It was one of those weeks. The same issue pounding at my brain, assaulting my sense of right and wrong and annoying the hell out of me. If the phone rang one more time it might become an unwanted missile.
I had just spent a considerable amount of time on the telephone talking to an insurance company case manager and their physician reviewer. I was being asked to justify the medical needs of one of my patients and to make the case of why they needed to stay in the rehabilitation hospital. Sounds fair enough -- good concept -- shouldn't be a problem.
Everybody stays calm and there will be no casualties. The reviewers for the insurance company are performing an important function to help manage their resources. I recognize that physicians are not always right and we have to draw the line on care somewhere, but where is the balance point in this equation? Who is the patient's voice? How loud of a voice does a disabled person have in our society? Who is their advocate?
What Took Place?
"Doctor, you just don't understand." Yes, that's what the person on the other end of the phone said to me. My patient is a 62 year old teacher who had severe bleeding in his brain and is still functioning at a low level. He has been in the hospital many weeks and the cost is getting everyone's attention. But, through outstanding aggressive care, this young man is talking, eating, moving and walking in the therapeutic pool. He has a wife who wants to take him home and a family who cares about him. His heart is good and he can live another 25 years.
Now, what is it I didn't understand? "You see doctor, George has been in the hospital a long time, so we really need to get him to a skilled nursing facility," she explained. "Didn't I understand the way it worked? Didn't I realize that my failure to cooperate could jeopardize our relationship in the future?" She wanted us to all work together on this. But, what was George's role in this? Who was working for George?
Am I Confused?
I hung up the phone, leaned back in my chair, grabbed for the oversized candy bar in my lower desk drawer that I saved for moments like these. I looked at an old picture of myself and my family. I guess I had acquired both a good deal of gray hair and a wrinkled, furrowed appearance. I did make more lists than I did in the past and "forgetting" was becoming a regular part of my vocabulary. What was it I didn't understand? I thought back to college days and the early Bob Dylan song, "The Times They Are a Changing." Was I out of step with the times- unable to adapt to the "new" way of practicing medicine? Had I become just another medical dinosaur who couldn't properly manage his patients under the constraints of our new methods of reimbursement? I don't think so!
As the medical director of a rehabilitation hospital for the last 23 years I have been intimately involved in making these adjustments -- the difficult art of managing costs while maintaining quality and patient satisfaction. No easy task, but one that everyone is diligently accomplishing. But, this was about more than these issues. This was about patient advocacy.
The players on all sides are reasonable and responsible people, but not always with compatible motivations and interests. The insurance company and its representatives want to ensure that their resources are appropriately utilized. The physician and facility want what is best for their patient while trying to maintain an amiable working relationship with an insurance company that they will have to work with again in the future. The patient and their family want anything and everything done, no matter what the cost, if there is still some hope of improvement.
The Physician As An Advocate
What can get lost in all of this is the responsibility of the physician to be an advocate for their patient. This is our job, our role, our Oath! It is what we do and any less would be a failure to act in the best interest of our patients. We must be their advocate, for, if not us, who?
It is a role easily forgotten in the chaos of modern medical practice. On those afternoons when we are tired, it is easy to give in to the voice on the phone and just say "OK -- I am tired of resisting." But, we can't. If we, as physicians, abandon our role as patient advocates there will be no one left -- no other line of defense. The nurse on the phone or the physician writing letters are just doing their jobs- it's not personal. The care of our patients is personal.
So, when we are tempted to give in and feel we can't buck the system any longer- we should take a deep breath, a bite of that favorite candy bar and remember that we are the advocate. We are a critical voice in assuring that our patients get what they need. Make no mistake, we do understand that it is a human being in that bed who, along with their family, is counting on us to do the right thing.
Like it or not, if not us, who?
Follow Richard C. Senelick, M.D. on Twitter: www.twitter.com/RichardSenelick
advocate. Can she know with certainty without asking? Trust in one's physician is an essential part of the healing process. In our world of financial accountability, limited resources, and realignment of physician loyalties, the physician/patient relationship is under siege. We all, patients and
physicians, are the losers.
I was diagnosed with a genetic immune problem, after having seen some of the "best" doctors in the country, being told I was seriously ill, but they could not tell me why, and almost dying. Then, I forced them to test me for the problem, which I had researched on my own. I was a former RN, Advanced Nurse Practitioner and Certified Registered Nurse and they were a little intimidated by the fact that I wrote them a note, since I couldn't talk at the time, and told them that I was sending the note to an attorney through my family about the matter. They tested me and found what I suggested within two hours, gave me gamma globulin, and antibiotics and I survied. I received a series of gamma globulin, but the problem returned when they ceased and once again, I went through the test me and a stimulation test proved it was not due to some steroids I was given, but rather a genetic problem.
As my doctor was negotiating with my insurance company, I took the bull by the horns, contacted three specialists in the field throughout the country, paid a $200 fee to each, to review my tests and confirm the diagnosis, and to agree as to the course of treatment. I sent them in to the case manager, along with a letter explaining I had researched it, agreed with my doctor and so did these "experts". It took 24 hours to get the okay for the treatment, and believe me, they have walked straight with me ever since. The doctors and the insurance company were in awe, because I had survived to the age at diagnosis, especially because of the demanding and stressful job, and the exposure to everythng under the sun in my work.