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In the trenches. - Nobody wears a white coat any more... — LiveJournal
...a tribute to becoming a doctor.
In the trenches.
Let's talk about the breakdown of the American medical system, O Best Beloved.

Firstly, I want to render an apology to turnberryknkn, because I know it's not his fault that his state is all messed up, but I am so angry with Michigan that I could just spit, and it all has to do with Medicaid.
In essence: Michigan Medicaid does not reimburse out of state providers for costs incurred by Michigan Medicaid recipients. I cannot see MI-Mcaid patients at the clinic except for a one time follow-up - we're not a provider, and we're across the state line. Our front office staff basically forbids it, because Medicaid is such a picky thing.

And now that that preface is out of the way, I want to introduce you to C.
I met C one night on call, when the ER doctor dragged me out of bed and down the stairs to meet a man who'd been woken from his sleep. He was pleasant, talkative, mid-forties, and very frightened. You see, one of the unwritten rules ofowning a body is that it should do what you tell it to and only what you tell it to. It should not, for example, awaken you a little after midnight by doing the Tomahawk Chop all by itself. In layman's terms, something is very wrong when that happens, and most people instinctively know that. Most people instinctively also know that the reason your body is acting on its own is that something is very wrong with your brain.
The brain frightens people. It frightens me. It's a great big thing with the consistency of Jell-O sitting up in your skull thinking all the time. It's hard to separate your brain from yourself, really, and yet it's sort of a separate entity. And everyone seems to know that when something is wrong with your brain, then nothing good can come of it. So C came in frightened, and we had nothing good to tell him.
I've got a sad case for you, the ER doc says to me. Here's a guy, smoker, mid-forties, woke up with his right arm doing karate chops. He's got a big mass in his chest and a couple little ones in his brain. And I know and he knows, in the undertones, that what he's saying is that here is a man who probably has metastatic lung cancer and is going to die.

I called the oncologist, called my staff, spoke quickly and concisely. And I asked C if there was anything I could do. He understood the situation, sighed. "What is there to do?"

Two days passed before I got the call from the radiologist. He'd gone down for a staging CT scan - chest-abdomen-pelvis, what can we find? Radiology called me up: You ought to know, before you biopsy. There's a big cavitary lesion here, looks more like infection. I recommend an MRI looking at that brain for abscess.
That's like going from death sentence to "possibility of parole", O Best Beloved. A brain abscess is a big deal, and it's potentially deadly, and it's hard to treat, but it can be treated. Brain-metastatic lung cancer is one of those diseases where palliation - improving quality of life rather than aiming for a cure - is the order of the day. Brain abscesses are treatable. We got the MRI.
MRI center called me. "Looks like an abscess to me." And so I called Infectious Diseases, and then on his recommendation I called Pulmonology and then I called Neurosurgery. Full-court press workup. Pulmonology did a bronchoscopy with transbronchial biopsies, and then the fun began.

By the next day, the biopsies had been lost - potentially sent to Utah - and the hunt was on for them.
Neurosurgery cruised by the chart every day writing a note of sorts:
"Afebrile. Dil level = (the day's anticonvulsant serum level). *illegible scribble*"
ID cruised by the chart every day and wrote a note that took twenty minutes to decipher:
Hey, can anyone read this? "Says...Wrong HIV test ordered AGAIN...something something biopsies....something something Michigan...something something antibiotics. Oh, and an order: Write TB test results HERE."
Fortunately, he also usually stopped by to swear at me about the complete incompetence of the hospital staff, so I got his update. He was also the one who informed me that what we really needed to do was to send this man to a Michigan hospital where they could follow-up with him somehow.
Heme-Onc cruised by the chart every day and wrote a note that was supremely unhelpful:
"Afebrile. No new seizures. Await biopsy results."
Pulmonology wrote a similar note, usually with an update on the status of the biopsies, and sometimes a speculation of what they would show.

Days passed. We determined that the biopsies were probably in Utah, then that they were definitely in Utah. They were being Fed-Ex'd back to the hospital. And all this time I'm working on discharge planning. And here, O Best Beloved, is where it breaks down.
Of my four consultants, only one had an office in Michigan and could serve Michigan Medicaid patients. The other three were going to be completely unhelpful, because there could be no follow-up. For my part, I went straight to Social Work.
"I have a patient here who's Mi-Caid pending. He's going to need a primary care physician to serve as a coordinator for his medical care." Because, O Best Beloved, primary care doctors are ideal for coordinating care. "Who can I send him to?" And she took a deep breath.
Probably nobody.
There are, it appears, a vanishingly small number of providers in his part of Michigan who take Medicaid. So few, in fact, that there were potentially no doctors at all for this man's primary care. She had a phone number of someone forty minutes or more away who might be able to find a provider in that region, possibly, if they weren't all full. And in the meantime he's spending all his time sitting in the hospital waiting for something to happen, and he would just as soon wait for us to give him his news at home as here. So I set up arrangements for him to see the one primary care physician I know he can see once : me. And I set up arrangements for him to see the oncologist in Michigan. And we send him home to await biopsy results.

Saturday morning, I get a page from ID. "You've got the nonspecific ST-T wave changes of biopsies here," he says. "We have to start over." And so on a Saturday morning I have to call this man and tell him that not only do we not have an answer, we don't have a clue how we're going to continue from here, but that I'll get in touch with people on Monday and formulate a plan. And he says to me:
I thought I'd been kicked out of your health system. How are you going to do that?

That broke my heart. And I told him that I wasn't giving up on him, no matter what, regardless of whether I was getting paid. I was going to keep trying to organize this until I could find a Michigan physician to take over. He sounded dubious, but he thanked me.

Monday I called the oncologist in Michigan. PET-CT won't be covered by Medicaid, he says. We'll have to do serial CT's and watch to see what happens. And I could have screamed. Here, O Best Beloved, is a nice man with a very severe problem who is being denied diagnostic studies because he's poor. These are studies that could make the difference between life and death - but Medicaid reimburses $40 for a PET-CT with read, so you can't get one. And the neurosurgeons aren't serving Michigan, so the brain biopsy is right out until someone finds this man a neurosurgeon or ID doctor in Michigan. And I don't know anyone in Michigan.
I called the patient, told him he needed to get in to see the oncologist as soon as he could, and talked with him for a bit. "My right leg is a little weak," he says. "But I think I might just be tired." I told him that if it didn't get better, he needed to get to an ER right away. Can't see him in the clinic.

The next day, triage nursing took a call from the patient's mother. "C can't use his right side at all." And I told them to tell her to go to the ER. In Michigan. And I crossed my fingers that maybe someone there would be able to get him the care he deserved.

And I could just cry.

now feeling:: angry

21 whispers echo . o O ( ... ) O o . whisper a word
fyrfitrmedic From: fyrfitrmedic Date: May 11th, 2006 02:54 pm (UTC) (etched in stone)
I despise some of what I've seen in managed care.

I'm tired of having to attempt to fix or at least hold together those folks sent home too soon by some cubicle-dweller with a pair of dice.
From: silmaril Date: May 11th, 2006 03:09 pm (UTC) (etched in stone)
And I could just cry.

You're not the only one. I think I'll link to this tomorrow, if you don't mind.
ayradyss From: ayradyss Date: May 11th, 2006 04:29 pm (UTC) (etched in stone)
Link awad.
clipdude From: clipdude Date: May 11th, 2006 10:16 pm (UTC) (etched in stone)
I'd like to link, too, if you don't mind.
ayradyss From: ayradyss Date: May 11th, 2006 10:19 pm (UTC) (etched in stone)
By all means.
fortuna_juvat From: fortuna_juvat Date: May 12th, 2006 02:38 am (UTC) (etched in stone)
Here's your third link of the night.

You keep telling yourself that we're in this to fight the good fight, but it's hard to see that through all the bullshit sometimes...
serennig From: serennig Date: May 11th, 2006 04:19 pm (UTC) (etched in stone)

There's plenty to complain about in Canadian health care. Plenty. More than plenty. I've heard so many wonderful things about the American system -- no wait times, CT's in every clinic nevermind town, and all this fantastic stuff. But here, the reminder that for such a system there is a price too.
deadrose From: deadrose Date: May 11th, 2006 06:27 pm (UTC) (etched in stone)
Yes, those comparisons never mention that your access to all that wonderful medicine is determined by your insurance company, who are concerned with profit above all. Well, except Medicaid, which seems to be run for the purpose of sadistic amusement.

The figures on the number of completely uninsured Americans are horrifying.

I've used both Canadian healthcare (lived in Ontario for several years) and American, including Medicaid. I've also worked in a physician's practice as the poor sod who spends her days trying to get the insurance companies to pay for services rendered. I could probably spend several hours typing out a long ranting screed about it all, but since I'm in the process of packing a house up for a move, it'll have to wait until that's been and done.

one_porous_page From: one_porous_page Date: May 11th, 2006 09:34 pm (UTC) (etched in stone)
Out of curiosity, which system did you prefer? The Canadian or American?
deadrose From: deadrose Date: May 12th, 2006 04:13 am (UTC) (etched in stone)
Neither, really. They're both good in some ways, bad in others, and horrendous in yet others.

When I gave birth to my second child in Canada, I was so disgusted that I signed myself out AMA the next morning, when they finally allowed me up to take a shower (one shower for the entire maternity ward) and there was nothing but a weak trickle of cold water. That was the last straw in a series of mishaps and confusions including my OB lying to me and the hospital thinking I was coming in for an elective caesarian when I was in there one day for a test.

It wasn't even the final insult though, that came a few weeks later when the samkje doctor took 2 minutes for my postnatal checkup, declared my diaphragm was still the right size and sent me on my way without noticing the large cystocele I'd developed. I didn't even have my period between those two births. Got pregnant when my baby was 5 1/2 months old, the first time his dad and I had managed to get a few hours for ourselves.

For that birth I hired a midwife out-of-pocket. Although I ended up having her in the hospital due to a partial placental abruption and a near-precipitous labor (which saved me the slice-and-dice), I ended up with a fat 9 lb 10 oz baby with 8/9 apgars, and was home an hour and a half after her birth. For you curious folks, the placenta was huge and fundally located, reaching up into the horns, therefore the first contractions peeled parts of it loose.

Here in the US, I have a little bit of an advantage over most people, as long as I'm living here in the Seattle area, as my father is still a practicing family physician. I don't have to travel by bus and ferry to get to a doctor that will accept Medicaid (I'm disabled) other than specialists, if one will see me. I still have to deal with the state deciding which medications are appropriate for me (decided purely by cost factor) and I've just given up on some kinds of care that people with good insurance would take for granted. Examples of things that drive me crazy here: my teenage son has Aspergers syndrome. He gets counseling from the one place on the island that does sliding scale or Medicaid work. Over the years he's seen a variety of people including one that thought if we only tapped on his head in certain patterns he'd be cured. For any sort of medication he has to go to a facility in Seattle that primarily serves the Medicaid community, yet has no clue. He went in there last week, for the first time in years, because he was having problems with anxiety and depression, mostly reactive in nature. He came home with a prescription for an *antipsychotic*, one that Medicaid won't even cover. Why? Because it will relieve his anxiety and help him sleep. Well yeah, so will knocking him unconscious every night, but I'm not about to do that either.

*coff* I'm afraid you've hit on one of my serious sore spots, and I could probably go on for several pages.

Canada's system is good for basic stuff, as long as you're not in a hurry. If you need to see a specialist, or are deemed too old (another sad anecdote I could tell), you get bupkis.

In the US, you get better specialty care (if you're insured) and *far* better emergency care - the emergency care you generally can get without regard to insurance. However, the costs will probably cause you to file bankruptcy if you don't qualify for low-income programs.

The doctors' offices take on most of the fight against the bureaucracies to get you treatment, from the simple 'mother-may-I' phone calls to diagnosis-by-code (they won't cover this, but if i call it *this* instead, they will)

I have to continue this in a second post because I'm over the limit for a comment ---
theweaselking From: theweaselking Date: May 19th, 2006 04:14 pm (UTC) (etched in stone)
I'm just getting the link to this post way, way after the fact, so I realise I'm a week late.

Where was this, in Canada, and when?

I have never, ever, under any circumstances, received anywhere near that kind of bad service from a Canadian doctor. The closest I've ever gotten was an intern who put a cast on badly and left me with pressure bruises when I went in and got it off again after a week of pain - but, then, my wrist was broken, so the pain was kinda expected.
deadrose From: deadrose Date: May 12th, 2006 04:14 am (UTC) (etched in stone)
I can't speak very well to how patients are treated in either country, really, because the minute I open my mouth around a doctor or nurse, they realize I'm in the know, so to speak. Many assume I'm a nurse :-P. It makes for some odd things though; for instance my family doctor in Canada couldn't remember my childrens' names most of the time (though he saw them as well), but the first thing he always asked was how my father's practice was going. I'd assume it was written in big letters at the top of my chart, but since in Canada (may have changed in the past 10-15 years) patients have no rights to see their records, I don't know. They wouldn't even release them to a doctor down here, just sent a single page scrawled summary for each of us.

So yeah. You asked a simple question and I've run off at the mouth fairly badly.

I'll just sit here and be quiet now.

one_porous_page From: one_porous_page Date: May 12th, 2006 02:52 pm (UTC) (etched in stone)

I love a good ramble

Thank you very much deadrose, for replying. That was eye opening, as I have no experience with the American Medical System. Being a young Canadian (mid 20's) living in our largest city, I've also had only good treatment so far (got a CT scan in 2 weeks...etc). But I hear the horror stories all the time from other people. Hopefully if Canada privatizes, I'll be working in the health care industry by then, and I'll be able to afford quality care. But the thought still worries me (what if I can't?).
turnberryknkn From: turnberryknkn Date: May 11th, 2006 11:08 pm (UTC) (etched in stone)
We do have a lot of wonderful stuff. *If* you have the money to pay for it all. If you don't, all that wonderful stuff might as well be on the far side of the moon. I'll tell you, if you've got the wrong kind of insurance -- or no insurance at all -- you can wait a *long* time for everything.

I've been involved in national medical activism and health policy since 1997, and I think the best possible summary of the American health care system is that it is, bar none, the best health care money can buy, if you have the money to buy it. Unfortunately, millions of Americans don't. Which is how you can have the most advanced care in the world coexisting with some of the worst public health measures in the industrialized world.
fortuna_juvat From: fortuna_juvat Date: May 12th, 2006 02:40 am (UTC) (etched in stone)
And sadly, those green "insure everyone" bracelets aren't quite as popular as their Live Strong counterparts.
coanteen From: coanteen Date: May 12th, 2006 01:54 am (UTC) (etched in stone)
True. When I read the bit about the PET-CT, I laughed. Over here he wouldn't be getting a PET-CT either, not because he was poor but because PET-CT? That's a pipe dream.

And we seem to have a similar problem with Quebec as the one with Michigan, about the reimbursement. Only I'm pretty sure we still treat the patients, and then...complain.
ayradyss From: ayradyss Date: May 12th, 2006 02:15 am (UTC) (etched in stone)
We have a roaming PET-CT. It comes to town on Tuesdays and Thursdays, I think.
coanteen From: coanteen Date: May 12th, 2006 02:27 am (UTC) (etched in stone)
i wonder if it could be kidnapped...
jelliclecat From: jelliclecat Date: May 11th, 2006 11:29 pm (UTC) (etched in stone)
I grew up in Michigan, and I always wondered what, exactly, Medicaid was for. I'm entirely outside the medical profession, and even I saw the pointlessness of it. It never seemed to be good for anything but disappointments. It covers next to nothing, and what it does cover is pretty darn useless in any given situation. I'm so sorry you (and he) have to deal with all of that garbage.
turnberryknkn From: turnberryknkn Date: May 12th, 2006 12:52 am (UTC) (etched in stone)

I really wish there was something I could say. But there really isn't, is there?

From: broken_onewon1 Date: May 12th, 2006 02:43 am (UTC) (etched in stone)
The worset thing about it to me is I'm SURE there is a better way to run things and help everyone and have evryone be treated fairly patients doctors and the insurnce people. But I'm just not smart enough to know what it is as i'm sure my spelling clearly demonstrates :)
21 whispers echo . o O ( ... ) O o . whisper a word