Corporate Medicine Kills Continuity of Care: It's All Just Business Now

For decades, one of the prime driving principles of medical care was the "physician-patient relationship."  And as part of this the idea that "continuity of care" is an essential feature of good medical care was unquestioned. 

Making sure the patient established a relationship with a doctor, who came to know her well, to follow her over years, who learned her way of expressing herself, who remembered what had happened to her in the past all seemed obvious advantages over a system in which the patient had to be "learned" by a new doctor with every visit. 

The difference between getting care at an Emergency Room or a "Doc-in-the-box" was continuity of care. In a brief visit, the physician does not have time to know all about the patient; he is solving a single problem and moving on. Hopefully, if there are underlying conditions or existing medications which might affect the choice of therapy, the new physician can catch that.

With the advent of the Electronic Medical Record, it was hoped that the whole sweep of the patient's history and medications would be available on line to any doctor, and so that information residing in the memory  of an individual physician would no longer be necessary. 

The problem is, the EMR has not lived up to expectations. The boilerplate format defeats any attempt to encapsulate medical history and medication lists are rarely updated and become massive and lose their usefulness. 

But the idea among medical administrators has become "Oh, none of these doctors stays for more than 3 years, so what difference does it make?"

Of course, the reason doctors who are corporate employees are moving is the first contract they get, typically for 2 years is the best they will ever see, so at the end of that period, their pay is cut, their workload increased and they start looking for another job and they are gone by year 3. 

From the administrator's point of view, their MBA programs taught them to look at doctors as if they are simply workers on an assembly line making widgets, so having to replace them is not a failing on the part of management. Doctors do not have to be "retrained" beyond getting them accustomed to a new EMR.

When the Portsmouth Hospital lost six specialty practices over the past year, the offices in the doctor's office building across the street from the hospital emptied out and the administrator who presided over all this was not perturbed. Sure, there was no longer neurology for the stroke patients, pulmonary for the asthmatics and emphysema patients, endocrinology for the diabetics, but there was also no longer all that rent for office space, or salaries for office staff and for doctors. Overhead fell dramatically. The balance sheet looked good.

The balance sheet for the hospital however, did not look quite so good--all those doctors "fed" the hospital, so in financial terms the hospital took a huge hit.  

And of course, what the MBA's did not understand was that losing all those specialists meant the patients got little or no care for those problems, which is to say, patient care suffered. But who has good metrics for "quality of care?"

The CEO of the hospital lost her job, but the administrator of the doctors' practices across the street got congratulated and got a promotion.

The fact is, continuity of care may not be as essential as we once thought it was. It certainly makes the patient feel happier, but sometimes having a new doctor every 3 years means the patient gets reassessed and things which are not working get questioned and improved. 

And patients do vote with their feet.  The rise of nurses doing Minute Medicine in pharmacies, of Walk In clinics where you need no appointment and can just show up when you find it most convenient and the ongoing use of Emergency Rooms by people who have a cough for three weeks or who need a blood pressure medication renewed or who have been having headaches and vomiting for two months but just haven't found a doctor all suggest people do not value that idea of good ol' Doc Brown, who knows me and who took care of all my family. They just want a prescription or a pain reliever, simple transaction with an anonymous provider. Don't give me something complicated; just give me a shot of something to make me feel good.

Who knows? Maybe this brave new world of corporate medicine, in which every patient is simply a customer and every practice a cost center really is more efficient.  Maybe the old one on one doctor/patient relationship is as outdated as making shoes by hand for each customer.  Maybe medicine will benefit from assembly line medicine.

Otter Time in Hampton

One of my friends lives on Viking Drive, in Hampton, and her back yard runs down to the stream that flows through the salt marshes.  Every year the otters come in to whelp their pups. 

Do you have a mother?  

These are "charismatic mammals." The National Oceanographic and Atomosheric Administration actually has a division called, "Charismatic Mammals" which I know about because one of my friends was a lawyer in that section. She had to deal with laws which concerned these mammals.  

Whenever you want to change the direction of an argument about the environment, global warming and ecology, and you are running up against the hard nosed businessmen who are talking about costs and money, all you have to do is trot out a few photos of these mammals in front of an auditorium of citizens and the mammals win.

"Oh," my lawyer friend says.  "We are not above pushing some emotional buttons, when we are facing off against industry. They have the money, but we have the otters, and the seals and the polar bears."  She laughs. "They really hate public hearings, the industry guys."

This emotional side of human beings can lead to some very bad places, but in the case of charismatic mammals, I think such pitches appeal to our better angels.

Lost In New Hampshire

Plaice Cove, Hampton

On the road, riding my new "fat tire" bicycle, I climbed the precipitous Nason Road, named after a man who raised a regiment from Hampton, New Hampshire, to fight in the Civil War.  I crossed Drinkwater Road and pedaled along Nason until the road ended in an unmarked road. Unmarked roads are the norm in this part of New Hampshire, where the natives seem to spurn the custom and practice of naming any road with a sign. I long ago concluded Granite Staters simply believe is you don't know where you are, you don't belong here.

Granite State, Not for Nothing

I turned right, which I took to be north and west, knowing the ocean is to my back, and found myself riding along a road in Hampton Falls, which is gorgeous, lined with fences to keep the horses in place.  The houses here are large, pristine and there are Trump signs.  

Kensington, N.H.

Finally, I passed a house with a Bernie sign and I stopped to ask the lady raking her lawn behind it if I could take a picture. 

"Sure," she said. "Why?"
"I just wanted to show my friends in Hampton there's a Bernie sign in Hampton Falls," I said. 
"Actually," she said. "You're in Kensington."
"I'm always lost in New Hampshire," I told her.
"Isn't everyone?" she replied and returned to raking.

Hampton Falls, NH, with goats

Down the road I ran into Route 108, which I knew would take me to Exeter.  

Passing by the athletic complex of Phillips Exeter Academy, I notice the new excavation for a Dance and Theater Center. The academy has an endowment of over 1 billion dollars.  Its campus is far more splendid than my college had.  It's a Disneyland sort of campus, with red brick buildings garnished with windows with white sills.  But I can never shake the idea that the students come here to live at age 14.  Leaving home at age 18 was pretty wrenching. I moved into my dorm and looked around and realized I was now 500 miles from home, and knew nobody.  Well, not exactly nobody. Two other kids from my high school came up to this college, but I didn't know either very well.  And, in those days there were no cell phones or Skype. A long distance phone call was expensive and we wrote letters then. But, even with Skype, leaving home must be a big deal, at age 14.

Hampton, NH 

Do these kids feel lost?

Continuing along Rte 27, which runs all the way back to the ocean, I reached Hampton and was struck by the trees.  During the winter you hardly notice them. But now they are coming into bloom. 

leafing up

The neighborhoods are modest here, but the trees are anything but.  They are bursting with bloom, proclaiming their wealth of blossom and leafiness. 

cedar shingles and gables

It was not a hard winter, but Spring in New Hampshire feels like a reward, earned or not.  The air is crisp and you feel lucky just to live here. 

Rte 27

Not Taking It Anymore: Banderillas Phone Trees

Why are you getting so worked up?

My office staff did an intervention on me the other day. 

It all exploded when a clerk on the other end of the phone asked me for my NPI number, which, of course, I have never memorized.   They could hear me shouting at this woman down the hall and they came down, three of them, to tell me the patients in the waiting room could hear me and it was disturbing everyone and they were never going to get me a caffeinated Cappacino at Dunkin Donuts again because they were sure it was the caffeine which had set me off.

It wasn't the caffeine.

It started with a "prior authorization" which is permission  the insurance company gives you to order a test or a drug for a patient which is not automatically approved. For some things, you have to speak with some 18 year old clerk in Oklahoma City who is sitting in front of his computer with two buttons to push, "No" or "Yes."

This time, my assistant had run interference and she had been given the telephone number of an actual, bone fide physician at the insurance company who would discuss with me the reasons for this test. I expected this to be very short conversation, since the test was a no brainer: If the test proved negative, the patient would not have to undergo surgery, thus saving the insurance company a bundle; if it was positive, the surgeon could plan for a more extensive surgery than if he did not know it was positive, in which case he would have to go in once to make the diagnosis and return a second time, with a second general anesthesia for the patient, for the definitive procedure.

I had set aside 15 minutes for this phone call, between patients. 

I dialed the number and got a phone tree: First you listen to a list of possible reasons the insurance company says you might have called. Press one if you want to do this in English. Then, if you are a patient calling about an emergency, hang up and dial 911.  Then, if you are a patient, press 1 if this is about a bill you have received; press 2 if this is about a bill you expect to receive; press 3 if this is about a bill which you have lost; press 4 if you live in Massachusetts; press 5 if you are not an American citizen; press 6 if you want to kill the governor. And so on.  

Fortunately, I had the option of pressing a number on my dial or speaking, so I just kept saying "Representative" and eventually the automatic voice said, "Did you say 'representative'?"

Five minutes deep into this I finally got a human being who asks me why I am bothering her and taxing the insurance's company's budget by insisting on speaking with a human being. I explain I have been given the name of a doctor, Dr. Whosit, and this number, and I am a physician calling about getting a "prior auth."

"Oh, that's a peer-to-peer."
"Whatever you want to call it. I want to speak with the doctor."
"I'll need your NPI number."
"Why?"
"Because I cannot forward your call without your NPI number."
"But why? You know who I am because you gave me this number and I know the name of the doctor I'm supposed to talk to and I can give you my address and office number and you can call me back there if you want to verify.  What gives you the right to ask for my NPI number?"
"You don't know your NPI number do you doctor?"
"No. But that's not the point. The point is you could ask for my DEA number or my social security number or my password, and none of it is necessary and I draw the line at these stupid rules which do not protect anyone."

It went on like that for a while, which is when my office staff came in, three women and did the intervention.

"You have to be nicer," they told me.

Press 4 if you want to stomp the phone

But I was like the bull in the arena. You know, they open the door and the bull runs out to face the bull fighter, but some bulls are not inclined to fight, so they have these banderillos guys who run up and stick metal tipped sticks called banderillas into the bull. Then there's a guy on a horse, I think he's the picador, who rides up and sticks the bull with a lance. So there is a long build up, during which they harass the bull and taunt the bull until he's so mad that when the guy with the red cape steps into the ring, the bull charges. 

Bad Temper from Bad Treatment 

Those banderillas  they stick in, that is what that voice tree on the telephone is. And the woman with the demand for the NPI number is the picador. 

Spare me that. 

Animal Intelligence

My wife talks to our dog.  I realize there's nothing unusual in that. Many people talk to their dogs. But I have heard my wife talking to our children, from infancy to adulthood, and she talks to the dog exactly the same way. When he was a puppy she started with single words, progressing to simple sentences as he grew and now that he's in middle age, age 6, she speaks to him in complex constructions, paragraphs. 

"You know," I remind her, "He is never going to reply."
She is not discouraged; she continues to talk to him, asks his opinions about contestants on "The Voice" or "Dancing with the Stars." He maintains a studied neutrality and has never endorsed anyone, which she takes as a great sign of his intelligence and discretion. He does watch the screen with an avidly which almost matches her own.

He is, in fact, quite reticent, even for a dog. He hardly ever barks. For years we thought he was mute, which concerned us because we thought he might be deaf mute, which could be a problem. But no, he barks on rare occasion, when some dog provokes him. Usually it's a dog, and often a fairly inoffensive dog, he simply takes a disliking to, for reasons he keeps to himself. Then he growls and barks and strains at the leash. But we can count on both hands the number of times that has happened. He's a pretty silent dog.

But this is not about our dog. It's about the two books reviewed in last week's New York Times Book Review about animal intelligence. 

Frans de Waal recounts a story about apes who were set up with a table and tea set at the London zoo and they "quickly mastered the teacups and teapot too. They sat there civilly, having tea."   I'm not sure I can believe this, but if they did, it is astonishing.    He claims this tableau of apes sitting around drinking teas like human beings so disturbed the human beings, they taught the apes to smash things up, the "reckless collision of beasts and high culture."  The apes had to be taught to be stupid, so as not to disturb human visitors to the zoo.

DeWaal compares primate intelligence to our own with a story about a psychologist who remarked, "It is inconceivable that you would ever see two chimpanzees carrying a log together."  But then he relates a story about 25 apes who worked together to prop up a tree trunk against the wall of their enclosure at a Dutch zoo and raided the restaurant next door.

Intelligence, of course, has less to do with being like human beings and more to do with how an animal can understand and exploit its environment. So a squirrel is not stupid because it does not count or multiply or do calculus. The squirrel's life is about remembering where it stored its nuts and apparently squirrels can do this better than most human beings, who cannot remember where they left their keys.

Human beings have been remarkably stupid when trying to assess animal intelligence: Researchers noted that apes seem to have poor memory for faces, but they were testing apes with human faces.  When they finally thought to test apes with ape faces, the apes did quite well. Human investigators evaluated  elephants for their ability to recognize themselves in a mirror but they gave the elephants human, not elephant sized mirrors, and the elephants  "failed" to recognized themselves.

The other book, by Jennifer Ackerman, "The Genius of Birds" relates a story about birds on an island without predators. Freed from the fear of cats or other birds of prey, they had time to experiment and master the use of a wide variety of tools.  She notes how birds  can fly in a flock of 400, changing direction without saying a word, "almost instantaneous ripples of movement in what appears to be one living curtain of bird."  How often have I seen this and never thought about the intelligence involved in all that?  Fish do it, too. You just see it and smile, but someone wonders: "How do they know?" Not to mention birds' capacity to navigate, and to find their way across a continent when I find it difficult, sometimes, finding Massachusetts.

Some great souls seem to appreciate all this in a way which eludes me:  Up the street a pair of birds built a nest in the Spring wreath on my neighbor's door. She promptly went on the internet and identified the birds as wrens or finches or whatever and discovered the parents are likely to abandon the nest if threatened, so she has not used her door and postponed the spring power washing of her home.  Of course, the wrens or whatever they are would never go on the internet to identify the owner of this house, but they had to good sense to choose the one woman in Hampton who would nurture them and take steps to keep them from harm.

 This is the same wonderful woman who hears local coyotes howling at night and promptly grabs a flash light and goes out for a walk, in hopes of seeing them, over the objections of her husband and children.  She attends coyote lectures whenever they are given locally (more and more lately since coyotes have moved in.)  She does not yet have chickens, or goats, but when the topic comes up at the local Democrats society meetings, she grows suspiciously quiet and follows every word of the discussion. It can't be long now.

So there are human beings out there, who appreciate animals, on some level.

In college, I had a summer job at the National Institutes of Health, which was supposed to look good on my application for medical school.  I spent the summer assisting at surgeries on rats, placing catheters in their livers to study the biochemistry of liver glucose production; we also implanted electrical monitoring devices into the brains of possums and toads to study sleep in "lower" species. I was not convinced then and am not now convinced that any of those animals gave their lives for a worthy cause. The dogs who gave their lives so Banting and Best could discover insulin died so others might live, much as soldiers landing on the beaches at Normandy, but most of the casualties I saw in the NIH labs were simply cruel and wasteful. The human beings studying those animals had designed experiments, which on their best days could not have been worth the sacrifice.  Those animals died so careers could advance, not so that science could advance.

I held a fish I caught in my hand once, and after agonizing, smashed it on the head with a rock and felt it die.  I was fishing on a Vanderbilt estate, of all places, invited by a member of that family who was married to a dean of my medical school.  We were fishing for dinner and the Vanderbilt gutted and prepared the fish. Of course, she had a lodge where the walls were lined with animal heads shot by her forebears, so gutting the fish did not bother her, and it was, or should have been delicious. I ate it but did not enjoy it. That fish had wriggled and struggled to be free and wanted to live and I killed it.  I still eat fish other people catch.  Salmon, mostly. Salmon are suicidal fish. They swim upstream, mate, turn belly up. Or maybe a bear gets them as they flop around in shallow water. I have no qualms about salmon.

But once, a huge, beautiful tuna washed up on Plaice Cove beach.  My dog saw it from the entrance near the parking lot and dragged me all the way to the far end of the beach, near the flag pole, which marks the border with the North Hampton part of the beach and he sniffed the tuna curiously. The dog had never met a tuna before and the beach walking regulars, some of whom have walked that beach for decades,  averred they have seen seals and all sorts of sea life wash up, but never an eight hundred pound tuna.  

I don't eat tuna any more. They are too magnificent.

John Snow Instructs

The Phantom has only had general anesthesia once, an experience millions across this country and around the world have had. Asking those who have had it, the Phantom has been repeatedly astonished how little it has seemed to have affected them. 

Most say, "Oh, I just wanted to be knocked out when they were doing whatever they were doing." For most, there  was the sense of relief at not having felt pain or fear during their surgical procedures. 

For the Phantom it was a profound existential experience. "Existential" is one of those words like "brilliant" or "awesome" which has been used to death, used up into meaninglessness.  The way "existential"  is used currently is to imply "significant" or profound, as in the Republican party is having an existential crisis, or a baseball team's season is starting poorly and they have to make an existential choice about trading for a new pitcher.   But for the Phantom it goes back to Sartre and Camus who were talking about the meaning of life, of being and nothingness.  For the existentialists the only meaning in life comes  from acts we each do to give our lives meaning. There is not meaning bestowed by God or any greater being. We live our lives, take action or fail to and then it's over: Poof. Nothingness.
We do something, make choices without asking what God wants us to do, or what Jesus would do, without reference to any higher power. We are simply in the position of the man who thinks he should dive into the river to save the child not because God is watching but because he must do it if nobody is watching, to live with his own judgement of himself.

When John Snow is brought back from dead by the Red Lady, Melisandre, people want to know what death was like.  Were there the dozen virgins, pearly gates, clouds and idyllic vistas?

No, John tells them. There was nothing. Simply nothing.

And that's exactly what I experienced under anesthesia: A big blank. Nothingness. One moment I have feelings, sensations, memory, fear, then...nothing.

I found that profoundly disturbing. Where had "I" been?  

Only one other time had that ever happened, when I was knocked unconscious in an auto accident, but when I came to, when consciousness returned there was a lot going and I didn't have time to reflect on it. 

After anesthesia I kept wondering and wonder to this day where I was. Which makes you wonder what consciousness is, having experienced the opposite. 

Where was I, for that matter, before I was born?

I did love the scene of John's resurrection:  You see his body there and his faithful dog lying beside him, and you just know the first creature to realize what's going on would be the one creature who never leaves his side: his dog. That seemed right.

And, of course it was a woman, the Red Woman, Melisandre who brings him back.  Last we saw her, she had aged before our eyes from the fetching woman into an old woman, with withered thighs, breasts, skin, hair in one of the most horrifying scenes in cinematic history. It was all the argument one needs to see aging as something pretty bleak and pathological. We can talk about teleomeres on the ends of chromosomes, ribosomes, epigenetics, but it comes down to horror until we understand more.

I'm not sure nothingness is horror, but it sure does impose a certain meaning on life--once you believe there is nothing after this life, you can never live life the same way.

Scarlet Letter and Jail Time for Women Having Abortions

The Phantom has to admit: He has not recently, if ever, considered whether it makes sense to punish a doctor who performs an abortion without also punishing the woman, who is, after all, if abortion is a crime, at least an accomplice.

If a woman  solicits a hit man to kill her husband, she is guilty of murder. Just ask Pam Smart.  So, if a woman solicits a doctor to "kill" her "baby" is she not complicit?

(All this sets aside whether or not abortion ought to be considered a crime.)

When faced with this question, the Donald shrugged and said, "Sure." 

Now he has reconsidered, apparently. Or, at least, he has elaborated.

He was asking me a theoretical, or just a question in theory, and I talked about it only from that standpoint. Of course not. And that was done, he said, you know, I guess it was theoretically, but he was asking me a rhetorical question, and I gave an answer. And by the way, people thought from an academic standpoint, and asked rhetorically, people said that answer was an unbelievable academic answer. But of course not, and I said that afterwards. Everybody understands that. 

If this doesn't clear things up, well then, I don't know what will.

After 8 years of President Barack Obama, who answers every question as if it is an invitation to a doctoral thesis, it is so refreshing to get a straightforward, no nonsense answer from his successor.