Hospital Billing and Insurance

The prompt for this next clinical reflection meeting at school was the following: To what extent are physicians' values and decisions responsible for the cost of health care, and what responsibility do we have to control costs? How cost-conscious have the physicians you have worked with been, and what rolled does financial stewardship have in the professional responsibilities of physicians? 

But like so many other things, I was still angry about dropping $175 at Walgreens the other day for 3 vials of lantus and two boxes of test strips, so I had trouble focusing:

I think it is fundamentally irresponsible to be a physician unaware of the costs of medicine and health care services. That being said, a lot of physicians don't want to worry themselves with the details. Have I ever worked with a physician who seemed to understand how much things cost for patients? Not really. No. But consider this: how many physicians actually have chronic illnesses? How many doctors are on a ton of prescriptions at any one time?

Out of Bounds

I’ve never been a huge fan of babies. Toddlers are cute and "children are our future", but neonates are really boring. In comparison with other newborns of the mammalian order, human babies are completely useless. Utterly useless… 30 days in and they can only coo? And they don’t start speaking intelligible words for at least 270 days? Not impressed.

But several weeks ago, a patient on the floor was a five month old and she was puffy-cheeked, bright-eyed, and adorable. A complicated perinatal period had ensured that she would require intensive additional medical attention indefinitely, and now she was back in the hospital with r/o aspiration pneumonia after a two week reprieve at home.

At five months of age, she was operating at a one to two month old level. There was no social smile, no babbling of words, no raking grasp. But she was able to grip my pointer finger whenever I placed it near her palm, and I thought that was a good sign. I spent a lot of time with this baby. Partially because I was trying to figure out what milestones she had missed as a way of quizzing myself on infant behavior, but mostly because she was adorable.

And I never saw the parents. For an entire week I watched this baby--rotating her head to help her plagiocephaly; baby talking at her so she could hear words; setting her on her stomach for tummy time to develop motor skills; smiling into her face so she could see facial expressions. And I never once saw the parents.

I checked in her files to figure out her family story. Several young children at home, maybe they weren’t ignoring her. Maybe they weren’t bad parents.

But I still worried. It’s weird how attached one can be to a thing that never smiles. And I wanted to guarantee her safety. I wanted to tell people about my frustrations and my fears for how this baby might grow up. But who would I tell? And in a hospital full of sick kids, was this kid any more special than anyone else? 

Yes. Of course. She was my patient. I was her hospital guardian. Every minute of free time I had on the wards I'd gown up, put my gloves on, and hold her hand while I tried to get her to smile.

Miraculously, somehow, I finally met the parents. Or rather, the patient did. They were a flurry of excitement as they entered the room, mother and father and brother. And suddenly her face was being kissed and her mother was pulling out tiny matching outfits from a shopping bag for her to try on before she was discharged home.

I was fortunate this time. This baby was going to be a burden on this family--no question. But this family had a lot of something that I wish I had seen more of as a child: love. I no longer felt a need to voice my concerns. But I wonder how distant I’ll be able to keep myself the next time I see a patient in need of more than just medical care.

Stereotypes in Medicine

It’s unfortunate that I want to go into family medicine, because I think the stereotypes about family practitioners are often times nonsensical. But I suppose it’s also good that both of my parents are kind, friendly surgeons, so stereotypes about medicine’s specialties don’t really hold true for me and my family. 

So surgery often gets stereotyped as being full of jerks. And while I think there are a lot of surgeons who seem to have an unnecessary and occasionally dangerously elevated sense of self-worth, you find that in other specialties, too, so I don’t think it’s terribly accurate.

Internal medicine people are obnoxious. It’s like they’ve convinced themselves that what they are doing is interesting, even though they’re stuck in a hospital all day dealing with dying people.

I want to say people going into radiology, ophthalmology, and dermatology are all terrible people who are in it for the money instead of really helping people. But that’s not true. And everybody’s idea of help is different. I don’t know why they’re interested in their fields, but technically, someone’s got to do it.

Emergency Medicine is full of hipsters. I don’t know how this happened, but it’s pretty accurate. People who are hipsters, people with ADHD, and people who get bored easily. As for their personalities, they’ve got their jerks and their saints, too.

Psychiatrists are indeed crazy. But I think that’s because if you have a mental illness yourself, dealing with medical students and physicians in other fields gets incredibly taxing. If I hear one more person reduce major depression to a simple affair that people should be able to handle without medicine, I may start applying to psychiatry residencies right then and there.

Neurology is full of people who are more emotionally stable than psychiatrists, but are still very, very weird. But understandably so. Like more professional psychiatrists. Or just more stuffy.

I like pediatricians. But I wouldn’t say they’re the nicest people in the world. Kids are just more tolerable than most other patient populations, so it’s easier for them to look happier while they work. Whether they are or not, nobody knows.

Obstetricians and Gynecologists are exactly like surgeons. Who will occasionally smile at patients because their patients are neonates.

And that pretty much covers it. Does this effect what I want to go into? Not really. It just makes me louder about defending my choice to go into family medicine, which most people seem to think is incredibly boring, despite the fact that, to me at least, it seems almost as exciting as emergency medicine (when you remove trauma cases) while also including continuity of care.

And to me at least, being a doctor means being a family physician. All other fields just add complexity—necessary or not—to the medical field.

Death, Dying, and A Defense Mechanism

So our school often has us write silly things to talk about our feelings. Which is dumb, since I no longer have any (a lie, but I don't seem to have any today). But sometimes they help me write random things for this blog, like Fixed and Dilated. Anyway, here was the prompt:

 Write about your interactions with a patient who died or was very ill. What sources of inspiration did you find in caring for this patient? How did your team manage the patient’s and the family’s  hope in the face of a poor prognosis or outcome?

And here was my response:

I’ve taken care of a lot of patients that later died.

And now that I think about it: I didn’t do anything special to comfort any single one of them. Because death is a terrible thing, and I wouldn’t want to share my last few days on earth being “comforted” by a medical student. So no, I haven’t actually jumped up to volunteer to annoy someone and their beleaguered family in their last days of life.

[Also, we haven’t been taught how to deal with death, right? Because that wasn’t a lecture and I’m not comfortable dealing with it now.]

But back to me thinking about how I’d want to die…. if I’m still mentally alert, I think I’d want two things: as many pain meds and anti-anxiolytics as I can tolerate and to be surrounded by my closest friends andall my living family members. I also wouldn’t want to be in a frickin’ hospital, but the odds are in favor of that so I guess I should start preparing now. One could make the argument that as you get older, and if you’re dying of a slowly progressive disease, your psychology changes to accept death, which is something I haven’t had to do yet as a “healthy” twenty-something. But I think that’s dumb. I had a patient tell me he was superman, that he was going to somehow defeat/prolong his battle with metastatic prostate cancer—and then I sat outside his hospital room and listened to his freshly-minted widow cry when he died five weeks later.

And I did nothing.

I could only find comfort in the fact that I had at one time spent a good thirty minutes with the patient explaining why we were holding him in the hospital overnight those five weeks earlier. But now I’m not sure if my need to talk through disease processes and hospital operations to the patients and their families is my way of comforting or just the defense mechanism of intellectualization. Because I have nothing to say. You’re going to die. I wish I could do something. I wish we could keep chatting about your interracial grandchildren, or about how pretty my earrings are, or clarifying that you’re at MOUNT SINAI HOSPITAL not in the KOREAN WAR, but I can’t stop your death. I can hold your hand. I can call your children. I can maintain eye contact. And I can tell you as much as I know. Which isn’t a lot.

Stress in Medicine

How do I cope with the stress of being a third year medical student?

At first I drank a lot. Alcohol. Beers and wines and champagnes and liquors. But hangovers in surgery don't mix. And then I remembered what our physiology professor had told us last year in a off-handed comment, about how alcohol abuse is very common in medicine. Well, I don't like following trends, so... I should find something cooler.

Then I tried caffeine. Not like coffee or tea. Like, obscure effervescent caffeine pills with added vitamins and minerals that you can only buy in Europe. They were citrus flavored but they tasted like chalk. And then I had a caffeine withdrawal headache. It was not fun.

So then I smoked a lot. Not cigarettes, because cigarettes kill. Every first year knows that. I smoked  e-cigarettes. And boy, they are so much cooler, because they light up when you inhale. But nicotine doesn't really do anything for me. So I stopped buying them from drug stores.

I've tried various vices and engaged in some virtuous activities, but the stress of third year is something that is impossible to deal with. Sometimes I just forget about all the things I have to fill out and send in, and just focus on what I'm doing right now. Whether that's playing games on my smart phone or hanging out with patients in waiting rooms, it doesn't matter. It's me time.

Hierarchies in Medicine

Despite my feminist background, I really do enjoy the hierarchy in medicine. Not because I think it’s helpful for anybody in the medical field, but because it makes sure there are checks and balances in patient care.

For example:

As a medical student, I have no idea what’s going on. Ever. In any given patient interaction, I will likely be the most confused person in the room. Even patient’s seem to know more about what’s going on then I do. But there’s a ton of reasons for this: my medical training is incomplete and, most likely, I’ve only worked at this hospital for a couple of weeks and I couldn’t find the nearest restroom or wherever they store tourniquets if I was offered enough money to cover my student loans.

But I’m not an idiot. I can catch errors. Very rarely I get to catch huge, major errors simply because I am the least busy person on the team. Like forgetting to order furosemide for the acute exacerbation of congestive heart failure patient. Really, it’s just an oversight. But I caught it and it changed management.

Doctors and residents are sometimes upset with me for not doing something or being “incompetent”, but it doesn’t matter, because I have an excuse: I’m an incompetent student. Whenever people give me criticism, it’s always in the form of, “One day, when you’re a resident/physician, you’ll be expected to…” which means that I’m not really expected to do much more than what I’m currently doing.

Virtues in Medicine

It was a dark gray day in late summer. No rain. Just cold, northern air that had brushed across my face as I walked from the "L" train stop to the hospital. It was 5 in the morning. This was surgery. You had to come early so you could pre-round, and pre-rounding was something I didn't enjoy. But I did it anyway because talking to patients about frivolous matters was better than getting yelled at for incomplete notes. "Have you been going to the bathroom?" "Are you eating alright?" "Have you been walking?" Waking up anyone else to ask questions like this would be insane. But after you've been operated on, you hand over your rights to interesting conversations and get to be awoken at any time for a barrage of inconsequentiality. My reasoning was simple: the surgeons seem to think these questions matter a lot, so I asked them.

Then we round. I enjoy rounding because I get to cross my arms behind my back and walk around the hospital quickly and quietly with my fellow medical students, a flock of baby ducks following behind residents. It is generally peaceful. Today it wasn't. Today we went to see a patient who has some form of nasty infection in her leg. How nasty? Well, surgery residents are highly sarcastic. But if they weren't flat out lying in the residents' room during sign-out, well then... this patient could possibly die from this infection. The solution? She needed her leg amputated. Late last night, during her admission, she had signed a consent form okay-ing the procedure. Now as we saw her, she was resisting. She wasn't going to lose her leg. A soft-spoken but snarky, sixty-something year old woman--this patient was refusing the operation for some reason. As a human being I could see the resistance in her face. I knew there was more to the story.

But the resident just asked the same old, stupid, inconsequential questions. And the wall separating us, hidden underneath white coats, and the patient, sickly and exposed behind a cheap hospital gown, shot right up. The rounding team left. Notes for the intern: send the patient over to internal medicine. Get them to deal with her.

After rounding, everyone disappears into operating suites. I stayed behind on the floors. And I went back to that old lady's room. I left my white coat at the nursing station, and I went and reintroduced myself to this woman. I broke the silence with some silly, history taking questions: "What brings you in?" "Where does it hurt?" Then I asked the question that nobody had asked because nobody took the time to connect with this patient. "Why don't you want to lose your leg?" Followed shortly by, to get around the wall, "Why don't you want to lose your leg, really?"

And everything spilled out. This patient's history of present illness, but what it really was, not with transformative language but with a story anybody but these surgeons could understand: Recently widowed, fifty pack year smoking history, mismanaged diabetes, shame at being in the hospital again, too embarrassed to call her only living relative, her son, to tell him that she might be dying, because what would he say, "Mom, why didn't you listen to me? You've got to take your medicine. You've got to stop smoking."

It's regrettable nobody took the time to figure out why this woman was refusing treatment. It only took a smile, friendliness, and fifteen minutes of my time.

"You should call your son. Tell him what's going on. And you should get this surgery." I had told her. And she did both of those things. The next time I saw her she was missing a leg. But she smiled when I walked into her room to pre-round on her.