Your Doctor And You: Contemporary Changes To The Doctor Patient Relationship

Your doctor and you together form a vital alliance for your health.

This relationship, like any, is going through some changes due to outside pressure from societal changes. Here are two main topics to discuss:


Yelp Reviews
As someone, a drug rep, said in the break room, during our discussion, 'You don't even need to look to ads to find a restaurant. You just say what region you are in, and look at Yelp, and go by the reviews.'

I scanned the room. Not one but TWO caregivers with awful reviews were present. I enjoy working with them both. And I acted dumb. I said, 'Does anyone really look at those reviews on themselves online, anyway? I do, but there is nothing there for me.'

They both had.

One--who is an oral surgeon who has Yelp reviews saying everything from he is too old to practice to he's in it only for the money--mentioned that once those reviews are up there is nothing you can do. There is no defense. He says his office really works on the wait times, because that is important to people. What he didn't know is I changed my plans for my son's oral surgery procedure to another specialist my orthodontist friend referred because of those online reviews--they were scathing, and I didn't want to take a chance with my son, even through I've known and adored working with this dental surgeon for years...and seen his skills in the O.R. as I anesthetize his patients.

The other, an OB-Gyn, was on call and cross covering for her colleague, who warned that a certain patient had drug-seeking behavior. (That's when people will lie and cheat and do anything to get a prescription for more pain meds). Sure enough, the patient called the physician, the physician did exactly what their colleague said to do with these patients, and the result is now online forever--she didn't even see me, I had so much pain, she is the worst doctor, she was rude, etc, etc.

When I was a professor, we were routinely evaluated by our students. The students did not know how critical it was to our advancement that we had 'good evaluations'. However, it was known by the department that some students are rather vindictive--so if there was a 2 or lower with no evidence to support it, the score was dropped from our permanent records. It was policy to counteract vindictiveness on the part of the students in the anesthesia program.

Often, it is because there is request for compensation for services rendered that lead to bad Yelp reviews on physicians, and other health providers. I follow them, but with a grain of salt. For example, in my choice of doctors for my thyroid, the one I wanted had reviews about the wait and the ease of making appointments. I thought against my initial choice because I didn't want to have trouble being seen.

In everything, use your intuition, your inner guidance, and heart.

Remember ridicule is one of the most potent weapons in the arsenal of the dark forces on the planet.


Obamacare
This is based on what I have overheard in the doctor's lounge and the doctor's dining room--
payments are now seventy percent of Medicare.

As you know, in certain parts of the country, the southwest/Arizona areas in particular, where due to the inability to make enough money to support a practice, many primary care doctors are REFUSING to accept Medicare patients. The retirees in those areas must drive three hours to Las Vegas to see a doctor.

And this is at Medicare Rates.

Apparently the Gold, Silver and Bronze 'levels' of Obamacare correspond to 'how much copayment the patient pays you'.

And there is concern about reimbursement due to the nature of the very high deductibles with the plan.

Hospital administration has encouraged participating physicians to 'collect the co-payment before seeing the patient'. This is because many patients do not pay their bills, and it goes to collection, which is expensive and doesn't always produce compensation.

Now there is a 'strategy' of sorts, where the smart doctors don't submit the billing until the patient has met their deductible--which they won't pay. Then they submit it. And all the other doctors who have submitted billing before are on the hook trying to find how to get the deductible actually paid to them.

It is a disaster in the making.

I also know with declining reimbursements, care is getting more limited. The gastroenterologist and I make about the same with, for example, a procedure such as upper GI endoscopy. But over there, a case I was assigned to, I got told to 'go for a coffee break' because the patient's insurance had denied anesthesia in favor of nurse conscious sedation. Either way, I didn't get paid. At least by not doing the case I did not expose myself to risk of something else going on with the patient that could lead to malpractice.

Every doctor taking care of a patient always is making a subtle assessment of benefit versus risk of treatment to the patient; what the patient does not know, is that at the same time, the doctor is weighing the benefit to risk of being sued by that patient at the same time. Every interaction opens up the risk for malpractice, even when the physician does not get paid. When the risk is too great the physician will refer out to another colleague and decline to treat the patient. Some patients are at very high risk for complications, and as the likely outcome is estimated, the physician decides that course to take for both of them.

I call this the 'post-wallet biopsy' era in medicine--those days of 'wallet-biopsy' are long over, and survival of the practice is now the number one factor on the physician's mind; mind you, there are lots of HMO's and big box organizations that are waiting in the wings for the practice to fail, to step in, and buy out the practice, making the physician an employee.


I hope you don't mind seeing it from inside the system.

Now it's time for some breakfast! I'm hungry.

P.S. BTW, there is a psychic who is coming to the area. Her readings are one hundred dollars and hour on the phone and two hundred dollars and hour in person. This is way more than an office visit would be paid in cash--it's about sixty-five dollars to see a physician, of course, it's a different kind of personal, and doesn't take an hour. It's about twenty minutes.


Aloha and Mahalos,
Namaste,

Reiki Doc

You Are My Life by Michael Jackson

http://youtu.be/YMcBmZw5Kh8

Reiki and the E.R.

An elderly loved one was admitted to the hospital recently.
As the doctor in the family, I was requested to come to the E.R. at once.
Sometimes, the 'Just for Today, I will do my work honestly' applies even on your day off.

I had to be a noodge. Do you know what a noodge is? A noodge is the person who stands up for the Truth, and annoys the heck out of people to get proper care for their loved one.

This family member had an eight-week history of malaise: not feeling well, not eating, needing help to walk. This was a change in the baseline activity level of a basically active senior.

The catch is that this loved one had a complex medical history, including diabetes brought on by steroid use in anti-rejection therapy for a solid-organ transplant.

Furthermore, this loved one, like my three other elderly loved ones who had passed on before, bought the motto of this 'big box healthcare organization' hook, line, and sinker. Somehow the five-dollar copay translates through as 'good care' to people who have lived through the Great Depression.

Blood sugar was over five hundred. The admitting internist wanted to send this loved one to the floor.

While I was in the E.R. for over six hours, and the hospital itself for eight, this is what I saw for treatment:

Glucose = off the charts. No diabetic ketoacidosis--yet.

Insulin ten units i.v.

Recheck in one hour. Glucose = four hundred and something.

No action. No insulin. Nada.

I ask about the plan of treatment with the E.R. nurse.

Delay while she calls the internist.

Ten units insulin i.v. PLUS eight units insulin subcutaneous.

No recheck as expected in an hour.

I ask again after two hours.

Recheck blood sugar. It is three hundred ninety.

The internist calls, and asks for me. This doctor says, 'I did test A and test B and test C and test D and test E and test F and...the results are A and B and C and D and E and F....'

I listen, acutely aware that this is a new doc, who is not yet able to synthesize a working diagnosis. This  physician is 'ruling out' everything on the differential (list of possible) diagnoses, but does not 'get it' that something seriously metabolic is going on. 

Here is the work up that should have been happening;
ABG (arterial blood gas)
Urine and serum osmolarity, and sodium (this was critically low)
Insulin drip
echocardiogram
in addition to the EKG, UA, lytes, CBC, renal ultrasound, chest x-ray and CT scan ordered.
(isn't it ironic how at the airport they x-ray your total body on the way in the gates but not at the E.R.?)

Guess what?
I said to the nurse, 'I know in my heart that is it was this intern's parent in this E.R. instead of mine, this intern would have been ten times more mean than I am being now!'
And the nurse looked at me, and let down her guard immediately, for I had spoken a Truth.

The internist agreed to ICU admission 'to make me feel better'.
Then I got told by same internist, 'The ICU physician refuses the admit because your loved one does not meet ICU criteria'

Guess what? The telemetry nurse refused the admission. The sugar was not controlled and too high.

Guess what? My parent experienced chest pain (I can't breathe I have pressure, and anginal equivalent) twice in front of me. You don't give one and a half liters of normal saline wide open to anyone over seventy. At the first time, we stopped the fluids, and the symptoms resolved. When the fluids were restarted later, on a pump, we mentioned in the hall that the patient was having chest pain. (I had programmed the monitor to track continuous EKG tracing, one lead, in the E.R. as it was only showing pulse ox and blood pressure before. I watched the ST segments steep depression, and knew the diastolic blood pressure was only thirty. I saw the ischemia happen before my eyes, just like in the O.R. Only there was no paper in the printer on on monitor to print out automatically with the alarms what had been going on).

Then everyone ran in the room.

The nurse in white scrubs came in. The one that knew what was what. Probably the house supervisor.
He asked why the sugar was so high and uncontrolled. And why there were all these different places to go--telemetry, ICU, DOU (step down).

I said it was because I 'squeaked'.

He looked at me, eye to eye, back to the rest of the E.R., and said, under his breath in the gayest 'you go girl' voice ever--You Did Right, looking around the room to make sure none of the Big Box Employees would rat on him. Over his shoulder, was the E.R. nurse, nodding their head, in support..
Again, in his sotto voce, 'Your parent needs DOU level of care. Needs an insulin drip. You did the right thing by speaking up.'

The internist came in the room, as I was holding my parent's hand while the nurse drew blood for troponins, a marker of cardiac injury. Transplant patients, like breast cancer patients, only have one arm for blood pressure cuffs, i.v.'s and blood draws. The veins are terrible.

I felt the internist bump into my aura. It was about six feet radius around me. The internist stopped.
The internist saw and understood everything, without words. I saw an extremely thin doc, with very well-developed veins, a runner, possible ultra-athlete, a top-of-the-class book-smart doc, still wearing a retainer, who chose Big Box so They Could Have A Life. In essence, they chose a 9-5 career in medicine.

I asked, 'what do you want to do about fluids? The i.v. maintenance is on hold.'
The internist touched the tubing and the beeping pump, and said, 'it is going'.
I said, 'no, the tubing is not connected to the patient, and the pump is on pause.' holding the end of the tubing and pointing to the pump, 'we need a decision to either restart it or hold the fluids'.

The internist stammered, walked out of the room. The pump kept beeping every two minutes. My sister and I took turns hitting the silence button, until after about ten minutes, I just turned the pump off.

What is the moral of the story:
The dark side of medicine today is that there is a difference in the standard of care between your doctor's mom and your own.

Let me repeat: there is a work ethic for 'care of the patient' that suddenly 'changes' when it is not just 'the patient' and it is 'the family member of the health care worker'.

Big Box Healthcare is a Business. End of story. Efficiency at patient care leads to more profit for shareholders.

When, every patient is considered someone's 'Auntie' or 'Uncle', a real breakthrough in Healthcare is going to happen. This is MUCH needed in medicine today. Even the ugliest, stinkiest street person, is still 'Auntie' or 'Uncle', just as much as the blood related 'Auntie' and 'Uncle' to the nurse, physician, physician assistance, nurse anesthetist, critical care nurse, E.R. nurse, orderly, nursing assistant, x-ray tech, echo tech, phlebotomist, janitor, dietary worker...and Reiki is going to be a huge part of this process.

Do you agree?


Namaste,

Reiki Doc