as I knew it…

Posted on Sunday 4 May 2014

    April is the cruellest month, breeding
    Lilacs out of the dead land, mixing
    Memory and desire, stirring
    Dull roots with spring rain…
    The Wasteland [1922] T.S. Eliot
Every year, I joke that rather than being a post-World War I lament about the burdens of hope, what Eliot was really writing about was Spring Pollen – that he was a fellow sufferer of seasonal allergies. But this year, it was more poignant, more like Walt Whitman in his 1865 eulogy to Abraham Lincoln:
    When lilacs last in the dooryard bloomed,
    And the great star early drooped in the western sky in the night,
    I mourned, and yet shall mourn with ever-returning spring…
In the week after Easter, I lost my two best friends of some forty years duration [in memory…]. We retired around the same time and moved to the mountains to grow old together, living within a couple of miles of each other. Beside being lifelong playmates, the two of them had more to do with shaping my values than any medical mentor, though they had nothing to do with medicine. Andy was a minister who, early on, left organized religion and lived it’s tenets rather than talking about them. Al was a decorated photojournalist who, among other things, chronicled the dark realities of the South and was instrumental in showing them to the world. This blog began life as to keep up with our other shared friends elsewhere, but Andy and Al weren’t the writing kind. When I turned to writing about more weighty matters, my daughter rebranded it to protest.

But this is not a eulogy, it’s about my recent encounters with Medicine and its current practices during my friends’ illnesses. The doctors were excellent except for the Emergency Room where some were okay and a couple were truly horrible. The best I can say is that I didn’t hit one of them [which says more about my restraint than his just due]. Which brings me to what I want to talk about. There were two main forces at work in our hospitals and medical systems that are diametric antipodes – struggling with each other in every single medical encounter.

At multiple points along the way, each of them needed to be in the hospital for diagnostic reasons, but apparently that’s a poor use of hospitals these days so we had to haul these two very ill men all over hell and half of Georgia [literally] to get the tests needed for diagnosis as itinerant outpatients. And there were numerous examples of ‘we can’t do this test [we need] until we do this other one [that we already know the result of]’. The tentacles of managed care utilization review spreadsheets were everywhere, usually unnecessarily obstructive, and drove us all nuts – concretely interfering with decent care. Consults that could’ve been done in a few minutes took days to schedule and coordinate with others doctors. The impact of the forces of restraint in medical spending were certainly apparent every day, everywhere.

On the other side of the coin, the waste and unnecessary expensive medical tests took my breath away. It was worst in Emergency Rooms where CAT Scans and MRIs were ordered as if you had to have one or more just to prove you’d been there. It felt like a mixture of fee churning, CYA, and defensive medicine – more like the primary purpose of an ER was to generate revenue rather than tend to the sick. That was true in the hospitals as well. There are rigid protocols for everything perverted to drive up costs rather than contain them [their original purpose]. I’ve been mostly blessed with health, so my stint on the "consumer side" of modern healthcare was more up-close than it has ever been, and left me with a bad taste in my mouth – both the outside influence of managed care restrictions and rules and the outrageous waste, expense, and excesses of the hospital corporations/PHARMA/etc. I felt something between shame and rage much too often in this last month for my liking. There are other things that need feeling when you’re losing your friends.

I tried to keep what was going on in my life out of what I was writing about Integrative or Collaborative Care, but on rereading, I think I failed at that. What I read sounded like perverse systems theory drivel with people jockeying for position. Even though I was a reluctant soldier, the best system of medical care I ever worked in by far was the US military on an overseas base. Part of that was because it was a healthy population. Part of it was because there were very few, if any, sociological problems – by definition, everybody was employable and employed, pretty much on the same level. But another piece was that it was genuinely Collaborative Care, Integrative Care, whatever you want to call it when there is a team of medical personnel working together. We were all in a centralized location, knew each other, ate lunch together, were paid the same, etc.  If you needed some help, it was just down the hall. I was an Internist then, but the Psychiatrists were an integral piece of that system.

The second best systems were the two megalithic City/County Charity Hospitals where I did my training [one now closed]. They were always on the brink of bankruptcy, underfunded, chaotic, and staffed largely by sleep deprived trainees. The patients were indigent and with a ton of pathology, but the healthcare was good, including psychiatry – collaborative. I would include the charity clinic where I now work in that group, though services are limited.

The worst, also by far, is the system I’ve dealt with the last months with my friends, private systems with the best doctors and the most medical resources. It’s because the regulatory forces, the intrusion of the managed care carriers, the phobia about hospitalization, and the carpetbagger profiteers have made one hell of a mess of things. I’ve left out the details because I expect most of you have stories of your own. I always said I didn’t want to age into one of those old guys who longed for "the good old days," but this particular April, I was mourning more than the final days of my friends. I mourned the loss of Medicine as I knew it…
    May 4, 2014 | 6:48 PM

    I am truly sorry for the loss of your friends. From your writing, it was clear that it was your closest friends even before your post today, yet I have to say after reading it, I cried. And, crying is something I rarely do. I know you prefer not to share your stories, yet, sharing your stories shows your human side, and it what we humans do that connect us to each other.

    I wanted to share this quote with you, for it is a good quote for troubled times, and it also shows why I find your work so important.

    Sam: I know. It’s all wrong. By rights we shouldn’t even be here. But we are. It’s like in the great stories, Mr. Frodo. The ones that really mattered. Full of darkness and danger, they were. And sometimes you didn’t want to know the end. Because how could the end be happy? How could the world go back to the way it was when so much bad had happened? But in the end, it’s only a passing thing, this shadow. Even darkness must pass. A new day will come. And when the sun shines it will shine out the clearer. Those were the stories that stayed with you. That meant something, even if you were too small to understand why. But I think, Mr. Frodo, I do understand. I know now. Folk in those stories had lots of chances of turning back, only they didn’t. They kept going. Because they were holding on to something.

    Frodo: What are we holding onto, Sam?

    Sam: That there’s some good in this world, Mr. Frodo… and it’s worth fighting for.

    I understand what you saw when you speak of real collaborative care. I saw it too, in the small town hospital where I worked. After having seen what I have while working in business, I know that it can never come from those who have to use a term like “patient-centered”. It can only come from you and providers like you. So, I am ever grateful for what you do at the clinic and that there is a clinic like this. Because, it lets me know that there’s still some good in this world.

    May 4, 2014 | 7:37 PM

    Tough post. Again, sorry for your losses. But, you are mostly out, and while you can claim you are still “in” per your volunteer work, you can walk away when you have to. Me, I am little more than four years from doing my eventual walk, but will be still 8 to 12 years from legitimate retirement.

    Maybe the system will implode by then?

    Steve Lucas
    May 4, 2014 | 8:21 PM

    Your post brought back a flood of memories of dealing with friends and family and their medical struggles. Equally frustrating is knowing there is a better way.

    My father told me we can only know how great a life we lived by the remembrance of those we leave behind. Your friends were truly great men to have had such a great impact on your life, and I am sure on so many others.

    Steve Lucas

    May 5, 2014 | 12:44 PM

    The Incident of the Hospital Bed was the worst.

    May 5, 2014 | 4:54 PM

    Very sorry for the loss of your two friends, Dr. Mickey.

    May 5, 2014 | 6:46 PM

    Sorry for your loss. I would have been honored to be your friend.

    May 5, 2014 | 8:39 PM

    My condolences. That you’ve had such wonderful friends is proof that you’ve been a wonderful friend. It is better to have loved and lost, no doubt, even though the loss is dear, it’s as dear as the gain. May your grief be pure.

    May 5, 2014 | 8:52 PM

    You were at an Air Force hospital? I was stationed on an Army post in Northern Germany and the medical services were dreadful. They kept telling me I wasn’t pregnant, so I had to buy four different sized uniforms before they had to relent and sign the paperwork so that I could get a paternity uniform. I had zero prenatal care. My daughter was stillborn, and I suspect that the radiation in the radar site, including that coming from the unprotected scope, was at fault, but the lack of prenatal care was significant.

    An Army dentist would not listen to me when I told him that I needed either twice as much Novocaine or needed to wait twice as long. He started to drill, I protested because it hurt like hell, then he put his knee into me and leaned in with the drill. I was limber enough to put my foot on his chest and kick him across the room so that I could get up and leave. I just don’t do the whole “victim” thing well, or at all, if I can help it.

    As far as HMOs go, I think Kaiser should be the flagship, though much improvements could be made, especially cutting out most “preventive” pharmaceuticals. My two caregiving clients who chose Kaiser, got good care. The other two got the HMO that requires two weeks of playing phone tag to get anything done, and a game of “nerves do regenerate” for a year until the patient could no longer serve for the nerve damage done during the hip replacement; and the HMO where one’s caregiver has to explain MRSA and VRSA to the doctor so that he’ll believe that the penicillin really didn’t work on what really wasn’t bed sores. That one didn’t really know what to do with the riff-raff.

    The V.A. is great, in many ways, and the system I’m in is one of the best in the country, according to my fellow vets; but I’m going to stop taking the statin, just like I stopped taking the beta-blockers, and will continue doing my best to discontinue as many medications as I can and not to take others whenever I’m convinced that I’m not convinced that there’s any real good reason to take one.

    The amount of harm that could be reduced by discontinuing medication and prescribing less must be worth a billion or so.

    Joseph Arpaia, MD
    May 6, 2014 | 10:40 PM

    My condolences. Other words fail me.

    berit bryn jensen
    May 7, 2014 | 12:55 PM

    I offer my sincere condolences, dr Nardo, and think that the love and respect you show your friends reflect beautifully on yourself.

    I read this on a bus home from a conference in Oslo, on a jumpy internet-connection. Suddenly a page appeared with sayings attributed to the ancient Chinese Confucius:

    “There are three ways to acquire new information. Thinking is the noblest. Copying is easiest. Experience is the most bitter.”

    I’ve lost my trust and pride in our singlepayer, free, publicly owned health and care systems, excellent in many ways, but patients suffer absurd levels of psychiatric coercion and examples of abject disregard of the old and frail and people with disabilities are abundant. Today one of my daughters said (quoting a teacher) that we do not see until we believe it…

    Thank you!

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