The Descent

cliffsIt haunted him, without mercy.

Strong, athletic, handsome, and personable, he seemed at life’s outset to be unfairly advantaged. His friends were many; a ladies man, by reputation, the life of every party, the love of every woman who gazed on him.

He was, by nature, a generous and gentle soul, a gift he received from his parents, humble and devout. He himself found religion attractive, and attended synagogue regularly with them. He had little use for the priests and the lawyers––he found them legalistic, arrogant, and judgmental––but embodied in his faith he discovered a formula for living: obey the law of God, and your life will be healthy and prosperous. Did not the Proverbs promise, “By humility and fear of the Lord are riches, and honor, and length of days”? He would do his part, and God His, and all would be well in life.

The climb had been arduous. Stronger and more agile than his friends, he had reached the top of the cliffs before them. His best friend, struggling behind him, lost his footing, and he reached back to save him from falling. His friend was saved — and his own life changed forever.

When he came to, he felt no pain — in fact, no sensation whatsoever. He heard the shouts and the dislodged rocks of his friends scrambling down the cliff; he tried to get up, but could not. He had survived the fall — and lived to wish he had not.

Weeks and months passed, with no improvement; his paralyzed body remained lifeless, though his mind, now a tortured prisoner, remained fully alive. Most of his friends drifted away, their discomfort in his presence so palpable that their absence was more relief than regret. The Four remained, though he saw no reason for them to do so, other than guilt, or some pathetic sense of charity to the crippled. His limbs withered and shriveled, twisted like the branches of those ancient trees on the cliffs. Racked by fevers, festering pressure sores, and wallowing in the excrement he could no longer control, he no longer had a life, but only a slow, agonizing, and hopeless descent toward death.

The Four visited him daily, alone, in pairs, and on occasion collectively. They cleaned him, tended his wounds, and tried to encourage him in his deepening depression, to no avail. As shriveled and twisted as his body had become, his soul became far more foul and fetid in its unquenched and raging bitterness. Self-pity, self-loathing, and a hopeless despondency descended upon him, crushing and torturing his spirit in a personal living hell. His friends prayed, read Scripture, and feigned faith in some deliverance of spirit, if not body; this only increased his cynicism and the sputtering rage he spewed toward God. How could a good God allow such an evil fate? Had he not kept his part of the bargain, only to be betrayed by a deity he had once trusted? Why did his friends torment him with this utter nonsense?

Then there was the humiliation he suffered at the hands of healers, who prayed and pranced and called down Heaven’s power to heal him; he had too little faith, they accused, when their futile foolishness failed. In this, they were most surely correct. Then, the day his friends dragged him to the Temple, to the priests, as Moses had prescribed. His bondage arose from hidden sin, they said: his own, or his parents. What sin was this, he challenged? The sin of saving a friend’s life? His parents had more righteousness in their little fingers than these prattling and pretentious fools — where was their repentance? The self-righteous religious cast him out of the Temple, and the long journey home was silent, and awkward, and hopeless.

The crowds were immense, if the stories be true — this charlatan must have some slick magic up his sleeve, and there was no shortage of gullible fools in the world to follow along. His angry protests were to no avail — must he go through this humiliation once again? — as the Four lifted him onto the cart and began the dusty and agonizing ride to ridicule. See the Master? Not even close — they could barely see the house for the mob. The Four muscled their way through the grumbling crowd, and ignoring the shouting owner, climbing a fig tree by the house. Before he could protest yet again, they lifted him onto the roof, nearly dropping him in the process — what a fitting and ironic end to his pathetic life that would be! Now what? They began to claw at the straw and tiles; curses arose from below as mud and straw and shards of clay tumbled onto upturned faces. Then they lowered him into the darkness.

He saw their eyes first: seated above the crowd, dressed in fine linen robes, their phylacteries glittering with fiery jewels, their eyes blazing with hatred and contempt seemingly from the very depths of Sheol. Then, turning, he saw at last the healer’s eyes: strong, kind, penetrating to the depths of his spirit. To see them was to gaze into eternity, and see its joy. He felt utterly naked — but not ashamed.

He smiled: “Son, your sins are forgiven.”

There was no challenge this time — he knew the sins of which the healer spoke: bitterness, unforgiveness, cynicism, ingratitude, the hatred of God, of life, the despair over lost promise and shattered hopes. There befell then a lightness, an extraordinary peace, the lifting of a burden far heavier than that his friends had borne in bringing him here. A smile crossed his face, for the first time in many years: could this be joy?

Amazed at his inner awakening, he failed to hear the gasps, to notice the stunned silence of the once-noisy crowd. There was only the angry, strident whispers, hushed at first, then ever more intense, like the growl of a ravenous predator: Blasphemy. Blasphemy! BLASPHEMY!

He looked back at the healer: there was no fear, no anger; naught but an enormous strength, his eyes afire with the conviction of truth. “That you may know that the Son of Man has the power on earth to forgive sins…” He looked directly into his eyes: “Arise, pick up your mat, and walk.” It was far more invitation than command.

It lasted but an instant, but seemed an eternity. Great warmth seared through his withered flesh. Tendons tight as iron loosened and stretched; his shriveled muscles softened and fleshed out; his papyrus-thin skin pinked and plumped into a vibrant glow. He sat up — before realizing he could not do so. Swinging his legs free, he stood — he stood!! — bent over, and rolled up his mat.

The crowd gasped, and cried, and praised God; he heard none of it, not even the joyful shouts of his friends on the roof. As he bounded out the door, every hand reached out to touch him, as if he, the healed, had the power of the healer. As the sounds of the crowds faded into the distance, he touched his newborn limbs, still stunned in disbelief about what had just happened.

There was much work to do; relationships to repair, amends to make, and the endless telling of his story to the amazement of all who would listen. He followed the Master throughout Galilee wherever he preached. Sitting among the thousands, he nevertheless saw Jesus look directly at him each time, and smile. It seemed as though the Master had even more joy at the healing of his crippled heart than he himself did — and his own was indescribable.

Many months after his healing, he wandered again into the desert, alone. The storm clouds were gathering: the hatred he had seen in the eyes of the religious leaders was ever more intense, and he sensed something dark and foreboding ahead in his Master’s mission. His own journey led him back to the cliffs, where his life had changed forever. His eyes gazed upward at their great height, then slowly descended to the rocks of brokenness below. He recalled his Master’s words, spoken so prophetically: “Greater love than this no man has, than to lay down his life for his friends.”

And finally, at long last, he understood.

In the Doldrums

Down dropt the breeze, the sails dropt down,
‘Twas sad as sad could be ;
And we did speak only to break
The silence of the sea !

All in a hot and copper sky,
The bloody Sun, at noon,
Right up above the mast did stand,
No bigger than the Moon.

Day after day, day after day,
We stuck, nor breath nor motion ;
As idle as a painted ship
Upon a painted ocean…

Her lips were red, her looks were free,
Her locks were yellow as gold :
Her skin was as white as leprosy,
The Night-mare LIFE-IN-DEATH was she,
Who thicks man’s blood with cold.

The doldrums.

Samuel Taylor Coleridge, in his epic poem Rime of the Ancient Mariner, depicts the dread of all ancient sailors: becalmed, abandoned by nature and fate, powerless to move forward and at the mercy of vast forces and spirits beyond their control.

In some measure, these have been days much like that. The past few months have been some of the most difficult of my professional career. There has been a sense of fatigue, of purposelessness, of weariness with the routine and the rush, the frustrations and failures inevitable in any life pursuit, but perhaps nowhere more so than in the practice of medicine.

It is a high calling, this profession — words which, while true, seem fatuous and hackneyed in an age marked by hard science and even harder cynicism. It is a vocation fraught with paradoxes and contradictions: compassion and cold steel; empathy and enervation; arrogance and humiliation; deep satisfaction and bone-wrenching sadness. Its rewards, while rich, seemingly come at the cost of your very life, as the slow extravasation from countless battle wounds weaken the spirit and shock the soul, sapping your strength, leaving but an empty, fractured vessel, gloriously engraved on the outside but pervious and parched within.

It is no one thing, this weariness, but a score.

It is the two hours spent filling out a mandatory online recredentialing form for an insurance company, insisting on intrusive and irrelevant information (“What is the mailing address and contact phone number of your high school (required)?”) so that their marketing department can claim they only use the “finest” physicians.

It is the three hours spent dictating charts after a 10-hour office, missing no detail that might lead to an insurance denial, a government audit, or a later lawsuit — and knowing you will be back before sunrise to finish those charts you no longer have the mental or physical energy to complete.

It is the mandate to comply with the endless and every-engulfing tsunami of government compliance regulations, demanding coding quality assurance, privacy protection, identity fraud, or pay-for-performance “programs” which would overwhelm entire QA departments at Lockheed-Martin or Raytheon, but which you are expected to implement, by yourself, for free, in your spare time.

It is the countless hats you wear every day: employer; small business owner; conflict resolution manager; IT consultant; accountant; complaint department clerk; therapist; social worker.

It is the garrulous patient who talks endlessly but never answers your questions, while you run ninety minutes behind schedule; the sullen patient who refuses to fill out your history form or answer your questions, demanding you “get that information from my other doctors”; the demented patient from the nursing home with no records, accompanied by an aide who knows nothing about her or why she is here; the angry patient who blames you for their disease, refuses to follow your advice, and who is certain that you are only seeing his sorry ass to make a buck off him; the uninsured patient who needs major surgery or expensive medications but has no way to afford it.

It is the patient in intractable severe pain, incurable by every means modern medicine has to offer, who sits weeping before you, her shriveled life constricted to never leaving her home or getting out of bed, who begs you for answers you do not have. It is the insurance company who refuses her next treatment because it does not meet their “treatment guidelines.” It is the state regulators who harass and threaten you as you manage her severe pain with carefully-managed, medically appropriate chronic opiates while they perceive you as an addict-enabling criminal.

It is the perfectly-performed surgery with a disastrous outcome; the excellent outcome that leaves a bitter patient because it did not meet their wildly-unrealistic expectations — which you told them it would not and could not meet; the out-of-town and out-of-touch daughter who demands everything be done for her dying father’s terminal cancer to assuage her guilt, hating you almost as much as she hated him.

Add to these the seemingly-daily debacles the freakonomics of health care in the new millennium: overhead costs spiraling at multiples of the inflation rate, as income dives inversely; ever larger numbers of legitimate treatments and services denied or criminally underpaid by government and the insurance industry cartel; the ludicrous notion that you can somehow provide the highest quality (or even barely adequate) care while being reimbursed substantially less than the costs to provide it; the horrifying freak show in Washington where corrupt and prevaricating politicians shamelessly conspire to destroy a noble profession and an extraordinary health care system to line their own pockets and acquire perpetual power and control.

And then there are the lawyers — aah, the lawyers.

I spent the better part of twenty years in the practice of medicine avoiding their clutches. I came to believe that careful, conscientiously-practiced professionalism, a willingness to spend substantially more time than my peers teaching and communicating with my patients, constantly striving to treat them with dignity, kindness, and respect, would prove a bulwark against the woes my professional peers suffered at the hands of an out-of-control legal system.

What a fool.

My first two malpractice suits came within a year of one another, now over ten years ago. Both were frivolous, and were tossed out of the courts for lack of evidence — after tens of thousands of dollars were spent on their defense. Both, incidentally, were triggered in large part by inappropriate comments by another physician (anyone who thinks physicians cover up for their peers is badly misguided — we are an arrogant lot, shooting our wounded and eating our children). During this same period, several other suits were threatened but never filed. Small comfort, indeed.

It is difficult to express the personal devastation afforded when accused in a medical malpractice lawsuit. It is an existential crisis, cutting to the heart of who you are as a professional, challenging motive, integrity, and competence. Anger, betrayal, self-doubt, fear, and sleeplessness become your daily bread. Every patient becomes a future litigant. An invisible attorney sits in the examining room on every visit, condemning and second-guessing your every decision and action, as you wildly check off every test and x-ray you can imagine to defend yourself against his future judgment: “Doctor, could you explain to the jury why you did not order this study, which could have diagnosed her disease before it became so advanced?” Check. “Doctor, could you read page 1235 of this medical reference — which you stated you have in your office — which points out how all patients with this disorder should be evaluated thus?” Check. “Doctor, isn’t it true that you dismissed his complaints as nothing to worry about, when in fact his cancer was eating away at him and you ignored its warning signs?” Check.

My current litigation, scheduled to come to trial this June after nearly three years in process, of course cannot be discussed here; perhaps I will discourse on the lessons learned therein — for they are legion – when it is resolved, one way or the other. Suffice it to say for now that it involves a child, and that the damages sought exceed the limits of my malpractice coverage by multiples of seven figures.

Sleep well, Doctor.

In truth, why would anyone choose to go into this profession today? Why would any sane man continue to practice medicine in this environment? Why, indeed, do I continue in this insanity?

As a man of faith, a Christian physician, the answers to these questions are far from simple. They cut to the very heart of free will in the service of God and man; of matters of purpose in life and submission in faith; of trust and obligation, gratitude and motives, prayer and practice. The high-sounding principles of pew and pulpit are now tested in the fiery crucible of life, and you discover that lofty ideals and strong convictions alone are insufficient ground on which to stand. The dark night of the soul strips away your props and annihilates all your pretensions; will there be anything left but ashes when the flames have died out?

Time will tell, I suppose, whether I stand on rock or sand.

May God be with me. May God be with us all.

The Sword of Grace

Third in an ongoing series on grace in Christianity:

  1. On Purpose
  2. Justification, Sanctification, & Grace

 
We struggled through some intimidating “God-words” — justification and sanctification — in my previous post, and in the process I lost both of my regular readers, leaving but a few wandering insomniacs whose Ambien prescription had just run short. For those now drifting back, whose eyes are just now unglazing, I touched on something of how Christianity works — or doesn’t, for many who have tread its well-worn path.

If nothing else, I hope for those who endured that irreverent review, that there arose at least a glimpse of the uniqueness of the Christian faith. Christianity is not merely another framework of moral codes by which to live. It is not comprised solely of the teachings of a charismatic leader, urging compliance to please or placate God or promulgating some hidden wisdom. It asserts at its very heart an outrageous claim: that those who relinquish their right to self-centered autonomy by submitting to God through the specific and exclusive portal of Christ will become judicially guiltless before their Creator. It further claims — perhaps even more outrageously — by this act to re-create the person so submitting, in a manner so thorough and profound that the individual can no longer be thought of as the same person who existed prior to that moment of choice and submission.

Yet if these claims are true, if this transformation be as radical and profound as its teachings and proponents assert, why then are those who lay hold of this conviction seemingly so little different from others who have not undergone this metamorphosis? If Christians are utterly transformed in the depth of their beings, why do they struggle and fail so often to be outwardly transformed as they should inevitably be by such a tectonic shift of the soul?

I was afraid you were going to ask that.

And I would be presumptuous and foolish to pretend that I have simple answers; I do not. What I do have is experience — the experience of many years of walking the Christian life, with stunning successes which proved all too fleeting, and disastrous failures which made a mockery of the high calling and lofty precepts of the convictions I hold dear. And I have shared this journey and experiences with many others, both past and present, whose path while wildly different in particulars is indistinguishable at its core.

What exactly is the nature of this transformation, this re-creation, which lays claim to a man in such mysterious manner? It is perhaps best described by what it is not.

It is not simply a change in thinking, a new perspective, a different set of opinions or a new worldview. If anything, the mind is the last bastion of resistance to its influence, and often the greatest enemy of the very change needed to transform the whole of one’s being.

It is not simply an emotional experience. Although emotions may be powerfully affected, emotions often serve to inhibit or distract from true progress, and are notoriously unreliable guides to its course.

It is not simply a change of the will, a setting of a new direction and discipline to achieve new goals and improve one’s life. The will, indeed, must be conquered, shackled, broken like a wild stallion to suit the purposes of this new Master. The will becomes but servant — rebellious, recalcitrant, resistant, remorseless, fighting its new overlord at every turn.

It is not simply a change of heart — although the heart lies closest to the seat of change, and senses its arrival before all else.

It is perhaps best described as a genesis; an arid fountainhead bursting forth with fresh spring water; an ancient stygian chamber shot through with dazzling shafts of light; a Phoenix arising from the ashes of the heart. There is a primordial recess in the soul of man, a silent sarcophagus unheralded and unseen, which springs to life like the burst of new flora at winter’s demise, when this dawn first breaks.

Thus is the experience of this new creation — but it is far more than mere renewal. It is as well — unexpectedly, surprisingly — a force of sedition with an unassailable foothold in a hostile land, seeking to undermine and overturn the tyranny of self with the sword of grace.

We are now at war. “I have come, not to bring peace, but the sword.”

Its effects are immediate, and often profound. There is a new vision, a grasp of things formerly hidden, a new light disclosing much which was cloaked in darkness, a profound and unbounded joy of discovery, and purpose, and optimism. We glory in the glint of sunlight reflecting off the helmets of our soldiers, marching in perfect unison, their colorful regalia stirring our hearts with visions of triumphant victory.

The reality is soon discovered to be starkly different. The cratered carnage of the battlefield, littered with the detritus of battles fought bravely but foolishly, sobers the spirit and saps the strength. The victory we hoped to be swift and painless now seems pyhrric if not pointless. Yet the failures are themselves at the point of the sword — they are, paradoxically, the means to triumph.

When a man becomes new in his spirit, he has engaged the very power of God in an irrevocable union whose outcome will be the full restoration of the purpose and relationship intended — by design — between the Creator and His creation. But the love which such a relationship demands must be utterly free, and hence the will and actions of man must be left unfettered and without coercion. This will, long subsumed to the service of self, must ultimately be turned to harmonious submission to the will of God, which desires, in freedom, the full integration of the new man into the wholeness and purpose of God’s design.

Though the inner change brought about by submission to God and our judicial pardon is profound, the mind and the will are steeped in a toxic brew of lifelong slavery to self. We have years of destructively pursuing that which seems right to us — of deceiving ourselves and others about our true thoughts and motives; of addictions and obsessions and hardened habits which have served to mitigate the pain and emptiness which our ego-enlargement have ultimately wrought. We lie to cover the shame; we react in anger, and resentment, and rage to cover the fears: fears of exposure and moral nakedness; fears of rejection; fears of failure; fears of existential insignificance. The sex, the booze, the pursuit of money and prestige, the materialism — all are exploited in search of integration and meaning, all leading only to more emptiness, more pain, more meaninglessness — and more of the same behaviors, over and over, endlessly.

Before our transformation, we are in a sense of one mind: this is the only life we know, the only tools we have at hand. Our inner and outer selves are on the same page, though the story is going nowhere and the final chapter looks bleak.

After our inner selves are transformed, however, the old contrivances no longer find consonance within; they find, instead, dis-ease. Our spirits are forging forward on a separate journey, and there is increasing tension between a mind and a will committed to failed, destructive solutions and an inner being seeking truth and wholeness.

We react to the inner discord our old life engenders with the tools we know best: we try, using knowledge, and effort, and will power, and discipline, to change the thoughts and actions we now know to be destructive. And we succeed — at first.

Sort of.

The behavior changes, but the thoughts and desires linger. The appearance improves, but the inner demons remain — if anything, they grow stronger, as each failure is a new victory for an old life. The struggle is draining and painful, disheartening and exhausting, as old habits persist and even prosper. With each failure, renewed commitment; with each relapse, new resolve. With each sortie, stalemate. Again. And again. And again.

And this, surprisingly, is exactly as it should be.

The mind and the will, unaided by grace, have no power to conquer the forces which bind them. They must be broken. There can be no resurrection of the dead until the dead be shown incapable of resurrection.

At some point in this long and fruitless journey, a juncture is reached. The wheels are coming off the car, and we’ve tired of pushing the pedal ever harder. It is a moment of choice: to resign ourselves to our old life, embrace our failure, and drown out the quiet pleadings of that inner voice; or submit, yet again, broken, falling headlong into the arms of grace, which alone can conquer that which is vastly larger than our feeble wills and darkened minds can overcome.

The sword of grace has slayed yet another stronghold of the old life. Another small parcel of the tyranny of self has been repurchased. We have been given what we could not gain by our own efforts, regardless how determined.

Cheer up. There are many more such battles ahead.

How then do we appropriate this liberating grace, this victory through surrender? There is no formula, for formulas are the haven of fools. But there are answers. The answers, I have found, are always simple — and never easy.

But that, my friends, is a topic for another day.

The Engine of Shame – II

This essay, the second of a two-part series, was originally posted in October 2005.
 
DRGWIn my previous post on guilt and shame, I discussed their nature and differences, their impact on personal and social life, and their instrumentality in much of our individual unhappiness and communal dysfunction. If indeed shame is the common thread of the human condition–fraught as it is with pain, suffering, and evil–it must be mastered and overcome if we are to bring a measure of joy to life and peace to our spirits and our social interactions.

Shame is the most private of personal emotions, thriving in the dark, secluded lairs of our souls. It is the secret never told, the fears never revealed, the dread of exposure and abandonment, our harshest judge and most merciless prosecutor. Yet like the Wizard of Oz, the man behind the curtain is far less intimidating than his booming voice in our subconscious mind.

The power of shame is the secret; its antidote, transparency and grace. Shame thrives in the dark recesses of the mind, where its accusations are amplified by repetition without external reference. Shame becomes self-verifying, as each new negative thought or emotion reinforces the theme that we are rejected and without worth. It is only by allowing the light of openness, trust, and honesty that this vicious cycle may be broken.
 
Continue reading “The Engine of Shame – II”

The Engine of Shame – I

This essay, the first of a two-part series, was originally posted in October 2005.
 

Steam locomotiveA wise friend–a man who helped me emerge from a period of considerable difficulty in my life–once taught me a simple lesson. In less than a minute, he handed me a gift which I have spent years only beginning to understand, integrating it into my life with agonizing slowness. It is a lesson which intellect cannot grasp or resolve, which faith only begins to illuminate–a simple principle which I believe lies close to the root of the human condition.

My friend taught me a simple distinction: the difference between guilt and shame.

While you no doubt think I am devolving into the linguistic morass of terminal psychobabble, I ask you to stick with me for a few moments. What you may discover is a key to understanding religion, terrorism, social ills such as crime and violence–and why the jerk in the next cubicle pushes your buttons so often.
Continue reading “The Engine of Shame – I”

Newt’s Reform Ideas 1 — Stop Paying the Crooks

Over at the Center for Health Information (HT: Hot Air), Newt Gingrich and Nancy Desmond have proposed a series of principles for reforming our health care system, to wit:

1. Stop Paying the Crooks. First, we must dramatically reduce healthcare fraud within our current healthcare system. Outright fraud — criminal activity — accounts for as much as 10 percent of all healthcare spending. That is more than $200 billion every year. Medicare alone could account for as much as $40 billion a year.

2. Move from a Paper-based to an Electronic Health System. As it stands now, it is simply impossible to keep up with fraud in a paper-based system. An electronic system would free tens of billions of dollars to be spent on investing on the kind of modern system that will transform healthcare. In addition, it would dramatically increase our ability to eliminate costly medical errors and to accelerate the adoption of new solutions and breakthroughs.

3. Tax Reform. The savings realized through very deliberately and very systematically eliminating fraud could be used to provide tax incentives and vouchers that would help cover those Americans who currently can \'t afford coverage. In addition, we need to expand tax incentives for insurance provided by small employers and the self-employed. Finally, elimination of capital gains taxes for investments in health-solution companies can greatly impact the creation advancement of new solutions that create better health at lower cost.

4. Create a Health-Based Health System. In essence, we must create a system that focuses on improving individual health. The best way to accomplish this is to find out what solutions are actually working today that save lives and save money and then design public policy to encourage their widespread adoption. For example, according to the Dartmouth Health Atlas, if the 6,000 hospitals in the country provided the same standard of care of the Intermountain or Mayo health clinics, Medicare alone would save 30 percent of total spending every year. We need to make best practices the minimum practice. We need the federal government and other healthcare stakeholders to consistently migrate to best practices that ensure quality, safety and better outcomes.

5. Reform Our Health Justice System. Currently, the U.S. civil justice system is the most expensive in the world — about double the average cost in virtually every other industrialized nation. But for all of the money spent, our civil justice system neither effectively compensates persons injured from medical negligence nor encourages the elimination of medical errors. Because physicians fear malpractice suits, defensive medicine (redundant, wasteful treatment designed to avoid lawsuits, not treat the patient) has become pervasive. CHT is developing a number of bold health-justice reforms including a “safe harbor” for physicians who followed clinical best practices in the treatment of a patient. Visit CHT’s Health Justice project page to learn more.

6. Invest in Scientific Research and Breakthroughs. We must accelerate and focus national efforts, re-engineer care delivery, and ultimately prevent diseases such as Alzheimer’s Disease and diabetes which are financially crippling our healthcare system.

My first reaction to this? Meh. Obamacare light.

On deeper reflection, however: Mini-meh. Not entirely without merit, but loaded with silliness and false assumptions.

What is it with these so-called policy gurus? Knowing little or nothing about how health care really works, they haul out the bromides and throw around statistics based on taking small numbers and projecting them across large populations, to come up with scary percentages which then echo around the web and inside the hollow heads of the parrots in media newsrooms. Oh, and our politicians then use this crapola to formulate policies, which always end up having massive unintended consequences and which never achieve the results promised. Newt’s a pretty bright guy — generally a far better idea man than a politician — but he’s whiffing at softballs thrown slowly, by and large, with this one.

So what’s my gripe? Where do I begin? How about at the beginning?

 ♦ Stop Paying the Crooks: Of course, brain-dead easy. Just find ’em and lock ’em up. Problem solved; billions saved; next problem!

Not quite so easy, in reality.

Look, fraud exists in Federal programs; it may actually be a pretty large chunk of change, although I’m more than a bit skeptical of the numbers being tossed around. Why? Well, first, if we knew exactly how much fraud there was in Federal health programs, we would, you know, go after it, no? All these numbers are nothing but projections — and projections based rather thinly on hard data, then amplified by applying them to large populations. Great for media play and making a political point, but invariably far, far off the mark.

Ever hear those public service ads which generate guilt by saying “One in five kids will go to bed hungry tonight in America.” Believe them? Of course not — they’re ludicrous on their face (unless you count the corpulent kids whose last Big Mac was 2 hours before bedtime…) . The gimmick used is non-representative sampling — and sampling is a huge problem: if 2% of physicians are found fraudulent in Miami, does that mean 2% are crooks in Topeka, or Flagstaff, or East Podunk? Highly unlikely — but that’s how these estimates are typically generated. So the line goes, “Eliminate fraud and we can have XX billion dollars to spend on such-and-such!” End result? There’s never as much fraud as you say (and a good deal of it is impossible to track down), and the promised billions never materialize.

Next problem is definitions: to paraphrase Bill Clinton, it depends on what the meaning of “is”, is — how exactly are you defining fraud?

Sure, no one argues with the dude who steals or fabricates a provider number, then bills Medicare for millions of dollars of non-existent medical services (although it is surprising how long it takes Medicare to catch on to such schemes). Some are almost as clever as politicians at stealing money. Bust ’em, lock ’em up, problem solved.

But what about the honest doc utterly befuddled, or too busy to spend half her time on, the mind-boggling complexity of medical service coding? Or the solo practitioner who can’t afford the huge hassle and administrative costs and burdens of a full-fledged compliance program? In the world of Medicare & Medicaid, such providers are also fraudulent. Try to be charitable to a poor Medicare patient and not bill them for their copay and deductible?

Fraud! Honest to God.

When physicians hear about new measures to stamp out fraud and abuse, they know exactly what that means: federal auditors, not health care professionals but bureaucrats, with infinitely deep pockets and unlimited time, sweeping into a busy medical practice, demanding hundreds of charts to review, disputing countless interpretations of complex, confusing, vague, and often contradictory regulations on what code should have been charged for such-and-such a service, with mind-boggling penalties per offense, no matter how trivial. Be prepared for a 6-figure attorney bill, on your dime, with little or no formal avenue for review or appeal — and still expect to settle in the end, hopefully for less than a mil.

Oh, and that settlement will become part of the national fraud statistics, finding some convenient multiplier, and generate some more truly shocking numbers about crooked doctors — when the chances are rather high in reality that that no real fraud occurred.

There is a pretty simple way to vastly reduce such fraud, of course: pay physicians by time, like virtually every other profession. Kill the complex coding system which by its very complexity breeds fraud, error, and confusion.

Will it ever happen? When Skip Gates dons a white hooded cape and burns crosses on lawns.

Human nature being what it is, you will never completely eliminate fraud. But you sure can crush a profession by trying.

There’s lots more to come, not all critical. Next post: Newt Part II: Move from a Paper-based to an Electronic Health System.

Back soon.

Three Men on a Friday

CalvaryThree men on a Friday, condemned to die. Ensnared by Roman justice, convicted, and sentenced to a lingering death of profound cruelty and excruciating agony.

The Romans knew how to do it right: execution designed to utterly humiliate its victims, and maximize their suffering–a public spectacle and object lesson to others about the foolishness of defying Roman authority. First used by the Persians in the time of Alexander the Great, and adopted by Rome from Carthage, crucifixion was so horrible and debasing a fate that it was not permitted for citizens of Rome. Victims hung for days, their corpses consumed by carrion.

Our knowledge of these three men is incomplete. Two are described in ancient texts as thieves, the other a preacher run afoul of religious leaders, delivered to the Romans under pretense of imperial threat. There should have been nothing unusual about this event: the Romans crucified criminals often, sometimes hundreds at a time. Yet these men, in this spectacle, were different: on these crosses hung all of mankind.

Two thieves and a preacher — an odd picture indeed. And even more peculiar: the most hated was the preacher. Taunted, insulted, ridiculed, reviled. A miracle worker, he, a man who supposedly healed the sick and raised the dead, yet now hung naked in humiliation and agony, unable to extricate himself from his dire circumstance. Even those convicted with him–themselves dying in unbearable pain and mortification — join the fray. Insulting the rabbi, demanding he set himself–and naturally, themselves as well–free. They know his reputation, yet selfish to the end, desire only their own deliverance.

But one thief is slowly transformed, in frailty considering his fate and the foolishness of demanding release when his punishment is just. And he marvels at the man hung nearby — why? Why does this preacher, unjustly executed, not proclaim innocence nor demand justice or vengeance? Why does he–amazingly–ask God to forgive those who have so cruelly and unjustly punished him? Why, in the extraordinary agony only crucifixion can bring, does he seem to have peace, acceptance, perhaps even joy?

His revulsion at the baying crowd, at the arrogance of his fellow convict reviling this man of character and grace, bursts forth in rebuke at him who ridicules: “This man has done no wrong!” Turning to the preacher, he makes a simple, yet humble, request: to be remembered. Only that. No deliverance from agony, no sparing of death, no wealth, prosperity, or glory, no miracles–only to be remembered.

The reply reverberates throughout history: “This day you shall be with me in Paradise.” A promise of hope, a promise of relationship, a promise of forgiveness, a promise of comfort, joy, healing, peace.

Three men on a cross. In these three men are all who have lived: two are guilty, one innocent. Two are justly executed, one unjustly. All three have chosen their fate: one thief to revile, ridicule, hate, blaspheme; one criminal to trust, to seek consideration and mercy from one greater; one man to submit to brutal and humiliating torture and death, willingly, for no crime committed — or for all crimes committed, everywhere and for all time. Yet only one promise given–to the one who, though guilty, trusted and turned.

Who was this man in the middle, this preacher? A charlatan, perhaps – but an impostor abandons his schemes when such consequences appear. Delusional, deceived zealot, or presumptuous fool? Such grace in agonal death is inconceivable were he any such man. What power did he have to make such a promise? What proof that the promise was delivered?

An empty grave. A promise delivered by a cavern abandoned, a stone rolled away. A gruesome death transformed into a life of hope, meaning and purpose for those who also trust.

The Crush of Covenant

Well, I finally did it: I quit.

Walked into the boss’s office, gave him a piece of my mind, tossed my resignation letter on the desk, and told him exactly what he do with his stinkin’ job. “Take this job and shove it”, as the country song goes.

Felt great. Been wantin’ to do this for a loooong time.

What led me to such a drastic, disgruntled display of ill-demeanor?

Here’s just a few vignettes from the past few days:

Monday 7 A.M: It’s Monday, my regular ER on call day. Full office scheduled. The ER calls — at exactly 7 A.M. Which means the weekend call guy, who goes off at 7:00, hasn’t answered his pages for the last 2 hours. Bastard. There’s a term for this: it’s called “dumping.”

The patient: a 90-something man with Alzheimer’s dementia, from a nursing home. Not any nursing home, mind you: one specializing in the care of Alzheimer’s patients. Ads on the radio about how caring and compassionate they are — you’ve heard ’em. Creme’ d’ la creme, and all that. Chronic Foley (urinary) catheter for incontinence. Despite their fawning attention, he somehow managed to grab his Foley and pull it out — with the balloon inflated, of course. He’s bleeding. A lot. The caring, attentive staff at the home has also neglected routine catheter care, so it has basically eaten its way through his penis. He now pees (if he could) through a hole just over the scrotum.

The ER staff can’t get the catheter back in. Not just because the anatomy ain’t quite normal (the P.A. is still trying to insert the catheter into the end of the penis, and can’t figure out why it won’t go in) — but he’s agitated. Really agitated. 4 nurses and counting to hold him down, still throwing punches. (great left hook!). Clearly this isn’t going to work — he’ll need to go to surgery ASAP, so this can be done under anesthesia — putting in a more permanent bladder catheter through a small hole in the low abdomen. With a big-ass balloon he can’t pull out. Hopefully.

Monday 9 A.M.: Inform my office staff that most of my busy morning office has to be rescheduled, the rest will have to wait. They are not happy. The patients rescheduled will not be happy – most have waited over 6 weeks for their appointment, and probably another 6 for their new one. C’est la vie. They will likely think my “medical emergency” means I’m on the 1st tee with my golfing buddies. Whatever. The more urgent ones will get squeezed into another day, already overbooked. Then they can be even more unhappy because the doctor is running late, and “Their appointment was at 10:00 A.M., dammit, and their time is valuable.”

Monday 1 P.M.: Back from surgery, the few longsuffering and surly patients from the morning clinic seen and (somewhat) assuaged. Short conference with my billing specialist, a soft-spoken pit bull with lipstick who daily does battle with the forces of evil and corruption (a.k.a., insurance carriers and Medicare), and wins an amazing number of battles. But not today.

Mr. Jones, you see, had a prostate problem. So he needed a fairly simple test to check for obstruction, called a uroflow, to evaluate whether his prostate was causing blockage. Charges for this procedure? About $325.

Sounds like a lot of money to pee in a jug. But it’s a very special jug. The equipment which measures and records his urinary efforts cost over 6 figures (it has a number of other highly specialized functions as well, lest you think it’s too extravagant for such a lowly task). The specialized catheters used to measure pressures for the more sophisticated tests cost well over $100 each — and are single-use disposables. Setup, cleanup, patient instruction and assistance by my back-office nurse, about 20 minutes of her salary, benefits, health insurance, 401(k) contributions. Overhead to keep the office open (rent, supplies, maintenance, malpractice insurance, licenses, etc., etc.), about $200 an hour. Oh, and my interpretation of the test and conclusions about how best to treat the patient is included in the fee.

What the insurance usually pays for the procedure: about $125.

What Mr.Jones’ insurance company paid: $0.

The reason? Mr. Jones’ policy doesn’t cover in-office surgery. “But peeing in a jug isn’t surgery!”, you protest. As did I. But the CPT service code has been incorrectly categorized as surgery by our friends at the AMA, in their massive annual tome used by insurers and federal payors to determine payments for medical services.

So I sat down and wrote a detailed appeal letter, explaining in a clear, courteous, and detailed manner that peeing in a jug is not surgery. Dictated, proof-read, sent off. My time? About 20 minutes. My reimbursement for that time? $0 (Called your attorney lately and chatted for 20 minutes, for free? Didn’t think so).

One month later, the response arrived: Appeal denied. The letter explained how the medical situation had been carefully reviewed: first, by their highly-trained Resource and Review Nurse; then by a panel of esteemed physicians and other health care providers; and finally, because of the seriousness of the matter, by their Medical Director (whose 7-figure income reflects the gravity and burden of such decisions). The verdict?

Peeing in a jug is surgery.

Of course, it is never prudent to take the last shred of hope from the hopeless, so they politely inform me that I may submit a Level II appeal — which requires pleading to the AMA that the categorization of peeing in a jug as surgery, in their massive annual CPT coding tome, is an error. And, of course, they will be more than happy to reconsider the matter once the AMA has agreed, and changed their rules.

Oh, and have a wonderful day! We cannot tell you how much we appreciate your outstanding care for our insured clients!

Monday, 1:10 P.M:: Billing conference, part II. Mr. Smith, another nursing home patient, had blood in the urine. Came to our office for a cystoscopy, a visual inspection of the bladder. Found he had a small bladder cancer, and was scheduled for surgery in a few weeks. Went back to the nursing home until then.

In the past, billing for such a procedure was simple: submit the claim to Medicare, get paid (about 40% of my billed fee, about 10-20% less than my overhead to perform the procedure) by Medicare a few weeks later.

Then Medicare changed the rules. Since Mr. Smith is in a nursing home, the nursing home must now bill for my cystoscopy, get paid by them — and then pay me, if and when they get around to it. But, of course, they have no motivation to do so — since I have no recourse against them if they fail to bill it, or bill it incompetently and get denied, or refuse to pay me.

So the executive summary: I get nada for Mr. Smith’s procedure.

The unintended consequence of this little change in Medicare regulations? Urologists and other specialists now refuse to do procedures in the office on nursing home patients, since they don’t get paid. The procedures either don’t get done — or the patient has to be admitted to the hospital when his bleeding gets bad enough, where his cystoscopy will be performed at a cost to Medicare of, oh, about 500-fold what it would have been if I did it in the office.

Medicare, of course, will be ecstatic: their payments for office procedures will plummet, after their careful review of regulations helped trim “wasteful and unnecessary medical spending” from their budget. The jump in costs for hospital procedures which results from this shell game are, of course, because of greedy health care providers, fraud and abuse, and more wasteful medical spending — and come out of a different pocket, so’ll they’ll never make the connection. The politicians are sure to trim those frivolous expenses as well, by carefully reviewing the regulations and implementing more “fraud and abuse” abuse, as they seek high quality, affordable health care coverage for all.

Tuesday, 1: P.M: Mr. Smith’s nurse from the Alzheimer’s Home calls, and says he has some blood in the urine from his new bladder catheter (which is expected). “How much?” “Dark pink, no clots.” “Have you irrigated it?” “Yes, and we’re sending him back to the hospital.” “Is the catheter draining well?” “Yes, but we’re going to send him back.” “Is he stable, blood pressure OK, any pain, blood count OK?” “Yes, do you want him to go by ambulance or do we call 911?” “He doesn’t need to go back to the hospital.” “Well, he’s going anyway. We can’t handle this.” Yeah, I guess that’s why they call it a nursing facility. God forbid you should deliver, you know, nursing care.

14 hours later he returns to the nursing home after an ER visit, perfectly stable medically, just as he was when he left the nursing home. About an $8-10,000 medical junket, because a nurse couldn’t, or wouldn’t, handle basic nursing care.

Wednesday 9:00 A.M.: Mr. Johnson is waiting when the office opens. His is a sad story: prostate cancer, had successful surgery to remove it, and is cured. Developed scar tissue afterward and couldn’t pee. Opened it up and he couldn’t not pee — bad incontinence. Had a prosthetic device placed, an artificial urinary sphincter, nine months ago. Worked beautifully, Mr. Johnson is happy. 8 months later, leaking again: Mr. Johnson is not happy.

Took him to surgery yesterday to repair it. A tiny leak had developed, and the pressure on the sphincter cuffs was lost — an uncommon but known problem with these devices. Replaced the components, hooked it up, tested it thoroughly, worked great. The device has a control valve located in the scrotal area to open the cuffs when you need to pee, which was one of the components replaced. It has a locking button, which holds the cuffs open, as things are too swollen and tender for the patient to use it for a while. Locked the cuffs open, tested it again several times, everything’s perfect.

He goes home, and can’t urinate. Somehow the lock released on its own — which isn’t supposed to happen. Goes to the ER, where they try to put a catheter in, rather indelicately, and left it in — which greatly increases the risk his sphincter prosthesis will get infected, and have to be removed. And he needs to go back to surgery, since it is far too painful to try to lock the cuffs open now, and he will need a temporary bladder drain through the skin until the swelling goes down.

Mr. Johnson is not happy. I am not happy.

Not to be too whiny, but the responsibility of this profession at times can be crushing. At the risk of seeming hyperbolic, you really do, to a greater or lesser degree, take patient’s lives in your hands when you assume their care. Not just the life-and-death stuff, although that’s sometimes part of it too. No, it’s the rest of their lives which come under your responsibility. It’s the drug to treat a serious disease, which causes serious side effects or unintended adverse effects on their other diseases. It’s the surgery to cure cancer which can have painful, disruptive, frustrating complications, even when the cancer is cured — and even when the surgery is competently and expertly performed. You are, in the end, responsible. When the side effects happen, you are responsible. When the patient fails to follow treatment advice, or has unrealistic expectations despite your best efforts to temper them, you are responsible. When the pharmacist sends the wrong drug; when the nurse fails to notice an important problem; when the technician doesn’t properly clean and sterilize the instrument; when the prosthesis fails to operate as designed: you are responsible.

Perhaps in some alternate universe, where Gucci-loafered lawyers with fat cigars parse guilt in mahogany-gilded chambers, the responsibility would be meted out in scrupulous fairness to all involved. But as a physician, where our relationship with the patient is one of covenant, not contract, those responsibilities become ours, because we commit to the patient’s best interest, no matter what, while orchestrating the complexities and complications of this enormous technological beast we call 21st century medicine. This gleaming beast can accomplish enormous good — or ghastly harm. And much of the behemoth we seek to command is not under our control — yet we remain responsible nevertheless. So we lash, kick, prod, and goad the monster, trying to reign in the mind-numbing complexity and tie up the endless loose ends, as the monster snarls back and snaps at your head or pummels you with its tail. And never forget your own frailty: perfection is unattainable despite your most obsessive, strenuous efforts. The country doc with his black bag could do little good and cause little harm; small errors today, even unrecognized, can multiply and spiral into disaster at frightening speed. This fact alone crushes many a doctor with its gravity, as witnessed by the high rates of physician burnout, suicide, divorce, and drug and alcohol problems.

The feeling is like a punch in the gut, only worse. I am not happy. I am depressed, and angry, and fearful, and discouraged — and convinced that with my level of competence I should be flipping burgers at McDonalds. Self-condemnation is a narcotic, savored and craved by perfectionists: noxious in flavor, but oddly salutary in the self-pitying comfort of its dark and fetid euphoria.

It does not pass easily.

Wednesday, Noon: Mr. Smith, with the Alzheimer’s, is back in the ER, and they are calling me. No preliminary call to me this time from his nursing home — they just sent him back. His 4-by-4 inch gauze dressing around his new bladder catheter is bloody — about a silver-dollar sized area. The ER doc sees and evaluates him: still demented, still medically stable as a rock, blood count unchanged. The ER doc changes his dressing, and sends him back to the nursing home. So, here we are, some $20-25,000 spent on this poor man, because his nurses are inept, lazy, incompetent, and can’t change a g*d-damned dressing. No one at the nursing home will have their pay docked because of this travesty; no one will be fired or fined. Medicare will pay its fractional part of the costs, oblivious to the incompetence which triggered it. The hospital will eat the difference.

And life in the circus of 21st century medicine will go on.

And so, enough is enough: the camel’s back has snapped. I quit. It’s not the first time, by any means; likely won’t be the last. My boss is very understanding, and he’s been through this all before. That’s one of the skills you need when you’re a self-employed, solo physician.

He knows I’ll be back at my desk tomorrow, as if nothing happened. Ready to start it all over again.

* All names are, of course, fictional.