By Michael Miller DO, FACOS, FAPWCA, WCC
There is a particularly memorable scene in the 1976 Film “Network” in which Anchorman Howard Beale (played by acting maven Peter Finch), learns that he has just two more weeks on the air because of declining ratings. His angst finally comes to the surface and in a burst of splenic venting ecstasy, he persuades his viewers to shout out of their windows "I'm as mad as hell, and I'm not going to take this anymore!"
Like Howard, I find myself seeing things that so unnerve, outrage and vex me that it is all I can do to not grab the nearest fluffy, soft security blanket and suffocate somebody with it.
Patients are right and we are right. While I would rather endure a Tabasco enema than willingly allow yet another bureaucratic oversight body to insert their uneducated proboscis into my or my patient’s business, recent events have forced me to realize that for better or worse, some oversight is needed to assure that things remain copacetic.
Bad ideas we deal with include the Stark Laws and their related cousin the “pay for referrals” prohibitions. Never mind that the legal profession who created these one-sided legislations is the only profession to have benefited since they make a fortune translating these decrees into untenable business arrangements. Regardless of the compensation, sending a patient to a bad doctor, a bad nursing home or bad hospital only results in widespread problems that no amount of money can dulcify. No legislation is needed to reinforce common sense.
Good ideas include at least two parts of Obamacare which allows children under 26 to stay on their parents insurance, and the mandate to cover pre-existing conditions. Another good idea may be those drones that have engendered significant paranoia among the uninformed and unimaginative. One of my favorite old adages is that “It’s only illegal if you get caught”. A corollary is “if you do nothing wrong, you have nothing to fear”. And so, why should a simple, privacy invading, “Mandatory Oversight” type of situation be a problem unless…you are doing something you shouldn’t be doing? And so, is having your choices monitored, condemned when wrong and supported when good such a bad idea? If your child behaved like that, wouldn’t you want to know?
Cases in point
The new nursing home consult was for a delightful 77 year-old female whose admitting diagnosis was for IV therapy for sepsis. Interestingly (and not surprisingly) she had a diagnosis of lower extremity cellulitis reinforced by the inferno-like 100.3°F maximum oral temperature, the white count of 18, 500 (does the machine even count that high?) and a swab culture (from the hospital wound care nurse) positive for the first 10 chapters in a microbiology book. My search of the accompanying records for the definitive (or even presumptive) cause of the sepsis was fruitless, but the low hanging fruit of red legs was too much for the hospitalist and his cohort in this crime, the ID doc to not pluck and identify throughout the chart. My inability to spell precludes me from listing the witches’ brew of antimicrobials now diluting her immune system. I recognized the handiwork of our local ID-iot for whom I have no question (based on far too many knee-jerk, erroneously diagnosed “infections” and seeing a myriad of antibiotic marinated patients) that he single handedly created MRSA! Of course, his tunnel vision to find a suitable diagnosis that matched his pre-planned but misguided panacea precluded him from identifying the yeast infection that made her buttock and thigh skin look like they had been treated by a Veg-a-Matic.
And so, firmly ensconced in the nursing home, (a sign on her door boldly proclaiming skin and secretion precautions due to the findings of the antiquated swab culture of leg drainage), the nurses awaited me to make sense of this intestinal twisting goulash. Of course, the astute reader immediately will jump on the fact that once again, science has overcome common sense and the legs were merely the hosts for incompetent veins, which needed only some semblance of evidence-based compression to resolve the issue. I ordered an oral and topical antifungal. Despite the overwhelming urge to stop three antibiotics du jour, that nebulous diagnosis of sepsis (even with the confabulated etiology) precluded me from a bout of premature maculation of their treatment. Why was there no one overseeing their haphazard attempt at treating this patient using the “Ready, Fire. Aim” technique? How could they be allowed to cause so much potential harm at so much cost when they were unequivocally wrong? How could this medical charade have been allowed to develop? Does the need to make a living usurp ethics? If an ID doc can’t prescribe an antibiotic, then what good are they?
The 45 year-old female self referred after “that other wound care center screwed me up”. Two large holes in her non-diabetic feet and massively swollen legs suggested more than met my eyes. After obtaining a history of rampant, psychopathic, malicious incompetence on the part of my predecessors (who actually are well thought of in our area), I completed my history, physical and decision-making (all of which was dutifully recorded on our now attested EHR, thank you). Fortunately, my recommendations differed somewhat from theirs and she and her husband agreed with the plan. Of course, when her wounds and legs failed to improve despite her “swear to God” assurances, I turned to her home health care agency who was planning to discharge her if her non-compliance persisted. A quick review of her records showed multiple “slept past the alarm” missed appointments (I myself do not require 14 hours of sleep per day) and used leg wraps brought in trash bags to show compliance, while her legs remained as fluid filled as a 3 year-old in a juice box factory. Why was this patient allowed to waste the time of her house call nurses, the money from our State medical support systems and moreover, my time and expertise when her actions and attitude belied her true intentions with respect to her condition? Could not someone (maybe the patient or her husband) have been honest with us all about their willingness to participate in the treatment she initially purported to want? Why was there not some “trigger mechanism” that basically shuts down the “eternal medicine” when the desired end result is simply not going to be achieved?
I make house calls to shut-ins with non-healing wounds and other conditions we all see in our facilities and clinics. The process is simple: I evaluate the patient, explain my findings and recommendations, answer their questions, get their buy-in, call the HHC agency, and leave orders with the case manager or nurse. I then thank the patient and head off to perform my next miracle. I actually believed that my orders, once given, would be carried out as issued and when questions arose or supplies did not, then communication would resolve the issue and great care would be the mantra of all involved.
I recently hired a physician associate who has shouldered the responsibility of following up my glut of single-visit house call patients. You can imagine my chagrin when he reported that a fair number not only were not getting the ordered treatments but in fact, many had never received anything remotely related despite my receiving and signing the 485 documents (which are the bible for the care of a given patient by their HHC agency). Ordered 4-layer leg wraps were translated into gauze wraps and petroleum jelly under film applied once a week if at all. Of course, the oversight case managers were aghast that the ordered care was not being done and assured me they would “look into it”. How can ordered care not be carried out? At what level did the breakdown occur? I recognize that the occasional unusual dressing I order sometimes have to be obtained, like calcium alginates, and foams and hydrogels. If you don’t have these on hand, then what exactly are you using for your bread and butter wound care? Ultimately, the care I initially ordered was initiated but, at the expense of several fruitless nursing visits and prolongation of patient discomfort and inconvenience.
I do not consider myself naïve and so realize that there will be glitches, misunderstandings, and inabilities that preclude best care from happening. We are human and even with genomic manipulation, the inherent ability to do inane things and make horrendous decisions will never be genetically modifiable. What we need is a system that watches, juxtaposes, vets and reacts. Just like the dreaded drone or at the very least, Jiminy Cricket, something needs to turbo charge not just our common sense, but our sense of fair play and our consciences. If a patient demonstrates their inability or unwillingness to choose “best care”, then their choice of substandard care need not be rewarded. Perhaps those death panels are right — you have the right to be stupid and/or make bad choices, we just don’t have to pay for it. Of course, the same must go for our well-intentioned but deluded colleagues. After a certain percentage of your cases are identified as worthy of Dr. Howard, Dr. Fine and Dr. Howard (better known as Moe, Larry and Shemp), then your medical license reverts to a Sponge Bob Fan Club certificate.
In short, what is needed is a way to assure that care is appropriate, cost-effective, and patient-centered. Moreover, it needs to be agreed to by the patient as part of their health care team, not merely as a means to revolt and demonstrate their own individual mandate. For our part, as health care professionals, we need to stop worrying about the fragile egos of our colleagues and have access to an oversight entity that is fair, equitable and founded on the principles of providing and assuring best care practices, not to promote an agenda of self righteousness. George Orwell’s 1984 and the concept of Big Brother may provoke a fear of loss of privacy and individuality, but the actions taking place in medicine on the part of ourselves and our patients shows that regardless of how you read the constitution, the ability to make bad decisions and act stupidly is a privilege, not a right. Unlike bees, we are free to make intelligent choices as we see fit. But to be sure …perhaps we need a different kind of drone.
Until we ramble again…
About The Author
Michael Miller DO, FACOS, FAPWCA 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.