Wound Care in Crisis – DarWoundism and Survival of the Entitled

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by Michael Miller DO, FACOS, FAPWCA, WCC

We have all seen the use of the term "Entitlement Mentality" in the media. Liberals decry its use by pointing out that the government has a duty to all citizens to assure that all people have the same rights. This argument tends to fall short when there is juxtaposition of families with multiple generations of "welfare" against those who chose to delay gratification to further their educations and become health care professionals and other occupations of service. We have all seen patients whose corpulence rivals that of Jabba the Hut and wondered not only how someone could allow themselves to mutate into such a state but more, how their loved ones could allow it. Of course, in the grand scheme of things, it does make for interesting reality television. Like the 55 year old male who had the equivalent of a '57 Chevy bypassed from him. Let's face it–regardless of how mechanistic you would like to believe we all are, regardless of your occupation, personal feelings always play a role. If not, then why would it matter if there were Republicans or Democrats sitting on our judiciary, as shouldn't the laws be interpreted based on their meaning and relationship to the US constitution and Bill of Rights and not which President appointed you to the bench?

What it Means to be a Health Care Provider Under Obamacare

The further we delve into the intricacies and nuances of Obamacare, the more I am realizing that one fact is absolutely immutable: There is going to be shifting of costs and on a magnitude equal to Facebook's IPO. What I mean is that we have already seen a plethora of guarantees metamorphosed into conditionalities. From "If you like your doctor, you can keep them" to "Good luck finding a doctor that will not only stay in practice but takes your insurance, has office hours convenient for you and is not afraid to call in pain pills if you need them."

Being a health care provider used to mean that you had deferred short term satisfaction for a longer period of training for which you received compensation, commensurate with the skills you acquired and used. That is not to say that other equally needed occupations should not be justly rewarded but rather that the bohemian training and trainers in the medical field were a gauntlet that once run, had it's share of rewards albeit deferred to much later.

Of course, that brings us to the problems we encounter with those suffering from either God-given or self-inflicted infirmities. We make house calls and see up to 50+ patients in a week in that endeavor. The myriad of personalities and situations encountered run the gamut from those who are truly in need versus those who define their need by their own poor choices and need for self gratification at the expense of us all.

Case 1 is the 540 pound bedbound woman with advanced lower extremity lymphedema and giant leg ulcers who had successfully out-eaten a gastric bypass and then a Roux-en-Y intestinal switch with the pleasant demeanor and genuine gratitude for our help in obtaining many needed services. Despite the horrific self-abuses so evident in this case, one could not help but feel empathy and yes, sympathy for her plight and that of her caregiving husband.

Case 2 is the partially paralyzed gunshot 35+ year old gang member who demanded visits between only certain hours and whose ischial and coccygeal pressure-based tissue injuries changed their appearance more often than Lady Gaga. After even his mother refused to care for him and left him under the premise of going shopping, his home health care nurse had to text him to awaken him and then give him ample time to prepare himself for their visit which he might refuse just before their arrival. His last visit by me found no answer to our repeated knocking after confirmation the day before of a "good time" to be there. After no response and heightened concern, a hidden key allowed entry which after 5 minutes of yelling for him in a one bedroom apartment, finally discovered him in bed, under the covers completely, from which his head finally emerged. His immediate response was anger that we had "disrespected him" by entering without his permission. Despite explaining our concerns, especially with his "carefree" substance-based lifestyle and lack of caregivers, we parted company at his request, leaving him to return to the blissful slumber we had interrupted, his care to be assumed by another entity of his choosing. The last information I received was he had found a non-wound trained internist to write his pain and wound orders and the home health care agency is still looking for the opportunity to sign off. His final thanks consisted of his middle finger raised high in gratitude.

We all want to say that we are ethical and compassionate and that the needs of the patient are always considered at the forefront of our actions. But, as humans, and moreover, as hard working dedicated health care professionals we need to ask ourselves, at what point do patients need to be held responsible for their actions both prior and present, and how should this affect the level of care provided to and for them. For better or worse, this miasma of health care legislation has forced us all to re-evaluate the intricate balance between care provision and care accountability.

We all remember the famous words of Mister Spock "The needs of the many outweigh the needs of the one." As a fragile human, my psyche cannot help but juxtapose my own family's health care and what we receive for what we pay against those I care for whose poor choices and situation have led them to be entitled to things that all too often seem unfair. The invalid woman with diabetes who lives with her daughter, a single mother of two who needs to get her car fixed so she can get her mother to the office to have her diabetic wound debrided certainly engenders compassion and sends my team into overdrive as they work to find a fix for her situation. The Medicaid recipient with quadriplegia with an 80 inch plasma TV and stereo system worthy of Mick Jagger talks freely about his next media purchase "once his check gets here." His full time aides giggle in response and yet, he receives the best care I can give him.

The Responsibility to Provide Health Care, Not Pass Judgement

Regardless of the cause, the surrounding factors, the nuances, or our personal feelings, patients deserve the best care we can give them. Growing up I could not understand how an attorney could defend an accused child molester, a murderer, a thief until I realized that as a health care provider, my duty is to provide the best care I can to all who seek it from me. My job does not include the ability to make judgment calls on suitability for cost expenditures. That responsibility falls to others. Moreover, the decisions belong to patients themselves which is the rightful place for them. But somebody has to pay for their decisions right or wrong. Survival of the fittest? That may take some radical redefining of the word fittest since it seems that being entitled to health care means that costs take second place to patient needs and satisfaction. As far as my take on this issue, I do what my Hippocratic Oath and my parent's upbringing guides me to do. Regardless of what you want to call this, just don't call me Darwin.

Until we ramble next time...

About The Author
Michael Miller DO, FACOS, FAPWCA, WCC is the Founder and Medical Director of The Wound Healing Centers of Indiana and IndyLymphedema, as well as a clinical consultant, teacher, inventor, and published author.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Understanding Your Wound Care Team


Excellent and full of the truths and ills of being a provider

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