Are You Paying Attention On The Right Things?

It's already 3:10 in the morning. I haven't sleep and yet still feeling so lucky.

One of my patients died yesterday. My wife of 31 years is asleep next to me. How lucky am I?

Judy came to me about 10 weeks ago with acute sciatica, and lower back pain.

It seemed simple enough at first, but by the end of week one, I sensed something completely unusual. Nothing gave her anything but very little relief. Nighttime was unbearable for her. Then she developed significant weakness of the legs and gait changes. Amazingly, her neuro signs were still unilateral nerve root, but that changed quickly after 48 hours. Something was "badly wrong" here, as one of my earliest professors would say.

Her husband, who had been under my care for 25 years, was with her every moment. Very much concerned and scared for Judy.

I called her PCP who immediately began a hospital intake after we both voiced concerns about unrelenting night pain and progressive leg weakness now justifying admission and a complete workup.

Judy went down hill fast. Initially, what started as a simple sciatica was next thought by her neurologist to be Gullien-Barre' Syndrome.

When the medication (steriod, etc.) did not have any significant effect, she then quickly had plasmaphoresis, and was sent to transitional care. She never made any significant improvements.

Very quickly, it was established she had some very aggressive non-specific demyelinating disease.

In essence, all this happened inside of 3 months.

Judy and Bob were married for 50 or so years and it was over in a flash. There is nothing any of us as her team would have done any different, or better. But, it still sucks.

Of course we see this as part of practice, and way more if you spend a lot of time in hospitals. I did four years of this type of transitional care while in college, and I still see the face of the pretty 23-year-old girl dying of a brain tumor, and many others 30+ years later.

So, yesterday morning, after my staff broke the news (we had called Bob the night before to check on Judy), instead of bitching about how so many obstacles are being hurled onto the path of us in practice, I felt really lucky. I immediately thought about my wife and daughter.

For some reason next I start thinking this morning about the doctor from an insurance carrier trying to lecture me last Monday morning on absolutely ridiculous daily record keeping, way beyond any standard of care. I told him so. I also told him I would gladly perform a high level encounter at each re-exam (including a very detailed PFSH on each CC, in the absence of changes, or any danger signs over the last 2 years. Yes, I did review it all on this case in question, and documented all reflexes, sensory, motor, ortho tests, no fever, night sweats, bowels, and bladder.

I also explained that the company he reviews for denies such follow-up services as "not medically necessary" for the same Dx, so this will cost the patient an additional 150 or so out of pocket, for each flare up of the SAME condition).

Just for good measure, he then tells me he cannot justify adjusting more than one area. For him, the pelvis, upper lumbar spine and TL Joints can't possibly need attention a 2-year postoperative laminectomy 62-year-old diabetic lady with back pain and sciatica. Even though her VAS scores went from 10-3, in 5 visits, that just did not adequately document a good outcome measure.

Huh?

I was thinking this is crazy. There's no common or rational clinical sense in this at all. This is not good chiropractic or good medicine. And I told him, "Screw all of this. Patient care always has to be the most important thing here". I'm pretty sure that he'll never get it.

A year ago, I feel that it still made sense to work for these people. Now, if this continues, they are history in my book.

Doctor, I'm very sure that you know that when seeing patients, your entire focus should be patient care. Of course, the challenge is to do it rationally, systematically and not blind sighted by irrelevant factors.

And when you're not with patients, make sure that you are focused on and spending time with the things and people that you value the most in life.

Because when it's done, that's all there is.