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?

Insulin and Eugenics... I am upset. This is a rant.

As a type 1 diabetic, I am often very angry. Usually this is secondary to hypoglycemia or an ability to eat something because I inadvertently left my insulin at home.

But today I am upset because I am running out of insulin and I only have $600 left in student loans until late February. Why is this a problem? Because as someone with good medical insurance, my doctors have always prescribed me humalog and lantus, which are bloody expensive without a prescription (and are actually still really expensive with a prescription and insurance: $50 each for what I need in a month). But as a medical student I don't have time to go see a doctor to get a prescription to get my bloody f***ing insulin. I am really upset because as I speak I have about enough humalog (lispro, short-acting insulin) to get me through to Monday, after which I guess I'll start employing a poor man's metformin: large amounts of acetaminophen and straight hard liquor. Your liver transaminases skyrocket, but you've effectively bludgeoned your body's best organ so badly that it stops going through with gluconeogenesis. Oh, and a ton of aerobic exercise makes your body more sensitive to the effects of lantus (glargine, long-acting insulin), so I guess I can look forward to dropping a few pant sizes and... cirrhosis. Lots of preventable, freaking cirrhosis.

I don't know what I'm supposed to do. There must be type 1's who are busier than me and have less time to see doctors. And I know there are type 1's who don't have health insurance because this country is absolutely terrible. So how can I get insulin at a reasonable price without having to see a doctor? Because, honestly, I've had diabetes for over ten years and I know my body's personalized ways of dealing with this disease in a way that literally no other health professional could understand. I know the tricks. I know the secrets of my metabolism. My A1c is always under 7.0 and my hypoglycemic events are now well controlled. I know what I'm doing.

SIDENOTE... no wait, MAIN POINT: I think it is absolute bullshit that people need prescriptions for something that their body erroneously stopped producing. Almost everyone else around me is making insulin, but just because my body f***ed up when I was thirteen, I have to spend thousands of dollars on a month's worth of high quality insulin? What kind of justice is that? Answer: it's not. It's wrong. It's condemning people to a constant economical disadvantage on top of the disease they've contracted who's co-morbidities will likely kill them if they don't control the aforementioned disease. In a country where medications aren't regulated to make them fairly priced (hell, I think they should be bloody f***ing free but I realize I'm incredibly biased) and health insurance is severely limited, we are essentially killing off diabetics. I realize that many type 1 diabetics can make it to reproductive age without dying first, but I've seen a 24 year old diabetic with f***ing gastroparesis--that's really severe neuropathy. And now that I've gone through OB-GYN, it becomes apparent that type 1 diabetics with A1c's of 13.6, like this 24 year old, would never be able to carry a healthy child to term. She will likely never produce any children because why? Because our health system is unjust? What sick kind of world is this?

And you know what's worse? The type 1 diabetic population that is under insured and hurting the most is minorities, specifically blacks. And you know what's f***ing insane about that? DIABETES IN AFRICAN POPULATIONS HAS NO DISCERNABLE GENETIC COMPONENT. Whereas caucasian type 1 diabetics usually have some weird HLA inherited predisposition sh*t. And yet, at least in Chicago, those people will be preferentially allowed to live with a disease that could be greatly reduced within the human population if only they were put to the slow and painful death that awaits most uninsured type 1 diabetics.



[edit]: Okay. So I calmed down a little bit. Let me just say that I recognize that a lot of white people don't have health insurance either. But at least in Chicago, economics and race are obnoxiously linked in a way that has already started to upset my psyche. So I'm sorry about that. The truth is, all type 1 diabetics are in an equally unfortunate place in a society where close health maintenance is ludicrously expensive.

And also, I don't think I do a good job of separating my emotion's from the job. Especially other type 1 diabetics so far along. Seeing another black, 24-year-old, type 1 diabetic, laying on a bed in the emergency department, clutching at her stomach and moaning for morphine, secondary to gastroparesis and then her resultant addiction to painkillers, really upset me I guess. I want to help them but I know that it's literally too late because you don't recover from severe autonomic neuropathy. You just suffer until you die. From something completely preventable.

I guess this whole thing bothers me, not just because on the whole diabetics are treated very poorly, but because I'm now a healthcare professional, and I am surrounded by physicians every day, but I don't think I can just ask them to write me a prescription for insulin because I'd rather go to work than call the doctor's office to set up an appointment, then call the dean of student affairs (another physician), and then the clerkship director (also a physician), and then drive to god knows where for a fifteen minute conversation with the doctor to write me a prescription so I can save $350 for something that almost everyone in the world doesn't think about.

It's upsetting. If I had my way, everyone with a type of medical/biochemical deficiency would be able to get whatever they need for next to nothing because that's what equality is. Hypothyroid? You get thyroxine, no problem. Chronically depressed? We'll get you an SSRI or maybe even some SNRI's if you're lucky and need more norepinephrine. Diabetic? We'll get you all the insulin you want. Because giving you anything less than that is a crime.




So this is where I read that Diabetes in blacks and asians is often idiopathic: http://www.aafp.org/afp/1998/1015/p1355.html
Although since I am both caucasian and african, I won't know if I have the idiopathic form until either A) my entire genome gets sequenced (I hear it's only $1000 now!) or B) they look for islet cell antibodies in my serum.

Full Circle

I still suck at board review tuesdays, but I seem to have developed a pattern of writing in every eight days, so expect me to write about something, I suppose, next Friday.

Although the real reason I haven't had anything to write about concerning boards is because I haven't studied. At all. For over a week. For over eight days.

I'm freaking out, but instead of doing something about it (namely, study) I seem incapable of doing anything productive.

I mean I'm studying for school, but school grades don't matter. Hah!

Eventually I'll probably get out of this slump. I can't imagine cramming for the boards. That sounds like a hell no one deserves, no matter how undisciplined, dumb, currently care free, or beautiful* that person may be.

Speaking of actual school, I'm excited for class tomorrow because our hit-or-miss pathology class will be hopefully educating the idiots in my class about what diabetes is. And honestly, I could learn some more about type 2 diabetes too. I'm sick of how much stuff we know about diabetes that isn't mine. I've been skimming tomorrow morning's notes for fun.... Wrong word... curiosity. Looks like a genetic component for type 1 diabetes has been proven in white people. Which is great for me, a curious, half-white person of child-bearing age who really wants to know if my genes are defective or if I'm just unlucky. I want, nay, need to get sequenced. Besides the diabetes I am literally perfect**.

Fortunately there is at least one amazing thing about the lecture notes for tomorrow:

Borg Picard in a diabetes lecture?! 

DAMN! I'm watching television (I was not kidding, I am a failure) and I just heard Lucy Liu say the word "neutrophil." Apparently she's an ex-doctor on the television show Elementary. I approve. And I am feeling pretty lucky. Maybe I will study tomorrow.

*I needed a pick-me-up.

**I still needed a pick-me-up.

And That's Delirium!

Recently I found out that hypoglycemia can precipitate the mental state of delirium. As a well controlled diabetic, I have a lot of hypoglycemic events, so I am versed in the various physiological and psychological events that coincide with a drop in blood sugar. However, the number of times I've been delirious because of hypoglycemia? It's hard to say--I only just discovered what delirium is (thanks clinical neuroscience!)

But I'm going to say I've been completely incapacitated by delirium secondary to hypoglycemia twice: once in the central rain forests of Costa Rica, and once again in the sixth row of Finch Auditorium at Rosalind Franklin University.

The first time--in Costa Rica, was innocent enough. I had lost a lot of weight rather precipitously. The temperature was always in the low eighties and I had to hike about ten miles everyday under the weight of climbing harnesses, bio-tags, poorly prepared, non-Skippy peanut butter sandwiches, and gallons and gallons of water. Regardless, when I returned to the states briefly to take the MCAT, I sidetracked and took a shopping trip to the Gap, only to realize I was a size four, which means I probably weighed about one-hundred-and-forty-five-pounds, placing my BMI at 20. Although still in the normal range, when you consider my amazing, incapable-of-becoming-osteoporotic bones, a BMI of 20 is deadly. Or at least deadly for a diabetic since I didn't have any excess stores of glycogen in my liver. All hypoglycemic events had to be dealt with by myself--not the glucagon my diabetic body was still capable of making.

Essentially this just meant waking up with hypoglycemia frequently and having to drink more gatorade. But one morning, I woke up with a huge existential crisis hovering around my incapacitated body. I will never know how low my blood sugar was--all I remember is that my roommates had already left for breakfast and I found myself alone in the jungle, surrounded by the creaks and caws and chirps of forest dwellers and the hot and sticky and humid air of the tropics. Oh yes, and an existential crisis.

There was a journal by my bed. I wasn't really recording much in it: we had actual journals to take down actual data--like the types of epiphytes on the branches held up by the forty meter tall trees we climbed. I had a journal to take down various soil measurements (soil is so cool! But that is neither hither nor thither). But by my bed was a journal of just short little ditties--observations really, of a rainforest. Or at least, that was all that was in it--ditties--until my blood sugar was freakishly low and I somehow located a pen and started tearing at the pages with it. I was terrified, in that moment, of death, without knowing why. I had no idea my blood sugar was low, just knew that God was holding me in his hands at that very moment, pondering whether to keep me on the planet or toss me out, into the abyss of Hades.

And I was terrified. My mind flashed, somehow, and without anything more than incredibly tangential reason, to Cat Stevens, and how he had decided to dedicate his life to god and become a muslim after he had almost died swimming in the atlantic ocean and got caught up underneath a rip tide. So I wrote a prayer, a plea, and a mantra on the quadrille lined pages of my yellow journal, demanding that god forgive me for all that I had done and to allow me to live a little longer.

Delirium had made me a sniveling religious fiend.

I eventually escaped such a fate when I--fortunately--started chewing on sugar tablets sitting next to my bed. I then made my way to a late breakfast, where my advisor berated me for my tardiness and my rather dulled affect. Oh, but if only I had known then what I know now: "I mean no disrespect, but unlike the rest of you, I just spent the last hour in delirium."

Anyway, the second delirious state happened literally an hour ago.

Having awoken five minutes before class started, I had no time to locate my test kit. But I had a headache, and I had gone to bed with a bowl of popcorn recently consumed, so I assumed that my blood sugar was the cause of the headache and thus I needed insulin. Well, within the next thirty minutes I realized that my blood sugar had probably been fine when I started feeling the chest tightening spasms of hypoglycemia. No matter! I had fruit snacks!

And thinking that I had avoided the ills of hypoglycemia, I settled in to taking notes on a lecture about epilepsy.

And here's where it gets interesting: Somewhere--about an hour and a half into lecture--I stopped being able to understand the slides I was reading on my computer. And then, shortly after that--the lecturer stopped making sense. I wanted to raise my hand at several points along the way--I wanted to clarify what he was saying because I was sure he was saying it wrong, but I didn't. Instead I just sat in awe that everyone else seemed to understand what was going on.

And then the madness truly sat in.

We switched to a new professor for a new class, and my head wouldn't stay straight on my shoulders, my neck wobbling side to side. I became obsessed with the fear that the professor would notice me in what would have looked like a sleeping position and that I'd be kicked out of class--or that I'd automatically get a 0% on my next exam. So I snapped my head up and sat up straight as possible. But it was useless, because inevitably my eyes would close and my head would fall forward and I'd look like I was sleeping again.

I tried to focus on my computer, on my notes, but they no longer made sense. I tried to play a little game on google+, Triple Town, to see if that would wake me up, but I was exhausted and I quickly closed the tab on my browser and was unable to pull up anything again. I was exhausted; not tired, just thoroughly incapable of movement or thought.

I soon became incredibly confused and scared. Didn't anyone else feel this way? Why did nothing make sense anymore. I could hear the words my professor was saying, but they didn't make any sense. I became preoccupied with a feeling that I didn't exist, or that if I did, I existed on a plane unlike the one everyone else seemed to belong to. Kind of like I was the only one who realized that this world was simply a matrix, and that I needed to find my way back to reality. But how to get there?

I needed help, but from whom?

I decided that I needed to go to either the counseling/health center at school--a five minute walk away from my current location--or to my mother, who I was beginning to doubt was actually my mom at all.

But at both locations I would have done the same thing: fallen on the ground and started yelling that this wasn't real and that someone needed to find out what was wrong with me. "Run all the tests!" I imagined yelling to anyone who would listen. There was something terribly wrong with me, I just didn't know what--but I needed to know. 

My daydreams kept escalating in preposterousness until I imagined grabbing a knife and stabbing myself in the heart to regain entry to the "real" world that was hanging just outside my grasp. The thought of stabbing myself terrified me. And that simple feeling--intense fear--called my logic to attention.

What if this was just hypoglycemia? So I formed a plan while my professor kept garbling through his lecture on... what was it? ... anticonvulsants?

Step 1: Get Food
Step 2: Wait to Feel Better
Step 3: Feel Better? If no, go to Mother
Step 4: Feel Better? If no, stab self in heart

Fortunately, after eating a snickers bar, a twix bar, one reese's peanut butter cup, and a can of coca-cola, the delirium surrounding me started to fizzle away. I was capable of speaking, although my tone and volume were way off when I asked one of my friends sitting in the row in front of me, nearly incoherently, where today's pathology quiz was going to be administered. But I was conscious, and the fear that I didn't exist or that I existed in a parallel universe or a mirror reality, quickly became nonsensical and strange. Shortly thereafter, I was conscious enough to begin writing this, an assessment of my mental status as it descended once again into a state I wouldn't recommend for anyone. And that's delirium for you.




(a little bit more for the intrepid reader):

so delirium can be caused by anything that wholly affects the brain. usually when i have just bad hypoglycemia (so not life threatening but unpleasant), i act like i have a frontal lobe lesion: poor planning, flat affect, avolition, etc. however, the two times i've become "delirious" from hypoglycemia, it's possible that I was under the spell of global cerebral ischemia (so involving the entire brain). And while it appears that to get global cerebral ischemia from hypoglycemia, low blood sugars have to occur chronically (i.e., insulinomas), I fully believe that an hour of really low blood glucose could knock a person delirious.

(the end)

I'm 23 right now so yea.

me

ermergerd

case study micro

24 year old diabetic

fungal infection

dies

that's my M3 year.

That awkward moment when diabetes is kind of cool for once.

[Note: There are some gross photos to follow. If you fall easy to nausea, I suggest not reading this post.]

Alternative title: Microbiology: it's happening on you.

Having diabetes is the absolute worst*. Yesterday, for example, I took to much insulin with my bedtime snack and two hours into sleeping I woke up in a hypoglycemic panic, and before I could grab the glucose tablets by my bed, I began hallucinating: a giant centipede with a human face--a human face without eyes, nose, or mouth--broke into my bedroom!!! Intense!!! And terrifying!!!

Anyway, so usually diabetes sucks. There's the lows and there's the highs (this isn't figuratively, this is literally, as in my hypo- and hyperglycemia). Regardless, thanks to diabetes I've also been given a small arsenal of medical tools to tell me how my body is doing. Usually they're quite mundane. But in certain circumstances I can use them to . It's like having constant access to back-alley, outpatient lab services.

Seven days ago I sustained a large, second-degree abrasion to my left knee. Hilariously, I didn't treat it because we had just learned about skin infections in Micro and I wanted to see if I could catch something hilarious like staphylococcus aureus. As a diabetic I am technically immunosuppressed.

Regardless, my knee ended up scabbing really badly. [gross pictures to follow]

*Diabetes isn't the absolute worst. But in my own life, it is.

Selfish Diabetic

Today when I woke up, I woke up with a headache. I cursed my decision to have chips last night as I was going to sleep. Too much glucose. Not enough insulin. I surveyed my skin and noticed I had developed those annoying lines you get from your bed sheets all over my arms. Peripheral edema. Yes. The hyperosmolarity of my blood would have caused an increased retention of fluid in my renal system. I checked my face in the mirror. Puffiness was present around my eyes, though perhaps that had occurred from not sleeping enough.

Fourteen minutes to class.

The oxidative stress of prolonged hyperglycemia on the body can cause diabetics to feel as though they need to sleep more. I have been taking an unnaturally large amount of Vitamin B throughout my medical school year. I do not know for sure if Vitamin B helps relieve oxidative stress--in fact, it very well might make it worse--but it's one of the things diabetics need to replenish according to Walgreens Pharmacies, so I take Vitamin B. I no longer always require eight hours of sleep, although sometimes...

Eight minutes to class.

Objects are falling into my backpack with little thought. Every day is more or less the same. One binder. One laptop. Always the same, though learning is always a little different. Finding my glucose meter, I decide to test. Sometimes I will be much higher than I think, will not take insulin, and spend the entire morning in the 200s. Glucose is 61?

So then what caused the edema? What caused the headache?

I think about my food intake at dinner as I guzzle some fruit snacks before leaving my apartment. Two minutes to class. What could my renal system have been doing while I slept? What about my endocrine system? What was my body doing that caused me to wake up the way I did? Exhausted? Edematous? But with a high core body temperature and a headache?

I wonder all these things and sometimes feel so close to drawing all the lines together and truly understanding how physiology interplays with biochemistry, then anatomy, and how all of these things affect my life. It is frustrating, but it is exciting--as if someone was carefully guiding me to enlightenment, nirvana, without my knowledge. Understanding why my body does the things it does will make me beyond happy. It will make me a fully realized human being.

This leaves me with a few thoughts: Why are there otherwise healthy people in medical school? And how can the few medical students I have met who confess they are only in this for the money... how can they study at all?

Correction: I've had a heart attack.

I have to make an important correction to last night's post entitled "Drug Surplus": Putting me on Lipitor, a drug that decreases cholesterol production by inhibiting the enzyme 3-hydroxy-3-methylglutaryl CoA (HMG-CoA) reductase, was the right thing for my endocrinologist to do. The literature approves of the treatment and medication I received. Because I've been reviewing my medical biochemistry notes, I can tell you that HMG-CoA reductase forms 3-hydroxy-3-methylglutaryl from acetyl CoA which is only a few mind boggling steps away from becoming cholesterol--which is bad. Unless it's the good kind (HDL).

But more importantly, I can tell you how I misread the risk assessment flow chart. I thought diabetes was simply a serious additional risk factor for the development of cardiovascular heart disease (CHD). I wish. Our lecturer today--a "diabetologist"--informed our lecture hall that diabetes was equivalent to having a heart attack. This was surprising to me, as I regularly do not grip my chest and yell, "Elizabeth, I'm comin'."

An equally attentive student asked whether type I and type II diabetes were considered equally dangerous in terms of cardiovascular disease. The diabetologist said "yes" and continued on with his lecture. I threw my hands up. Really? I've had a heart attack? Well, in that case, I guess being on Lipitor isn't that bad, because clearly I'm going to die any day now. Imagine having your first heart attack at age 13. Fascinating.

After lecture, a girl in my same row remarked that during one of our clinical correlation anatomy lectures, the doctor had innocuously stated that women with congenital sclerosis were eight times as likely to develop breast cancer. Just rolled right over that. Didn't say much more about it after that. Just thought it would be a fun statistic for everyone to know--not to be tested on it, but to let that information sink in to some of us with the unpleasant likeness of an unwanted guest or a recurrent nightmare.

Ignorance is bliss.

It's like our professors don't realize that while we all want to be physicians, we are also human. It's not just a flaw in the schools of medicine. It's a problem with our society. Doctors need to be flawless. We expect more of them than we expect of our own family members. They need to know everything and they need to tell us everything. They are omniscient, otherwise they aren't worth going back to. In this way, we expect them to be less like traditional professionals and to be more like gods. Unfortunately, they have problems too. I can't say for sure, but I'm guessing about a third of my class went into medicine because they either had a close relationship with a friend or a relative who had a serious illness, or because they themselves had or continue to have a life altering medical condition.

But we're just people. We don't like being reminded of our imperfections. Especially when our imperfections are highly correlated with increased morbidity and mortality, death and disease.

I know we have to know all the intricate details of disease and life and how the one influences the other, but sometimes, just every once in a while, it'd be great if it was understood that we were human and, just like most of humanity, scared of our own passing. So instead of getting widely-believed, sadistic statistics crammed down our throats, perhaps those sadistic statistics could be sugar coated? Not too much, though. Or at least, not too much for me.

I'm diabetic and apparently I have to watch my cholesterol.

An Interesting Aside: I'm Diabetic

Today one of the lecturers for one of my classes decided to tell everyone an exciting "diabetes-related" finding. I no longer remember how it related to Embryology, but the point was something like this: EVEN DIABETICS WITH GOOD CONTROL OF THEIR SUGARS END UP SUFFERING THE COMPLICATIONS OF DIABETES IN THE LONG RUN. WHY? OH, WELL, BECAUSE THE INITIAL SPIKE IN BLOOD GLUCOSE CAUSES METHYLATION OF THE DNA WHICH LEADS TO COMPLICATIONS SUCH AS BLINDNESS, AMPUTATIONS, LOSS OF HEARING, LOWER QUALITY OF LIFE, ETCETERA. Why the hell did this professor feel like this was a necessary sidenote? I don't know. Maybe because he talks like someone raised firmly on the Mason-Dixon line and cutting to the point doesn't make a whole lot of FUCKING SENSE to those people. So yes. Elora Apantaku, the beautiful, kind of hilarious, kind of lovely ELORA APANTAKU, will be losing her long legs and her perceptive …






I started crying. No sense in continuing. Fuck.