Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for May, 2010

Doctor, Cover Thine Own…

…well, you know.

It finally happened; I have finally made decisions that were based primarily on covering my own  ass.  One of these decisions was strategic, and the other one was directly related to the care of one particular patient. Let me explain.

The first decision, the strategic decision, had to do with performing consultations in the hospital setting. These have never been a whole lot of fun, and they have never been a terribly profitable venture from a business standpoint. But for many years I, and most other off ophthalmologists in my community, have performed hospital consultations at the request of both community primary care physicians and hospitalists, pretty much whenever we were asked. Almost none of these consultations was mandatory, an examination that absolutely had to occur during the time of hospitalization. Oddly enough, or perhaps not so oddly, a significant percentage of the patients for whom these consultations were performed were uninsured, way more than the likelihood of this occurring due to chance.

That was okay, though, for the longest of times. Everybody was doing it, performing these consultations, and those of us who did so received a kind of “good Samaritan” benefit of the doubt. You see, we do such extraordinarily good work as a specialty, and that work is so terribly dependent on very advanced technology including large, expensive, and mobile equipment, that every consultation that we performed in the hospital setting was a pale, inferior product in comparison to a consultation performed in our offices. As time has gone on my sense that I would continue to receive this “good Samaritan” dispensation has disappeared. I have  come to feel more and more vulnerable, more and more concerned that the inherent deficiencies of the hospital consultation in  ophthalmology make it more likely that I will miss something important despite my best efforts.

And so I am now declining to  accept hospital consultations except when I am obligated to do so as part of my turn covering the emergency room.

Now, you could accuse me of being selfish, of using everything above as a simple rationalization to stop doing something that is inconvenient and unprofitable. It’s ALWAYS been inconvenient and unprofitable! What has changed is that it now feels more dangerous to ME.

I’ve struggled with this decision, frankly. In the end, though, the decision to stop doing consultations in the hospital was actually rather easy because the quality of care that I was able to provide in that setting was so dramatically inferior to the quality of care that I have been able to provide in my offices. It was a different event, a different decision made in the context of caring for one, individual patient that has brought home just how pervasive this climate of fear in which all physicians live has become. Faced with the decision that hinged on my safety versus the convenience and care experience of one of my patients, THIS time I chose my own safety, and I made the decision in a nanosecond.

My patient was scheduled for cataract surgery on her left eye. During her prep in the pre-op holding area it became clear right away that she had prepared at home for surgery on her right eye, putting her preoperative eyedrops in the wrong eye despite our verbal and written instructions to the contrary. What  should we do, the nurses asked? Easy answer: cancel the case. But her son had to take off work, and another family member took off work to stay home with her this afternoon. Easy answer: cancel the case.

It wasn’t always this way. Years ago, in the early 90s, a patient prepped the wrong eye for glaucoma surgery. Knowing that I was planning on doing both eyes eventually I simply changed course, changed all the paperwork, and went ahead and did the eye that she had prepped. Things are different now, though. There is a paper thin line between “other eye” surgery and “wrong eye surgery”. Wrong eye surgery is a “never event”, one of those things that is simply inexcusable, and one of those things that various and sundry watchdogs are looking to find. Take a chance on some overzealous, faceless, nameless functionary, perhaps someone who has never been involved in the surgical process confusing “other eye” surgery with “wrong eye. surgery? Not a chance…cancel the case.

And that was that. For the first time in my career I had put my own ass ahead of the convenience and experience of my patient. I willingly and knowingly inconvenienced by patient and her family, even though the eventual plan was to remove both of her cataracts, because I was afraid to change the surgical plan at the last minute. Afraid that some red flag would be raised because I had changed the surgical site. Afraid to expose myself to those overzealous, nameless, faceless functionaries.

I covered my own ass!

Again, one could accuse me of being self-serving, self-righteous even. This was the first time that I had ever knowingly made this kind of decision, and frankly I can’t even remember a time when I made a similar decision for a similar reason. What was so extraordinary was how instantly I came to this conclusion, how quickly the words “cancel the case” came out of my mouth, and how completely comfortable I am with the decision. Me, the champion of patient-centered medicine, borderline obsessed with the crusade to bring the best customer – centered practices from the best consumer service industries to medical care. I instantly and knowingly put my own self protection ahead of the convenience and experience of my patient and her family.

To be honest, both the patient and her son were very understanding, and she has gone on to have very successful cataract surgery on the correct eye. No harm no foul, as the basketball great Bill Russell would put it. But that’s not really true, is it? An entire system is set up in such a way that my decision has become the  ONLY viable decision. Only the foolhardy, the reckless, or the naïve would do anything else. It’s a non-choice anymore. We physicians, descendents of those who willingly and knowingly walked among lepers and ENTERED plague-infested cities, fearless in our professional service, we have finally met our match. Terrified by those nameless, faceless, functionaries, cowed by those most definitely named, whose pictures grace the covers of our phone books, we are now left with but one  course of action.

Physician, cover thine own ass.

Random Thoughts 16 May 2010

Bob Ryan, the great Boston Globe sportswriter, is famous for a writing style in which he simply jots down short little “thoughlets”. He basically just throws out whatever’s on his mind, expanding on some thoughts, and just letting others dangle, tiny little flags sent up the flagpole. If you’ve ever read him, and if you pay attention, you notice that he occasionally revisits these “thoughtlets” with a much deeper examination.  This technique or style has been ripped off by countless other sportswriters, usually without attribution.

Over the course of my day-to-day life I find myself interested in countless little ideas, tiny thoughts, or random observations. Not all of them are worthy of the full attention of the “Restless Mind”, but I think a lot of them really  ARE interesting, and I really hate to lose  them. So I thought on occasion I, too, would steal this technique from Mr. Ryan, only I am going to openly acknowledge that it’s his, and openly thank him for giving me the idea. So, without further ado, here are some  random thoughts banging around between my ears…

1.)  Lacrosse.  I am absolutely up to my eyeballs in lacrosse this weekend, and loving every minute of it. My son Randy had a  game yesterday, and looking back I realized that I spent at least six hours in front of ESPNU watching NCAA lacrosse as well. It’s really a fantastic sport. I’m a little guy, and lacrosse would’ve been a great sport for me when I was younger. Unfortunately, I didn’t come upon lacroses until I was a high school junior, and I didn’t get a chance to actually play lacrosse until I was in college. I was a pretty typical football player turned lacrosse player — great wheels, no stick. I was a defensive midfielder before the position actually  existed. “Hey, Darrell, see that kid over there? Yeah, that one. The one who knows how to play lacrosse. Go beat the crap out of him and don’t let him score!” Yup, I was THAT guy.

When my oldest son, Danny, started playing in junior high school I rekindled my love for the game. I’ve been telling people for years that lacrosse is the perfect game for boys. You get to do everything your mother ever told you NOT to do: you get to run with a stick, and you get to HIT people with! Seriously, how good is THAT?! It’s funny, though, because it’s exactly this part of the sport that is putting this wonderful, lovely game at risk in our local public high school.

You see, our athletic director is concerned that lacrosse is inherently a dangerous sport. He’s concerned that the injury rate is, or will be, much higher than all other sports simply because it’s lacrosse. I don’t think that’s the case. As a matter of fact, after watching very high level lacrosse on television this weekend, I’m convinced it’s not the case. I say this after having watched my youngest son, Randy, get the snot beaten out of him in his last three games (Randy is an attackman who plays the “X.” position; he has the ball an awful lot making him an inviting target).

What the athletic director is actually seeing it is a rather unskilled version of the game. As such it’s really not any different from unskilled versions of any other contact sport. Who among us hasn’t seen an unskilled basketball team rough up the team made of five extremely skilled but rather slight hoopsters? Or the soccer team that consists of brutes, muscling their opponents off the ball? Or the classic example, the hockey team whose tactics consist largely of muggings on skates? No, it’s not the game. Lacrosse is no more or nor no less injury-prone than any other contact sport.

It’s really quite beautiful, and I have to make sure our athletic director realizes this.

2.)  Women’s lacrosse. If you love men’s lacrosse you’ve probably watched a game or two of women’s lacrosse. While I write this I’m watching the Virginia women beat Towson State in a playoff game. They have lacrosse sticks, they shoot at 6′ x 6′ goals, and the ball spends an awful lot of time in the air being passed from player to player. The similarities seem to end there, though. It’s a totally different game!

I’m I’m reminded of watching my sister play field hockey in high school. Man, talk about a game with lots and lots of rules, totally impenetrable to all but the chosen few who have been initiated in some secret athletic rite. I could never figure out why any whistle was blown in field hockey, and I have to confess that I’m just as bewildered watching women’s lacrosse. The women are very fast, clearly elite athletes, and they’re certainly holding lacrosse sticks and shooting at lacrosse goals.

I hope I figure out women’s lacrosse in less time than it took me to figure out field hockey!

3.) There was a  very insightful article, an interview of the great economist Gary Becker in the Wall Street Journal couple of weeks ago. Becker touched on all kinds of topics, and spent a little bit of time on one that’s very close to my world, namely healthcare economics. He’s a little frustrated, heck were ALL a little frustrated by the willful obfuscation foisted upon the great unwashed mass of humanity that doesn’t work inside the Washington DC beltway when it comes to health care economics.

A case in point is the effect of out-of-pocket expenses on the overall amount of money that is spent on healthcare in any given country. In the United States we presently spend about 17% of our GDP on healthcare. Out-of-pocket expenses make up only about 12% of total health-care spending. In Switzerland, however, a country widely acclaimed for a very effective health care system, and equally acclaimed for spending only 11% of GDP on healthcare, the Swiss have out-of-pocket expenses equal to about 31% of total spending.

Swiss consumers of medical care are assumed to  have the ability to make complex medical decisions on their own behalf. Do you think maybe, just MAYBE there is a correlation here? Do you think that perhaps the fact that Swiss patients individually own 31% of the skin in the game has anything to do with driving overall healthcare costs lower? That perhaps the fact that every healthcare transaction is roughly 1/3 the responsibility of a patient, thereby involving every single patient in the financial aspects of every single health care decision, might be in part responsible for a lower percentage of the GDP being spent on healthcare?

Nah. Couldn’t be that.

4.)  Aches and pains. My partner Greg Kaye turned 41 years old this week. Greg actually handled the “turning 41″ part much better than I did 50, only finding it difficult over the last month or so. Greg is also a former athlete, just a little less  ”former” then yours truly. But Greg has struggled over the last month or so because of a couple of nagging injuries which have limited his athletic exploits, and consequently reminded him that he is no longer 21.

I’ve got pretty much the same chronic infirmities that I’ve had for several years. I’ve made my peace with them, at least I think I have. The difference for me now is that every time something new crops up I’m having a hard time putting aside the thought that it’s not just a little niggling effect of being 50 years old, but that it might actually be something serious. I’m starting to see friends, and friends of friends die. Some of them are dying from common things, and some of them are dying from relatively uncommon, weird things. I have a little bruise on my trachea right now. In all likelihood that’s all it is. The good news: I probably won’t put a tie on for a week or so. The bad news: until I put a tie back on I’m going to be wondering.

We used to call this “medical students disease”, the phenomenon where every medical student came down with whatever disease we happen to be studying at the time. I apparently was never cured of “medical students disease”!

How Doctors (Don’t) Get Paid

I got a bill the other day for care that was provided to a member of my family. The care was provided at one of the huge behemoths here in Cleveland. Now, this was just an office visit, not anything exotic like a fancy test or some new surgical procedure. And yet, there it was, at the bottom of the billing statement: “facility charge”. I knew it would be there, but still seeing it made me chuckle. “Facility charge.” What a great gig! Not only do you get to charge for the professional services provided, but you get to put a separate fee to cover your overhead on the bill! Dude, where can I sign up?

Well, that’s just the point. I CAN’T sign up for that cruise. You see, I’m a physician in private practice. You know, old-time medicine. The doctor owns his own business, pays the rent, makes payroll every two weeks. If something breaks he or she writes a check. Exactly like the pediatrician when you were a kid who gave you that scratch on your shoulder when it was time for your polio vaccination. No “facility charge” associated with that visit! Nope, Just a few dollars passing between your mom and the lady manning the front desk. You never really thought about what happened to those few dollars, of course. Heck, you were only seven! Your mom never really thought about it either.

Until recently the vast  majority of medical care provided in the United States, at least care that came from physicians, was provided at the hands of private practitioners like me and like that pediatrician you saw with your snotty nose as a kid. Contrary to the wishes of countless faceless bureaucrats in Washington, a significant percentage of care continues to be provided in exactly the same way. Even in very large, institutional medical groups a “facility charge” is nothing but a happy fantasy. The money that your insurance company pays to your doctor does NOT go into your doctor’s checking account until all of the bills are paid

This is why the proposed 21% cut in physician’s fees for the care of Medicare patients is so much bigger than even 21%. This is also why it’s so difficult for patients who are covered by Medicaid to find a doctor. The notion that somehow increasing the Medicaid rolls, taking people off of the uninsured list and placing them on the bigger list of people whose medical care might be covered by Medicaid, is such a farce. People who have Medicaid now have enormous difficulties getting access to the care that they need. What makes those same faceless bureaucrats think that they have made any headway increasing access to medical care by putting more people on Medicaid? Doctors and most hospitals avoid seeing patients on Medicaid, just as they will avoid seeing patients on Medicare if that 21% cut goes through, because they DON’T GET PAID.

Well, how about technology? Is it possible to increase the efficiency of doctors working in their offices with the use of new technology? Efficiency, yes. Efficiency while making sure that our doctors get paid, no.A USA Today article looking at the daily workload of primary care doctors found an average of 55 services performed each day in a 4  doctor group that went unpaid. Services like answering phone calls and refilling prescriptions, reviewing lab reports or consultation reports, or interacting with patients by e-mail.  On the face of it,  increased access to your doctor through alternate venues, something different than coming in to the office where the bricks and mortar have to be paid for makes sense. It makes sense, that is, if the doctor gets paid for it!

Why should you care if your doctor gets paid? I mean, didn’t President Obama point out how much pediatricians get paid for taking out a  patient’s tonsils (read that carefully)? Wasn’t it some huge number that made no sense? Aren’t we supposed to be moving toward a system where doctors are paid a salary, where there’s no incentive to order extra tests or do extra procedures since we know that doctors are incapable of separating their own economic interest from the best interests of the patients in 2010? You know, like World Class Hospital, repeatedly beatified by both the President and those same nameless, faceless bureaucrats in Washington, held aloft as the shining beacon of hope, the one true path to higher quality care at lower cost.

Funny, that. The World Class Hospital is actually an extremely good example of both the best and the worst of where healthcare economics has been and where it might yet go. The World Class Hospital is enormously successful financially because it has mastered the arcane business of doing as much as possible for each patient within the rules of the billing game. There would also be that “facility charge” thing where the bricks and mortar are covered by a surcharge. Although the doctors at the World Class Hospital do indeed work for a “salary”, in many cases that salary is tied directly to not only their own personal production, but also to the amount of money that is generated at the institution as a secondary effect of their labors. Human nature being what it is this produces two very different types of behavior on the part of doctors at the World Class Hospital, and indeed doctors everywhere who are paid like this. While there is still upside, room to do more work and thereby prove that a doctor should be paid more, the doctors are always available. Ready to work. Access to these doctors is rarely a problem.

Unfortunately, the opposite also occurs. Once a certain salary level has been reached many doctors simply slow down. It’s a funny quirk in the system, salaries are rarely if ever decreased. Why work harder if there is neither incentive to do so, nor disincentive not to? The best example I’ve seen recently is a group of general surgeons formerly in private practice who sold their group to the World Class Hospital. This group used to be noted in the community, especially among primary care doctors, for the amazing availability of the surgeons. Whenever a patient needed surgery, or whenever a patient needed a surgical consult, one of these doctors was ALWAYS available. Now? Not so much. 9-to-5, Monday through Friday. Why? Well, they don’t get paid for all of that availability anymore.

It’s a funny thing, money as an incentive. It’s an even funnier thing, how forgetful everyone becomes about money as an incentive when it comes to paying doctors. The mantra from Washington regarding “health care reform” has been the fantasy of better care and greater access at a lower cost. Doctors  to work harder, work longer, and be available to all of us whenever we need them.  We want this as we walk around with “alligator arms”, unable and unwilling to reach for our checkbooks, appalled by a $15.00 co-pay, insulted that there might be some service or care that’s NOT COVERED BY INSURANCE. More and more for less and less… who wouldn’t want that?  I do wonder, though, what the reaction would be if all doctors handed their patient an itemized “bill”   detailing what happens to that egregious $15 co-pay. At last count in our office? Exactly $3.00 to me.

You know, come to think of it, I got paid pretty well in the year 2000. I think I’d be okay with my 2000 salary; you can even keep the 1% pay raise. I’d be willing to work for my year 2000 salary, maybe with a little cost-of-living raise, you know, like the one those nameless, faceless Washington bureaucrats get every year. I’d even be willing to work the way I’ve always worked, available pretty much 24 – 7, 365. How would I do that, you wonder?

Well, let’s talk about that “facility charge”…

Mirrors, Ski Trips, and Soul Patches

Who do you see when you look in the mirror? When it’s just you and the mirror, and no one else, whose gaze do you meet coming from the mirror? Each one of us travels the highway of life cloaked in various masks and disguises, ever more complex shields between  what others see of us, and what we see when we stand alone, bared, in front of the mirror. Do you ever do this? Stand in front of the mirror stripped bare of all artifice, neither masked nor cloaked? What do you see? Who looks back?

It’s funny; whenever it’s me doing the looking the guy who looks back always has a soul patch!

So much of our lives are spent creating the image seen by others. What does Mommy want me to do? What would Daddy think of this? It starts very early, you know. We don’t even know we’re doing it. We get better and better at it once we leave the house, perhaps to a friend’s house to play, but certainly when we first enter school. We learned that a certain pose, a certain way of speaking, indeed the very way we stand elicits a response from the person standing opposite us. In a way, that person is another kind of mirror, except that this mirror shows us the effect of our “makeup”, our masks, our armor.

Who among us hasn’t experienced the intense, deep, boring pain that comes from sharing some deep confidence with a friend only to have that friend break our trust and share whatever that confidence was with someone else. We see a part of our true selves reflected in that circulating confidence; it’s always a painful experience, isn’t it? The lesson here is that baring the reflection of our true self can be painful. And so, we don’t.

Moving on we project for a purpose. Meeting our college roommate for the first time, that first job interview, lunch with the boss’s boss. What’s in the “mirror” is really more of a projection of someone sitting next to you or standing in front of you, and less a projection of you, who you really are. There’s nothing wrong or bad here — we simply do what we need to do. But in doing so we often drive that pure reflection of who we really are deeper and deeper, further and further from whom we appear to be.

Many of us sneak a little bit of self into the public projection, almost like an inside joke which is hidden from almost everyone. Maybe it’s a tiny tattoo on the inside of your ankle or that third hole in your year which you only fill for “outside consumption” in the most comforting and welcome circumstances. Nobody can see your tattoo, and nobody knows what type of the earring fills that hole, but YOU do. For me it’s a soul patch.

Now my wife, the single most important person in my life bar none, HATES my soul patch. Hates every version that I might dream up. Hates it long and dark; hates it short, neat, and trimmed. I had a mustache and a goatee around the time of my 40th birthday (no issues turning 40, mind you) and frankly I thought I looked pretty darn cool! It worked for little while, until that is it started to get gray. My lovely daughter, Megan, asked me to shave it as a Sweet 16th birthday gift to her and POOF, away it went. But every now and then the soul patch reappeared, tolerated for progressively shorter periods of time and always wiped clean at the behest of my beautiful bride. Except when I looked in the mirror, when it was just me and who I really think “me” is. I always see the soul patch.

If you do spend some time in front of a mirror and if you do open your eyes enough to take in that true image of who you really are the next thing you realize is how very rare are the occasions when the person who shows up is that reflection in the mirror. They are almost “never” events. When they happen, and when you all of a sudden realize that THIS event is one of those times, it can be almost magical. Think about it. You’re in a place and you’re with people and it’s so comfortable that the person YOU see in the mirror, the person you think you really are, is the exact person who shows up. And that version of you stays! You’re in a place it with people who know you, the exact version of you that looks back from the mere when you allow yourself to see who you really are.

It almost never happens, and the few times that it does create memories that are like monuments. Your own “Mount Rushmore” event. You return to those memories, you return to those events as  if they were touchstones, little shortcuts to who you really are. I had one in my 40s that is so meaningful that I can remember all of the details as if I just came home. My friends Bruce and Kathy invited Beth and me and three other couples to be their guests for an “adults only” ski trip. We spent five days in Telluride; Beth was injured and she didn’t even ski. Every minute that I was there I was exactly the man who stares back at me from the mirror. It doesn’t always turn out this way, but for me it was an extremely positive experience. I really liked the guy walking around in my clothes, and everyone else seemed pretty good with him, too. For five days the guy who looks back at me from the mirror when I’m looking at the guy I really think I am and I were one and the same.

It hasn’t really happened like that since then. Oh sure, there are little snippets here and there. A date with Beth, an hour in the office, a morning session at a Crossfit certification was my son Randy. But nothing like five days. Yet, when I’m there in front of the mirror, just me and the Darrell I think I am, it’s still the guy who spent five days in Telluride with friends new and old, all of whom saw the same person I see in the mirror.

So who are YOU when you look in the mirror and the person you really think you are is standing right there in front of you? Do you do this? Shorn of all disguises, all masks, all forms of armor and defense, who looks back at you when you are looking… for you? What do you look like? Who do you see?

I always see a soul patch…

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