PING

“Arlington Ford, can I help you?”

Customer – “The motor in my car is going Ping, Ping, Ping.  Can you tell me what’s wrong with it and what I can do to stop it?”

“Of course, we can.  Why don’t you make an appointment and we’ll have one of our mechanics look into it.”

Customer – “Can I talk to the mechanic?  I’m sure it’s nothing and he’ll be able to tell me what to do.”

“Our mechanics are all working on cars right now.  I’ll set up an appointment for you.”

Customer – “Can you have a mechanic call me on his break?  It will only take a minute.  I can’t come in.  My insurance only covers collision, I can’t take off any time from work, and I can’t afford to pay you.  I want to know if I can fix it.  Please have a mechanic call me.”

“I’ll have one of our service managers call you later today.”

Service Manager – “Mr. Ping, it’s really difficult to tell you what is pinging without checking over the car.”

Customer – “If you’ll just stay on the line, I’ll walk out to the car and turn it on.  You can listen over the phone.”

Service Manager – “Mr. Ping… walking sounds, door opening, car starting…Mr. Ping, I can’t hear anything and I have to help other customers.  I’ll put you through to the appointment desk, please hold.”

Customer – “You guys are all the same.  You just want me to come in so you can run a bunch of unnecessary tests and charge me a fortune!  I’ll drive down to the auto parts store and see if they can tell me want to do!”

Substitute doc for service manager and patient for customer and you have a true-life picture of an average day in the life of a doctor.  Just as listening to a ping over the phone is essentially worthless to a mechanic, trying to accurately diagnose an illness over the phone is as, well.  The difference is the mechanic who gives advise over the phone is not likely to make a fatal mistake.

If your body is pinging, bring it to a qualified doc.  Invest the time and money necessary to keep your body safe and healthy.

NEW YEAR, NEW RULES

“Medicare for all,” who are they kidding.  The medical world will never be free from the profit mongering insurance industry.  Upset about the cost of medical care?  Take one look at the profit statement of any health insurance company or Pharmacy Benefits Manager and you’ll realize where the real money is!  

For one moment, look beyond the insurer’s bottom line profit and look at their gross income.  Realize that there are thousands of people making billions of dollars running one of the largest bureaucracies in the world.  Now, add to those numbers the added overhead your doc shoulders in coders, billing staff, and time spent in prior authorization activities and you’ll realize why we have the most expensive medical system in the world. We also have the insurance industry feeding money into almost all of the political campaigns, assuring the continued control over healthcare in the US.

So, when I tell you I’m angry, you shouldn’t be surprised.  What you might find surprising, is why I’m angry today.  I’ve accepted the fact that my profession has been kidnapped by terrorist in the guise of insurers and Medicare.  I’ve accepted that we will forever be enslaved by those who steal our precious healthcare dollars all the while blaming the cost on those greedy, inefficient docs.  What I can’t accept is the human suffering caused by the insurer’s quest for ever growing profits.

With the New Year comes new formularies. Major Pharmacy Benefits managers (another name for insurer) will decide to take product number one off formulary and replace it with product number 2. All patients covered by their organization will be forced to change medications as of January first.  If my patient refuses to abandon the treatment that has worked well for him/her over the years, he/she will be forced to pay an exorbitant fee to continue on your current medication.

Why force a large number of patients to abandon their previously successful treatment and take a chance on getting ill?  PROFIT, pure and simple!  The insurer has found a way to cut its expense and is willing to potentially sacrifice the health of its customers for a larger profit margin! 

Unfortunately, patients will need to see their docs before starting on their new medicine and may well need to have multiple visits to the doc’s office before they are stable on their new medication.  Some will not do well on their new medication and some may even end up in the hospital.  

The pity of the matter is that to increase the Pharmacy Benefits Manager’s (PBM) profit, both the patient and the health insurance company that covers the patient’s office visits will be forced to incur the added expense associated with the medication change.

It’s utter madness!  We should all be sick of it!  Unfortunately, there is not much we can do about it and, next year, the PBM’s formulary is likely to change again.

MUSINGS OF A FAMILY DOC

I wrote this article in 2013.  I never reach my goal of practicing Free Medicine and I’m sure FM will never come into existent.  The medical profession cannot be resuscitated.  “AI” (artificial intelligence) is the way of the future and the texting generations will accept it fully.

Unfortunately. They will never establish a Doctor/Patient relationship. “ AI” will take into account many factors when prescribing a treatment course.  You can be sure number one on the list will be a cost benefit ratio.  “AI” will follow protocols and protocols will be created and run by its masters, the insurance industry and government.!

October 23, 2013

When I grow up, I want to practice “Free Medicine!”  You may be asking yourself, “What is free medicine?  Does he mean he wants to run a free clinic or give out free pills?”  “Free Medicine (FM)” is a concept I just created in response to a comment from a reader on yesterday’s article.  My reader is a brilliant doc, educator and writer who serves both as mentor and colleague.

Dr M’s comment pointed out the fact that primary care docs are already a medical bargain.  While the world clamors over the ever-rising cost of medical care, Dr. M reminded me that the cost of seeing a primary care doc is miniscule in comparison to the cost of chemotherapy, surgery or going to the Emergency Room.

“Free Medicine” is an old idea whose time has come.  FM means being able to practice medicine as it was meant to be practiced, unencumbered by governmental and insurer rules and regulations.  Yes, I dream of being able to provide the individualized care my patients both need and deserve without artificial constraints, prior authorizations, codes, etc.  

FM means the ability to shelter my patients’ most private problems from the intrusion of modern-day medicine’s fixation on sharing virtually everything with insurers, government workers and statisticians.  While their intent may be laudable, the information amassed in “The Cloud” may be used to destroy the very health we are pledged to preserve (witness the anxiety and depression of those whose data was recently stolen from a large hospital chain).

FM opens a physician’s mind, allowing him/her to be creative in coming up with difficult to make diagnoses and treatment plans.  “Best Practices” close the physicians mind, stressing compliance with “established” protocols.  Heed my warning, cookbook medicine, better known as evidenced based medicine, has infested my profession and stolen our freedom to think and act as highly educated professionals.

“Free Medicine” means being a DOCTOR, not a provider, gatekeeper or service technician.  FM means working for you, my patient; not corporate America.  Yes, I dream of being free.  I also have nightmares.  In my nightmare, I am being sucked into a huge vortex, falling uncontrollably into the world of ACO bondage.  I know there has to be a way out:  I just can’t see it!  Finally, it’s there; the door to freedom opens.

What is cost of freedom?  What’s it worth to you?  Will you be sucked into a world where your healthcare is provided in accordance with protocols created by insurers and Medicare or will you break free?  Will I survive long enough to find my door to freedom?  I pray so!

My door to freedom lies in cutting the tether that binds me to the accursed computer and its EMR.  Breaking off from Medicare and insurers and starting a fee for service/cash only practice of medicine is freedom.  Once again, proudly hanging out my shingle and opening my door to all that would want to come in, all that cherish their freedom, is freedom.

Primary care accounts for a miniscule amount of the cost of medicine in this country.  If we were free from filing insurance and Medicare claims and free from coding and accumulating meaningless reams of data, we primary care docs could reduce our fees and do what we love best:  care for you, the patient, who places your life in our hands.

Yes, I dream of the day I am part of the “Free Medicine” movement.  The question is, will you join me?  I can’t do it unless you think freedom is worth paying for.  I cannot exit the vortex and leave all those souls I am currently responsible for to be sucked into the depths of illness without me.  I am truly torn! Captains are supposed to go down with their ship, aren’t they?  

“Attention on deck.  The ship is sinking!  All hands man the lifeboats!”

NEED?

Over the last 30 years, I have been privileged to care for many children.  Some of those children I delivered; others came into my practice at various stages of their lives.  It has been my privilege to care for the children of those children.  During my 30 year tenure, I have witnessed many trends, some transitory some not, some good, some not.  Of all the trends, the worst I have seen is that the children in my community seem to be growing needier.

This trend to “need” more is not a surprise.  Parents have always worked to give their children more than they had.  T.V. commercials play on “need” to sell their goods.  Your teeth are not white enough.  Your hair is not lustrous enough. You need a new phone, car, T.V., and you definitely need to “Go to Jareds!”  

The problem is needy people feel bad.  Some even take their own lives.  This community has witnessed too many suicides.  It is time to declare “NEED” as one of those dirty four-letter words and ban its use.  Every time our children say “Mom, I need  …” we have to reorient them and proclaim that they “WANT …” instead.  Needs are food, clothing, a roof over your head, love of a parent and an education.  The rest are “WANTS”.  It is OK to want something.  You can work for what you want.  It is not OK to be needy.

There is one more “NEED” that I want to talk about.  We need to be thankful for what we have.  Many of us take our house, car, food and all the rest for granted.  After all, everyone has those things.  We “need” to go back to those days when dinner conversations started with what we were thankful for rather than what we “need”.

EXPECTATIONS

I just read an article about expectations in medicine.  Expectations can make or break a relationship.  They can be the source of great excitement and joy or of great disappointment and sadness.  Expectations, in medicine need to be clearly defined and, when possible, successfully met.

Several years ago, I did a full physical on a new patient.  Patient “X” had been referred to me by a mutual friend and I did my usual, thorough job.  I was dismayed when my friend called me to report how disappointed patient “X” had been!

I called patient “X” to discuss the results of his exam and why he felt I did a “crappy” job.  Mr. “X” started with, “Doc, I like you, but you did not do/order a stress test, Carotid Doppler, lung function test, PSA or colonoscopy.  I went to Dr. “Y” and he ordered them for me!”  To Mr. “X’s” surprise, I asked him why he thought he needed those tests.  Mr. “X” responded, “My partners’ docs ordered those tests.”

In retrospect, the problem was obvious.  Mr. “X” had expectations I did not meet.  I had expectations, as well.  My expectation was that Mr. “X” wanted a thorough, customized physical.  “Mr. “X”, I’m sorry you were unhappy.  Let me venture a guess:  your partners are all in their mid-sixties.”  His answer was “yes”.  “Mr. “X”, had you been in your sixties, I would have ordered those tests and perhaps more.  You are 41 years old and, with your personal and family history, as well as excellent physical condition, I did not feel you warranted any of those tests.”

Mr. “X” cancelled all of his tests and sees me yearly for his exam.  I learned a valuable lesson.  My patients’ expectations may not match mine.  Setting realistic expectations are an important part of any doctor-patient relationship.  Patients must recognize that doctors have expectations and doctors must realize that patients have their own, distinct expectations.

Expectations can range from fantasy to reality.  In the medical arena, it is crucial that expectations be founded in reality.  As your doc, I expect you to follow my instructions.  I expect that, if you are going to vary from my instructions, you will let me know.  These are realistic expectations.  

An example of false or unrealistic expectations would be if you were 75 pounds overweight, drank a bottle of wine and six cocktails, and smoked two packs a day; and I expected you to lose your excess weight while giving up smoking and alcohol simultaneously within 6 months.  (I would give the above patient at least 6 1/2 months). 

Sometimes I set unrealistic expectations for myself and my patients.  When the stakes are high enough, you do what you have to do in order to survive.  Unrealistic expectations can be met when truly necessary!

Patients often set unrealistic expectations.  The most common example of an unrealistic expectation is when the patient, mentioned above, expects his doc to cure his cough, repair his damaged liver, and save him from the heart attack he is about to have.  Doctors don’t heal patients; they help patients heal themselves.  Expecting your doc to save you from a sinking ship while you are punching holes in the hull is another example of false expectations.

So, what can you do?  Discuss your expectations with your doc.  Let him/her know exactly what you want; what you are thinking.  Be sure of what your doc expects of you.  Expect that your doc will work your expectations.  If he/she falls short, discuss it with him.  Work at meeting your doc’s expectation.  Expect that your doc will confront your shortcomings, as well.  Most of all, be honest with yourself and your doctor.

P.S. – I believe in miracles.  I have been blessed to see many miracles in the last 40 years of practice.  It is ok to have false or “fantasy” expectations, as long as you know that the only way they will come true is to receive a miracle.  It is not OK to sell yourself on false hope as the vast majority of time it will end in disaster.  

WORK TO BE HAPPY

Ever noticed that being happy can be hard work?  I have.  For the most part, my patients are hardworking individuals and lead blessed lives.  Most of them have jobs, homes, family, and food on their tables.  Their Blessing Lists are full!

So why do they have to work so hard to be happy?  There are lots of reasons to be unhappy.  Sometimes, my patients are unhappy because they or their spouse are married to their jobs and not their families. I addressed this issue in “Another Kind of Affair”.

Sometimes, they are unhappy because they don’t have “enough.”  Did I tell you the story about the identical twins that lived identical lives and had identical fortunes?  One of the twins had “everything” and was a happy man; the other had “enough” and was not happy!  It’s often a matter of attitude.  Even though the twin with “enough” had the same things his brother with “everything” had, he wanted more.  What he was missing was an attitude of gratitude for what he had!

Sometimes, life is going fine and illness strikes you or a loved one.  When illness strikes, you really have to work hard to maintain any degree of happiness!  When I lay out my “Wellthy” lifestyle plan for a patient, I ask him to establish five retirement funds:   a financial fund, a physical fund, a nutritional fund, an emotional fund, and a spiritual fund.  I tell him that, to be truly “Wellthy,” he needs to make deposits in each of these funds on a regular basis.  I warn him that putting off deposits in any of these funds could spell catastrophe.

When illness suddenly strikes you or a loved one, the deposits you’ve made in your emotional and spiritual funds will provide the assets you need to draw on to maintain “happy.”  Remembering the good times spent rather than regretting time wasted is essential.  In “Don’t Delay the Happy,” I wrote, “sometimes there are no more ‘one day.”  Enjoying every day and saving memories will help you get through those days where no amount of work will maintain your “happy.”

I often tell my patients that “spirituality” is the glue that holds a “wellthy” account together.  According to Wikipedia, spirituality can be defined as “an inner path enabling a person to discover the essence of his/her being; or the “deepest values and meanings by which people live.”[2] Spiritual practices, including meditationprayer, and contemplation, are intended to develop an individual’s inner life.”  It’s that inner life and the understanding of the essence of his/her being, that will help sustain your “Wellthy” plan through sickness and loss. 

Yes, being happy often takes work.  As in any endeavor, having a game plan helps.  Make your Blessings List and read it night and day.  Make sure those you love know you love them.  Invest in your “Wellthy” accounts on a regular basis.  And, most of all, don’t delay the happy!   

ANOTHER TYPE OF AN AFFAIR

Is your loved one having an affair?  No, not a sexual affair with another human.  I’m referring to an affair with his job!  Yes, some people are bigamists, married to their jobs and their spouses.  Is your spouse married to his work?

A work affair can be worse than a physical entanglement with another human.  It can be harder to break up with work than with a human lover.  An affair with your job can be just as destructive to your marriage and can cost you your life.

Not long ago, I saw a leader of American industry whose job took precedence over all else.  Being responsible for a Fortune 500 company’s success is an awesome responsibility.  The company demands constant attention, nurturing and stroking the company’s growth. Responding to changing needs.  Being a successful corporate leader requires long hours, travel, business meals, and more, leaving no time for self and family.

As in any affair, denial plays a major role.  The unfaithful spouse will deny any impropriety, claiming that his/her long hours at work are spent on behalf of his family!  He/she claims that he/she works long hours in order to provide financial security for his/her family.   He/she claims that, one day, he/she will retire and enjoy his/her family and life.

As a patient, the office bigamist often neglects his health, skipping appointments, running out of medicine, and complaining that there is never time for exercise.  Certainly, business lunches and dinner are not amenable to proper eating habits.

Diets and Other Unnatural Acts was partially inspired by just such a corporate giant.  Being married to your business may provide for financial success and security, but money without health and family is worthless.  Carl was living proof.

Are you married to your work?  Is your work an abusive spouse?  Does it demand so much of you that there is no time to take care of yourself or others?  Or are you a stress junky?  A success junky? 

Sometimes business demands are not the problem.  Sometimes the personal need for success creates stresses that are self-imposed.  I’ve written about the two brothers, one whose has “everything” and the other who has “enough.”  Both brothers have identical assets, the difference is perspective.

Whether you are a work bigamist or a stress/success junky, it’s time to change your perspective!  Money without health is worthless.  Over the last 30 years, I have seen many patients sacrifice their health and family relationships in the name of making a living.  I have seen many spouses cheat on their loved ones by marrying their businesses.  In every case, the only thing the family ever wanted was time with their father/mother/spouse.

Success in your job is important.  Success as a spouse and family man/woman is more important.  They need not be exclusive of one another.  Make your health and your family your primary responsibility.  They will be with you long after your business is gone.  Don’t wait until your health fails or your family is irreversibly estranged.  Remember, the life you save may be your own and that life is important to others.

GLASS VS. BRASS

Yesterday, I published Jugglers and Midlife Crisis.  I often use the analogy of juggling when dealing with the assorted problems my patients have.  I was explaining my concept to a patient, explaining that I envision us as professional jugglers, constantly tossing balls into the air and catching them.  Each ball represents a part of our lives and those of others.  Yes, others toss us balls to juggle, as well.  Some of us don’t know how to say no and end up juggling both their own problems, as well of those of many others (a topic for a future article).

Some of us are better than others at juggling the day to day tasks we all face and how well we juggle those tasks directly relates to the level of stress we experience.  Using my model, I ask my patients to name each ball they are juggling (and who owns them) and then take them out of the air, one by one, placing them on the table.  By doing this exercise, patients can then organize their problems into groups and then slowly reduce the tasks they are juggling by removing those they can’t deal with, working with smaller groups, and finally finish their tasks in a more reasonable manner.

The patient referenced above was a teacher and life coach.  She was familiar with my approach and took the time to share her version of juggling with me.  I want to share it with you, as it is excellent.  She told me that there are two basic forms of balls we all deal with:  one set are made of glass, the other is made from brass.

Glass balls are fragile, and, if you drop them, they shatter into a million pieces.  They cannot be repaired. Glass balls relate to health, family, and friends.  Brass balls are all the others.  If you drop a brass ball, you can always pick it up.  It may be marred or dented but can be repaired or replaced.

So, when you are hard at work juggling all the problems and tasks you have to deal with every day, remember which are made of glass and handle them with care.  In a pinch, let the brass balls fall to the ground.  Catch and cradle the glass ones until they are safely put away, then go back and clean up the mess.

JUGGLERS

We are all jugglers. At every age and stage of life, we juggle from the time we get up to the time we go to sleep. Some of us are really proficient at juggling, others struggle. Often, the young juggler finds the act of juggling entertaining, even exhilarating. As time passes and life becomes more complex, juggling becomes stressful. By now, you are probably confused, wondering where I’m going and if you should close out of this blog. Stay for a minute more. 

We juggle personal, family, work and social issues. Think of each task you have to do today as a baton in the air. When you catch it, you need to finish it so you can catch the next one. In your early life, you have just a few batons in the air. In time, you add new ones. So, your wife asks you to buy play tickets. You finally have a chance to do so. You have that baton in hand when your boss comes in and tells you he needs those figures he asked for yesterday, right now. So, you toss the play tickets in the air and catch your boss’s baton. You start churning out the needed figures when your mother calls; her computer is broken. You catch that baton and toss it in the air with the one labeled play tickets. The baton the IRS tossed you last month won’t leave you alone. You’ll tackle it later; so, for the time being, you keep catching and tossing it back into the air. In time you have so many batons in the air, that as soon as you catch one, you have to toss it back for fear of dropping the next one.

Boom, you dropped one and it shatters. Boom, boom, boom, you drop more. Welcome to a midlife crisis. When you are juggling so many items that you can’t possibly keep them in the air, you crash and so do those around you. I treated midlife crisis all too often. Sometimes my fed up, overwhelmed patient simply quits juggling, turns and walks away (or gets admitted to the hospital). ALL, THE BATONS COME CRASHING DOWN AT ONCE! IT’S A DISASTER! Family, friends and work suffer simultaneously. Other times my patient manages to safely deposit enough items on the floor to maintain some semblance of life and tries to rebuild.

So, what can we jugglers do? One recipe for success looks like this:

  1. On a regular basis, everyone should take a break from juggling. 
  • Put each baton carefully down on the table and step back. 
  • Analyze what is on the table. 
  • Get three boxes and label them past, present and future. 
  • Sort the batons in to three piles: those that you can do nothing with; those that need immediate attention; and those that you can’t do anything with but will need to be handled in the future. 
  • Fill the boxes. 
  • Only juggle the items in the current box. 

Too often, my patients have old items (guilt, regrets, hurts) in the air, catching and tossing them to no avail. Getting them out of the air and into the past box is a big relief. Putting them away frees up time to work on the current box.

Often, my patients are tossing and catching items that are coming up at some time in the future (jury duty, a visit from the dreaded in-laws, colonoscopy). They cannot do anything with those items now, but they can’t quite let them go either. Putting them in the future box frees up time to work on current items. 

With added time and less batons in the air, you can get proficient at finishing and throwing away those items that need present time attention. As you deal more efficiently with the present box, you’ll find time to go into the future box, remove and finish those items and avoid that dreaded midlife crisis. When you are really doing well, empty the items in the past box into the waste basket.

What if the above recipe doesn’t work? That’s when you turn to counseling, family and community. A skilled counselor will help you safely get the batons out of the air. The counselor will help you sort each item and move it to a place of safety for future action. Perhaps you need to toss a few items to your family and your community. Perhaps you need to say NO to those who are tossing their batons to you. There are many ways to avoid the crisis. Whatever you do, just don’t quit and walk away!

I TOLD YOU SO

When is it ok to say, “I told you so”? Most of us suppress the urge to say, “I told you so” while trying not to make a friend or relative feel worse than they already do. After all, saying “I told you so” really doesn’t accomplish anything. Or does it? 

Does being right feel good? Most of the time, it feels great to be right. An “I told you so” loudly declares, “I was right!” I guess the polite thing to do is to feel good inside but, outwardly, be sympathetic. 

In my profession, I would rather be wrong about a great deal of things than be right and have to suppress my “I told you so.” Confusing, isn’t it? Let me explain. 

Mrs. “S” has smoked 2 packs per day for the 28 years I’ve known her. For many of those years, I’ve warned her that the price she would pay for smoking would be a life of misery. She ignored me. She felt fine. Her usual refrain was “I have a friend who is 95 and smokes three packs of Camels a day and he is fine. You, docs, just hate cigarettes.” 

Mrs. “S’s” was in the office the other day. She is recovering from pneumonia and can’t understand why she can’t breathe. She is using maximum doses of her albuterol, Spireva, and Advair and just can’t catch her breath. She wants me to do something. Her docs aren’t helping her and she wants me to speak to them. She feels horrible. Brushing her teeth is a chore. 

While Mrs. “S” lungs were marginal before she got pneumonia, she still had enough lung capacity to function. The pneumonia finished the destruction of her lungs she began 50 years ago. Mrs. “S” is out of lung and is going to be oxygen dependent for the rest of her life. Her lifestyle is changing rapidly. She is angry and demands “fix me!” Unfortunately, no one can. 

Sure, I will send Mrs. “S” to another pulmonologist. He will do a full battery of pulmonary function tests and diagnose her with end stage lung disease. He will start oxygen, maybe add pulmonary physical therapy, and switch her meds around. That’s what specialists do. Unfortunately, he has little to offer. Verifying the diagnosis will only serve to reinforce how bad her situation is. 

Mrs. “S” will become sedentary. She still insists she is cutting down on cigarettes and is only smoking 3 a day. I explained that “only three a day” is like saying “I only plunge the knife in my chest three times a day”. Why hassle her now, after all, her lungs are shot! The answer is easy. Oxygen is flammable. 

Mrs. “S’s” heart is strong. Her brain is sharp. She will probably have a long time to regret smoking. She may well end up in a hospital bed and then a nursing home before her life ends. Her treatments will be expensive. Medicare will pick up much of the bill. Eventually, her treatments will exhaust the nest egg she and her husband accumulated. Mr. “S” will become her caregiver. They will apply for Medicaid. 

Even a self-righteous “I told you so” couldn’t make me feel better. I would rather that I had been wrong about her smoking. I would have rather her be able to say, “See, doc, I’m 100 years old, still smoking and still breathing on my own.” That would have been great. Instead, I get to watch a 70-year-old struggle to find her next breath. 

Are you still smoking?