interventions that require an initial outlay of money on my part (e.g., for IV supplies, crutches, medications), it is reassuring to see that even when my clinic records are subjected to the most extensive, nitpicking, professional analysis--a 100% review is just that--there is no evidence of fraud.  Medicare is paying me, slowly--because it's a painstakingly human process to analyze records--but it is authorizing payment.
     Here's the two-timing problem.  One branch of the government--the prosecutors and FBI--are attempting to indict me for Medicare fraud, have already exacted punishment, and continue to hold me hostage through fear-engendering tactics.  Another branch of the same government--Medicare and its billing and coding experts--has determined, after reviewing every single page of every single record--that there isn't evidence of fraud.   I have not changed the way I practice, or the way I bill:  it is the same has it has been for twelve years, since I first opened a solo clinic.  Therefore, I must assume that my system of providing medical care and billing for it is legitimate, in the eyes of the government.
     What does a person do when one arm of the government says one thing, and the other arm says something completely opposite?  It's schizoid, or else it's hypocritical, and just plain absurd.
    

The Biggest Frustration in Solo Practice

     Even before the FBI decided to raid my office and inform Medicare, directly or indirectly, that it didn't have to pay me for the patients I continued to see, the biggest frustration in solo practice was getting paid.
     My billing staff and I have given up on trying to reach anyone who can tell us why Medicare hasn't been paying for my services.   No one seems to know.  But when was the last time you heard a government worker say, "I don't know what's going on"?  Instead, we've heard a broad range of explanations for non-payment, none of which can be substantiated.  There is no room for my defense.  Medicare's defense against our questions is simply to ignore our calls and letters.
     Not including efforts to understand the government's actions, my office spends 100 hours per week trying to get paid for the work we do.  I have two full-time billing staff, who enter charges, post payments, and appeal non-payments.  In addition, there are front office staff you spend part of their time calling insurance companies in advance, or trolling through their complicated websites to find out if a patient's plan covers care in our office.
     Very often, the coverage is so complicated we have trouble explaining the exceptions and variable co-pays to patients.  For example, a patient may have a $500 deductible, but it doesn't apply to a preventive visit.  So the patient schedules a preventive visit, thinking "that's free," but then reports a list of worrisome symptoms.  To figure out what the symptoms mean, I may recommend some tests.
     For an x-ray, that same patient may need to pay 20% of the charge pre-set by the insurance company, but for an ultrasound, the patient may need to meet the full amount of the deductible before getting any insurance help.  If labs are necessary, some might be covered, arbitrarily labeled as "routine," but others, such as a test for lupus or celiac disease, might not be covered.  Some labs might be paid for only if the sample is sent to a specific lab, with whom the insurance company has negotiated a cut-rate--so if we want to get an immediate result with the same test in our office, we have to do it for free.  It's not permissible for the patient to pay out-of-pocket for any tests unless they're non-covered or the money will be applied toward the deductible, and the tests are "pre-authorized."  If I wish to do a skin surgery, I may have to get permission from the insurance company in advance, so it can't be done the same day.  For some insurance companies, I only need to get permission after the first three, or five surgeries of the year.  But the insurance company can't tell me if another doctor has already done surgeries this year, and the patient has met the maximum number of surgeries allowed...then I don't know whether I need an override or not.
     The 100 hours of work applied toward collecting from insurance companies doesn't include the hours I spend each evening reviewing charges and chart documentation, as I have always done, to confirm that all services for which we are billing were actually provided, and the documentation proves it.
     Medical Economics reports the following after reviewing data from a physician survey.  "Primary care physicians are frustrated by a seemingly endless bureaucracy to collect the lowest rates in healthcare....The frustration for most physicians focuses on the day-to-day negotiation of care and the work involved just to get paid.  The work involved to stay current with the throng of electronic filings and paperwork surrounding coding, billing, reimbursement, denials and collections is inordinate."
     The medical clinics described in this report say that the majority of payments are received within 3 months, with Medicare taking 60 days to pay.  But in my office, Medicare refuses to pay every claim, requiring copies of all office notes and procedures performed, before its agents will reconsider.  We need more filing clerks to do all the copying for Medicare, and then we have to make a run to the post office every day to send out the paper proof.  Then, one year later, we may receive payment.  At least, that's the time-frame under which we're working now.
     Would you wait a year to--maybe--get paid for your work?  Sure, I would--if I knew the patient and had a sense of his or her dire circumstances.  But not 100% of the time--I couldn't survive.  And not for the government, not after what it's done to me.
     No one thinks things are going to get better.  I don't see a light at the end of the tunnel, not for me, and not for all the doctors so far lucky enough to have escaped the government's scrutiny and refusals to pay.  Most of them are hiding out in gigantic medical conglomerates anyway.  But I'd rather go back to hoeing potatoes.

My Clinic is in Line with Affordable Care

     The Affordable Care Act spotlights primary care as the answer to many of the nation's healthcare problems.  Money for healthcare, it says, should be spent on physicians who meet quality standards, prevent bad outcomes, and keep overall costs down.  These have been precisely my objectives with all the patients I've seen in the last twenty years.  Even those who came to see me because of a cold, or an ingrown toenail, were subjected to questions about their overall health--usually questions unrelated to their presenting complaint.
     I didn't know this was wrong.  It didn't occur to me that someone in the government might think I was just trying to make a few extra bucks on the patients who had chosen me to look after them.  Sure, they came in with runny noses and sore toes, but if I could get them to think about quitting smoking, or wear their seat belts or let me check out the nagging GI or neurologic symptoms they listed on their intake questionnaires, I felt I was doing everyone a favor.
     Family practice training focuses on prevention.  Prevention requires physicians to ask about subjects patients are reluctant to bring up--but won't forgive, either, if a doctor rushes in and out without addressing anything but the chief complaint.  These include questions about incontinence, drinking, sexual functioning, drug use, bad eating habits, depression, insomnia, early warning signs of heart disease, memory loss, and cancer risks.
     Patients especially won't forgive--nor should they--a doctor who doesn't ask age-appropriate questions and find underlying problems, especially if they develop a serious health problem later.  Most problems can be prevented, or caught early, by a circumspect physician.
     The statistics on malpractice lawsuits are proof that patients want more than acute care:  failure to make an important diagnosis in a timely way is the leading cause of medical malpractice cases.  Failure to diagnose cancer is at the top of the list.
     But patients never walk in and say, "Doc, I think I might have cancer."  It takes a discerning diagnostician to ask the right questions, and to feel around in the darkness for information.  Feeling around in the darkness often means asking more questions, doing a careful physical exam, and running a few tests.  Better to pay for information early, than to shell out for end-stage disease later--not to mention the pain and suffering that goes along with delayed diagnoses.   At least, that's been my philosophy.  I have been an aggressive physician, with the attitude that if you don't ask, you won't get clues, and if you don't look, you won't find anything.
     In a turnaround typical of government, the very methodology I have been using is likely to be the subject of the government's investigation of my clinic, as well as an example of the new solution to our healthcare woes in America.
     How, I ask, can I be indicted for practicing medicine in a way that is now being touted as the standard of care, and the basis for the Affordable Care Act?
     The new instructive is to allow primary care doctors to be at the helm of the medical system, and to spend time and money early as a way of preventing costly extravaganzas in the ICU's of our hospitals later.  Well, government folks, that's been my modus operandi all along.  If you're going to label it fraud, I'd like to know how my style of medical practice differs from what the Affordable Care Act is now going to mandate.    

Survival

     A certain capacity for dissociation is a prerequisite for surviving catastrophe.  When a person's life is disintegrating, via loss or tragedy, the grief can be unbearable.  Dissociation is an almost automatic process by which a person can both be, and not be.
     Individuals who have experienced severe trauma may know it well:  they leave the scene of the present, so to speak, thereby escaping immediate pain.  Dissociation is described as a psychological coping strategy, as in multiple personality disorder.  But there are spiritual components to the experience, in that one recognizes the self as not entirely corporeal:  what's happening is happening to someone not-me, but to my material aspect, my body, my three-dimensional life caught up in the space-time continuum.  The real that-which-I-am is someone else.  Or, what's happening is part of a necessary process of transformation, akin to forging metal into an object of beauty and worth, a conversion of raw materials into an alloy or composite with a completely different nature. It's an alchemical operation whereby a base substance is acted upon--rudely, painfully, gloriously--so as to effect a change in its very nature.
     My life is just such a material substance, undergoing transformation.  I no longer believe in the person I have been:  a medical doctor, a person with a fixed social role, a parent, property owner, businesswoman, someone in the prime of life, someone of this world.
     Whoever grows must endure being acted upon by forces from within and without, and this is the circumstance in which I find myself now.  I can distance myself from it as a way of enduring the pain, but then I must return to live as material substance, an immanent human being, or be subject to a kind of death.
     I have discovered through dissociative techniques during which I pay strict attention to what is happening to me as though it is happening to someone else, that I am not being destroyed at all, but am being offered something new, a gift, though its nature is not at all clear.
     If the channels through which energy circulate can remain open, if one can hold steady, watching and waiting without saying No to the inevitable, then the processes of destruction and creation are not opposites, but the very same thing.
   

My Car Crash

     Do bad things happen in bundles?  If so, how big are the bundles, and when do they end?
     Two weeks ago, I was driving home from work on four-lane Highway 20 in the drizzling rain.  The speed limit is 65 mph, but I was going 55.  I had lost my cell phone two weeks prior, so my hands were both on the steering wheel and my attention was on the road.
     A car pulled out in front of me.  I pressed on the brakes, calculated my options, swerved to avoid T-boning him--but with just thirty yards of lead time--couldn't avoid hitting his rear end.  His car spun around twice, hitting the flashing red stoplight, and mine lost power and brakes.  I pulled onto the grassy shoulder of the road far ahead.
     Here's the part I want to try to understand.
     I made sure my son, Carmine, was okay.  We walked back to the scene of the accident and saw the driver of the other car walking with a wide-based gait--glad he was alive, I thought.
     "Can you call 9-1-1 for me?" he asked, handing me his phone.
     "Why can't you call?" I responded.
     "I can't dial it," he said.
     So I made the call, reported the accident, and watched the driver.
     When the police and highway patrol fellows arrived, and were taking down information, I asked why they weren't doing a sobriety test.
     "What do you mean?"  they asked.
     "Why aren't you alcohol tesing that driver--and me, too, for that matter?"
     "He doesn't smell of alcohol," one officer asnwered politely.
     "Since when is your nose the gold-standard for deciding whether a person's judgment is impaired?" I asked.
     "Ma'am," he answered.  "We have other methods for determining what's needed in situations like this."
     "Like what?"
     "His eyes aren't bloodshot, for instance."
     "It takes a lot of alcohol for that to happen," I said.
     "And he seems to be walking okay," the office went on.
     "But he couldn't dial his phone after the accident, and a witness told me she thought he seemed 'under the influence..'"
     "The state allows us to make the determination about alcohol testing," the officer informed me.
     "That driver made a very poor decision when he pulled out in front of me.  He could not have been looking for oncoming traffic.  I would like to request, formally, that an alcohol test be done on him," I stated.  "It matters to me."
     "You don't seem to understand," the officer said, as though I were straining his patience.  "We don't carry breathalizers in every car.  We have to call someone to bring us one, when we need it."
     "Would you please call a police car with a breathalizer?"
     "Ma'am," he said, "those devices cost about $10,000 each.  We only use them when we need them."
     "I think one is needed now," I said.
     "Please, let us do our job," he replied.
     "No wonder there are so many drunk drivers on the road," I answered.  Then, the officer laughed.
     We waited two hours for the tow truck.  I understood, standing in the rain and swarmed by mosquitoes, why they call this place a swampland.
     When my insurance agent called to record my version of the accident, she told me that I would have to pay a $1,000 deductible, unless the other driver's insurance company agreed that it was all his fault.
     "But it was all his fault," I said.  "He violated the right of way."
     "They'll argue against that, as they always do," she told me.
     "But, if he'd had an alcohol test, and it was positive, would they still argue against it?"  I asked.
     "Certainly not," she said.  "Then they'd pay it."
     Do we really leave it up to the discretion of police officers, at the scene of an accident, to determine the need for a sobriety testing--even when gross misjudgment is the cause?   Shouldn't every person be tested, at every accident, as a way of curtailing drunk driving?  Or are people like me just supposed to feel "lucky" when we sidestep death, as my son and I did, that night?
     I do feel lucky, but the next person might not.

Paranoid postscript:  I told this story to a relative (someone following my blog) who asked if the "accident" might have been planned, and the driver who pulled in front of me a hit man.  It's true, he was driving an ex-police car, and he pulled into oncoming traffic as though blind, and in slow motion. But really, who would want to do something like that, to me?  What could be the motive?  I told my well-meaning relative to chill out.
    
    

PQRS

     Just what we need:  more paperwork.
     PQRS is a program that is supposed to make sure doctors are doing the right tests on patients.
     Doctors who don't fill out the paperwork and don't submit a bunch of new codes to Medicare, along with all the usual office visit and procedure codes, will have their pay rates cut in January.
     No one ever remembers what the acronym expands into, so I looked it up (again)--for this blogpost:  Physician Quality Reporting Initiative.  One hundred seventy nine parameters are being measured by the government.  Doctors can choose the ones that matter most to them, but then we have to prove we've followed the guidelines.
     Last year I entered all the paperwork for the bone density testing PQRS.  I was supposed to get a bonus, but it never showed up.  I found out later that for bone density reporting I was supposed to have entered codes for every month of the year, in those months.  Instead, I entered the right number of patients, with the correct codes to "report" how well I'm doing, but didn't report some in each month--therefore, I "failed."  I did bone density testing on every patient for whom the screening is recommended--except in the rare cases when patients declined--but I didn't take the government's test right
     This year I'm doing vascular disease reporting--like a lazy student, I figure out that it only requires three months of data.  Who knows why?  There might be explanations for the different reporting standards for bone density versus vascular disease versus the other one hundred seventy-seven "quality measures" the government has put into place, but they escape me.  The instructions for completing the forms and submitting information are more arcane than anything we do in regular old medicine.  I think regular old medicine has fallen by the wayside.  Writing about and reporting about regular old medicine seems to have taken the place of actually doing medicine.
     One of my doctor friends told me that he's dropped out of Medicare and Medicaid--and that Blue Cross dropped him.  He's charging cash for patient visits:  $200/hour (less than half of some of the lawyers I've had the past two years).  Today I envy him, because he doesn't have to learn all 68,000 new ICD-10 codes, or look at all the forms for entering PQRS data, or hold his breath for his Medicare "report card" to come out next year.
     "Does this patient have vascular disease?  Is this patient's blood pressure under 140/90?  Is this patient on aspirin?  Is this patient's LDL below 110?"  I fill in squares, send a bunch of new G-codes along with the claims for services I provided to the patient on the same day, and in this way let the government know how well I'm doing.  Then the government grades me based on the answers I provided, and my pay rate is attached to how well I'm doing.  It's a little like telling the IRS how much money you should be taxed, without having to show W-2 or 1099 forms to back up your figures.  Can't doctors just make up the answers?
     Do patients believe that if the government forces doctors to fill out reports on the quality of their medical services, we'll have better healthcare?

Thanks, EMR Mandate, for the Useless Office Notes

     "What happened at your oncology appointment last month?" I asked my patient.
     "Don't you have the report in your chart?"
     I found it:  seven single-spaced pages.  I studied it carefully, while the patient stared at me.  I was struggling to figure out what the oncologist was saying, or thinking, or planning to do with the patient.
     "What did he say?" I asked again.
     "Isn't it in the chart?"  the patient countered.  He wanted my interpretation.
     So, I read through all the pages, most of which reiterated information from prior notes--stuff I already knew:  his medications, past medical problems, the type of cancer, allergies to medicines, results of prior tests.
     One page was full of things like:
     "Eyes:  System reviewed, all negative."
     "Ears, nose, mouth, throat, neck:  System reviewed, all negative."
     "Endocrine:  System reviewed, all negative."
     "Abdomen:  System reviewed, all negative."
     Another page listed all the labs that had been done in the past year--but not the most recent ones, which I needed to see.
     Another page was documentation of a physical exam--but it didn't seem to apply to my patient, who was right in front of me.  Instead, it consisted of items from a drop-down menu, most of which were irrelevant, if not downright dumb.  The psychiatric exam, for example, stated:  "Affect normal;  follows commands;  appropriate behavior."
     Follows commands?  Were we talking about a dog?
     The cardiovascular exam stated:  "Regular rate and rhythm, S1, S2, no murmurs, rubs or gallops."  But--the patient has had a heart murmur for years, and it's pretty loud.  Had I made a mistake?  I listened to his heart--same 3/6 murmur as always.
     "Did the doctor lie you down, and push on your abdomen while looking at your neck?"  I asked.
     "No, I was in the chair the whole time," he said.
     That meant the part of the report that said "No JVD" was something from the drop-down menu, too--easy to click, but not a part of the actual exam that day.
     I kept flipping the pages, reading--and re-reading--words that amounted to balderdash.  Then I saw the section I needed, "Impression."
     Yes!
     What's your impression, Mr. Oncologist?  What's going on with my patient's cancer?  Has it come back?  If so, where?  If not, how should I keep an eye on him?  And what do you propose, if anything?
     My patient was getting nervous.  It was taking me so long.
     "So, what does it say?"  he asked.
     It's often the case that patients come to a family doctor to get a translation of what the specialist told them--this was one of those times.
     I have the blasted report in front of me as I write this blogpost, hours later, but I still can't find answers to my simple questions, nor is there in the seven pages of verbiage anyone who resembles the patient I know, or information about his actual condition.
     The last page of the report is a bunch of superfluities like:
      "E & M.  This excludes teaching time and all billable procedures."
     "The above plan has been discussed with patient." 
     "Greater than 50% of the time spent in this patient's care was face-to-face time spent in counseling, evaluation, and coordination of care for his cancer."
     "I personally reviewed the pertinent medical records, laboratory data, and radiographic images."
     So many words, so little meaning...
     Once upon a time, in a fairy tale land, I could pick up the phone and talk casually with an oncologist--w'd have a chat about our patient.  We'd put our heads together, and come up with ideas about what might work, based on who the patient was and what he might want.  I'd learn a thing or two about cancer trials, new medicines, treatment successes.
     Sometimes I'd catch up on a few other patients, too, or "run a new patient by" the specialist, to see if it was an appropriate referral.  The specialist would thank me.  It was all very cordial.
     Once upon a time, the notes I got from specialists were a paragraph or two long, loaded with meaning, containing exactly what I needed to know to answer a patient's questions, allowing me to proceed in tandem with the treatment plan.  The patient was better off.  Doctors had sensible correspondence with one another, using abbreviated nuggets of information. We had time to see lots more patients.  We saved a ton of paper.  And we loved what we did.
     Alas, those days are lost and gone forever.
      
     

The Nitty-Gritty of Testing

     A good family doctor puts a stethoscope on every patient's heart and lungs.  No one argues with this testing, despite report after report about the low yield of physical exams when it comes to finding serious pathology.  In addition to the stethoscope exam, I also look at or palpate every patient's eyes, ears, scalp, nose, throat, skin, abdomen, back and legs.  Research doesn't show that this uncovers disease, either, at least not directly.
     I do real exams, anyway.  First, they're quick and easy.  Second, I never know what I might find.  Third, it's a laying on of hands, a way to connect with the patient, proof that I'm not afraid of what I might find.  Fourth, the more often I do a physical exam, the more sensitive I become to the small findings that point to sleeping wolves.  Fifth, they are proof that I care.
     Consider my new pond.  The first ten times I walked around it, I didn't see much:  deer tracks, eagles in the sky, water.  The next ten times I saw more:  raccoon spoor, phlox blooming under the brush, mole trails, tiny white flowers on the tufts of the long grass.  By the hundredth go-round, I was attending to the stick bugs underwater, and paw prints belonging to a coyote.  Now I notice new anthills, the slime-paths left by slugs, gelatinous clusters of frog-eggs, a sandhill crane's nest.
     Doing the same thing day after day turns doctors into highly sensitive seers.  We may not "find something" directly, any more than I have found the actual raccoon when I see its five-toed print in the sand, but little discrepancies make us say, "Something's up, here--your thyroid isn't supposed to feel like that, your belly shouldn't have a little fluid wave, your heart has a new sound...you don't look right."  Cancer has a certain look.  Strep has a smell.  Liver problems make the skin look devitalized.  An ailing heart or narrow carotids come across as a certain lassitude of speech.
     Are we supposed to write this stuff down?  Are we supposed to make it intelligible to a coding clerk who's following orders to downcode, reduce payments, deny coverage?  Does anyone really believe that what a specialist in any field is doing can be quantified, item by item, in a linear way?
     There are certain tests doctors are expected to do, whether there's a symptom or not.  Mammograms and colonoscopies fall into this category, and so do "vital signs" like blood pressure, body-mass index, temperature.  Pap tests used to be de rigeur, until lately when the rules changed again, and got too complicated to remember.  Official guidelines make it bad medicine for us not to obtain screening tests on certain populations.
     Other tests require a symptom, or an abnormality found during an exam.  There's a lot of  latitude here--and that's the gray area insurance companies (and the federal government) are banking on, when they take back money.  They inform me, for instance, I shouldn't have done an EKG on a patient, and I won't get paid--because the reason for the test ("patient has palpitations") is written on the EKG paper, next to my interpretation ("PVC's" or "bundle branch block")--proof that I made a diagnosis after the fact.  That's their phrase--what are they talking about?   I didn't write in the chart note that the patient had a symptom--therefore, I didn't have a reason to do the test.  I'm told, in so many words, that I "made up a reason" to do an EKG.  I've stopped fretting and arguing about such stupidity, and order  EKG's whether they'll be paid or not.
     Maybe this is the reason the government raided my office:  I must be doing tests that aren't necessary.  That EKG "wasn't necessary" because the patient's complaint was elicited by me through questioning, rather than volunteered at the outset.  Never mind that it may reveal a problem.  Similarly, when I order ultrasounds because of subtle findings during a physical exam, or because of things patients tell me when I explore the vague territory of a symptom, the government may also consider them unnecessary.  
     Since when did the government get in the business of medicine?  Is this really what Obama was bragging about when he said how much money has been "recovered" in anti-Medicare-fraud efforts?
     The tests I order are an extension of my eyes and ears, confirmation and documentation of what I think I perceive.  It's the proper use of this equipment:  diagnostic detective work.
     I could send patients to the hospital for these tests--a needless inconvenience and postponement of results.  But insurance companies would save, since half the patients probably wouldn't show up.   I could skip the tests, guessing about the diagnosis, instead.  Or I could simply bank on the odds--most patients don't have serious problems.  Why bother thinking about them?
     Now, that's a game plan that could save everyone money this week.  Do as little as possible.  Try not to think.  Keep my eyes and hands off patients.  Don't order tests.
     Come to think of it, that's exactly what my billing specialist told me last week.  He processes the payments--I mean, non-payments--for the clinic.
     "Don't do any tests on Medicare patients," he commanded me.  "Don't do anything--just the visit."
     And then, to prove his point, he flashed a Medicare EOB with zeros all the way down:  "You're not getting paid for them, anyway."  
     It's true.  The government's agents at Medicare have been sanctioning me through non-payments for being too thorough.  It's a waste of money, they say.  Until, I bet, they're the ones with a medical problem.

Moles

     In espionage, a mole is someone who is recruited to work his way into an organization as a secret agent, or long-term informant, to supply firsthand data to an agency, incriminating his boss while being paid by the boss.  Other terms for moles are:  sleeper agents, double agents, insider threats, agents of influence, and traitors.
     Moles are also furry little animals with polydactyl hands, like humans, and long noses--creatures who live a subterranean life and are rarely seen, unless the cat brings one in.  In my yard there is evidence of moles everywhere.  They churn serpentine patterns in the earth, evident at the surface of the lawn, as they tunnel their way towards secret destinations.  The function of these tunnels is to catch worms, which fall into the tunnels and are quickly eaten, or paralyzed with a toxin in the mole's saliva, then saved for future meals.  Some moles can kill and eat a worm in less than 0.3 seconds.  Thousands of worms have been found in the storage dens of moles, that's how effective they are at killing.
     Is there a mole in my office?  I wouldn't know, to be honest, because a very good mole would remain incognito.  When working for the government or in large corporations, moles become long-term spies, sometimes making entire careers out of posing as regular employees and informing their real bosses who among the employee pool is slacking, or disgruntled, or embezzling, or otherwise taking down the organization in disintegrating ways.  In an office like mine, a mole would be someone hired by the government to turn against my office enterprise--perhaps someone who worked for me, originally, then was recruited by the government.  The mole himself is a disintegrating agent, because his very presence triggers an alarm, at a subconscious level, which is picked up by everyone in the organization.
     Yesterday a vascular tech applicant was scheduled for an interview with me, followed by a training session on our ultrasound units .  She chose the date and time herself, to make sure she could be there.  When she didn't show up, one of my employees called to find out what happened.  The applicant made numerous excuses, still holding out the possibility that she would come, or maybe she wouldn't, she wasn't sure, she needed "more information."
     "She asked me a lot more questions than a normal applicant," my employee, also an ultrasound tech, told me.
     "Like what?" I asked.
     "Like, did I know what I was doing?  And did you know what your were doing?  And, what were our credentials."
     "I am suspicious about her," I said.
     "She also kept asking how many studies could she get a day.  She said it wouldn't be worth it if she couldn't get a lot of studies.  She wanted a guarantee that she'd make a lot of money."
     "What did you tell her?"  I asked.
     "I told her the truth.  The number of studies we do depends on the patients.  We can't predict this for her.  But she wanted me to tell her there would be lots of studies, as though she was hoping we'd say she could decide when and on whom to do the studies."
     "She can't do that.  It's up to providers to make decisions about when an ultrasound is necessary.  You can't give her any guarantees, especially not with an independent contractor position.  She was probably a spy for the FBI."
     "That makes sense," said my tech.  "She didn't act like the usual job applicant.  She pressured me too much.  She tried to get me to say things that could get you into trouble."
     When I spoke on the phone with this so-called job applicant, she asked me, over and over, "Are you qualified to read ultrasounds?  Are you trained to do this?"
     She didn't leave space in the conversation for me to interview her, and she brushed off my questions as though real answers weren't necessary.  When I asked her what studies she could do, her only answer was, "vascular studies."  It seemed to me that she didn't know how to be specific, because she didn't know anything about ultrasound work.
     This is a message to the FBI.  If you want to trip us up with spies, or moles, you're going to have to do a whole lot better at it.  It's obvious that you haven't found anything real to support your suspended case against me, so you have to try to manufacture a problem.  But you're not doing a good job at that either.  I'm not a worm, and there aren't any worms around here for you to catch.  You don't even seem to know the difference between a worm and a twig.
     Please send an ultrasound tech spy who knows how to do ultrasounds, and who shows up for the interview.  Tell the applicant to stop asking so many transparent questions.
     Please also send someone who can do a few studies in my office, so I get something out of this charade, too.  I need, specifically, a certified, experienced vascular technician who can do echocardiograms, and studies of the carotids, lower extremity arterial and venous circulation, and aorta.  We will train him or her on our Sonosite equipment.  The job pays the tech per study, and the tech will be reported as an independent contractor.  There is no guarantee about the number of studies the applicant will "get."  We need someone one day per week.
     In exchange for having a mole in our office, I will answer any questions you wish, and will give the mole--to pass on to you--all the reports and data pertaining to ultrasounds in my clinic.  I think this is a fair deal.  Otherwise, don't waste my time by sending fakers, people who don't know the first thing about ultrasounds, or medicine, and who are god-awful liars, to boot.