I'm Going To Have To Sue Medicare

     Medicare hasn't paid my clinic for ancillary services for nearly two years.  That means it hasn't paid for IV's, x-rays, surgeries, labs, ultrasounds, casts, heart monitors, flu shots or Pap tests.
     It's not a punishment or take-back for overpayments.  Medicare simply sends a standard letter requesting copies of the patient's chart "before payment," then sends another once the records are received, saying all the services were deemed "unnecessary."  There is no one at Medicare who can explain why.  Once, Medicare responded to our perpetual queries and said that a registered nurse had reviewed our documentation and deemed every single service unnecessary.  Medicare is a factory zipping off these letters like thumbtacks, and I suppose it's saving America lots of money.
    True, after one and a half years of 100% scrutiny of my office records, Medicare now pays for every patient visit without demanding documentation first.  But I perform diagnostic procedures and treatments in the clinic, too, saving patients the trouble of having to go all over town before getting better.  Medicare withholds payment for all my work, even after its offices have received my records--thousands of pages.
     Medicare replacement policies, on the other hand, have paid for every service--and they, too, ask (sporadically) for copies of documentation to confirm that the services were "necessary" and "legitimate."  Replacement policies are issued by insurance carriers that supplant Medicare, providing similar coverage for medical services and exacting a fee from Medicare for "managing patients" at lower cost, or at least with less hassle.  Blue Cross, United Healthcare, Humana and AARP are some of the replacement policy companies which attract Medicare patients by promising lower co-pays and deductibles, or better inpatient coverage.  They follow Medicare's protocols for spot-checking and paying doctors.
     The only difference is, they pay my clinic for a parallel population of patients, and Medicare doesn't.  It makes no sense.
     "You're providing the same care, for the same types of patients, for the very same reasons," my billing clerk told me in frustration, "but the Medicare replacement policies pay you, after looking at the same caliber of record-keeping--and Medicare doesn't."
     "Why is Medicare refusing every single service I provide?" I complain.
     "I don't know," he said.  "It doesn't make sense.  And their appeals procedure doesn't work."
     Yesterday, a new Medicare patient arrived at my office in a wheelchair.  She was a sprightly woman--eighty but looking twenty years younger--and had tripped and fallen--like an eighty-year-old.  It looked as though she'd broken her ankle and elbow.
     "I came here because you're three blocks from my house!" she exclaimed, "and I need your x-ray machine."
     "I can't do x-rays for you," I told her.
     "Why in heaven's name not?" she demanded.
     "Well, I'm not sure why not," I fumbled.
     "My husband will have your goat, if I don't get x-rayed," she warned me.  "And my elbow hurts!"
     I looked at her left forearm, where she'd fallen onto a cement sidewalk.  It had a small scrape, but the bones were misaligned, and she flinched and slapped me with her other hand when I touched it.
     "What are you trying to do?" she reprimanded.  "Make it worse?"
     Her left ankle was puffed up like a tennis ball and had begun to turn purple.  She couldn't bear weight on it--hence the wheelchair, which my assistant had rolled out to the parking lot to help her into an exam room.
     I was wondering how to proceed.  I'm not used to being a traffic cop (known in the industry as "gatekeeper"), pointing every patient who comes to see me in the direction of other medical facilities:  x-ray, lab, bone density, orthopedics.  We do most everything under one roof.
     If my patient's ankle was broken, I wanted to know now.  If she needed a splint and crutches, I'd get them out of my supply closet and fit them today.  If a cast was required, she could return in two days, when the swelling had gone down, and I'd unroll the wet fiberglass over cotton padding to immobilize the bones until they healed.
     "I have an x-ray unit, casting materials, and crutches right here, but I can't give them to you," I informed her, "because Medicare won't pay me for any of it.
     "Well, then, let me pay you," she said, reaching for her handbag.
     "No, no, no," I remonstrated, "that's illegal."
     "By Jove, it's not illegal in my book," she told me.  "You have something I need, and I have the cash to pay you."
     Medicare forbids Medicare providers like me from accepting cash payments for medical services.  All medical tests and treatments must be processed through the Medicare system.
     "I'm sorry," I said.  "I can't take your money.  But I can call an ambulance for you."
     Never mind that the cost of an ambulance is twice that of x-rays and treatment in my clinic.)
     "I don't need an ambulance.  I need a doctor who can treat me.  What good are you?" she shouted.  "Why did I even come here?"
     I felt terrible.  She was right.  It was as though Medicare had tied my hands and feet.  I couldn't do anything for her, unless I did it for free--as I've been doing for the past year.  And this week, definitively, I had decided to stop giving Medicare freebies.
     One of my nurses walked in.
     "No, Dr. C.  You can't do it."
     She had read my mind.
     "You told us, No more procedures for Medicare patients.  You need to follow your own rule."  She was right:  we couldn't afford to serve half our patients for nothing...I had to stop.
     So, I sent my patient to the hospital in pain, and she was unhappy, and I was frustrated and, finally, I was angry.
     Therefore, I'm going to have to sue Medicare to get payment for the services I have already provided their "beneficiaries" (my patients).  I've never sued anyone before, but enough is enough.
     Can I sue Medicare?  Can I sue the government?  Doesn't the government have sovereign immunity?
     Besides, isn't ours a government of the people, by the people, for the people...I mean, aren't you and I the government, and could we--would we want to--sue ourselves?
  

Patients, #13, "I Just Want To Be Happy"

     "I just want to be happy," Julia said.  She looked at me expectantly
     She wasn't a patient with clinical depression--but someone with unreasonable expectations of life, or at least of medicine.  There isn't an ICD-9 code for that. 
     Some patients think doctors can give them a pill or treatment that will makes them feel as exuberant as the perfect-looking people in advertsements for antidepressants.  As an art form, advertising is beautiful.  As a tool for manipulating viewers' wills, it's toxic and invidious.  It has made a mess of people's psyches by promising the impossible--especially happiness.
     "What do you mean, you want to be happy?"  I asked.
     "I don't know," she said.  "Happy...you know.  I don't want to be sad."
     "But sadness might be the right feeling for you, these days," I suggested.
     "What?" she raised her eyebrows.  "Sad isn't good.  I don't want my kids to see me like this."
     In the ensuing conversation I found out that Julia was in the middle of a divorce, and had lost her mother six months ago, and her grandfather two months before that.  She couldn't find a job, she was having trouble losing weight, and her teenage daughter hated her.  They fought all the time. 
     "Something would be wrong with you, if you were happy right now," I told her.  "Sadness is the appropriate feeling for what's happening to you.  Your life is sad."
     "What can you do about it," she asked.
     "There isn't anything to do about your sadness except feel it.  You have to wait for it to wear itself out."
     "You mean, I have to keep feeling like this?"
     "That would be the best thing," I said.  "Just let yourself be sad."
     "I can't belive you're telling me that," she answered.  "What about Zoloft?  My sister got that from her doctor.  Can you prescribe it?  Would it work for me?"
     "Does your sister feel better on it?"
     "Not really."
     I suggested that Julia visit with me every week for a few weeks, so I could monitor her.  Perhaps I was missing something.  Or, maybe there were things she could do in her life to keep from sinking under the weight of sadness.  She agreed, and even seemed cheered by the suggestion.
     Then I remembered that her insurance, Medicaid, had passed a new rule saying that patients aren't allowed more than two doctor visits a month, no matter what.  I don't believe this rule will cut costs in the long run, but I'm not the governor of Florida.  I'd have to see Julia at no cost. 
     It's Thursday night, 10 pm, and I'm almost finished with the day's charting.  After this week's 120 patients, I feel sad, too.  The weight of people's suffering is a mantle of sadness doctors carry.  It's not like being at a fashion show, or the mall--but more like a house of mirrors, where everyone's troubles seem like everyone else's and like my own.  We aren't so different, when it comes to pain.
     Sadness is part of the human condition, an equalizer.  Sharing and normalizing it are the reasons group therapy works.  There's never been a panacea for unhappiness, and there never will be.  But if Julia comes to see me every week, and we talk together, her sadness will probably begin to feel okay.  Then, since this is how the world works, it will begin to give way to something else.
    
        

MinuteClinics Make Me Sick

     The idea of a minute-clinic is so bad that every time I hear about one opening, I feel sick.
     Now, a new MinuteClinic has opened in Gainesville. 
     From a business standpoint, it's a great idea--for the business owner.  Leave it to a corporate entity (what a surprise!) to figure this out, by reading the minds of their future clients and playing to their wishes.  Patients are lured into the clinic by the promise of a quick fix--Americans hate to wait!  Their legitimate health concerns are quashed by bright lights, cheerful smiles and the polished surface of a medical establishment with a mall atmosphere, in the same way that concerns about one's life are erased in the fluorescent glow of garbage merchandise at Walmart.  The corporation gets rich by doing nothing.  The patient comes in, signs a release of liability, pays a fee, and gets--well, pretty much nothing of value. 
     Here is the link to an article about the new MinuteClinic in Gainesville:

     www.gainesville.com/article/20121127/ARTICLES/121129659

     Here's what's wrong with the "news" (really a mini-advertisement) about the MinuteClinic:
     1.  "New Clinics fill a niche for routine healthcare." 
     What's "routine healthcare?"  And where's the "niche"?  These terms makes are just a lot of noise. 
     When a patient visits a minute-clinic with a specific complaint, is the provider going to have time in that "minute" to address the long list of other health issues that are supposed to be addressed as part of routine healthcare?  No--the patient is likely to get a bandaid.  That bandaid is probably going to be a prescription for antibiotics (most "diagnoses" will be one of the default triad--sinusitis/bronchitis/UTI--made by providers who got a license, presumably, to prescribe antibiotics).
     Moreover, every patient at a MinuteClinic will be told to go to his or her primary care provider (this is the MinuteClinic's escape from liability) for the hard work of treating underlying disease processes (that's real medicine).
     2.  "This one-stop clinic"--What's one-stop about a clinic that doesn't have x-ray, spirometry, ultrasound, bone density testing, a lab, a stress test, IV apparatus or a full set of immuizations?"   The patient who has anything that can't be "treated" with an antibiotic prescription is going to be referred out.  That's not one-stop care.
     3.  The MinuteClinic has "just about everything you'd find in a regular doctor's office:  eye chart, blood pressure cuff, strep test, and flu shots."  Wrong.  Is this a joke?  Is my clinic the only doctor's office equipped with more than the four items above?  Not to mention that a real doctor's office has a doctor.  I still think that makes a difference.  A minute-clinic, however, is staffed by someone who is playing doctor.  If you want to be treated by your someone in grade school, go to a minute-clinic.
     4.  MinuteClinics imply that fast equals good, and that medical care doesn't have to entail long waits for quality service.  But high-quality medical care takes as long as it takes for a doctor to ask a lot of relevant questions, ascertain the degree of reliability of the answers, and reduce a great deal of complex information to a set of working diagnoses and treatments.  This is never going to be fast--certainly not "in a minute."
     5.  MinuteClinics give people false reassurance about their symptoms.  "Oh, it's only a UTI," I can hear patients say--then they end up having bladder cancer.  "I just have bronchitis," is what a patient with mycobacterium avium is likely to be told, by someone who doesn't even know what mycobacterium is.
     I think Americans should do away with urgent care centers and minute-clinic establishments, instead giving patient access to antibiotics, contraceptive pills, morning-after pills, anti-inflammatories and selected other medicines over-the-counter, so they can self-treat their ailments, as they do in many foreign countries.  The overregulation of relatively safe medications has created a market for minute-clinics, where nurse-practitioners give a fale impression of providing safe and reliable medical care, when in fact all they're doing is handing out quick prescriptions for knee-jerk medications.
     Minute-clinics don't fill a niche, so much as make the jobs of primary care physicians harder by delaying patients from seeking important, comprehensive medical care when they need it, and by communicating the message that medical treatment doesn't have to be complicated.  Medical treatment is complicated, and the human body is a delicately balanced organism.  You wouldn't call a furniture-polisher to tune your Steinway, so why trust your body to a minute-clinic?
     It would be better for patients to buy what they think they need at the drugstore, after reading about their symptoms on Web-MD.  Then, when they finally decide they ought to see a doctor, let's give them the genuine article.
      

The Government Speaks

     It's a small utterance, and it makes its way to my ears every ninety days.
     As a consequence of the government's forfeitures of the clinic's and my personal bank account holdings, there is a requirement that the government's agents either take a specific action, or explain why they have not taken any action regarding the money they took.  They need to show cause for depriving the clinic of its liquid assets, or say why they're not showing cause.
     They have ninety days to do this.  The forfeitures occurred fifteen months ago.  The clinic is solvent again and doing well, despite forced losses incurred by the government's unjustifiable actions, but the forfeited money remains in limbo.  Starting last November the government has issued an explanation for not returning the funds, and for not explaining its reasons for taking the funds.
     Here's the explanation I received yesterday--no different from the other four previously sent:
     
     STATUS REPORT

     COMES NOW, Plaintiff, by and through its undersigned Assistant United States Attorney, and provides the following status of the above-referenced case to the court:
     1.  The undersigned hereby informs the court that while the criminal investigation continues, it is in the best interest of the Claimant and the Government to continue the stay in this civil case.
     2.  The United States will file a status report every 90 days until the resolution of the criminal investigation. 
                                     Respectfully submitted,
                                     PAMELA C. MARSH
                                    United States Attorney

My attorney sent this to me with a note saying, "No action is required on your part."  What action might that be?  
     The government speaks in a monotone.  If I write back to Ms. Marsh, asking, "Why did you take all the money from my bank accounts?"  she will respond, representing our government, "We need more time for the investigation."
     If I say, "You're ruining me!  Give back my belongings?"  the government will respond, "We need more time for the investigation."
     If I ask, "How is this helping the American people, or my patients, or the Medicare system, or all you government officials?"  it will say, "We need more time for the investigation."
     Delays, extensions, and empty language were invented, I think, for government use.  "When the government speaks, no one comprehends."   If you don't know what I mean, try reading the instruction manual for an IRS tax return.
     My lawyers used to say, "Be glad they're not taking any action--that's a good sign!"  Now, they don't say anything.

How To Eat Less Meat

     Opinions abound as to whether humans are "meant" to eat meat or not.  

     It's clear, however, that as a species we are omnivores, and our survival has depended on it.  We put into our mouths just about anything catchable or remotely digestible, and can tolerate long stretches of starvation (up to seven months for normal weight people).  No doubt our adaptable GI tracts and down-regulating metabolic systems have been key factors in our ability to thrive in the animal kingdom.  Perhaps only the cockroach surpasses us in gastrointestinal ingenuity.

     Most people say they'd like to eat less meat.  Among my patients, ninety percent of whom have suboptimal lipid profiles, most should reduce animal protein in their diets for the sake of their health.  Animal products are high in saturated fats, which clog small blood vessels and cause strokes and heart attacks.  Twenty-first century animal products in the United States are loaded with chemicals, not least of which are adrenaline and its biological by-products.  

     Adrenalin is another term for cortisol, a stress hormone which skyrockets when animals are kept in close quarters, force-fed, denied access to the outdoors, and treated with cruelty.  It is a sad consequence of our purposeful divorce from everything natural that Americans exercise unnecessary barbarism in the production of meat, and that most of us ignore this immorality as we gluttonize ourselves with meat--far too much meat.

     Why do people get so hungry for meat, fish, and cheese?  Patients who try to reduce their intake find themselves craving certain things:  a big steak, bacon, cheeseburgers, chicken nuggets.  

     I think what they hanker for is glutamate.  It's a taste that causes cravings as powerful as those for sugar, salt, and fat.  There's nothing wrong with these cravings--they're built into our nature.  Glutamate is an amino acid that's present in high quantities in meat, fish, and cheese. It's associated with the "fifth taste," known as umami. 

     Umami is a term that comes from the Japanese word for "deliciousness."  Our taste buds are geared to pick it up, just as they register salty, sweet, sour and bitter flavors--but what they're registering is glutamate.  In 1908 Professor Kikunae Ikeada "discovered" monosodium glutamate by isolating glutamic acid from a seaweed, kombu, and ionizing it.  Thus, MSG was born and patented, and has been used in cooking in western countries ever since.  It was the target of Chinese-restaurant syndrome, a constellation of symptoms including headache and dizziness unfairly attributed to MSG, and suffered a loss in popularity for many years.  But it is probably very safe, since the body breaks down MSG into glutamic acid readily, and glutamic acid is present in many foods.

     Which brings me to the point of this post.  If you want to eat less meat, you have to increase your intake of foods that are high in glutamic acid, or glutamate.  The modern American diet doesn't include many of these foods, hence our craving for meat and other animal products.  You could simply add MSG to all your vegetables and non-meat foods, but it doesn't seem right to veer to far from traditional cooking lore, and MSG is a modern, laboratory-produced crystalline substance, unlike salt, which is found along seashores, or sugar, which is boiled down from cane or beets.  Adding MSG to foods seems like something astronauts would do, because they have to, not earthbound humans with a long and well-documented history of cooking and eating wisdom.

     The foods high in glutamate are those our ancestors made, preserved and ate.  They are foods that are making their way back into the American diet, inch by inch, and they are high in nutritional substances not yet well understood, and not found in many other places.  We all need to learn to make them, and cook with them, and think of them when we eat.  It's easy to renounce meat, and even to become a complete vegetarian if you know how to include umami with the other four flavors in cooking.  Glutamate stimulates brain receptors, and may promote a sense of well-being.

     High amounts of umami are found in the following foods:  tomatoes, tamari or soy sauce, anchovies, mushrooms (especially shiitake), nutritional yeast, olives, marmite, miso, kombu, umeboshi plums, ketchup, wasabi, vinegar, beer, wine, parmesan cheese, sauerkraut, tempeh, and all fermented foods.  Traditional cooking from all cultures includes foods with umami.

   Many of these products are loaded with probiotics--those all-important organisms that seed our GI tracts and help to boost our immune systems, and which is so often associated with yogurt.  (In fact, most yogurt brands probably contain no probiotics--you have only to try to make your own yogurt with a "starter" of commercial yogurt to find that there aren't enough active lactobacilli in a store-bought yogurt to get a culture going, which is proof that they're a worthless source of probiotics.)

     Any vegetarian cookbook worth the paper it's written on will include umami-containing ingredients in most of its recipes--or at least at every meal--otherwise a key flavor will be missing, and the cook's family and guests will leave the table feeling hungry, with a vague sense that something was missing.  They'll blame it on the fact that the food was "vegetarian"--when the problem will have been:  no umami.  They'll leave your table to rush to the nearest fast-food joint and satisfy the craving for umami by gorging on a few burgers with ketchup.

     If the concept of adding umami to your diet in forms besides meat seems daunting, go slowly.  Learn to make a few things with one or more of the ingredients above, and eliminate meat from the meal.  See if it makes a difference.  The less meat you eat, the longer you're likely to live, if the regions with the longest life-expectancy (Okinawa; Sardinia; Ikaria; Loma Linda) are any clue.  

     

Walking the Corridors Late at Night

     I found myself walking up and down the long hallways of my office in the dark last evening.  Although I live in the country and don't budge on the weekends, today I had reason to drive to Gainesville, so I stopped off at the clinic on my way home to pick up a few items I'd forgotten in the rush to get home before Thanksgiving--a bag of shredded paper for my chickens, my empty lunch containers, a piece of pH paper to check the acidity of the pond.
     But those things could have waited.  Really, I think, I wanted to feel the place where I spend so much of my life, with the magical ghosts of medicine on the sidelines, taking a break, recharging for Monday, and my own spirit hovering in the shadows of a clinic that bears my name--my father's name--and carries our shared decades of immersion in the lives of others, and our insistent belief that we could save the lives of others.
     I ran my hands over the EKG machine, and the smooth, clean surfaces of the ultrasound units, studying the keyboards, marveling at the power beneath them.  They are precious, well-used watchdogs, identifying exactly what's wrong with patients when my brain is supposing many possibilities.  I held one of the transducers in my palm--such stupendous technology, given to me to read its code, and translate for my patients.  These pieces of equipment have served me like dutiful beasts of burden, day after day for years, and it is hard not to anthropomorphize them, hard not to imagine they have personalities of their own, and a relationship to me.
     Then I made my way in the strange pink glow cast by the red emergency lights to the x-ray room, where digital machinery can peer straight through the human form to its framework.  This apparatus has made my job easy, unveiling, via subtle densities, a telltale hairline fracture of the radius, or the fat pad that accompanies an ankle sprain, or the ominous shadow masquerading as lung parenchyma--a shadow that never fails to send a wave of terror up my spine:  cancer, do something, do something fast!
     How will I get along without all these implements, my arms and legs, which have been given meaning and purpose by my medical training and will, helping me to make diagnoses and outsmart disease, allowing me to make mortgage payments, plant trees, and pay for my sons' college educations?  
How does a hunter hunt without his pack of dogs?  How does a hunter stop hunting, when the season is over?  What will I do with my time?  I should have a plan, I know.  But I don't.
     I stood in the billing office, a jungle of paper--boxes and boxes of it--and file cabinets, and sticky notes, and manila folders with labels:  Enter Charges, Rebill, Appeal, Send Records...and the biggest piles, which might as well say, Give Up--These Claims Will Never Get Paid, and You'll Never Win.  
     I sat in an exam room on one of the blue swivel stool that affords a 360-degree view of my patient, lively children, concerned spouses, cabinets, bulletin boards, the ophthalmoscope-otoscope wall set.  I pressed the buzzer which I use to summon a nurse, and the sound cracked the heavy silence like a small plane taking off.  After that, it was quiet as a morgue, the noise having made the stillness in the clinic even keener, so that it stung.
     Two bank representatives toured the clinic last week, preparing to lease the building to someone else after February.  The bank had foreclosed on the previous owner and took over my lease shortly after I moved in.  I would have bought this building, now fully equipped, but my prospects didn't feel secure.  Then the raid happened, and I knew they weren't secure.  I began to give up on the whole idea of medicine, at least as a way of life for me.  I never thought of myself as the type to give up.
     Don't be sentimental, I told myself.  There's nothing to gain from that.  Move on, something else will show up.
     This week at home I planted more flower bulbs--tulips, this time.  Now there are hundreds of daffodils and tulips in potentia, sitting in the cold, dark earth, waiting.  
     Something will emerge from this mass of possibility.  It has to. 

Do I Really Want To Quit?

     This is a tough question.
     I think about medicine and my patients all the time.  When I quit, what will fill all that mental space?      Physicians don't give up their medical affiliations just because they stop practicing their trade.
     My brother, David, went to medical school, then did one year of internship.  After that, he decided to work as an emergency room doctor for a few years to pay some of his debts.
     In his first year out of school he got sued by the family of a patient whose daughter, a hospital nurse, had stopped him in the hospital corridor and asked him to check out a mole.
     "You'd better go see a dermatologist right now about that," he said.
     She died a year later of malignant melanoma, not having taken his advice.  She hadn't been his patient, so he didn't have medical records documenting the "hallway visit" or his advice that she seek immediate medical advice.  It was his word against the unfortunate woman's family's word.
     The lawsuit dragged on and on and my brother, discouraged, stopped practicing medicine forever.  That was thirty-two years ago.  He worked for the pharmaceutical company, Wyeth, for many years, then retired.
     He had been a practicing doctor for exactly one year, and never again felt the desire to work as a clinician with patients.  Nevertheless, every two years for thirty-two years he has renewed his medical license, paid the fees, and continued to belong to the club.  He still reads medical journals, and when the conversation turns to medicine, he joins in with so much erudition and enthusiasm you would think he had been practicing medicine for decades.
     It's a hard identity to give up.  The dues we pay to become physicians--many years of nothing but studying; a decade or more of sleep deprivation; living, thinking, breathing medicine; making crucial decisions that have dire consequences; drawing to ourselves people who look up to us and stake their lives on us;  constantly living with the uncertainties of ill-health, difficult diagnoses, and inadequate research;  faced with death, constantly, the prospect of death, death, death--these factors cement our perceptions of ourselves, permanently.
     I will quit practicing medicine, but I can't quit being a doctor.  The choice to attend medical school and identify myself as a healer was one I made for life.  What it will mean for me to be a doctor once I close the doors of my practice and stop treating patients--that's not easy to imagine, not easy at all.

A Psychological Theory to Explain Placebos

     Thomas Edison believed there were fifteen little people living inside his head.
     True, he lived in the mystical age of Mesmer, when people were "taken by fits," and seances were considered by many to be serious endeavors, and the scientific method--which is the chief characteristic of modernity--did not yet have overarching influence.
     But Thomas Edison was someone with terrific brain power, a man whose 1,093 patents are responsible for the phonograph, telephone, incandescent light bulb, storage batteries, tape recorder, waterproof paint, cement kiln, conveyor belts, and many other forward-thinking inventions.  So we can't chalk him up as a complete kook when it comes to his idea that his mind was not completely his own.  He considered himself to be a composite of multiple beings.
     The idea of multiple personalities housed within one "person" doesn't have to belong to the realm of pathology.  It does require that we take a different view of ourselves.  We are all multiple personalities.  The one "personality" who stands at the foreground of the troop may get credit for a person's self-appointed identity, but it usually takes no more than a little nudge for another to come forward, elbowing out the rest to express anger, peevishness, childlike exhilaration, and uncharacteristic annoyance, or to do something "completely out of character"--getting us in trouble, making us ill, causing accidents, becoming seductive, turning into the life of the party, or producing something of stunning creativity.
     The theory of Healthy Multiplicity holds that many people can occupy one physical body.  What we call "a person" is instead considered a community of people housed in a physical being.  The idea of multiple personality disorder may stem from an understanding that some of us are capable of "channeling" the different personalities we encompass in ways that confuse--or, in the case of creative geniuses and mimes, e.g., Robin Williams--impress everyone else.  It may be a matter of cultural necessity that we project ourselves as singular, but we all know how easy it can be to slip out of our norm and become "other," by drinking too much alcohol, or suffering extreme stress, or missing sleep, or being in situations that trigger subpersonalities to the helm.  "The devil made me do it," we say, or, "I don't know what got into me."  Mozart reported that his symphonies wrote themselves, and he simply acted as a scribe.  He was driven by an irrepressible, inner other to give pen to the concerto, opera and orchestral scores that poured into his imagination.
     Carl Jung attempted to lend scientific credence to the idea of multiplicity with his theory of complexes.  He developed the Word Association Test to demonstrate that each of us is really a collection of semi-repressed personalities that superintend our actions, often in sequence, depending on the circumstances.  Jung used a galvanometer to measure the skin temperature of subjects in his experiments, and a stopwatch to measure the response time when they were asked to give quick, associative responses to a list of words.  Some words were highly charged for certain people, and not for others, but everyone was shown to have delayed responses and increased sweating and skin temperature.
     Jung's famous experiment became the basis for the lie detector, which is still in use today.  But "lie detector" is probably a misnomer.  Who, may I ask, is lying?  If each of us is a multiplicity, then the liar is really a sub-personality stepping into the foreground and telling its own truth.  "I'm pissed off," it may say, or "I ought to steal that wallet."
     When a placebo works, it's not because it has been given to the rational, superior, take-charge person who presents his best self to the doctor (and would disdain placebos outright), but because it's interacting with one of the subpersonalities--someone who has a lot of clout in the enactment of health within the physical body.  Placebos are given to the person's plant manager, or operational systems executive--to a foreman who works in the basement of the body where the pipes and thermostats are housed.  It doesn't matter if the scientifically oriented persona of the person doesn't believe in the treatment.  The sub-personalities don't care about science.  They need a tool to tweak a few nuts and bolts, or open energy channels, or turn off a flooding pipe, and the placebo is that tool.  The situation allows for the placebo to reach the proper mechanic, and when it works, the patient gets well.
     So, let's not pooh-pooh placebos.  Doctors used them all the time, whether they admit it or not--whether they know it or not.  The moment a patient enters the doctor's office, the stage is set for something to work.  Whether it's an outright placebo or a very toxic pharmaceutical hardly matters. The doctor's skill in conversing with the patient's subpersonalities is key, not the material treatment or substance administered.

Thanksgiving

     Thank you for this country in which everyone has a voice.
     Thank you for the efforts of people everywhere to improve the lives of those who were not born equal.
     Thank you for the possibility of making a difference.
     Thank you for the rebelliousness of the young.
     Thank you for the equanimity of the old.
     Thank you for good health, when it settles down inside us, and for illness, when it delivers its important messages.
     Thank you for peace, inner and outer.
     Thank you for wildflowers, which emerge from dry earth like good news.
     Thank you for the farmers at the farmers market, because they are making an effort.
     Thank you for everyone who makes an effort.
     Thank you for this world, which is beautiful.
  
  
     

Selling the Clinic's Medical Equipment

     If I don't think about how much money and effort it took to outfit the clinic, I'm okay.
     That was in the past, anyway.  The past doesn't have much weight, compared to the present.
     I have to empty the 4,000-square-foot clinic, all twenty rooms and five hallways, by January 31st.  That gives me a little more than two months.  My lease on the building ends February 15th. 
     There isn't a "market" for medical equipment right now.  Doctors are skittish, medical centers are waiting for proof that life will go on in the medical field after Obamacare really gets cracking.
     We started posting medical and office equipment on Ebay, but shipping it requires a lot of personnel time, and my staff has been pruned steadily since the FBI's raid.
     As it turns out, a hospital in Guatemala will accept all our equipment as a donation, and will pay for a semi truck to pick it up and haul it through Mexico into Guatemala. 
     Several years ago I attended a medical conference in Guatemala, high up in the mountains in Atitlan.  Much of the conference involved visiting small medical establishments that serve local populations.  We visited a hospital in Guatemala City, too, and it looked like a throwback to the 1940's.  It was the year after a giant mudslide destroyed many mountain villages and killed people.  It was also a year when the horrors of Darfur were being made public.  My problems seemed very small, indeed--and they still do.
     Medical clinics in Guatemala are inadequately staffed and supplied.  Most women in rural areas have never had so much as a Pap test.  The people need volunteer doctors and nurses, and they need equipment.  Therefore, I am happy that the exam tables, digital x-ray unit, bone densitometer, spirometers, EKG's ultrasounds and everything else in the office--thing's I'm "losing"--will be donated to a good cause.  Perhaps I should be thanking the federal government for making this possible.
    

All in a Day's Work

     Today, I saw a 10-year-old who couldn't breathe out of his nose.  He had blue-white nasal mucosa.  We did nasal irrigation, prescribed nasal spray for allergies, and tried to persuade his parents to let me help them quit smoking.
     Then, I took a 7.5 cm crusted, funny-shaped, rapidly growing basal cell cancer off a patient's neck-chest junction, and had to do a plastic surgery to cover the opening. Since it's the fourth skin cancer I've removed, and he has another large one above his left eyebrow, I know something serious is going on with his immune system, and have set out to find out what.
     Lab tests confirmed a case of West Nile virus in a patient whose left lung pneumonia looked unusual to me last week, and whose symptoms of fever, chills, night sweats and nausea seemed to signify a problem even more serious than penumonia.  Tests for Lyme disease, influenza, erlichiosis, HIV, and Eastern Equine virus were negative.  But West Nile titers were positive.  The patient doesn't have encephalitis, hepatitis, or nephritis, and therefore is better off recuperating at home with the treatments I gave her.  Rest, rest, rest, I said.  Meanwhile, I called her daughter to keep an eye out for complications, should they occur, and be prepared to take her to the hospital.
     A newly diagnosed twenty-something HIV patient is beginning to accept his need to take medication to keep his CD4 count and viral load down.  After telling him about his test results he fell into a deep depression.  The lymph nodes in his chest, revealed on a CT scan, were enormous.  He refused to see an Infectious Disease specialist, or even go to the Health Department.  Finally, he started the prescription for Atripla we gave him, and now the lymph nodes in his chest are going down.  He feels better, but asked--can he still have children?
     Another patient hasn't been able to sit down for three days.  Examining her with an anoscope, I saw a thrombosed internal hemorrhoid, and treated it.
     A young couple brought in their six-month-old baby, who has been coughing and running a fever of 101.8.  They had gone to the ER last night, but after waiting for eight hours without being seen, drove to my office this morning. The baby was cheerful, but a chest x-ray showed pneumonia.  "Oh, my God," the father said, then told me that a family member's baby died of pneumonia not long ago.  Undoing the notion that his baby was likely to die took a little time--then I used the opportunity to say all both parents and grandparents should quit smoking, as a way of improving the baby's health.
     A 40-year-old woman has been picking a scab off a nodule on the bridge of her nose, but it keeps coming back.  It was a sebaceous cyst to me--but might have been skin cancer, so I did surgery to remove it.
     A man with cellulitis of his leg came back to be checked after three rounds of IV antibiotics and an Unna boot wrap.  The original ulcer, caused by poor venous circulation, was getting better:  islands of normal tissue had sprung up in the center of the red speckled skinless area, which was the size of a half-dollar.  The cause:  he weighs more than 400 pounds, and the veins in his legs can't return fluid fast enough to his heart, so the fluid pools in the tissues, and seeps through the skin, causing breakdown of skin cells.  He's lost 40 pounds in three months, which I thought was great.
     A young woman with positive tests for a clotting disorder (antiphospholipid anitbodies) wanted to know if she could take birth control pills.  She refused my suggestion to get a Mirena IUD, because she's worried it will hurt.  But she agreed to Depo-Provera shots.  Estrogen-containing contraceptives might increase her risk of a blood clot, and are contraindicated.  If she gets pregnant, I said, it will be a high-risk pregnancy.
     A patient with hepatitis C can't stop using pain pills.  He doesn't want to have a liver biopsy.   Nor does he want interferon treatment--because he knows it will cause depression.  His liver enzymes are sky-high, suggesting damage of the liver at the cellular level.  He knows that hepatitis C is one of the biggest causes of liver cancer.  He quit drinking alcohol, for which I commended him, but refuses AA and NA.  "Don't yell at me, Doc," he says, in a self-berating way.  But I would never yell at a patient, never.
     A young man's asthma is suddenly worse.  He can't breathe without coughing.  His chest x-ray is normal, but his spirometry shows a breathing capacity at 50% of what it ought to be.  We ran some tests and treated him with antihistamines and inhalers.  He may need prednisone, but I have to figure out why he's having this problem.  I wonder if he might have been exposed to airborne toxins at home or work.
     A woman has a hole in the septum of her nose.  She swears she's never used cocaine, or snorted any drugs.  She doesn't use Neosynephrine nasal spray.  Maybe she has an abscess in the root of one of her lateral incisors, and it has eroded through her cartilage--this is not impossible, but would be very unusual.  Off to the dentist she goes.
     A patient with a malignant melanoma on her arm, came back for surgery of another site, where biopsy of a tiny freckle between her toes revealed an atypical nevus, or pre-melanoma.  Lucky you looked there, I told the nurse-practitioner.  An assistant held the toes apart so I could remove the lesion in the web space, a tricky maneuver that took just a few minutes. 
     A 375 pound patient wants to be referred for gastric bypass.  She has tried many dietary regimens, as well as pills to lose weight.  I agree that she needs a gastric bypass, since she now has diabetes, high blood pressure that persists even with three medications, back pain, knee arthritis, and high cholesterol.  But her insurance, Medicaid, won't cover the procedure--either that, or it pays so little no surgeons in the area will accept Medicaid patients for gastric bypass surgery.  "But they'll pay for me to have a heart attack, right?"  she asked in frustration.  "Right," I said.
     A young woman believes her partner is cheating on her.  "Did you ask him?" I wanted to know.  She said she did, and he denied it.  She wants to be tested for STD's, anyway.  I wonder if she's the one with another partner, but won't tell me for fear of being judged.  Almost no one ever tells me he or she is the one "cheating"--it's always the partner who's implicated.  If we could all accept that half the world cheats, and that it might even be "normal" to cheat, maybe I'd  get the straight story.  But that would mean overhauling religion, and it doesn't matter, anyway.  I ran assays on her for all seven testable STD's:  HIV, syphilis, chlamydia, gonorrhea, trichomonas, genital herpes, and human papillomavirus.
     Another patient's golf-ball sized abscess, angry and blistering, which we lanced last week, releasing copious amounts of foul, blue-cheese material, is now almost gone.  I gave the her daughter credit, because she has applied hot compresses to the area four times a day.  In three weeks I'll remove the little cyst that got the whole thing started.  Now I see a skin cancer near the abscess, and proceed to biopsy it.  The patient spent thirty years in the blazing sun as a migrant farm worker, and he skin is paying the price.
     Thank goodness for my wonderful staff, because without them I couldn't accomplish a third of what I do in a day.  The phone rings a hundred times a day, and they field the calls, scheduling appointments, copying records, making referrals.  They order supplies, sterilize equipment, set up surgeries, draw blood, do IV's
     Five patients needed physical exams, there were two Pap tests, three had arthritis, one had a fractured vertebra, one had heart failure from cardiomyopathy, and two had sinusitis.  We placed two Holter monitors, scheduled three stress tests, gave well-child immunizations, administered several B-12 shots, dressed a wound, took out stitches, did  ten x-rays and seven ultrasounds, and had telephone conferences with many more.  Dozens of faxes arrived with requests for signatures for home care orders or medication refills.  We made referrals for mammograms and colonoscopies.  I sent one patient to the ophthalmologist.  Last week, when the weather was cold, there were many joint and sciatic injections for arthritis, but none today.  I scheduled a patient for an endometrial biopsy.  When the last person left at 6:30, I had three stacks of charts to finish, and a pile of phone messages to answer.  Forty patients asked for our help, and we gave it.
     The only ICD-9 code I had to look up, because I have so many memorized, was West Nile virus: 066.40--but it's changing to A92.30 next year.
     I won't need it then.
    
    
    

A Compressed Life

     I had the choice, yesterday--Sunday--of writing in my blog or planting flower bulbs in the garden along the front walkway.
     Carmine and I gathered our things:  weed bucket, trowel, bulbs.  Otherwise, he would have had to sit and stare at me as I sat in front of the computer for an hour.  That didn't seem fair.
     When you add it up, a life contains only so much "free time."  For me, that amounts to fourteen hours a week when I am not guiding and prompting Carmine, my autistic son, or sleeping, or working at the clinic.
     I wonder if other people are constantly thinking about this, as I am?
     There are fourteen hours a week when I am not beholden to anyone.  In these hours, my mind belongs only to me.  I feel time-rich:  it used to be, like many working mothers, that I had zero hours--in the days when I raised my sons and worked sixteen-hour days, feeling guilty all the time about not being a good enough parent, not being present enough for anyone.
     I could have sacrificed sleep, which I often did as a way of "stealing" free time when the boys were sleeping, so that the small, patient fox-cub of my imagination wouldn't wander alone in the woods, and starve.
     Why do so many people make the choice to smoke weed or snort cocaine in the free time allotted them?  It's a little like selling one's brain for something else--a disorienting amusement park ride, from which you come out with... what?  One-third of my patients have positive drug tests.  But almost none can tell me why. 
     "Why are you spending your brain like this," I ask? 
     We only have so much time to feel our way through the world.   Don't people like what's in their heads?
     Every week has 168 hours.  Forty are spent working, at least for most employed people, and five or ten driving, and a few getting ready for work, and fifty-six sleeping.  And forty--it seems--talking, texting, or facebooking.  Then there are TV, meals, laundry, showering.
     There's not much left, after that. 
     What is left is the time we have to make ourselves into who we are.  Sometimes I look at my patients--and myself--and ask:  Who are these people?  Are we trying to become something, or are we who we are by default, because we haven't thought about it at all?
     Dropping bulbs in holes in the ground, covering them with sandy humus, replacing the stray earthworm trundled out of sleep in scoops of upturned earth, smiling at Carmine in the gray-blue light, felt like doing something that wasn't by default.  It was person-building.
     It's nice, too, to be engrossed in activity that doesn't have as its reference point the stupid government.
     In March, when a hundred daffodils poke up through the ground, the government won't matter at all.

My 200th Post: A Synopsis

     Once upon a time I was a happy doctor.
     I traveled from exam room to exam room every day, marveling at the variation among humans and their adaptability, studying medical journals and texts at night, taking care of my children, tending a garden, and falling into the deep, exhausted sleep of personal fulfillment every night.  I loved my work.
     Then came coding.  When I started my own medical clinic, I thought how wonderful it was to own a business, making decisions--without bureaucratic holdups--for the good of patients and employees, expanding the number of services we offered, and carving out a little niche in a rural area.  Patients were happy.  We did a lot of good.  My integrity meant everything, because I understood it to be the foundation of a successful business.
     But this was not just any business.  I couldn't simply offer a product or service, the way a grocery stores or steam-cleaning businesses do, and get paid in cash when the job was done.  I had to code for what I did, using a new abstruse, almost hieroglyphic language, and I had to describe in painstaking detail every conversation I had, and the reasons for the time I spent with patients, and the subject matter, and I had to provide explanations the government thought were acceptable, and I couldn't do anything without the government's approval, which was always given or withheld until long after the medical visit, after the treatment.
     Everyone knows that if you wait until after a person or organization receives a service, the chances of getting paid for that service go way down.  Isn't that why hotels switched, long ago, to a system whereby guests pay in advance for their stay, not after?  And gas stations--which used to allow clients to fill their tanks first, then walk into the little store and pay--now requiring cash or a credit card up front?  They stopped because people ripped them off.
     The government, it turns out, is no different.  It rips off doctors all the time, via Medicare and Medicaid, by refusing to pay for medical services for patients, claiming that it does so to save taxpayers money, and using a host of excuses that have to do with coding errors, documentation inadequacies, and decisions about what should and shouldn't have been done for patients--excuses that come from a place high in the sky, where money matters more than care, and where more money is spent than ever should be, in the long run, because proper care isn't paid for up front.  The government has taught other insurance companies, like Blue Cross, United Healthcare, and Aetna, its tactics.  Now everyone has joined in the game of auditing doctors, and routinely denying them payment.
     Sometimes the government rips off doctors in far bigger ways.  It places something like classified ads for special high-paying jobs in all its mail communications with Medicare and Medicaid recipients:  the job of Whistleblower.  "If you think your doctor made a mistake, and you want to make a lot of money without losing a dime, call us..." the ad goes. "Call us immediately."
     Whether there are grounds for such reports or not, the fact that an individual has filed a report gives the government immediate license to break and enter.  Its agents tell a judge that they have sufficient reason to suspect fraud, and the judge gives them permission--contained in sealed affidavits that no one else can see--to take a clinic's charts, supplies and money.  It can take everything, and keep it.
     The government isn't looking for wrongdoing, particularly--it's looking for money.  Its agents are selective about which medical practices it raids:  there has to be sufficient money to take back, which is a term Medicare uses, and the government uses, and is synonymous with steal.
     One day, thirty or forty FBI agents raided my clinic, terrorizing patients and staff with their stern voices and gun-filled holsters.  They took all the patients' charts, and dozens of brand-new IUD's, and all ninety vials of medicine earmarked for specific patients:  Reclast, Boniva, Synvisc, Orthovisc, Restylene.  They also went to the bank and withdrew the clinic's working assets, as well as all the cash in my personal bank accounts. These bank forfeitures totaled $400,000, which demolished the clinic, at least temporarily.  The banks closed our accounts, fearful they had been dealing with a delinquent.  The local TV station reported the event as though it were one more lurid crime story.
     Patients were not deterred.  They continued to fill the waiting room and ask for medical help.  They were angry, wanted their charts back, and couldn't get answers from the FBI.  But my license and board certification remained intact, and my staff and I mustered the energy to get back to work.  Two weeks after the raid the clinic was on its feet, albeit with a reduced staff, and empty chart-racks, and the mood of shock and horror that can pervade a place after an unjust attack.
     The government's so-called investigation of Colasante Clinic started in June 2010, when a whistleblower, Pat McCullough, filed a report as a way of deflecting attention for her expertly orchestrated takeover, pillage, and destruction of a fully-functioning, solvent clinic in Hawthorne, which she purchased from me, saying she wanted to help people.  Instead, she sold the equipment, misrepresented the clinic's assets as a tactic for borrowing money from banks, and dissolved the business a year later, when there were no more profits to be extracted from it.  She was granted bankruptcy relief shortly thereafter, without much scrutiny, and now waits for her whistleblower suit against me to pay off.   The government seems to have eaten out of her hand.  Of course, it stood to gain, too.
     Now, I am tired in the way people get tired when ignorance, greed and corruption cause harm and win out.  The government has been silent for twenty-nine months.  It has kept its reasons for the raid and take-back secret;  it has influenced Medicare to stop paying for most of my services to patients;  it has kept all the supplies, charts and money that belonged to the clinic.
     Why not?   The government is protected by a bulwark of statutes that were passed into legislation without much public understanding of their implications for doctors and patients, such as the Health Insurance Portability and Improvement Act of 1996, the Medicare Modernization Act of 2003, the Tax Relief and Health Care Act of 2006, and the Patient Protection and Affordable Care Act of 2010. 
     "The government" is just a bunch of flawed people, who need to prove to the American people that they're cracking down on fraud, and they do so by taking money from physicians--who don't have the resources, time, or legal protection conferred by due process to fight back.  In addition, it is advertising its good deeds to the public, as a way, for example, of justifying the FBI's $8 billion budget per year,  that it has "recovered" billions of dollars in money from doctors, who are bad and should not have been paid, and perhaps should be "regulated" even more.
     I am closing my medical clinic on January 31, 2013, having given the requisite 90-day notice to all insurance carriers, having canceled my lease, malpractice insurance, and general office liability coverage, having notified AHCA, CLIA, the licensing board, and all other agencies whose approval to run a clinic and practice medicine took so much work to obtain.  I am closing my medical clinic, not because I can't make a living any more, not because I have been shut down or denied the privilege of practicing medicine, but because I am disgusted.
     I am closing my clinic and discontinuing the practice of medicine exactly when America needs doctors most, to meet the upcoming demand for medical care that will hit the country on January 1st when Obamacare's wide-open promise to provide medical care to all uninsured citizens must be fulfilled.
     I hope my story is not a common one.  Many doctors tell me they are also disgusted with the current state of medicine in this country, and are dropping Medicare, or opting out of doctoring altogether.  Maybe it's not everyone.  Maybe they will wait to see if things improve with the new healthcare plan.  That would be good, but it's not for me.  Good luck, America, I say.  Good luck.

Watching a Chicken Lay an Egg

     There aren't many better ways to spend an hour and a half on Saturday morning than in the henhouse.  I went out today, as usual, to clean the nesting boxes and bring the birds some scraps:  wilted lettuce, sprouts, squash peelings and seeds, a stuffed pepper from last week, cheese rinds.
     One way to tell if your chickens are healthy or not is by watching their reaction when you enter the chicken yard with something in your hands.  Chickens have good eyes and are very observant.  So, if they don't crowd around your legs, making it difficult to cross to the feeding tin without tripping, something is wrong.  If they don't cluck and flap with enough commotion to drown out the crows in nearby trees, it's a sure sign of a problem.  A chicken who rebuffs you, or toddles in the opposite direction, or stays in its dustbath hole, is sick.
     This morning my hens were all happily underfoot.  Even the five new Rhode Island Reds I acquired last week--rescuing them from someone else's stew pot--seemed to have new vitality, despite the beating they were taking as the cruel and inscrutable mechanics of the pecking order held sway.  Some of them were missing feathers at the base of the tail, while others had been extra skittish, scooting down an alley between the chicken house and the chain link fence whenever one of the incumbents looked in its direction.
     "Fight back!" I want say to the new chickens.  "Don't you realize how strong you are?  You can't let those bullies convince you you're nothing!"
      How odd, I realized, for me to be egging them on like a punitive coach in the boxing ring.  Was I giving myself a peptalk?  Am I running from bullies?
      A product of the '60's, I raised my sons with pacifist values:  peace, love, tolerance.
     But, reflecting back on those days, they, too, fought like roosters with their bullying age mates.  I was called away from patients to come into the principal's office to hear the latest bad-behavior story more times than I can remember.  The boys did hundreds of push-ups at night and asked for barbells to beef up their physiques.  So much for overturning Darwinian dynamics.  It doesn't pay to be meek, I guess.  If you're a chicken, it can be the death of you.
     Perhaps the prospect of new, savory treats got the chickens' oviducts going, because within ten minutes of my arrival two of them were making loud birth announcements in the vicinity of the hen boxes.  These are the sixteen wooden boxes I had built and keep lined with clean hay or shredded paper from my office, so the hens have a choice about where to nest.  But they usually select one of just three spots, always the same--sometimes leaving, by the end of the day, six eggs in a single nesting box.  Since hens don't lay, at most, more than one egg a day, it's obvious that one hen's good idea becomes the others' copycat decisions.
     It's not easy to lay an egg.  In fact, it's an astounding accomplishment.  Whenever I lift a chicken, gently, around its middle, I can hardly believe how little it weighs.  That an egg is created at all within such a fragile frame--poofy feathers and hollow bones--is remarkable;  that eggs are produced on a regular basis from lowly materials like millet, corn, dried peas and kitchen scraps is beyond belief.
     I stood in the darkened henhouse watching the two Delaware and Barred Rock hens scratching at their bedding to make padded depressions for the incipient eggs.  They were fussy and tense, elongating their necks and chests in a maneuver that seemed intended to wiggle something through their digestive tracts, then burrowing their heads and huddling into downy balls.
     They stared at me during the nesting ritual--calling attention to my unmannerliness in overstaying my visit--and refused to make quick business of their egg-laying.  I stared right back, intent on watching the process from beginning to end, and so it went.  They held out, and so did I.
     I had to swat a good many mosquitoes out there in the henhouse, despite the coolness of the morning, and when one or another of the flock wandered in to check on me I'd hold out my palm with a freshly killed mosquito for it to peck and eat.  They got used to this and would bite my finger when I wasn't looking, as if to say, "Where's my morsel?"
      Every time I made a move to swish away a mosquito, the laying hens stood up, bothered.  They'd cluck loudly, ruffle their feathers, or preen a little, and look at me:  When are you going to get out of here, so we can get through with this?
     The Barred Rock was in the far corner doing some twirls to find a good position.  Her vent--an opening just below the tail, and the place where eggs are released--was opening and closing in the shape of a smile, so I knew a delivery was close.  A few minutes later, without a sound, she jumped down and ran out of the house.  I figured she just wasn't going to make a public affair of the egg-laying, and had found a way to halt the process.  Darn!  Then I looked in the box--she'd laid an egg without a sound.  What a trickster.  I missed it.
     I positioned myself right in front of the Delaware hen.  This was one of the executives of the flock, second in command and a bit of a show-off.  She fluffed out her plumage and opened her beak, and out of her mouth came squawks that carried such a sense of urgency some of the lowly Reds quivered and went running in circles outside.  Exactly in tandem with her vocal outpouring was a series of opening and closing motions of her vent, visible to me as she faced the wall.
     Like mammals, hens are born with all the yolks they'll need in a lifetime.  During their most productive time--age six months to three years--their ovaries release a yolk every twenty five hours, the time it takes for the albumin (white part), membrane and shell to be formed.  Twenty of these hours are devoted to shell production.  Hens need large amounts of calcium in their diets to lay down shells;  I often give them back their own washed, crushed eggshells, which they gobble greedily.  My chicken books say that too much calcium causes hens to become fat, and fat hens don't lay well.  But running around a large coop or back yard keeps hens trim--even those who, like mine, have constant access to plentiful amounts of feed.
     Without any more of the usual, loud, boastful fanfare associated with egg-laying, this Delaware hen stood tall in the nesting box, marched in place a few steps, and undulated her neck and torso like a belly dancer while the vent under her tail squeezed out, in four tries, one perfect egg.  The hen is white, but her egg was burnt-caramel brown, with the bloom still moist on the surface.  As it dried, the color lightened until it looked like beach sand.
     She hopped down from the box and headed for the watering can, taking in long draughts without stopping for air.  Laying chickens can drink up to two quarts of water a day.  Then she edged all the other chickens away from the tray of extra snacks I'd brought, and snooted around for cheese and sprouts.  She was hungry.  It takes about 3/4 cup of feed a day for a free-range chicken to make a single egg.
     I took the egg and brought it up to my cheek, marveling at the warmth and perfect smoothness of the shell.  It smelled clean and new, and I was grateful to have it in my palm.  Is it possible to feel close to a chicken?  Do the chickens know, or care?  Does it mean something, that we depend on one another?
     Walking back to the house under a gray sky, I wondered.
  
    
         

Who Are We?

     Have you ever thought about what it is your personality is based on?  Did you forge it yourself--that basis--or did you borrow it whole-hog without reservation or even the scantiest reflection, from something circulating in the culture--or, terrible to consider, from something on TV or the unending waves of advertising hype, the tidal flows of glossy, pretty, affecting, hollow imagery that just keep pouring over us, day after day, to give us the shoddy impression that our lives really are about something sort of important?
     Is your life about something sort of important?  Is mine?  Do our lives matter one bit in the grand scheme of this noisy, populated, free-floating, amoral era in which we are sharing, all of us together, in a manner of speaking, a version of community?
     For many of us our lives are mostly focused on what other people think of us.  We need admiration, or at least constant acceptance, and to get it we think we have to suppress aspects of our personalities that are kind of dark, dragon-like, hungry, ugly, sadistic, willing to tear one another apart for a bit of the flesh of the carrion that got left on the ground when some poor soul got ripped apart by the world and still had a little meat left on its bones.
     The problem with defining yourself by what other people think of you is that most people aren't thinking about you at all, ever, or about anyone for that matter--they're thinking about themselves and what other people think about them, in a strange, recursive, empty, falling-back-on-others way--or else they're not thinking at all.  They're punching words into their cell phones, or checking Facebook pages, or wondering what to buy next, what to eat next, what movie to see or song to download.  They're communicating to everyone they know, "I'm here!  I'm here!  And next, I'm going to be there!"  But there isn't any content beyond that, at least not much that I can see.
     What is your life about, really?  I am constantly asking this question of my patients in one way or another--who are you?  What exactly are you trying to do on earth, in your short life?  Because I can't really help you toward wellness without knowing what you're hoping to accomplish or understand, any more than I could gear you up for a trip without knowing your destination.
     There has to be, first, an assumption that you are part of a body-entire, the human race, and that your small actions or conscious refusals to act will have an effect on the configuration and lumbering progress of this big blob of humanity as it moves amoeba-like through the vastness of time.  So, the first thing I say to people, especially teenagers, who seem to believe they're tangential to humanity, is, You matter.  You matter more than you think.
     It's true, I'm sure of it.  Your thoughts matter, your dreams matter, your petty annoyances and preferences and hungers, pains, grief, hates and indifference matter.  They add salt, spice, and body to the human endeavor.  They have an effect on everything, and you need to be as aware as possible of this effect, because once you put it out there--and you can't not be putting something out there at all times--once you put it out there, you get little messages back, like notes in small cloudy beaten-up bottles washed up on the shore, often in the form of strange moods or cravings, or apathy, or in dream fragments that attach themselves like tiny snails to your wakefulness when you arise from bed and stumble creekily to the bathroom to wash up.
     It's your job to attend to these things, just as it's your job, and mine, to attend to the little symptoms that present themselves in the vehicle of your corporeal body, which is nothing more than a message-machine conveying to you information like a GPS as to your whereabouts and the likelihood that you will be here or there and possibly somewhere you don't want to be at all, like Siberia or the Mojave desert, if you don't change your course soon.  Because where you're headed has something to do, really, with where we're all headed.  So we have to help one another as much as we can.  We're all together in this, the project of being human, perhaps of showing God what it's like to be human.
     That's the other orientation I see most often.  If people aren't taking clues about who they are from their belief about what other people are thinking of them, they're using God as a reference point.  And I mean God with a capital "G," because for these people God is a real being with a name and an identity, and embodying a whole set of standards for how we ought to be behaving, standards that vary very little across denominations and are mostly about loving one another and giving back to the world and submitting to the supernumerary authority of the maker of the universe.
     It doesn't matter that these ideas are pretty old-fashioned, and completely out of line with the science and philosophy of modernity:  people live, at least from the standpoint of metaphysics, a couple hundred years behind the times.  We may just recently have absorbed most of Descartes, and all of Copernicus, for example.
     We are still a perplexingly religious tribe, with stragglers who call themselves atheists or new-agers and are undertaking to pull everyone else into the pioneer land of let's-fix-this-world-ourselves-and-stop-praying-to-god-for-miracles.
     Most people refer to the concept--or insistence of reality--of God as a way of declaring who they are, and what they are about.  They do get messages back--which is exactly what I exhort my patients to do--messages about whether they're on the right or wrong path, messages they perceive as coming from God, in answer to their prayers, or just gratuitous information from their higher power.  This is probably a good thing, which is why I'm not against religion, not at all.
     But I don't think you have to declare yourself a member of a religion, or a child of a particular God, to live a good, honest, self-appraising, consciously contributory life.  Those of us who adopt a conventional creed have to be careful, if we're going to be truly conscious, not to default to that faith's canned tenets every time something new and different challenges our sensibility.  And those who are just winging it have to avoid falling into the quagmire of advertising and gadgetry, cultural trends and news clips, easy answers and the rigidity of certainty--and all the propagandizing that keeps us sated as fat turkeys, and steals our souls, and turns us into ballast for a tyrannical government's ship, headed somewhere we really, really don't want to go.
      

Too Little, Too Late?

     New legislation may be in the works to curb Medicare's harassment of doctors.
     Sam Graves, a republican representative from Missouri, introduced legislation in October that may reform the rampant auditing of doctors by Medicare.
     The Medicare Audit Improvement Act of 2012 (House of Representatives 6575) would limit the amount of documentation Medicare can request before paying doctors for medical services.  If the Act is passed in Congress, Medicare would not be allowed to request records for more than 2% of all submitted charges in a prepayment audit, or 500 requests within any 45 days at a medical facility.
     It is unfortunate that this legislation, if passed, would take effect in January 2013--long after my clinic has had to produce copies of records in response to thousands of Medicare requests, and still had not received payment for most patient services.
    For twenty-one months Colasante Clinic has been subjected to a 100% prepayment review by Medicare--no 2% limit for me!-- including many requests for office notes that were confiscated by the FBI in its raid on my clinic, and essentially impossible to get back.
    True, the FBI has put in place a complicated process by which my staff are supposed to be able to request (and pay for) copies of our looted patient charts--sort of like paying ransom to get your kidnapped child back.  But the time limit imposed by Medicare for returning records is 30-45 days, and the FBI and prosecutor couldn't move that fast--especially since Medicare was demanding heaps and heaps of copies--not to mention that the degree of efficiency required in a solo clinic like mine precludes using staff for long periods of time to request and send copies of records.  We were strong-armed, in effect, into relinquishing payment for all those medical visits and services.
     Given how few services were paid by Medicare even after we sent copies of patient records to prove that we provided necessary services, it would have been a waste anyway.
     I guess I should have stopped seeing all Medicare patients forever, after the raid on my clinic.  But I kept assuming that Medicare's auditing professionals would see from all the records we did send, that we were providing necessary services and documenting adequately.  I forgot that Medicare, like other giant corporate-type enterprises with money as the bottom line, would train its auditors to use any means whatsoever to deny me payment.  Not only do they train them, they reward them with a percentage of the money taken back from doctors, or never paid at all.
     The Medicare Audit Improvement Act of 2012 would be step in the right direction for all of us.  I think it just might be the first piece of legislation to limit, rather than expand, the powers of Medicare.  It would penalize Medicare for making errors in payment as a result of faulty audits.  It would prevent the Medicare Secretary from conducting audits in the first place, unless there is evidence of a "widespread payment error rate"--which is set at 40%.
     Since Medicare's auditors seem to be trained to call just about anything in the chart note an "error," then as long as there is no clarity about how documentation errors are defined, Medicare's practice of badgering doctors like me is unlikely to end.  Moreover, Medicare will be able to publish on the internet the results of its audits, denials, and reviews--which could make doctors look like incompetent billers, or even thieves, when in fact the Medicare documentation guidelines themselves are so full of labyrinthine language and contradictions that writing a simple office note becomes a major effort, and is many times more complicated and fraught with risk than analyzing and diagnosing the sick patient about whom the note is being written in the first place.
   One part of the proposed legislation disallows nurses (like the Registered Nurse in my previous note) from issuing denials of payment for medical necessity, unless a physician reviews each denial as well, and signs it.
     It has been my experience that nurses--whatever their wonderful qualities--are not able to determine whether a medical service ordered by a physician is "necessary" or not.  Nurses simply are not trained to think in this way, and don't make decisions based on an understanding of pathophysiology.  Therefore, they are likely to deny payment for many services they can't fathom, especially if they are put in front of piles of documents at a Medicare office desk, and given bonuses for tabulating trivial reasons for not paying for services.
     Medicare's current "recovery program" is aligned to take back money from doctors and hospitals and put it into the depleted Medicare Trust Fund, without considering how this affects the way physicians care for patients, or the treatment of illness.  Physicians who perceive that they will not be paid for services, whether they consider them necessary or not, will simply not provide those services--to the patient's detriment.
     The American Hospital Association (AHA) issued a letter endorsing the proposed Medicare audit restrictions, and pointing out that physicians currently have no real appeal rights under the current system, nor do they have time or cash flow to hire lawyers to oppose the systematic take-backs by Medicare.  Every day I hear about one or two more physicians who have decided to drop Medicare altogether, because of the misguided recovery audit program.
     Vice President Rick Pollack of the AHA writes:  "[Medicare] recovery auditors are paid contingency fee payments, a potential conflict of interest, leading to concerns that they focus on claims and services that have the highest likelihood of error, in order to increase their fees.  Hospitals are experiencing a significant number of inappropriate denials amounting to hundreds of thousands of dollars in unjust recoupment payments for medically necessary care...and hospitals are then successfully overturning RAC denials 75 percent of the time."
     Hospitals may be able to finance disputes with Medicare over denials of payments, but solo doctors certainly can't do this.  Therefore, solo doctors give up that 75 percent (or more) of payments withheld by auditors for services the physicians must have considered necessary, or they wouldn't have ordered them.  These are funds that are unfairly returned to Medicare (if it was ever paid out at all), and become boast-money for the feds all the way up to the president:  Look how much money we took back from doctors and hospitals who were stealing from the American people.  It's an ugly lie that makes big government look good to people who don't know better.
     Pollack summarizes the problem we all face, by insisting that "medical auditors be kept out of medical decisions that should be between patients and their physicians."
     As things currently stand, Medicare auditors face no penalties at all for making mistakes when they deny payments to physicians, or when they say that a physician provided services that weren't "necessary."  In fact, the current auditing system encourages auditors to deny as many services as possible, by giving as a reward a percentage of the "savings" taken back from doctors.  This is a corrupt way to run a government program, it is grossly unfair to doctors, and it should be illegal.
     If the Medicare Audit Improvement Act is passed, auditors will face financial penalties for making errors, and physicians may have some of their due process rights restored, at least when it comes to the problem of infuriating Medicare payment denials.
  
        

Go to Hell, Medicare

     When Medicare has the barrel of a muzzle-loader aimed at your head, you've got to duck and hand over your wallet.  Or the keys to the whole store.  Either way, your life is messed up.
     But why does Medicare have a rifle pointed at me?
     I will probably never know.
     It's not enough to say, as a doctor--a perfect stranger--commenting about my blog, said:
     "A whistleblower reported you--and for nothing.  Why not?  There's no penalty.  Then, that gave Medicare carte blanche to stop paying you, and to 'take back' money in a maneuver one might consider sleight-of-hand except that it's completely legitimized within the system of rules invented by Medicare itself."
     That's not enough of an explanation, because we're a rational society, and we try to be fair.  Taking back money in this way is stealing.  A government that steals from its citizens is...well, committing suicide.
     I have initiated innumerable requests for information from Medicare, sending certified letters, making phone calls--curious, polite, insistent, or outright hostile (the clerks who answer never fail to maintain the exact same tepid tone, repeating their bromides robot-like, in a manner ingeniously designed to fuel homicidal rage in the inquirer)--sending faxes, recruiting my attorneys to make important get-something-done lawyer-phone calls, following Medicare's "procedures" for appealing unfair treatment.
     But there aren't any procedures.  The whole thing is a farce.  Medicare is an expert at avoidant behavior.  Medicare never answers questions outright.  It's criminal.
     Medicare is the criminal, not me.
     Yesterday I received, on my desk, a "response" from the despotic non-person we all refer to as Medicare--as though it really is someone, or something.  But Medicare is simply the stone-faced handmaiden for a rotten, bloated, self-important government.
     We are all participating--mostly in a passive way--in this government that is no longer of us, or for us, but acts against the interests of the people who pay for it--sometimes in vague or sidelong ways, at other times directly, with force, without defensible provocation, and causing nuclear-type destruction with fallout that is likely to take years to detect and measure.  The officials who administer government power seem to have separated themselves from the rest of us--as though they, with-incontestable clout,  applied when it suits them--are superior, constitutionally different, and entitled to everything we have, in fact, entitled to us, our very beings. 
     The aforementioned "response," was nothing more than a repetition of the same non-information Medicare sent before:  long lists of non-payments, supposedly for patients--whose names and other identifying information had been carefully eliminated from the document, and could, in fact, have been concocted by Medicare--with "explanations" (for not paying me) that were imprecise and speculative, but nonetheless immune to refutation:  "documentation insufficient, necessity of procedure uncertain, confusion about whether a shot should have been given or not, illegible signature, etc., etc."
     Needless to say, without the name of patients it was impossible for me to research each listed non-payment and send a rebuttal, in the form of proof that the procedure was necessary, and the documentation was sufficient.  (How much proof  is needed, anyway--for example, for flu shots, which we are instructed by Medicare to give its beneficiaries?  Sending documentation of each shot, along with the lot number and expiration date of the vial, and the patient, and the site, has not been enough--the hundreds of flu shots we gave last year have been denied for payment, repeatedly--therefore, I no longer purchase and give flue shots, which means my patients generally don't get them.  Now, isn't that saving a lot for Medicare?)
     The [bogus] explanatory letter stated, with no small grandeur, that a real, live Registered Nurse (capital letters used by Medicare, to underscore the impression of authority because such authority isn't real, and must be fabricated) reviewed the records we sent (thousands of pages, painstakingly copied by my staff and delivered, per Medicare rules, by snail mail--driven day after day to an official post office by my bookkeeper, who saves the receipts--records with handwriting documenting all the services we have provided over the past twenty-one months, during which scads of medical services were provided to fifteen-hundred-odd patients, services which often kept patients out of harm's way, or out of the hospital, services which, nevertheless, Medicare, in its great wisdom, has refused to pay for without "proof" that in fact I, a legitimate doctor, took care of actual patients who really wanted my help and needed the services I gave them)--this Registered Nurse, made the decision that my patient-care should be covered.
     Medicare's Registered Nurse instructed Medicare not to pay my office for 85% of my services, saying that in his/her opinion, those services weren't--weren't what?  
     I have no idea. I can't understand the cryptic messages encoded in thirty (?) pages of columns and not referable to any patients I know, which, as far as Medicare is concerned, makes it okay for this agency--which safeguards money my patients deposited over their working lives--not to pay me for the medical care my staff and I dispensed.
      Is it possible that the x-rays and EKG's and IV treatments for pneumonia, and last year's flu shots--were never done?  Or, at least in my office, are not justifiable?  Not documented clearly enough?  Were the patients not real?  Is my office not good enough?  Am I not a board-certified, licensed, credentialed, tax-paying, working physician?  
     Do I not exist??  What's going on, Medicare?  What do you think you're doing?
     Well, as it turns out, I can't argue with a Registered Nurse.  I'm not even allowed to know who it is.  And I can't fight with a motherboard.  There are no entry points in the armor Medicare uses to barricade itself from people like me, who want real answers in plain English.
     My patients, many of whom implore me--their long-time doctor--to stay in business, have no power, either--even though it's their money, contributed over their working lives, that Medicare is messing around with.
     Clearly, the decisions made between a doctor and patient about that patient's care are subordinate to the decisions made by a nurse in front of a computer in an office run on a nine-to-five schedule by Medicare.  Especially when Medicare's primary motive is not to pay.  It's going bankrupt, after all.  At least, that's what they say.
     Medicare, I'm kicking you out of my life.  You're a lying, cheating, embezzling monster.  I hope you fold up and die.
     To my patients, I say,  I can't take care of you as long as there's a muzzle-loader jammed up against  my brain.  I'm sorry.  I've tried, you know I have.