Saying Goodbye

It's Friday afternoon and I check the day's schedule. A name jumps out at me and I groan a little and worry--what am I going to say to someone I've treated for twenty years, who's my age and just been admitted to hospice care? If this is goodbye, how do I as a physician, who is more than an acquaintance but not quite a friend, handle this appointment?

All kinds of things go through my head. Do I really want to charge for this? How bad will he look? Can I keep from crying? Is there anything I can do for him anyway? Will I ask the right questions? Will I say the right things?

He comes with a relative. He is living alone but they have found a nursing home that he liked today and he hopes to transition there quickly. He has one sorrow and one fear. He needs to find a home for his dog of 14 years. He shows me a picture of a cute lap dog of some sort. Amazingly, during his last hospital stay he met someone who is willing to take care of the dog. His fear is how breathless he will be near the end. I reassure him that every effort will be made to make him comfortable and he should not suffer.

We talk a little about his parents, with whom he has been estranged for some time. He assures me that he has spoken with them. They are older and have had their own medical challenges. I cannot imagine how they feel. He jokes a little about his relationship with them.

Finally it is time for him to go. He looks tired, but not that ill. He asks me if he should try to eat, he doesn't have much appetite, and I encourage him to eat whatever he wants. He stands up and gives me a hug, whispering "I love you" in my ear as he does. After reminding me that the phone is a good method of communication, he leaves.

I am lost in thought and emotion but still have two more patients to see. I take a breath, walk into the next room and apologize for my tardiness. It's probably obvious that I'm upset but the rhythm of seeing patients takes over and somehow, reassures me.

A Very Personal Understanding of Aging

My todo list is overflowing, my emails are piling up, I have 17 pages to read in my book and all of these are things I enjoy doing. But my mother has just called me for the fifth time in less than 60 minutes about the new safety monitor we got her for Christmas, the 5Star Urgent Response. New things challenge her and the idea of having both a cell phone and this device is beyond her ability to assimilate. As I sit at the kitchen bar trying to concentrate on any number of items the phone rings two more times. It's not that I don't want to work more but my spirit is broken by the phone calls. I give up and walk toward the stairs to the bedroom. My mother must have picked up on my frustration because when the phone rings again, it is not mine. My husband picks up his phone which is playing "Mother-in-Law" (see below).  

Over the years, as my patients have aged along with me, they have told me their woeful stories regarding their parents. I knew my time would come and over the last year my 84 year old mother has diminished with each month. She refuses to take any "more" medication and, like many of the dementia patients I've treated, doesn't see the problem. Since the evidence on the "Alzheimer's medications" is not all that convincing anyway[1], I am not willing to fight over it. She limits her driving mainly to daytime and to places she knows. But if you throw anything out of the ordinary, like the new device that she needs to clip on her person and charge every night, it becomes a nightmare. Not only for her but for me and my husband as well. 

My daughter has already approached her about moving into a personal care home but she will have none of it. She has good days and bad days. My job keeps me busy and disinclined to force the conversation. It is coming. My patients have prepared me for it and I thank them for this. But just like them, there is a black hole of dread that I see approaching. One thing for sure, while I will avoid discussing what is a personal matter, my empathy will go out to the next adult child dealing with their unwilling parent. 

1. http://consumerhealthchoices.org/wp-content/uploads/2012/08/BBD-Alzheimers-Full.pdf

Cynical Thoughts about Medical Insurance

Is anyone else irritated by medical insurance companies' efforts to improve the health of their members by encouraging them to do recommended tests based on claims-made data? Recently, a patient asked me if he should get the pulmonary function tests his insurance company recommended based on his asthma diagnosis. He does have mild intermittent asthma. He uses a steroid inhaler once a year during the spring for about a month and might use his rescue inhaler with exercise four or five other times during the year. If you check the guidelines put out by the National Asthma Education and Prevention Program it is recommended that a spirometry test or PFTs be performed annually to assess any changes in lung function. The fact is, this patient has been treating his asthma the same way for about fifteen years. He feels fine. So will doing PFTs make a difference? We discussed it (over Christmas and through the patient portal, which I love) and decided that doing testing was unlikely to cause a change in therapy. Since he had better things to do than PFTs he would prefer to skip the tests. Hopefully he won't see an increase in his premium for refusing to follow his insurance company's medical advice. Does this make me worry about becoming nothing more than a flunky ordering tests for patients based on Humana or Aetna or Anthem's "best practices"? In a word, yes.

What irritates me more, is being faxed long lists of patient names with recommendations for mammograms, colonoscopies or diabetic eye exams. Our office is supposed to pull those charts and encourage patients to have their preventive exams. Of course if we do pull them, it turns out the "claims-made" data from the insurance company isn't all that accurate and many patients have already had their tests done. Thus another waste of the office employees' time pulling charts. Hopefully it will be easier with electronic records.

I suppose the cynic in me wonders "What's the angle here?". Does the the upper management of these companies really care about the members they insure that much? Is that what it takes to continue to make the obscene salaries their positions pay (see chart below)? When Humana sends me yet another envelope full of "healthy" coupons in their quarterly newsletter that shows me how much money they saved me with my last doctor visit, complete with lots of "healthy advice" enclosed, why does it make me roll my eyes?

When I want medical advice I will talk to my doctor or find an expert on-line, I will not talk to my insurance company. I do not want or need coupons from Humana. Nor do I want my insurance company to remind me of preventive care visits via my telephone. My patients are thrilled by it, however. "Humana pays for me to go to Silver Sneakers! Isn't that great?" or "A free 30-day Jenny Craig membership is available, what do you think doc?" 

Just call me Thomas, because I am a doubter. Nothing is truly free in the insurance business, so somewhere along the line the consumer is paying for the SilverSneaker membership and the salary of the individual who is soliciting companies to provide coupons from the insurance company. Please, just pay my claims and not give me such a headache trying to obtain my prescription from your 90 day pharmacy service. That's what I would call good service! 

http://www.ama-assn.org/amednews/2012/images/gbisf0531a.pdf