Carl

April 6

It was the message a physician never wants to hear. Mrs. Thompson had called my house to say that her husband, Carl, had had a heart attack or possibly a stroke. An elderly man, Carl had been discharged from the hospital two weeks before after a bout of intractable nausea and vomiting that, for a number of reasons, I had written off as a bad gastroenteritis. His abdominal series had been negative, and he was dressed, taking fluids and ready to sign himself out the next morning. I made him promise to go for an upper GI as an outpatient, which he did. It was normal.

Two weeks later, Carl's wife called to say he had been vomiting all night, but he refused to come in. I prescribed Compazine, and his vomiting had stopped by morning. That evening, he experienced a near-sudden-death episode while sitting on the toilet. A neighbor started CPR, and Carl survived his arrival at the hospital but was severely dehydrated and hypokalemic, in renal failure and anuric, with evidence of pancreatitis and a large, evolving MI. That's when I received the call.

We corrected Carl's fluid and electrolyte abnormalities that night but transferred him to a tertiary care center the following morning. There, he continued to deteriorate and was taken to surgery, where he was found to have a small bowel obstruction, infarcting too much of his small bowel to resect. His belly was closed and his life support was turned off.

I agonized over Carl for several days. Could I have been more insistent about his being seen or should I have called him an ambulance? Was I too complacent or just not paying enough attention? Would it have made a difference? Carl was one of those bad-outcome patients we live with, feel bad about and beat ourselves up over and who, in their death, remind us that we all have feet of clay.

The last straw

April 10

Adam, a young internist in town, told me today he's thinking of going into anesthesiology. He says he likes primary care but isn't making any money at it, and the paperwork — especially for preauthorizations — is killing him.

Recently, after prescribing Celebrex for an 87-year-old female patient, he received a questionnaire about it from the patient's insurance company. “First, they asked how old the patient is. They know how old she is; they insure her and have her Social Security number,” Adam said. “Then they asked if she's ever had a trial of any other anti-inflammatories. They know she has tried several others because their pharmacy filled those prescriptions. Then they asked if she's ever had a bleeding ulcer. They know she had one two years ago because they paid for her hospitalization. Finally, they asked if her arthritis is a chronic condition. They know it is because they've insured her for 20 years and she's carried that diagnosis all along.

“Why are they doing this?” Adam asked. “Are they stupid? No, they're just hassling me. At least, in anesthesiology, someone else has to get the authorizations — the patient, the surgeon, the referring doctor — anyone but me.”

If Adam were making good money, he probably wouldn't care about the hassles, but he doesn't feel he earns what he's worth. “If I were the best car mechanic in town, or the best builder, I could charge what I liked and people would pay it,” he once told me. “But we're all paid the same for what we do, regardless of our skill.”

I saw his point. Insurance companies, HMOs and employers don't really credential us; we credential ourselves. Given equal credentials, payers don't have to concern themselves with which physicians provide superior care, only with which come in with the lowest bid or which will accept their terms for preferred provider status. “But don't you care about the quality of care?” I once asked a managed care executive.

“Oh,” he said, “quality is assured when you've been granted a medical degree or board certification. We assume you're all the same after that.”

Juggling act

April 13

Isabel, my office manager, constantly amazes me with the number of tasks she is able to perform simultaneously. Yesterday morning she had both phone lines going. On one was a patient needing an appointment for an annual physical; on the other was a claims representative for an insurance company. A patient was sitting in front of her waiting to schedule a return appointment, and in walked a new patient who needed to register — while I had just placed some tubes of blood on her desk that required processing. Somewhere in the waiting room an impish preteen was dropping medicine bottles from our collection into our fish tank, and a drug rep was hovering about waiting for the opportunity to pass out some Post-Its and pens. Someone less adept would have cried uncle, but Isabel seems to thrive on tasks. She says staying busy makes the time go faster. “Boy, that was an exhausting day,” she'll say at 5 p.m. “Would you mind backing up the files for me? I'm late for dance class.”