Deep Waters

The following essay was originally posted in June 2005. The story is a true one, although the names have been changed.

 
Lake ClarkThey say that hell is hot. Sometimes, however, it is very, very cold.

Jim loved Alaska — it had been his home since birth. God’s country: wild, unpredictable, spectacular in beauty–there was no place like it on earth. Cities were a necessary evil, with their services and surliness, but out in the wild was where life could be found. Out among the glaciers, the ragged mountains framing the endless blue sky like jagged, broken glass, out where grizzlies snatched salmon from raging rapids, shortening their march to death as they fought wild currents to reach their spawning grounds. Out where eagles graced the sky, soaring above green fir spires and spotless snow fields. Out where God lived, where a man could see His hand, and hear His voice.

Jim lived a simple life of simple faith. He loved his wife as he loved the land, and together they were blessed with six children–three older girls, the twin boys, and a baby son their most recent gift. Each was a treasure greater than the next. Their lives were story book: The lodge they owned nestled near the shores of Lake Clark, a large inland glacial sea, mirroring the snow-peaked mountains surrounding it. Summers were busy–hunting and fishing tours, visitors from afar seeking trophies and photographs, decked in newly-purchased gear from REI in the lower 48. Jim loved to fly–the float planes lifted gracefully from the lake, carrying their awestruck passengers over endless miles of breathtaking beauty to some far-away stream where tied flies touched water and fish broke airborne for their last meal.

Out in the bush, relationships were few in number but rich and deep. Church was more than a Sunday obligation–it was a place where life was shared, joys celebrated, suffering comforted–a place where faith begot works, where love put on snowshoes and helped stack the winter’s wood. Family life was alive, ripe with blueberries picked, hikes to the falls, and quiet nights beside campfires. Summers passed quickly at Bible camp, concentric ripples of cannonballs and giggles of joy rolling across the lake from the old dock. Dates with dad and high tea with mom found no competition from mindless cartoons, and bedtime prayers thanked Jesus for His goodness and God for His gifts.

Winter was time for quiet reflection, as the short days and deep snows kept sportsmen far away, and school and indoor chores made the time pass slowly but with purpose. The plane was their lifeline: what few roads there were became impassible in deep snow, and flights to Anchorage a necessity for supplies and health care. The girls came along often, although the younger boys stayed with friends and relatives for lack of space.

Jim had tens of thousands of hours of flying experience, a skill which paid rich dividends in the harsh, capricious winters of south Alaska–there was little in the way of flying conditions he had not challenged and mastered. So this flight to Anchorage in February was a pleasant surprise: the low gray skies broke open to display the rare winter glory of sunshine on pristine snowfields, the glorious tinted rim of Alaska Range peaks and deep seas of Cook Inlet. The supplies garnered and the girls’ dental care completed, they took off for the return flight to home and hearth.

The storm struck without warning, a white she-devil blown in from the Gulf, the Cessna buffeted by sharp, hard winds as visibility and ceiling dropped precipitously. The instruments held true, and countless hours of difficult flying forged Jim’s nerves steely and his focus intent. Mom held the girls’ hands, distracting them from natural fears with songs and stories and heads held to breast, her own pounding heart betraying her calm demeanor. “Will we be OK, mommy?” “Jesus will bring us home, honey.”

The GPS told Jim they were indeed near home–the lighthouse in space beaconing safety and rest. By reckoning they should be near the lake, just a few miles out from the landing strip. But Nature had not finished yet, her rage reserved for one final blow.

A whiteout in a small plane is dreadful beyond imagining. Suspended between earth and sky, with no point of reference, no sense of up or down, sensory deprivation in a aluminum rocket. Your training trusts your instruments, but instinct and eyes scream for visual confirmation. There! On the right! Through a brief window in the suffocating white blindfold, a dark line: the outline of the lake shore. Jim banked the plane toward this beacon of hope. “Are we home yet, daddy?” “Almost there, honey.”

But wild Nature held one last vengeance: an atypical winter thaw had opened a long dark crack in the ice, normally frozen solid in February. The line Jim saw was not the shore. The plane hit water at airspeed.

The prop and windshield exploded. The cabin filled instantly with icy water, as Jim craned his neck to reach the fast-retreating air, still restrained by his harness. Years of wilderness training sprung to life, as without a thought he grabbed his Bowie and cut free the webbing. He struggled with the girls’ restraints, hopelessly locked between seats crumpled by the impact. His wife was nowhere to be seen. Time was up–the air was gone. He broke from the cabin, gasping for air at the surface, hoping to dive and try again to free his treasures. It was not to be: the plane sank like a millstone, 600 feet to the bottom of the frozen fjord, entombing the family he worshiped.

In shock, he looked around. His wife, by some miracle, thrown from the plane at impact, had struggled to the surface and clung to a floating berg. Spared from a frigid tomb, they stood on a fragile shelf of thin and breaking ice. Over two miles from the shore, clothing soaked through in sub-zero temperatures, their survival was still a loser’s bet. Slowly they worked their way shoreward, breaking through the ice at times, body temperatures dropping despite their exhausting physical efforts. Guided by some hand unseen, they finally fell exhausted on shore, finding shelter in an empty lodge. Blinded by cold and head trauma sustained in the crash, Jim was led into the cabin by his wife, who cut off his frozen clothes and started a fire.

Friends awaiting their arrival grew anxious, and the Air National Guard was called. A Pavehawk helicopter–battling the same merciless weather–located the crash site, and ultimately reached them at the cabin. Even then, they could not be evacuated, as conditions grounded the rescue helicopter until morning. A friend flew a Piper cub–braving the same horrendous storm–to bring arctic sleeping bags and warm food. Bravery, love, and duty had spared their lives.

Months passed. Physical healing came quickly, but the rawness of heart wept like an open sore, gently salved by friends and faith, prayers and potlucks, tears and thankfulness. The boys were precious as never before, but the emptiness of heart left by a lost child cannot be filled. The rage at God passes–slowly–as strength flows from trust born of countless old decisions to set aside self and act in faith. But the memories remain–the laughter lost, the peace of a sleeping child, the love of a flower picked, the unexpected hug. There is no answer to “why?“–only time, and trust, and talk, and the tender whispering of a gentle Spirit. Yet one haunting regret refused to die: the vasectomy Jim had undergone after their last son–expeditious at the time, financially prudent–was now a self-imposed prison in a home filled with people, yet achingly empty.

And so they sat in my office, seeking my skills to restore what no man should be asked to provide–hope and happiness. And they told their story, my heart aching with each small detail disclosed. Jim was a man of enormous character and strength, his wife still bearing the unspeakable pain on her face–yet there was no shame in the tears that welled up in their eyes. As I gently probed deeper with almost unseemly curiosity, I was drawn in by the most remarkable revelation: these two would stand. Theirs was a strength not merely of hardiness, or training, or steely denial hiding a dying heart, but of power beyond the means of any mortal. They had faced the hell that men fear even to consider, and conquered it. There was glory in their weeping, victory in their agony. They would never be alone, and never be defeated. I, the proud expert, felt strangely insignificant in their presence.

The surgery went well, and early recovery smoothly. As I spoke with Jim before he left for home, he talked about the girls who had loved their daddy and whom he still loved so deeply. “You know, if I could fly to heaven and bring them back, they would not want to come. Their happiness is complete, ours still unfulfilled. Jesus has indeed brought them home.”

Killing Mercy

The ethics of euthanasia, which as an issue generally stays just barely on our radar screens, given the host of contentious social issues taking up our political and cultural bandwidth, nevertheless may ultimately prove to be an enormous dilemma, with profound impact on both our lives as a society and as individuals. While the issue has only occasionally nosed into the political limelight–usually associated with some initiative regarding physician-assisted suicide–the underlying currents which keep this matter very much alive are powerful and unlikely to be resolved easily or painlessly.

There is broad appeal for the idea of euthanasia. It seems to fit perfectly into our Western democratic principles of the autonomy of the individual, rights and freedom, and the desire to control our own destinies. It seems as well an ideal solution to an out-of-control health care system, where technology and advances in life-sustaining capabilities seem to have taken on a life of their own, driving health care costs to extraordinary levels in the final years of our life, and seemingly removing much of the dignity we believe should be the inherent right of the dying. Patient’s families watch helplessly as their loved ones appear to be strung along in their dying days, tubes and wires exiting from every orifice, a relentless train of unknown physicians and ever-changing nurses breezing in and out of their rooms to tweak this medication or that machine. We all wish for something different for ourselves as well as our loved ones, but seem to be incapable of bringing that vision to fruition.

Euthanasia offers what appears to be an ideal solution to many of these difficulties. We love the idea that the individual may choose the time and place of their own demise; we see an easy and painless exit to prolonged suffering; we visualize a measure of mastery returning to a situation where are all seems out of control; we see a solution to pointless expenditures of vast sums of money on patients with little or no hope of recovery. It is for these reasons that initiatives to legalize this process are commonly called “death with dignity” or some similar euphemism reflecting these positive aspects–and when put forward, often find as a result a substantial degree of public approval.

This appeal grows ever stronger as our culture increasingly emphasizes personal autonomy and de-emphasizes social responsibility. We are, after all, the captains of our own ship, are we not? A culture which believes that individual behavior should be virtually without limit as long as “no one is harmed” can see little or no rational reason why such individual autonomy should not be extended to end-of-life decisions.

The reality, unfortunately, is that “no one is harmed” is a uniquely inadequate standard for human behavior, and our autonomy is far less than we would like to believe. It assumes that human behavior occurs in a vacuum. Thus we hear that sexual relations between consenting adults are entirely reasonable if “no one is harmed”–a standard commonly applied to relationships outside of marriage, for example, which often end up having a profound and destructive effect both on the spouse–and particularly on the children. “No one is harmed” serves as mere justification for autonomous behavior while denying or minimizing the inevitable adverse consequences of this behavior. When Joe has an affair with Susie at the office, and ends up in divorce court as a result, there can be little question that many are harmed: Joe’s children, not the least; his wife; perhaps the husband and children of the woman with whom he has had an affair. Yet in the heat of passion, “no one is harmed” is self-evident–believed even if false. And to mention these obvious ramifications of a supposedly “harmless” behavior is to be “judgmental” and therefore must be assiduously avoided.

But the consequences are real, and their ripple effect throughout society is profound: to cite one simple example, children from broken homes are far more prone to become involved in gangs or crime, to be abused sexually or physically; to initiate early sexual activity and become unwed mothers; to under-perform academically, and to have greater difficulty with relationships as teenagers and adults. These effects–particularly when magnified on a society-wide scale–have effects vastly broader than the personal lives of those who have made such autonomous choices.

Similarly, an argument is often used by libertarians (and others) for drug legalization using this same hold-harmless rationale. After all, who could argue with personal drug use in the privacy of your home, since “no one is harmed?” No one is harmed, of course–unless the residual, unrecognized effects of your drug use affects your reflexes while driving the next day, resulting in an accident; or impairs your judgment at work, costing your employer money or resulting in a workplace injury; or when, in the psychotic paranoia of PCP use, you decide your neighbor is trying to kill you, and beat him senseless with a baseball bat; or when the drug itself, in those so physiologically prone, leads to addictive behavior which proves destructive not merely to the individual, but to family, fellow workers, and society as a whole. Burning up every spare dollar of a family’s finances to support a drug habit, and stealing to support it–surely not an unusual scenario–can hardly be qualified as “no one is harmed.” To claim that there is no societal impact from such individual autonomous behavior is profoundly naive, and represents nothing more than wishful thinking.

But what about euthanasia? Surely it is reasonable to end the life of someone who is suffering unbearably, who is beyond the help of medical science, and who has no hope of survival, is it not? This, of course, is the scenario most commonly presented when legalization of euthanasia is promoted. It should be stated without equivocation that such cases do indeed exist, and represent perhaps the most difficult circumstances in which to argue against euthanasia. But it should also be said that such cases are becoming far less common as pain management techniques and physician training in terminal care improve: in my experience, and in the experience of many of my peers who care for the terminally ill, is a rare occurrence indeed that a patient cannot have even severe, intractable pain managed successfully.

But the core arguments used in support of euthanasia in such dire circumstances are easily extended to other terminal situations–or situations not so very terminal at all. Intractable terminal pain merges seamlessly into hopeless prognosis, regardless of time frame; then flows without interruption to chronic diseases such as multiple sclerosis or severe disabilities. Once the principle of death as compassion becomes the guiding rule, the Grim Reaper will undergo metamorphosis into an angel of light, ready to serve one and all who suffer needlessly.

To mitigate the risk of this so-called “slippery slope,” it has been suggested that safeguards against such mission creep be crafted. Such measures may invoke mandatory second opinions, waiting periods, or committee review, prior to approval of an act of euthanasia. That such measures are ultimately doomed to fail is self-evident: in effect, they impose a roadblock between patient autonomy and relief of suffering and its amelioration through euthanasia–and thus run counter to the core principle sustaining it. It is not difficult to foresee that such roadblocks will quickly be made less “burdensome,” if not rendered utterly impotent, by relentless pressures to prevent patients from needlessly suffering, regardless of their underlying disease.

Perhaps more importantly, the process of assessing and approving an act of euthanasia through second opinions or committee review is not some ethically neutral decision, such as vetting budget items or inventory purchases. Those who serve in such advisory or regulatory capacity must by necessity be open to–indeed supportive of–the idea of euthanasia, lest all reviewed cases be denied. As demand for euthanasia increases, such approvals will become rubber-stamped formalities, existing solely to provide defensive cover for unrestricted assisted termination.

But such arguments against euthanasia are in essence process-oriented, and miss the much larger picture of the effects of individual euthanasia on our collective attitudes about life and death, and our societal constitution. There can be little question that the practice of actively terminating ill or dying patients will have a profound effect on the physicians who engage in this practice. The first few patients euthanized may be done in a spirit of compassion and mercy–but repetition deadens the soul and habitualizes the process. This is routinely seen in many areas of health care training and practice: the first cut of a novice surgeon is frightening and intimidating; the thousandth incision occurs with nary a thought. One’s first autopsy is ghoulish; the hundredth merely objective fact-finding. Euthanasia, practiced regularly, becomes simply another tool: this can be readily seen in the statistics from the Netherlands, where even 15 years ago, a startling percentage of reported cases of euthanasia by physicians took place without explicit patient request — reflecting far more a utilitarian attitude toward euthanasia than some diabolical conspiracy to terminate the terminal. The detached clinicians, utterly desensitized to the act of taking a life, now utilize it as they would the initiation of parenteral nutrition or the decision to remove a diseased gallbladder.

Such false assumptions about the objective impartiality of the decision-making process leading to euthanasia can be seen as well when looking at the family dynamics of this process. We are presented with the picture of the sad but compassionate family, quietly and peacefully coming to the conclusion that Dad–with his full assent, of course–should mercifully have his suffering ended with a simple, painless injection. Lost in this idyllic fantasy is the reality of life in families. Anyone who has gone through the death of a parent and the settlement of an estate knows first-hand the fault lines such a life crisis can expose: old grievances brought back to life, old hot buttons pushed, greed and avarice bubbling to the surface like a toxic witch’s brew. Does brother John want Dad’s dignified death so he can cop the insurance cash for his gambling habit? Does sister Sue, who hates her father and hasn’t spoken to him in years, now suddenly want his prompt demise out of genuine concern for his comfort and dignity? Are the children–watching the estate get decimated by the costs of terminal care–really being objective about their desire for Mom’s peaceful assisted death? And does Mom, who knows she’s dying, feel pressured to ask for the needle so she won’t be a burden to her children? Bitter divisions will arise in families who favor euthanasia and those who oppose it–whether because of their relationship, good or bad, with the parent, or their moral and ethical convictions. To make euthanasia the solution to difficult problems of death and dying, as suggested by its proponents, will instead require the death of our spirits: a societal hardness of heart whose effects will reach far and wide throughout areas of life and culture far beyond the dying process. Mercy killing will kill our mercy; death with dignity so delivered will leave us not dignified but degraded.

The driving force behind legalized euthanasia and physician-assisted suicide is patient autonomy: the desire to maintain control over the dying process, by which, is it hoped, we will maintain our personal dignity. But the end result of legalized euthanasia will instead, in many cases, be loss of patient autonomy. When legalized, medical termination of life will by necessity be instituted with a host of safeguards to prevent its abuse. Such safeguards will include restricting the procedure to those in dire straights: intolerable suffering, a few months to live, and the like. Inherent in these safeguards are the seeds of the death of patient autonomy: such determinations must rely on medical judgments–and therefore will ultimately lie in the hands of physicians rather than patients. It will be physicians who will decide what is intractable pain; it is physicians who will judge how long you have to live; it is physicians who will have the last say on whether your life has hope or is no longer worth living. Such decisions may well be contested–but the legal system will defer to the judgment of the health care profession in these matters. Patient autonomy will quickly become physician autocracy. For those who request euthanasia, it will be easy; for those who do not wish it, but fit the criteria, it will also be far too easy.

This has been the legal and practical evolution of euthanasia in the Netherlands. The legal progression from patient autonomy with safeguards to virtual absence of restrictions on euthanasia is detailed in a superb paper from Brooklyn Law School’s Journal of International Law (available here as a PDF), in which this evolution is detailed:

Soon after the Alkmaar case was decided, the Royal Dutch Medical Association (KNMG) published a set of due care guidelines that purported to define the circumstances in which Dutch physicians could ethically perform euthanasia.

The KNMG guidelines stated that, in order for a physician to respond to a euthanasia request with due care,

  • The euthanasia request must be voluntary, persistent, and well-considered.
  • The patient must suffer from intolerable and incurable pain and a discernible, terminal illness.

Thereafter, Dutch courts adopted the KNMG guidelines as the legal prerequisites of due care in a series of cases between 1985 and 2001. Despite the integration of the KNMG’s due care provisions, courts remained confused regarding what clinical circumstances satisfied the requirements of due care. In 1985, a court acquitted an anesthesiologist who provided euthanasia to a woman suffering from multiple sclerosis. The court thereby eliminated the due care requirement that a patient must suffer from a terminal illness. By 1986, courts decided that a patient need not suffer from physical pain; mental anguish would also satisfy the intolerable pain due care requirement.

Similarly, all reported prosecutions of euthanasia prior to 1993 involved patients who suffered from either physical or mental pain. Then, in the 1993 Assen case, a district court acquitted a physician who had performed active voluntary euthanasia on an otherwise healthy, forty-three year old woman. The patient did not suffer from any diagnosable physical or mental condition, but had recently lost both of her sons and had divorced her husband. With the Assen case, Dutch courts seemed to abandon the requirement that a patient suffer from intolerable pain or, for that matter, from any discernible medical condition as a pre-condition for the noodtoestand [necessity] defense.

The requisite ambiguity of all such safeguards will invariably result in their legal dilution to the point of meaninglessness–a process which increasingly facilitates the expansion not only of voluntary, but also involuntary euthanasia. This is inevitable when one transitions from a fixed, inviolable principle (it is always wrong for a physician to kill a patient) to a relative standard (you may end their lives under certain circumstances). The “certain circumstances” are negotiable, and once established, will evolve, slowly but inexorably, toward little or no standards at all. When the goalposts are movable, we should not be surprised when they actually get moved.

Another effect rarely considered by those favoring euthanasia is its effect on the relationship between patients and their physicians. The physician-patient relationship at its core depends upon trust: the confidence which a patient has that their physician always has their best interests at heart. This is a critical component of the medical covenant–which may involve inflicting pain and hardship (such as surgery, chemotherapy, or other painful or risky treatments) on the patient for their ultimate benefit. Underlying this trust is the patient’s confidence that the physician will never deliberately do them harm.

Once physicians are empowered to terminate life, this trust will invariably erode. This erosion will occur, even were involuntary euthanasia never to occur–a highly unlikely scenario, given the Dutch experience. It will erode because the patient will now understand that the physician has been given the power to cause them great harm, to kill them–with the full legal and ethical sanction of the law. And the knowledge of this will engender fear: fear that the physician may abuse this power; fear that he or she may misinterpret your end-of-life wishes; fear that he may end your life for improper motives, yet justify it later as a legal and ethical act. The inevitable occurrence of involuntary euthanasia–which in an environment of legalized voluntary euthanasia will rarely if ever be prosecuted–will only augment this fear, especially among the elderly and the disabled. In the Netherlands, many seniors carry cards specifying that they do not wish to have their lives terminated–a reflection of a widespread concern that such an occurrence is not uncommon, and is feared.

Montana judge: man has right to assisted suicide

Effects on physicians:

Helen

Effects on Physicians

PHYSICIAN-ASSISTED SUICIDE IN OREGON:
A MEDICAL PERSPECTIVE

A Life Not Long

sunset

Recently, I’ve been ruminating on a topic which a frequent topic online and elsewhere: the endless pursuit of a longer, or eternal, life.

Here’s the question I’ve been pondering: is it an absolute good to be continually striving for a longer life span? Such a question may seem a bit odd coming from a physician, whose mission it is to restore and maintain health and prolong life. But a recent article describing the striking changes in health and longevity of our present age, seemingly presents this achievement as an absolute good, and thereby left me a tad uneasy — perhaps because I find myself increasingly ambivalent about this unceasing pursuit of longer life.

Of course, long life and good health have always been considered blessings, as indeed they are. But long life in particular seems to have become a goal unto itself — and from where I stand is most decidedly a mixed blessing.

Many of the most difficult health problems with which we battle, which drain our limited resources, are largely a function of our longer life spans. Pick a problem: cancer, heart disease, dementia, crippling arthritis, stroke — all of these increase significantly with age, and can result in profound physical and mental disability. In many cases, we are living longer, but doing so restricted by physical or mental limitations which make such a longer life burdensome, both to ourselves and to others. Is it a positive good to live to age 90, spending the last 10 or more years with dementia, not knowing who you are nor recognizing your own friends or family? Is it a positive good to be kept alive by aggressive medical therapy for heart failure or emphysema, yet barely able to function physically? Is it worthwhile undergoing highly toxic chemotherapy or disfiguring surgery to cure cancer, thereby sparing a life then severely impaired by the treatment which saved that life?

These questions, in some way, cut to the very heart of what it means to be human. Is our humanity enriched simply by living longer? Does longer life automatically imply more happiness–or are we simply adding years of pain, disability, unhappiness, burden? The breathlessness with which authors often speak of greater longevity, or the cure or solution to these intractable health problems, seems to imply a naive optimism, both from the standpoint of likely outcomes, and from the assumption that a vastly longer life will be a vastly better life. Ignored in such rosy projections are key elements of the human condition — those of moral fiber and spiritual health, those of character and spirit. For we who live longer in such an idyllic world may not live better: we may indeed live far worse. Should we somehow master these illnesses which cripple us in our old age, and thereby live beyond our years, will we then encounter new, even more frightening illnesses and disabilities? And what of the spirit? Will a man who lives longer thereby have a longer opportunity to do good, or rather to do evil? Will longevity increase our wisdom, or augment our depravity? Will we, like Dorian Gray, awake to find our ageless beauty but a shell for our monstrous souls?

Such ruminations bring to mind a friend, a good man who died young. Matt was a physician, a tall, lanky lad with sharp bony features and deep, intense eyes. He was possessed of a brilliant mind, a superb physician, but left his mark on life not solely through medicine nor merely by intellect. A convert to Christianity as a young adult, Matt embraced his new faith with a passion and province rarely seen. His medical practice became a mission field. His flame burned so brightly it was uncomfortable to draw near: he was as likely to diagnose your festering spiritual condition as your daunting medical illness — and had no compunction about drilling to the core of what he perceived to be the root of the problem. Such men make you uneasy, for they sweep away the veneer of polite correction and diplomatic encouragement which we physicians are trained to deliver. Like some gifted surgeon of the soul, he cast sharp shadows rather than soft blurs, brandishing his brilliant insight on your now-naked condition. The polished conventions of medicine were never his strength — a characteristic which endeared him not at all to many in his profession. But his patients — those who could endure his honesty and strength of character — were passionate in their devotion to him, personally and professionally. For he was a man of extraordinary compassion and generosity, seeing countless patients at no charge, giving generously of his time and finances far beyond the modest means earned from his always-struggling practice.

The call I received from another friend, a general surgeon, requesting an assist at his surgery, was an unsettling one: Matt had developed a growth in his left adrenal gland. His surgery went deftly, with much confidence that the lesion had been fully excised. The pathology proved otherwise: Matt had an extremely rare, highly aggressive form of adrenal cancer. Fewer than 100 cases had been reported worldwide, and there was no known successful treatment. Nevertheless, as much for his wife and two boys as for himself, he underwent highly toxic chemotherapy, which sapped his strength and left him enfeebled. In spite of this, the tumor grew rapidly, causing extreme pain and rapid deterioration, bulging like some loathsome demon seeking to burst forth from his frail body. I saw him regularly, although in retrospect not nearly often enough, and never heard him complain; his waning energies were spent with his family, and he never lost the intense flame of faith. Indeed, as his weakened body increasingly became no more than life support for his cancer, wasting him physically and leaving him pale and sallow, there grew in him a spirit so remarkable that one was drawn to him despite the natural repulsion of watching death’s demonic march.

Matt died at age 38, alert and joyful to the end. His funeral was a most remarkable event: at an age in life where most would be happy to have sufficient friends to bear one’s casket, his funeral service at a large church was filled to overflowing — thousands of friends, patients, and professional peers paying their respects in a ceremony far more celebration than mourning. There was an open time for testimony — and such a time it was, as one after another took to the lectern to speak through tears of how Matt had touched their lives; of services rendered, small and large, unknown before that day; of funny anecdotes and sad remembrances which left few eyes dry, and not one soul of that large crowd untouched or unmoved.

A journey such as his casts critical light on our mindless pursuit of life lived only to endure longer. In Matt’s short life he brought more good into the world, touched more people, changed more lives, than I could ever hope to do were I to live a century more. It boils down to purpose: mere years are no substitute for a life lived with passion, striving for some goal greater than self, with transcendent purpose multiplying and compounding each waking moment. This is a life well-lived, whether long or short, whether weakened or well.

Like all, I trust, I hope to live life long, and seek a journey lived in good health and sound mind. But even more — far more indeed — do I desire that those days yet remaining — be they long or short — be rich in purpose, wise in time spent, drenched in prayer, and graced by love for others and for God.

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.

Revolution of the Soul

In the past several days, through the lens of my profession, I have been given a rather stark and disturbing vision of our current cultural revolution. It is, it seems, a revolution every bit as pervasive and transformational — and destructive — as China’s Cultural Revolution of the 60s — and indeed may be but a different manifestation of a global transformation which transpired in those very same decades in the West. Ideas have consequences, as they say, and we are watching them bear fruit before our very eyes in a slow-motion train wreck which seems now to be accelerating at a disturbing rate.

Exhibit 1: Phyllis Chesler’s recent piece, “Every hospital patient has a story“, at PajamasMedia. It is a piece to be read to completion, including its lengthy comment section. Therein she details a recent experience during a hospital stay for a hip replacement, with a rather remarkable litany of rudeness, neglect, indifference, and suffering sustained at the hands of her healers, at an upscale New York hospital. Her story is shocking enough, and revelatory; the comments provide even further insight, running the expected gamut of such a piece in the New Media. There are those simply shocked; those sharing similar horror stories; those relaying far better experiences in contrast; those defending doctors and nurses, those attacking them. There is the obligate wackjob who blames the AMA, and the usual finger-pointing: not enough nurses, too much paperwork, inadequate pay scales to draw quality; the evil insurance companies and the government. All mostly true, to greater or lesser degree — but all missing the core dysfunction by a wide mark. At the final period of her post, one comes away with a sense of hopeless, feeling out of control and angry, despairing that such a situation may be even a part of our reality (and not knowing how large a part it may be), yet at a loss to prevent its malignant progression through our remaining hospitals which may have been spared to date, the encroachment of such a toxic stew of callousness, indifference, and coldness. There seems, in the end, little cause for optimism.

Exhibit 2: It is late, nearly 9 P.M., seeing a final consult at the end of a punishing call day, in the ICU. The patient, chronologically young yet physiologically Methuselan, lies in his bed, oxygen mask affixed to his face by heavy straps, bleeding, as he has for months, from a tumor in his kidney. He would not survive surgery, nor even radiological intervention to stem the hemorrhage by strangling its arterial lifeline. He is, furthermore, in the parlance of modern medicine, “non-compliant”: refusing treatments and diagnostic studies; rude and abusive to nurses and physicians alike; demanding to go home though unlikely to survive there for any significant length of time.

The nurse — young, competent, smart, hard-working, the very best of the modern nursing profession — apprises me of his situation, closing with this knockout punch: “You know, we just passed that initiative — you know, the suicide one. He’d be an excellent candidate.”

She wasn’t joking.

Taken a bit off guard, I responded that it is most unwise to give physicians the power to kill you, for we will become very good at it, and impossible to stop once we are.

She continued: “No, I would love to work for a Dr. Kevorkian. Be an Angel of Death, you know?”

“I know”, I muttered under my breath, as she ran off to another bedside, competently and with great efficiency, to adjust some ventilator or fine-tune some dopamine drip. And hopefully do nothing more.

These vignettes in modern medicine are really not about medicine at all. They are in truth about a culture which has lost its compassion. Our calloused and cynical society has become a raging river fed by a thousand foul and fetid streams. We have, by turns, taught our children that ethics are situational and values neutral; taught our women that compassion and service are signs of weakness, that they must become hard and heartless like the men they hate; taught our men that success and the respect of others comes not through character and integrity but through callousness, cynicism, and greed; and taught ourselves that we are a law unto ourselves, the sole and final arbiter of what is right and what is good.

We have, in our post-modern and post-Christian culture, inexorably and irrevocably turned from our roots in Christian morality and worldview, which was the foundation and font of that which we now know — or used to know — as Western Civilization. Yes, we have preserved the tinsel and the trappings, the gilded and glittering exterior of a decaying sarcophagus, where we speak self-righteously of rights while denying their origin in the divine spark within the human spirit, made in the image of God; where we bray about liberty, but are enslaved to its bejeweled impostor, the damsel of decadence and libertinism; where compassion is naught but another government program to address the consequences of our own aberrant and irresponsible behavior, duly justified, rationalized, and denied. Others must pay so that I may play, you know.

This toxic stew of self-centered callousness has percolated into every pore of our society. In health care, the effects are universal and pernicious. Patients demand perfection, trusting the wisdom of a web browser over the experience of a physician — then running to their attorney to redress every poor outcome which their disease or their destructive lifestyles have helped bring about. Physicians, hardened and cynical from countless battles with corrupt insurance companies, lawyers, and Stalinist government regulation, forget that they exist solely to serve the patient with compassion and self-sacrifice, and that financial recompense is secondary to healing and empathy. Nurses have in large measure become administrators, made ever more remote from their patients by mountains of paperwork and impossible nurse-to-patient ratios, their patient-critical tasks delegated to underlings poorly trained and ill-treated. Hospital administrators are MBAs, with no interest or clue about what constitutes good health care, and are indifferent so long as their departments are profitable and their marketing wizards successful as they trumpet “Care with Compassion” in TV ads, radio, and muzac on hold.

The list could go on far longer, but the theme is clear: we have as a culture become utterly self-focused, trusting no one, demanding our rights while neglecting our responsibilities, seeking to be profitable rather than professional. We have abandoned the responsibility to be patient and caring of others, forgiving of human shortcomings and humble about the limits of our abilities — a responsibility not merely of those in health care but of human beings in civil society. We have, through the dubious gift of extraordinary technological advances, industrialized our profession, and replaced a sacred covenant of commitment to the patient’s best — and its corollary of the patient’s trust in the integrity and motives of physicians and nurses — with the cold legality of contract medicine. Small wonder we are treated as fungible commodities in doctors’ offices and hospital beds. Small wonder we will be euthanized when we have exhausted our compassion quotient, dispatched by highly efficient providers delivering “Death with Dignity.”

This utter self-obsession and cynical callousness is by no means limited to health care. We long for “bipartisanship” in government (by which we hope for reasoned men of principle to come together for the good of those they represent), but get instead the blood-lust of modern politics, where power trumps principle, money is king, and votes are bought and sold like chattel. Lawyers sue everything that breathes — and much that doesn’t — raking in billions while their “victimized clients” get pocket change they can believe in. Airlines pack in passengers like cattle, lose your bags, and toss you a bag of peanuts for your trouble. Road rage is rampant, rudeness rules, rip-offs too common to count. The coarseness in culture is extraordinary — in language, art, media, fashion, and behavior. It is revealing how shocked we find ourselves when encounter someone — regardless of the venue — who is actually pleasant, helpful, courteous, and kind; we have come to expect and tolerate far worse as a matter of course.

The revolution which started in the 60s with the “me” generation is bearing its bitter fruit — though its aging proponents will never admit it. And sadly, there’s no going back: the changes which have infiltrated and infected the culture, inoculated through education, media, entertainment, scientific rationalism, and a relentless and highly successful assault on reason and tradition, are permanent, and their consequences will only grow in magnitude.

So it’s time for a counter-revolution.

There is an alternative to our current cultural narcissism with its corrosive, calloused, destructive bent. It is not a new government program, nor a political movement; no demonstrations in the street, no marches on Washington. Its core ideology is over 2000 years old, and the foot soldiers of the revolution are already widely dispersed throughout the culture.

This revolutionary force is called Christianity, and it’s long past time to raise the banner and spring into action.

The true antidote to the nihilism and corruption of the age will be found, as it has always been, in the church. It has since its inception been a revolutionary force, transforming the hopeless and purposeless anarchy of the pagan world of its infancy by bringing light, hope and joy where there was none before.

It can happen again.

The church, of course, has to no small degree been co-opted by the culture it should have transformed. From TV evangelists preaching God-ordained health and wealth to liberal denominations rejecting the core truths of their foundation and worshiping instead the god of government and humanistic socialism; from pederast priests to episcopal sodomy, Christianity in the West has whored itself to a prosperous but decadent culture. Its salt has lost its saltiness, and it has, not surprisingly, been trampled underfoot by men.

It is time to return to our First Love. It is time once again to become light to an dark and stygian world. It is time for a revolution of the soul.

We must, first and foremost, be about grace and truth. We must begin with the truth of our calling: to be holy, transformed by the power of Christ and the work of the Spirit. We are, by nature of our new birth in Christ, His ambassadors: we are to be the face, the hands, the heart, the words, the compassion of Him who saved us.

The task is enormous, yet for each of us, the steps are small, easily achievable yet enormously powerful.

It must begin with a renewed commitment to obedience and submission to Christ, a willingness to fully subject ourselves to His will, rather than trying to bend His will to ours. It means getting serious about church attendance — not merely as a consumer but as an active participant. We need to renew our devotion to prayer, to Scripture reading, study, and memorization, to fellowship with other Christians. These are simple steps which ground us in truth, and give us access to that power which can first of all transform us, then radiate out to all around us.

Then we must act like the counter-culturists we claim to be. Be patient with those who are difficult; be generous in time and money; express gratitude to those around us (when was the last time you wrote a thank you note to your doctor, your contractor, your attorney, to the manager of the store employee who helped you?). Lose the profanity; guard your tongue. Repair broken relationships, as best you can. Be joyful in difficult times, knowing that God is at work in your life despite your difficulties. Be compassionate rather than judgmental to those whose life choices are destructive or misguided. The tattoos and piercings we ridicule are cries of desperation from those hungering for purpose and meaning.

These things will not come easily to many of us who claim to be Christians, as we have become complacent in our self-gratification and comfortable compromises, fearful of being viewed as extremist or weird, rejected and ridiculed.

Get over it.

You may just find that such renewed passion for Christ and love for others might, just might, transform your life.

And you might just find that it will change the world.

Got a better idea? Good, I didn’t think so.

Let’s get started.

The Bounty Hunter


I’ve been feeling a bit remiss (but only a bit) about my light posting of late — but hey, it’s summertime, and if Vanderleun can take a vacation, well, why not me?

But of course there’s always something which comes up, which demands some comment — such as this little blurb in the Wall Street Journal today:

Medicare Auditors Recover $700 Million in Overpayments

 
Auditors have recovered nearly $700 million in Medicare overpayments to hospitals and other medical providers in a half-dozen states under a controversial program that pays the auditing firms a portion of amounts they identify.

The program has drawn fire from health-care providers, and hospitals in particular, who call it overly aggressive and too confrontational. But the federal Centers for Medicare and Medicaid Services has supported the move and is in the process of expanding it nationally.

In all, the agency’s recovery audit contractor program caught $1.03 billion of improper payments over about three years, primarily in New York, California and Florida, about $992.7 million of which was overpayments by Medicare. The audits also identified about $38 million that providers should have received but didn’t. (Three states were added toward the end of the trial program, but accounted for only a small part of the recoveries, Medicare officials said.)

The program’s expenses amounted to about 20 cents on the dollar, including $187.2 million paid to the audit firms, and medical providers successfully challenged about $60 million of overpayments identified by the auditors. In the end, about $694 million has been returned to the Medicare trust funds, the Medicare agency said. The auditors reviewed a total of $317 billion in claims.

“All in all, we’re very happy with the results,” said Tim Hill, the agency’s chief financial officer and director of its office of financial management. “It returned a lot of money to the trust fund, particularly when you think that we’re talking about three states.”

I’ll bet you’re very happy, Mr. Hill.

Now, at first glance, this would appear to one of Medicare’s already notorious fraud and abuse investigations, carried out by OIG, but no — there’s no accusation of fraud involved here, although the government is more than happy to let this implication stand.

What this involves is demanding refunds based on different interpretations of Medicare’s mind-boggling regulations. So you provide a health care service, and bill Medicare based on your best understanding of its Byzantine regulations, and get paid. Then, at some future date, a third-party auditor, hired by the Feds, reviews the claim and decides — with no input from clinicians or other health care experts — that you were paid in error. Out goes the notice, pay up or else. Of course, this is always a highly objective, impartial review — the fact that the auditor gets a hefty cut of the refund has absolutely no influence on their judgment, none whatsoever.

Of course, you have a right to appeal — on your own dime and time, hiring your lawyers and taking time off from your practice to prove to the bounty hunter that your interpretation of the regulations is the correct one, and his is wrong. If you win, you get to keep the cash you already earned — minus a small stipend for lost time and lawyers fees. So, on that disputed $35 you got for an office call, you might come out, oh, $20,000 short, give or take a few thousand. But hey: You won!! Ain’t it grand?

Of course the low rate of appeals, entirely predictable based on the above freakonomics, is seen as proof that the audits are finding real problems:

Mr. Hill pointed to the low appeal rate — about 14% of overcharges were appealed, and 4.6% of the total were overturned — as evidence that the audits succeeded. “We know that we got the right answer,” he said.

If an 800-pound gorilla wants to make love to you, it’s always best to fake an orgasm. And the luvin’ ain’t over ’till the gorilla says it’s over…

Of course, these auditors also expend large amounts of time and energy looking for cases where you were underpaid:

RACs [Recovery Audit Contracts] are authorized to review payments for the previous 4 years. The software they use is more capable of picking up overpayments than it is underpayments. This discrepancy is borne out by a CMS report showing that 97% of improper payments in fiscal year 2006 were overpayments, and only 3% were underpayments. No money has been reported as having been returned to physicians because of underpayment.

At this point, the program has been primarily focused on hospitals in a few states, but is being rolled out nationwide, and will quickly be auditing physicians and other health care providers.

I have spoken a considerable length about the maze which is our current reimbursement system. It makes perfect sense, in a way, for the Feds to do exactly this: use bounty hunters to exploit the system’s complexity and inscrutability. They will no doubt recover a bundle of money, keeping the band playing on the Titanic for a few more years.

But sooner or later there’ll be a price to be paid — and that price is access. Repeated pay cuts such as the currently stalled 10.4% Medicare fee reduction being bantered around Congress, combined with heavy-handed recovery audits such as these, will drive physicians to the exits in droves. It is already nearly impossible in our area to find a primary care physician who accepts Medicare patients; a few more years of this B.S. and you’ll likely get a pretty clean sweep: best of luck finding anyone who will see you if you have Medicare or any other Federal health insurance.

Happy hunting on your audits, Mr. Hill.

Crossing That Dark River

Often in the sturm und drang of a world gone mad, there comes, through the chaos and insanity, some brief moment of clarity. Such times pass by quickly, and are quickly forgotten — as this brief instance might have been, courtesy of my neighboring bell weather state of Oregon: (HT: Hot Air)

Last month her lung cancer, in remission for about two years, was back. After her oncologist prescribed a cancer drug that could slow the cancer growth and extend her life, [Barbara] Wagner was notified that the Oregon Health Plan wouldn’t cover it.

It would cover comfort and care, including, if she chose, doctor-assisted suicide.

… Treatment of advanced cancer meant to prolong life, or change the course of this disease, is not covered by the Oregon Health Plan, said the unsigned letter Wagner received from LIPA, the Eugene company that administers the plan in Lane County.

Officials of LIPA and the state policy-making Health Services Commission say they’ve not changed how they cover treatment of recurrent cancer.

But local oncologists say they’ve seen a change and that their Oregon Health Plan patients with advanced cancer no longer get coverage for chemotherapy if it is considered comfort care.

It doesn’t adhere to the standards of care set out in the oncology community, said Dr. John Caton, an oncologist at Willamette Valley Cancer Center.

Studies have found that chemotherapy can decrease pain and time spent in the hospital and increases quality of life, Caton said.

The Oregon Health Plan started out rationing health care in 1994.

We have, at last, arrived. The destination was never much in doubt — once the threshold of medical manslaughter had been breached, wrapped as always in comforting words of compassion and dignity, it was only a matter of time before our pragmatism trumped our principles. Once the absolute that physicians should be healers not hangmen was heaved overboard, it was inevitable that the relentless march of relativism would reach its logical port of call.

Death, after all, is expensive — the most expensive thing in life. It was not always so. In remote pasts, it was the very currency of life, short and brutal, with man’s primitive intellect sufficient solely to deal out death, not to defer it. There followed upon this time some glimmer of light and hope, wherein death’s timetable remained unfettered, but its stranglehold and certainty were tempered by a new hope and vision of humanity. We became in that time something more than mortal creatures, something extraordinary, an unspeakable treasure entombed within a fragile and decomposing frame. We became, something more than our mortal bodies; we became, something greater than our pain; we became, something whose beauty shown through even the ghastly horrors of the hour of our demise. Our prophets — then heeded — triumphantly thrust their swords through the dark heart of death: “Death, where is your victory? Death, where is your sting?” We became, in that moment, something more than the physical, something greater than our short and brutish mortality. We became, indeed, truly human, for the very first time.

That humanity transcended and transformed all that we were and were to become, making us unique among creation not only in the foreknowledge of our death, but our transcendence of death itself. Life had meaning beyond the grave — and therefore had far more weight at the threshold of the tomb. Suffering became more than mere fate, but rather sacrifice and purification, preparation and salvation. The wholeness of the soul trumped the health of the body; death was transformed from hopeless certainty to triumphant transition.

But we knew better. We pursued the good, only to destroy the best. We set our minds to conquer death, to destroy disease, to end all pain, to become pure and perfect and permanent. We succeeded beyond our wildest dreams. The diseases which slaughtered us were themselves slayed; the illnesses which tortured and tormented us fell before us. Our lives grew long, and healthier, more comfortable, and more productive. Our newfound longevity and greater health gave rise to ever more miracles, allowing us to pour out our intemperate and precipitous riches with drunken abandon upon dreams of death defeated.

Yet on the flanks of our salient there lay waiting the forces which would strangle and surround our triumphant advance. Our supply lines grew thin; the very lifeblood of our armies of science and medicine, that which made our soldiers not machines but men, grew emaciated and hoary, flaccid and frail. We neglected the soul which sustained our science; the spirit which brought healing to medicine grew cachectic and cold.

So here we stand. We have squandered great wealth to defeat death — only to find ourselves impoverished, and turning to death itself for our answers. The succubus we sought to defeat now dominates us, for she is a lusty and insatiable whore. We have sacrificed our humanity, our compassion, our empathy, our humility in the face of a force far greater than ourselves, while forgetting the power and grace and the vision which first led us and empowered us on this grand crusade. Our weapons are now turned upon us; let the slaughter begin.

We will, no doubt, congratulate ourselves on the wealth we save. We will no doubt develop ever more ingenious and efficient means to facilitate our self-immolation while comforting ourselves with our vast knowledge and perceived compassion. Those who treasure life at its end, who find in and through its suffering and debilitation the joy of relationships, and meaning, and mercy, and grace, will become our enemies, for they will siphon off mammon much needed to mitigate the consequences of our madness.

It has been said, once, that where our treasure is, there will our heart be also. We have poured our treasure in untold measure into conquering death — finding succor in our victories, while forgetting how to die. The boatman now awaits us to carry us across that dark river — and we have insufficient moral currency to ignore his call.

Cinnamon Boy

cinammon

I wanna live
with a cinnamon girl
I could be happy
the rest of my life
With my cinnamon girl.

    — Neil Young
 
You can’t make this stuff up, really…

Joe is an old patient, been seein’ him since I started practice some 25 years ago. Nice guy, but a little — shall we say? — quirky. Big into herbs and alternative medicine, sees a naturopath who performs prostate massage on him until it stops hurting (or death, whichever comes first). Has some chronic prostatitis, and his love life leaves much to be desired — especially since his Asian concubine left him hanging, taking all of her magic potions with her.

“The thrill is gone,” as B.B. King would say.

So he comes in for his annual checkup.

“How ya’ doin’, Joe?”

“Pretty well, although my prostate still burns at times.”

“Been on any antibiotics for that?”

“Naw, don’t take those things, you know. Too toxic. But I did try another treatment.”

“Do tell.”

“Well, you know that cinnamon has healing powers.”

“Didn’t know that.”

“Yeah, I had a stubborn rash on my leg, and it cleared up after using cinnamon on it.”

“Interesting.”

“So I decided to try it for my prostate.”

Gulp. “How’d … you do that?”

“Well, I filled up a condom with it, and put it on, and worked it into the opening.”

Reflexly, I cross my legs, holding his chart tightly on my lap.

“How’d that go?”

“Hurt like hell!”

Ya think?

“Did it help any?”

“No — and I don’t think I’m gonna try it again. But I’ve got some other ideas…”

Perhaps next time he should blend it with sugar and berries, and make a tart…