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.
16 thoughts on “The Crush of Covenant”
very well written and entertaining
As a fellow doc, I feel your pain. (I’m one of those evil ER guys ;-) Don’t despair. Realize that you are doing God’s work when you care for the sick and injured. A day off or two wouldn’t hurt though—-of course, when you need one the most, they are the hardest to take.
What a nightmare! Thank goodness you can blog. Without this outlet you might be at risk for doing something destructive.(fwiw, I learned something new. Never heard of a prosthetic urinary sphincter. What will they think of next? The idea of a catheter for men makes me cringe anyway. Female anatomy has to be a less challenging proposition.)
My mother’s funeral was two days ago following a mercifully quick stay in hospice protocol at the nursing home which was her home for the last year. I never dreamed she would be cared for in such an excellent facility. The difference between her care and what you described may be it’s nonprofit status. There were no ads for this place. I’m sure we found it through Divine intervention.
Every time you mentioned insurance I got frustrated. The more I think about it the more I hate how insurance companies ration health care. Even in my Mom’s case the only glitch derived from insurance and she was a Medicaid client! Long story, but true. I’ll tell about it some time. Let’s hope the insurance problems can be resolved soon before we all go crazy.
Like all covenants, there’s a blessing and a curse…
…poor theology in this circumstance, maybe; perhaps if you recall the “suffering for gooding good”?
A rich reward.
Sigh. that would be “doing good”. It’s been one of those days…
I am dating a doctor’s daughter and have heard quite a few horror stories about the medical field. He has owned his own practice in a small Kansas town for about 17 years now. The expenses are insane! All the overhead plus insurance companies screwing you over left and right. It’s no wonder people can’t afford medical care.
Then of course incompetent medical staff. Doc has been fortunate to have had an excellent staff over the years but I have heard of a number of real jerks out there. Sadly, most of them worked at nursing homes. What a horrible place to “dump” our loved ones.
Thanks for your story. It is really entertaining.
couldn’t agree more. Buddy, hey. I feel your pain. And I am a solo doc. I just hope you can deal with it, and continue to fight the fight with those nimrods in their high rises, who give ‘expert review’ (and in truth- judicial power) over your decisions as a health care provider. I wish you luck.
Excellent, well-written article. Many thanks to this physician, and those like him, who persevere daily through myriad tasks and frustrations to deliver the best medical care they can. Keep fighting the fight–we owe our lives, and our thanks, to each and every one of you.
And we truly want national healthcare? I don’t think so. The problem is lack of competition for insurance coverage and the destruction of the covenant between patient and doctor thanks to all the gatekeepers. By the way, where is the family of the nursing home patient?????
Thanks for this post. I will pray that God continue to sustain you and encourage you as you serve your patients. I am sure you are a blessing to them, so try to endure anyway. I always love the Mother Theresa prayer about “do it anyway…”
My husband and I have had to battle nursing homes over the appalling medical care for a grandmother, and three parents and hospital visits for many other elderly relatives and we can relate to all you describe. However, we also had our share of having to stay in the hospital with them just to be sure they got bedpans, drinks, meds on time, etc. It is barbaric that with all the cant of families being allowed in the hospital, all it really is about is lightening the load on the nursing staff who are swamped with paperwork. The lucky ones with loving family may get cared for. But the ones without get ignored. Particularly if demented, or demanding or perceived as unpleasant or a hopeless case.
Our internist of 18 years up and actually quit because of just such as you describe. A year later, the replacement one I found (I am healthy, so it is just in case one of those middle aged test results come out badly some day) has also quit for similar reasons. Our family has now given up and will just go to the ER if we get sick. Despite having insurance. From the patient’s perspective, one wants a long term relationship with a physician so that when one is truly ill they are better able to treat. Seems quaint nowadays.
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