augmenting a living will

For the Ragtag Daily Prompt: anticipate. Anticipate can mean thinking ahead.

I wrote this in 2009 under the title “Better than a living will.” I think both living wills and POLST forms help families. Do you have one?

A living will is better than nothing, but unfortunately they are written by lawyers and don’t answer key questions. The number one cause of death in the United States is heart disease. The living will usually says “if two doctors certify that I am terminal within six months, don’t use extraordinary measures.” This has three main problems. One is what constitutes an extraordinary measure? Two, doctors are usually somewhat in denial and aren’t very good at saying when someone has only six months to live: for hospice people are often referred within days of death. Three: the most common cause of death is heart disease. Think about heart disease: if you are having a heart attack, the two doctors haven’t a clue whether you are terminal in the next 6 months. Actually your heart could stop in the next 5 minutes and then they would be very comfortable saying that you are dead, but the real question is “Do you want a natural death?”

People say they want a natural death but when confronted with a form, they often are a bit squeamish. In the state of Washington we have a POLST form: Physician Orders for Life-Sustaining Treatment. This is much more helpful and practical than the living will and it is meant to augment it, not replace it. It has four questions. The first is “Patient has no pulse and is not breathing.” This means that the person is dead. Does that person want an attempt at resuscitation? Check resuscitate or do not resuscitate. I ask if people want a natural death and people agree that resuscitation is not natural. Also, if someone is in their 70s or older, if the resuscitation is successful (mostly not) they are likely to have some brain damage from lack of oxygen. People often say, “Well, bring me back if I’m going to be okay.” I say that unfortunately our higher power has not provided us with a little pop up thing like roasting turkeys have that says “Done.” We really don’t know. We may have opinions, especially if the person is 40 and otherwise healthy versus 83 and has had a quadruple bypass and died three previous times. We have 8 minutes to bring someone back, so if you want to be resuscitated, die in the emergency room. The odds are much better. Also, most of the security guards at Las Vegas casinos have brought back more people than I have, because they have the automatic defibrillators and they are quick to put them on when someone wins a jackpot, grabs their chest, and keels over. If someone asks what I would do if I were them, I do answer. It depends on age and health. As a doctor I want to bring someone back if they are reasonably healthy and there is a decent chance. I don’t really want to do CPR on 90 year olds because it doesn’t work and their ribs break. Ick.

I once was doing a form with an elderly couple. The husband had already had more than one heart attack and he had been resuscitated from a cardiac arrest once already. I asked about a natural death and if he wanted to be resuscitated again and he said, “No, I don’t want that.” His wife elbowed him, “Yes you do.” He said, “I do? Why?” She said, “You have to stick around to take care of me!” He said, “Oh, okay. Yes, I do.” He WAS taking excellent care of her: she had by then had “end-stage” emphysema since she had come to our clinic 12 years earlier. I asked the pulmonologist how that could be and she said, “Some people are just wrapped in cotton wool by their families and they can stay around for years.” I don’t mind if someone wants to be recusitated even if I think it’s medically futile, because most people make sensible choices. If someone is really frightened of death, at a certain point no doctor can keep them around if the body has stopped working. There are really very few cases like comas or brain injury where someone can be kept alive on a machine. It is extremely rare.

I was discussing the choice with a woman in her 80s and her daughter and the 80 year old said, “I don’t want to think about this.” I said, “It may be uncomfortable to think about, but if you don’t tell me and your daughter what you prefer, we would have to guess. We don’t want to guess and we would probably err on the side of doing too much.” She grimaced, but she did make the decisions. The POLST form and living will are only used when we can’t ask someone, so a person who can talk can change their mind.

Question two is “Medical interventions”, asking how much intervention you think you would like. There are four levels on our revised form. The most interventional is defibrillation (shock), intubation (ventilator) and CPR. Since I live in a rural area, I also have the luxury of asking whether people want to be transferred to a big hospital. I explain that I can use medicine for a heart attack, but I don’t have a heart doctor or surgeon and I can’t do stents or surgery or bypasses or anything besides medicines and oxygen. Sometimes being rural protects people who don’t want much intervention, since the cardiologist and pulmonologist and gastroenterologist aren’t down the hall. Who would refuse to be transferred? A man who had two previous heart surgeries said, “I don’t want to wake up with that scar on my chest again. It hurts.” A frail man in his upper 80s had pneumonia and a tricky heart and kidneys. We said that we were family doctors and a cardiologist and nephrologist and pulmonologist would no doubt do more and they could do some monitoring that we couldn’t. He said, “Do the best you can for me here. I trust you and my family is here and I will either pull through or I won’t.” Four days later we told the family that he wasn’t. If we protected his lungs and heart from too much fluid, his kidneys failed more, and if we helped his kidneys, he couldn’t breathe. We changed to comfort care and he was surrounded by his family. I think that we all felt comfortable that we had given him the most respectful care possible and had honored his wishes. The second most interventional choice on the form is “All care above and consider oral/nasal airway, bag-mask/demand valve, monitor cardiac rhythm, medication, IV fluids.” The least interventional is comfort care only: “Oral and body hygeine, reasonable efforts to offer food and fluids orally, medication, positioning, wound care, warmth, appropriate lighting and other measures to relieve pain and suffering. Privacy and respect for the dignity and humanity of the patient/resident. Transfer only if comfort measures fail.” I like the thoroughness of the comfort measures.

The third question is “Antibiotics”. Three choices: no antibiotics unless needed for comfort, no invasive(IM/IV)antibiotics or full treatment. Who would choose no antibiotics? Sometimes someone with end stage cancer or a very disabling disease, like Lou Gehrig’s. Someone with a terminal illness who is not going to get better and is ready.

The fourth question is “Artificially Administered Fluids and Nutrition.” Three choices again: No feeding tube/IV fluids (provide other measures to assure comfort), no long term feeding tube/IV fluids (provide other measures to assure comfort), or full treatment. Most people choose the second. Most people would like nutritional support if they have a reasonable chance of getting better. An elderly frail person with pneumonia sometimes needs iv feeding, or after surgery or after a bad accident. Most people do not want long term feeding by iv or tube if they are in a coma or have severe brain injury to the point where they can’t even eat.

I am very happy to have the POLST form and it is an excellent augmentation to the living wills. It is very comforting to families as well. If a widowed mother has discussed her decisions with me and signed the form, then it doesn’t fall to her three children to make decisions about how much care to give. She has left them and me a map and guidelines and we try to follow them as best we can. We are not left with the fear that maybe we did too little and that we should have done more. The hardest decision with a loved one is when to stop intervening.

I want the POLST form to have one more section. Question five: “Memory loss”. If you have lost your memory to the point where you no longer recognize family, you have forgotten personal hygiene and toilet training, you may not even be able to speak any more, do you still want other things treated? My answer is no, for me. Too many of our hospital patients are frail, elderly, demented and the hospital confuses them. They often call out or cry or scream at night because it is frightening to be in another place and they don’t like having their blood drawn. Sometimes we have to drug them or use restraints in order to treat the pneumonia or urinary tract infection. I really wonder how ethical it is. The problem is that by the time they have lost their memory, they can’t really say, “no, don’t keep treating me.” Except for one woman. I have one lovely woman who has been at our nursing home for more than 4 years. She realized that she was losing her memory and said to her husband, “I don’t want any drugs, no ivs, no feeding tubes ever. And I never want to go to the hospital again.” He visits her every day and talks to her. Sometimes she won’t let me examine her on my routine visit, but that is okay. Once she ran a fever of 102 for two days and didn’t eat or drink anything. I checked with her husband and he stuck with her wishes. The fever went away and she got better. I am so happy that she doesn’t have to have medicines or any blood draws or anything that she doesn’t want. Another woman told me that she’d gone to our hospital family group on death and dying. Her husband had lost his memory and was in a nursing home, having gotten to the point of not recognizing her and not remembering toilet training. She said that the group said, “He’s not dead.” and weren’t very welcoming. She said, “They don’t understand. He’s left his body and all I have is the live shell. He’s really gone and he left slowly, bit by bit. They don’t understand that the part that was him IS dead.”

I don’t think that doctors are terribly good at doing POLST forms with people. For a while I thought it was because my partners were younger than I was. Then I moved to a clinic where two doctors had left and they were both older than me. They had lots of people over age 65 and practically none of them had POLST forms. I’m not saying that people under 65 should not have a form. They really should, especially if they care about that coma scenario. But I REALLY think that people over 65 should have a chance to address this. Our form is bright green and after it is filled out I scan it into the computer and then the owner is supposed to put the original on his/her refrigerator, where the ambulance crew knows to check for it. Someone still might end up with a ventilation tube temporarily, if they become unconscious in a public place and the crew has no guidance. They too have to err on the side of doing more rather than less. I theorize that doctors’ discomfort with the POLST form stems from a mostly unconscious idea that their job is to “make people better.” I have been interested in end of life issues since medical school and it occurred to me that if I thought of my job as to “save” people or keep them alive, then I was going to have a 100% failure rate, because actually everyone dies eventually. Instead I thought that my job was to help as best I could with a good life and a good death. It is turning out that no two people define a good death in the same way. It is entirely individual. My job turns out to be partly about telling people and families when I think death is approaching and helping them define their good death.

To see if your state has a POLST form: https://polst.org/

primary care medicine: schedule

I see patients from 8:30 or 8:00 am until 2:00 pm.

We have people say, “You are off after 2:00.”

Well, no. Most days I work for 2-3 hours beyond the patient contact time. Sometimes I come in early and sometimes it is from 2pm to 5pm and sometimes it is the weekend or into the evening.

So what am I doing?

  1. returning phone calls
  2. doing refills. To do a refill I check when the patient was last seen and whether they are due for laboratory.
  3. reading specialist notes and updating medicine lists, diagnoses and contacting patients to get tests or follow up that the specialist has recommended
  4. reviewing lab results and sending a letter or signing to be scanned and to be available at the follow up visit or calling the patient
  5. reading emergency room notes and hospital discharge summaries and setting those patients up for follow up, updating medicine lists and adding to diagnosis lists.
  6. dealing with multiple stupid letters from insurance companies questioning the medication that I have prescribed. Mostly I mail these to patients.
  7. running my small business: long term planning, short term planning, advertising, commercial insurance
  8. 50 hours of continuing medical education yearly
  9.  Updating my medical license, medical specialty board eligibility, business license, CAQH, DEA number, Clia lab waiver, medicare’s shifting rules, medicaid’s shifting rules, tricare’s rules, and 1300 insurance company’s shifting rules and medicine rejections and prior authorizations even for a medicine a person has been on for 20 years.
  10. Worrying about small business costs as reimbursement costs drop: health insurance. Retirement. L&I. Employees. Malpractice insurance, small business insurance, the lease, staff costs.
  11.  Discussing and updating medical supplies and equipment, office supplies and equipment
  12. Updating clinic policies and paperwork per the change in laws. Have you read the Obamacare Law? Over 3000 pages. HIPAA. The DEA. Recommendations from the CDC, federal laws, state laws, internet security, patient financial and social security security.
  13. Trying to track what we collect. That is, say I bill $200.00. Since I accept insurance, the insurer will tell me what is the “allowed” amount per me contracting as a “preferred” provider. The “allowed” amount is really the contracted amount. Then the insurance company either pays it or says that the patient has a deductible. This could be $150 per year or $5000.00 per year. With medicare I then have to bill a secondary if the person has it and then anything left is billed to the patient. Oh, don’t forget copays, if they don’t pay that we have to bill it. So to get paid the complete contracted amount, aka “allowed” we may have to submit bills to two or even three insurances and the patient. We might be done two months after the patient is seen.
  14. Trying to convince recalcitrant computers and printers and equipment that indeed, it doesn’t have a virus, oh, or maybe it does, and fixing them.

My goals are to give excellent care AND to work 40 hours a week. Half of my patients are over 65 and many are complicated, with multiple chronic illnesses.  When I saw patients 4 days a week for 8 hours, with an hour hospital clinic meeting every day, I also spent at least an additional 8 hours and more trying to keep up with most of those things above. The average family practice physician makes more money than I do. But they also report working 60-70 hours a week on average. I do not think this is good for patients or doctors or doctors’ families or their spouses or children. The primary care burn out report rose from 40% to 50% of the doctors surveyed.

We need change, we need it now, and we need to be realistic about how much work is healthy.

When I was still delivering babies, women would ask if I could guarantee doing the delivery. I would explain: “We do call for up to 72 hours. If you go into labor at the end of that, you would rather have a physician who is awake and rested and has good judgement. Besides, I’m a bit grumpy after 72 hours. ” And they agreed that they really don’t want an exhausted burned out physician.

I took the photograph of Mordechai, our skeleton, today. She is genuine plastic. I wish she would do some of the paperwork, but at least she lightens things by making us laugh. She gets various wigs and outfits and sometimes comes out to show a patient a hip joint.

I am NOT attracted to paperwork. I think I am repelled. For the Daily Prompt: magnetic.

 

Fraud in Medicine: Heartwood

Here in my neck of the woods, people are continuing to quit medicine. Two  managers who have worked in the clinics eaten by the hospital are leaving on the same day, after 30 years. And another woman doctor, around my age, is retiring from medicine. She is NOT medicare age.

Meanwhile, the Mayo Clinic is publishing articles about how to turn older physicians into “heartwood”.

http://www.mayoclinicproceedings.org/article/S0025-6196(15)00469-3/fulltext

“As trees age, the older cells at the core of the trunk lose some of their ability to conduct water. The tree allows these innermost cells to retire…. This stiffened heartwood core…continues to help structurally support the tree…. Here a tree honors its elderly cells by letting them rest but still giving them something meaningful to do. We non-trees could take a lesson from that.” Spike Carlsen

Oh, wow, let’s honor the elderly. Even elderly physicians. Instead of what, killing them? Currently we dishonor them, right?

But what is the core of the issue? Skim down to “Decreased patient contact”:

“Already, many physicians are choosing to decrease their work to less than full-time, with resultant decreased patient encounters and decreased institutional revenue. Prorating compensation to match full-time equivalent worked will aid in financial balance, but the continued cost of benefits will remain. However, when that benefit expense is compared with the expense of recruiting a new physician (estimated by some to approach $250,000 per physician), the cost of supporting part-time practicing physicians becomes more attractive.”

Ok, so the core of the matter. “Decreased institutional revenue” and the employer still has to pay BENEFITS. NOTHING ABOUT THE QUALITY OF CARE FOR PATIENTS.

Again, the problem is still that you can’t really “do” a patient in twenty minutes, and that full time is really 60 or more hours a week. To be thorough, I  have to absorb the clinical picture for each patient: chief complaint, history of present illness, past medical history, allergies, family history, social history (this includes tobacco, drugs and alcohol), vital signs, review of systems and physical exam. And old records, x-rays, pathology reports, surgical reports, laboratory reports. I fought with my administration about the 18 patient a day quota. I said: ok, I have a patient every twenty minutes for 4 hours in the morning, a meeting scheduled at lunch, four hours in the afternoon. When am I supposed to call a specialist, do refills, read the lab results, look at xray results, call a patient at home to be sure they are ok? The administration replied that I should only spend 8 minutes with the patient and then I would have 12 minutes between patients to do paperwork. I replied that they’d picked the Electronic Medical Record telling us that we could do the note in the room. I could, after three years of practice. But it nearly always took me twenty-five minutes. I would hit send and our referral person had so much experience that she could have the referral approved before my patient made it to the front desk. BUT I felt like I was running as fast as I possibly could all day on a treadmill. Also, the hour lunch meetings pissed me off. I get 20 minutes with a patient and they get an hour meeting? Hell, no! I set my pager for a 20 minute alarm every time I went into a meeting and I walked out when it buzzed. I needed to REST!

After a few weeks of treadmill, I dropped a half clinic day. But of course that didn’t go into effect for another month and I was tired and ran late daily. And every 9 hour clinic day generated two hours of paperwork minimum: nights, weekends, 5 am when I would not get interrupted and could THINK. Do you really want a doctor to review your lab work when they are really tired and have worked for 11 hours or 24 hours? Might they miss something? It might have been best if I had been quiet and just cancelled two people a day, since the front desk knew I was not coming out of any room until I was done, but I argued instead.

The point is, you would like to see a doctor who listens and is thorough. You do not actually want a medical system where there all these other people who read your patient history forms and enter them in to the computer and your doctor tries to find the time to read it, like drinking from a fire hose. If we want doctors and patients to be happy, then doctors need time with patients and we need to off the insurance companies who add more and more and more complicated requirements for the most minimal care. One system, one set of rules, we’ll fight over the details, medicare for all.

Fraud in medicine: why “help” won’t help

This article:  Doctors wasting over two thirds of their time doing paperwork showed up on Facebook yesterday.

The problem is that “hiring people to help with paperwork” will not help.

Why? We’ve already done that and it’s a huge mess.

For example: I was referred to an Ear Nose and Throat Specialist at one of the Seattle Mecca hospitals. I had to travel two hours and then in the waiting room I was given a four page patient history to fill out. I filled it out. I had been referred by a Neurologist, who sent a letter and note. After I filled out the forms, HIPAA and “you will pay if your stupid insurance won’t” and address and consent to be treated and yada yada…. I waited.

At last I was shown to a very luxurious room. There a medical assistant asked me many of the same questions that I’d filled out on the form and which were already in the letter and note from the neurologist. She typed these into the EMR- electronic medical record. Then she left. And I waited.

At last the distinguished otolaryngologist entered the room. He said, “I see that you are here for chronic sinus infections.”

“No.” I said. “I am not.”

Silence.

“I see that you did not read anything I filled out and I am a physician and I drove two hours to see you.”

Silence. “Um.” he said. “Uh, why are you here?”

“Strep A sepsis twice and we want to know if my tonsils should be removed.”

Right. So… all that paper you fill out before the physician saw you? Yeah, like, my impression is that physicians don’t read it until after you leave. And maybe mostly don’t EVER read it.

I plan to find out the next time I have to see a specialist. I will write “you don’t read this anyhow, so I am not filling this shit out” on page 2 and see if the specialist notices. Bet you money they don’t. Though when they yell at their staff for not entering my medication allergies or the review of systems, they might notice.

So… I am a primary care physician. What do I do?

A new patient has one form: name, address, insurance information, hipaa and “you pay if your insurance doesn’t”.

I do the health history myself in the room entering it in the first visit, which takes 45 minutes to an hour. WHOA! INEFFICIENT! Nope. Actually it is brutally efficient. For four reasons:

One — I enter it myself and ask the questions myself and I am really fast at it.

Two — now I know the person, because I went over all of it: complaint, history of present illness, past medical history, social history, allergies, review of systems, and I ask people to bring all their pills including supplements to the first visit and I enter them too. And I look at the bottles. I don’t like vitamins with 6667% of the Recommended Dietary Allowance of any vitamin, lots of vitamins now have herbs in them too and I would not recommend taking cow thymus, labeled as bovine thymus.

Three — Now I don’t have to spend time reading forms filled out in the waiting room or a history entered by someone else, because I don’t have time to do that anyhow. I did it all in the visit. I will still have to read old records and any labs or xray results or consult notes or pathology reports and hey, where do you think the waiting room paperwork falls in that priority list? Yeah, like never.

Four — I hand people a copy of the note as they leave and ask them to read it and to bring corrections if I got it wrong. They go from thinking that I am a drone staring at the laptop to saying, “Hey, she typed nearly everything I said (and she has three spelling errors).”

Because the truth is that medicine is really complicated now and it just doesn’t help to have more people “do the paperwork”. I have to read the notes and labs and reports myself, because I am the physician.

There are three things that WOULD help:

1. One set of rules. Hello, the insurance companies, all 500ish of them send us postcards and emails every week saying “Hey, we’ve changed what we cover, meaning we cover less and we have new improved and more complicated prior authorization rules! Go to our website to read all about it.” Guess how often I have time to do that. NEVER NEVER NEVER. I read medicare’s rules. So medicare for all, single payer is partly to have ONE SET OF RULES. I can memorize miles of rules, but not if they are changing in 500 companies every week. Shell game. Also, prior authorization means “your insurance company is making your doctor fill out paperwork in hopes that they can delay or refuse the care your doctor thinks is best for you.”

2. One electronic medical record. Right now there are about 500 of them too and none of them talk to each other so we are all “paperless”. Ha. It’s worse than ever, because we get 100 pages or 200 or 300 of printed out electronic medical record for every single new patient. I need two more big file cabinets for my “paperless” office. Hong Kong did it in 9 months. What, are we wimps? Make a decision.

3. Standardization of lab and xray and home health and physical therapy and nursing home and rehab and hospital order forms. Because every stupid lab form is different: not only arranged differently but also the lab panels are different, the requirements for what that lab wants to fill the order is different and the results are arranged differently on the page. Hello. Stupid, right? Any efficiency expert would laugh.

And that’s how we could really help doctors help patients.

Fraud in medicine: FAXMANIA!!

All right, the latest trend in the complete insanity that is the United States Medical Corporate Black Hole Eating The American Dream: FAXMANIA!!!!

I am a Veterans Choice rural provider. Well, I thought I was. But turns out even though the VA keeps calling me to accept new veterans who are more than 40 miles from the nearest VA, they have not paid me for one visit in 2015. And I did between 20 and 30.

Because, you see, even though they have me listed as a Veterans Choice Provider, the paper work is SPECIAL and it has to be PERFECT and we have to fax EVERYTHING.

So I have to fax every single clinic note to Veterans Choice. Where, presumably, they lose it and have plausible deniability. Also, when a patient comes to see me, they are only approved for ONE NEW PATIENT VISIT, TWO FOLLOW UP VISITS, WITHIN THE STATED DATES, which is two months. Then I have to fill out a form and send it to Veterans Choice, who sends it to triwest, to get approval to continue to be my patient’s primary care doctor FOR ONE YEAR ONLY. Then I have to remember to do it again. AND I have to fill out a form to send to Veterans Choice, who sends it to triwest, for every single referral or test more complicated (read: expensive) than an xray AND for labwork AND don’t forget to fax a copy of every clinic note to Veterans Choice so they know I did it AND now for one patient’s medicine, I have ALSO fax a copy of every note to his VA PRIMARY CARE DOCTOR so that she will refill his pain medicine because: Hell if I know, apparently it’s EASIER to fill from her than me because the VA has no frigging idea who I am.

And the Veterans Choice 40 mile rule? We have two patients now from Whidby Island. They have to take a ferry to see me. Yes, they can bring a car on the ferry. Yes, they can get here except when the ferry is canceled for very low tides or weather….Yes, it’s insane.

Meanwhile, this note from the State of Washington Health Care Authority, aka medicaid: “The Contractor shall require that when subcontracted provider organizations with certified EHRs see an Apple Health Managed Care enrollee, they send a care summary (CCDA) from the providers EHR to the WA Link4Health Clinical Data Repository beginning no later than February 1, 2017.” Translation? Oh, we have to send bloody proof that we saw the bloody patient in the form of a CCDA electronically OR ELSE! OR ELSE WE ARE BREAKING THE LAW! They wouldn’t want to fire us but you betcha they would love to fine the hell out of us. Note: This requirement only applies to provider organizations who have already invested in certified EHR technology.

Hi, Big Brother.

Now, fax is HIPAA compliant, as long as we include the cover disclaimer that IF WE SENT IT TO THE WRONG PLACE SHRED WITHOUT READING OR YOU WILL BE STRUCK DEAD BY LIGHTENING FROM THE SKY GODS AND/OR THE ORBITING LASER HIPAA POLICE.

And meanwhile I have lab order forms for the three labs in town (all completely different and even with different panels) and one in Sequim, also 6 different forms for 6 different places for xrays, CT scans, MRIs, a form for the Vascular imaging, a form for cardiology, different ones for each physical therapy office. Now the DMV disabled parking form must be accompanied by a prescription on legal Washington State prescription paper saying yeah, he is disabled. Why use one piece of paper when you can require two?

When I fill out lab orders for the local hospital, the patients sometimes say, “Can you fax that over?”

“Yes,” I say, “but they lose 50% of them.” No, really. We fax them and keep a copy and then the patient goes in and the lab calls and says, “We don’t have the order.” I am not sure if they are “lost” or just in a pile to be entered into the TIME SAVING ELECTRONIC MEDICAL RECORD COMPUTER SYSTEM THAT MAKES EVERYTHING FASTER AND MADE US PAPERLESS EXCEPT FOR THE TEN MILLION FAXES DAILY. “You are better off picking it up and handing it to them, or I can mail it to you.” The other day a patient asked if that was malice, since I am not in the hospital system. “No,” I said, “I think they have laid people off until there aren’t enough and the corporation dumps the long timers that know stuff and cost more.”

Once I was working on a holiday Monday. I had a patient who I thought had a new arrythmia. I called the hospital and asked the tech if we could do an outpatient ECG on this holiday.

“I don’t know.” the tech said.

There was a silence. I wondered if the tech would ask someone in authority.

“I’m new.” said the tech. “They’ve laid a lot of people off.”

Someone in authority WAS present. “We can do one on a holiday.” I said firmly. “I will send her right over. Call me when it’s done.” So the tech did it.

Where medicaid goes, medicare follows and then the insurance companies will too. Next, I predict that we will have to fax every note to the appropriate company every single visit, and to the secondary insurance too. And then they will install a video camera in each office and videotape every clinic visit…. and I will either be a physician in another country or be doing something else….

 

What, you say, does the shack have to do with this? I can always go live there, off the grid, if I can’t stand the paperwork and hoops I have to jump through. It is a play house at my family’s land on a lake in Ontario, built in the 1970s. Friends and I put a new roof on this year: their 6 year old was delighted. It would be frightfully cold in the winter and anyhow, I can only stand straight in the middle….