Posts under ‘healthcare’

The Obama-Biden Transition Team is requesting that all interested citizens pay a visit to the transition’s website, Change.gov, and voice ideas and concerns regarding American health care and health care reform. By clicking here, you can go directly to the web page dedicated to the health care agenda and submit your opinions and views.

The Obama-Biden web page discusses health care in this manner:

“On health care reform, the American people are too often offered two extremes — government-run health care with higher taxes or letting the insurance companies operate without rules. Barack Obama and Joe Biden believe both of these extremes are wrong, and that’s why they’ve proposed a plan that strengthens employer coverage, makes insurance companies accountable and ensures patient choice of doctor and care without government interference.

“The Obama-Biden plan provides affordable, accessible health care for all Americans, builds on the existing health care system, and uses existing providers, doctors, and plans. Under the Obama-Biden plan, patients will be able to make health care decisions with their doctors, instead of being blocked by insurance company bureaucrats.

“Under the plan, if you like your current health insurance, nothing changes, except your costs will go down by as much as $2,500 per year. If you don’t have health insurance, you will have a choice of new, affordable health insurance options.”

Allegedly, the plan would:

• Require insurance companies to cover pre-existing conditions so all Americans regardless of their health status or history can get comprehensive benefits at fair and stable premiums.
• Create a new Small Business Health Tax Credit to help small businesses provide affordable health insurance to their employees.
• Lower costs for businesses by covering a portion of the catastrophic health costs they pay in return for lower premiums for employees.
• Prevent insurers from overcharging doctors for their malpractice insurance and invest in proven strategies to reduce preventable medical errors.
• Make employer contributions more fair by requiring large employers that do not offer coverage or make a meaningful contribution to the cost of quality health coverage for their employees to contribute a percentage of payroll toward the costs of their employees’ health care.
• Establish a National Health Insurance Exchange with a range of private insurance options as well as a new public plan based on benefits available to members of Congress that will allow individuals and small businesses to buy affordable health coverage.
• Ensure everyone who needs it will receive a tax credit for their premiums.
• Lower drug costs by allowing the importation of safe medicines from other developed countries, increasing the use of generic drugs in public programs, and taking on drug companies that block cheaper generic medicines from the market.
• Require hospitals to collect and report health care cost and quality data.
• Reduce the costs of catastrophic illnesses for employers and their employees.
• Reform the insurance market to increase competition by taking on anticompetitive activity that drives up prices without improving quality of care.

I am personally dubious that insurance company practices can be sufficiently reformed to prevent abuses. I am also dubious that such a ponderous system administered by both the federal government and employers will not prove incredibly complex and difficult to manage for employers, government officials, insurers, providers, and consumers alike.

In terms of the plan, I would also like to see the following:

• details regarding a more robust national plan of preventive health care initiatives
• sufficient funding for public health initiatives
• sufficient funding for emergency preparedness and the national Medical Reserve Corps
• a comprehensive plan to decrease the nursing shortage, including grants and loan forgiveness
• a plan to assuage the nationwide shortage of primary care physicians
• a plan to create an Office of the National Nurse

Despite my reservations, doubts, and dubiousness, it is indeed exciting to see a new administration apparently dedicated to transparency, as well as the active participation of all Americans in the process of change that is underway.

Meanwhile, I am willing to suspend my disbelief, listen to the conversation, join in on the conversation when I have something useful to say, and watch as the story unfolds. These are exciting and nerve-wracking times, and I do indeed hope that the change that has been promised will indeed be delivered. Until that time, patience is one virtue we will all need to put into practice.

In a report published by Open Secrets, a non-partisan guide to how money influences politics in the United States, the amount of money spent by lobbyists representing the health care industry is truly astounding.

According to a review of lobbyists’ spending in Washington, D.C. during 2007, the health care industry itself spent $445 million dollars (nearly half a billion dollars) on lobbying contributions, 15.9% of all lobbying money spent during that calendar year.

Breaking down the numbers further, 51% of all healthcare lobbying was spent by—you guessed it—Big Pharma and medical products companies, for a total of $227 million.

Next, health insurance companies spent $138 million, and you can rest assured that they were not asking Congress to support universal healthcare legislation.

Following on the heels of health insurers, hospitals and nursing homes spent a paltry $91 million dollars, and interestingly enough, the American Medical Association itself spent $22.1 million on lobbying.

With all of this money flying around the halls of Congress in the form of dinners, golf games, campaign contributions, cruises, vacations, summer home rentals and the like, it’s no wonder meaningful healthcare reform never seems to manifest itself. On average, $832,000 is spent on each member of the Senate and the House, money that is obviously paid to influence votes and potentially supercede the public interest.

As a nurse who sees the effects of a cumbersome and expensive healthcare system here on the ground, it is entirely unclear to me how so much money can legally be spent on buying power while the powerless struggle to make ends meet and care for their families.

When a senior citizen has to decide between food and prescriptions, something is wrong.

When a person becomes disabled but is forced to lose his home in order to pay his medical bills before his disability is approved, something is amiss.

When millions of children are still uninsured in this country, we are misguided.

When 45 million Americans lack health insurance, we are missing the point.

And when half a billion dollars can be frivolously spent on nothing but the purchasing of political power, we have lost our minds and our way.

Having just interviewed for a position with a home health agency whose territory covers a large swath of rural countryside, I am appreciating the challenges and difficulties of delivering care in such a setting. Whereas the city—where I currently provide home health care—finds patients in an area of high population density and relatively close geographic proximity, serving patients who live in mostly single family homes in far-flung sections of the countryside is an entirely different story.

When considering such matters, I recall how Dr. Paul Farmer, the founder of Partners in Health (recently featured on “60 Minutes“), created teams of trained lay outreach workers to bring care to patients living in rural isolation.

Native American reservations face great challenges when it comes to the delivery of home health care. The Center for Rural Health at the University of North Dakota School of Medicine use their resources to drive policy and develop care models vis-a-vis rural health and the delivery of medical care in rural areas.

Even the Health Resources and Services Administration of the U.S. Department of Health and Human Services has an Office of Rural Health Policy that strives to improve rural health care around the country.

It is now an accepted fact that physicians are leaving primary care and family practice in droves as specialization becomes the ultimate goal. More and more medical students choose specialties other than primary care as the cost of medical school skyrockets and the subsequent debt after graduation becomes even more astronomical.

While much is written about a nursing shortage which is feared to be worsening by the day, a physician shortage–especially of primary care physicians—is also taking hold, and one can easily extrapolate that any nurse or physician shortage is bound to have a devastating effect on rural health around the country. Many articles recount how doctors are in high demand, and strategies to lure health care workers to rural areas are discussed in stories and reports from Australia, Norway, and elsewhere.

Rural health is a subject which has never captured my imagination, yet today’s interview and a few clicks of the mouse were enough to make me dig just a little deeper. While strategies and policies to offset the growing national shortage of nurses and doctors are developed and implemented, those living in rural areas are sure to be hoping that they don’t get left in the proverbial dust.

I was fascinated today while listening to a recent health-related interview on NPR’s Fresh Air with Terry Gross. The subject of the interview was Suzanne Mintz, author of the new book, A Family Caregiver Speaks Up, and co-founder and president of the National Family Caregivers Association.

Ms. Mintz is the wife and caregiver of her husband, a man living with Multiple Sclerosis since 1974. Over the course of the interview, she recounts harrowing tales of hospital discharges devoid of planning, of caregiver burnout, of turning to neighbors in emergent circumstances to assist with transfers and other activities of daily living. Ms. Mintz laments the American healthcare system’s apparent blindness to the acuity of patients as they are discharged to home with woefully unprepared families and caregivers shouldering the burdens of increasingly complex care.

The subtitle of Mintz’s book, “It Doesn’t Have to Be This Hard“, speaks to the fact that Mintz is a caregiver who cares about other caregivers, and has penned a book with the goal of providing resources and empowerment to those responsible for the care of loved ones living at home. Additionally, The National Family Caregivers Association appears to offer resources, connection, Pen Pal programs, advocacy, volunteers, workshops, trainings, and much more to the tens of millions of Americans who choose to care for their loved ones in this Herculean manner.

During the course of the interview, Mintz lamented the lack of seasoned professionals who can coordinate the care of chronically ill patients and provide support and resources to families. Having recently left my job with a Disability Care Coordination Organization (DCCO), I would like to know what experiences Ms. Mintz and her organization have had with DCCOs—if any—and how her organization and various DCCOs could partner with state and federal government to improve care management programs, and to increase access to such programs for families across the country.

Providing care for a chronically ill loved one at home is no small undertaking these days, and while sick family members were generally cared for at home throughout the early twentieth century, doing so in this current economic climate has become next to impossible for so many families. Hard evidence is available that the majority of home foreclosures and bankruptcies in this country are not caused by frivolous spending and credit card use on the part of homeowners. People in this country are losing their homes due to the high cost of healthcare and from losing their jobs and careers due to illness. Astronomical medical costs, a sour economy, a pharmaceutical industry run amok in the halls of Congress, and a healthcare system driven by profit and market forces have all contributed to untold suffering for patients and caregivers alike. It is a sad state of affairs, and heroic people like Mintz are working hard to assuage that suffering, one family at a time.

I looked at the test results and knew immediately what it illustrated—my patient is diabetic. Not only is this patient newly diagnosed, I have been directly involved in diagnosing four new diabetics this year alone. Diabetes, along with morbid obesity, is truly an American epidemic, and the Latino community is most likely the hardest hit.

According to the New York Times, public health officials are expecting “a huge wave of new cases (that) could overwhelm the public health system and engulf growing numbers of the young, creating a city where hospitals are swamped by the disease’s handiwork, (and) schools scramble for resources as they accommodate diabetic children.” And just imagine the effect on the workforce, productivity, and the cost of healthcare.

With a food supply imbued with fats and sugars, a growing population of obese, poorly educated and poverty-stricken citizens, and a society which thrives on convenience, speed, and a sedentary life on remote control, the stage is set for an epidemic of proportions never before imagined. As Americans become sicker and more disabled, and a larger portion of the society reaches old age, healthcare premiums and the cost of healthcare in general could very well outstrip the ability to properly care for those aging with chronic illness.

Disparities in how healthcare dollars are spent play a large role in the tactics used to improve public health and educate the populace. According to the same New York Times article mentioned above, 1,000 New Yorkers were infected with TB last year in the face of a $27 million expenditure on TB prevention and treatment. Meanwhile, with diabetes expected to engulf more than 1 million New Yorkers in short order, New York allots less than $1 million for diabetes education and outreach each year. There is a calculus of scale when dealing with disease, and we seem to be failing the class miserably.

The American Diabetes Association estimates that the cost to the nation for the care of individuals with diabetes in 2002 amounted to approximately $132 billion. For the treatment of all cancers combined, the country spent approximately $171 billion that same yeat. Simple math will tell anyone paying close enough attention that the epidemic of obesity and diabetes in America must be brought under control, or we will have a public health nightmare beyond our wildest dreams within a generation.

So, when I educate my patient about his new diagnosis of diabetes, I am not just doing it for him. Of course, I share with my patient the goal of a long and healthy life free from the ravages of an insidious and potentially fatal chronic disease. More broadly, I strive to also keep him healthy for the good of the society, the healthcare system, the economy, and the future care of others who will some day need to benefit from high quality healthcare just as he does now. The sugar coursing through his blood does its damage quite silently, and it is my job to partner with my patient so that he does not become just one more statistic related to the development of avoidable kidney damage and preventable blindness.

When it comes to this new 21st-century epidemic of diabetes and obesity, the current news—and the predictions for the future of American health and healthcare—is anything but sweet.

It was incredibly refreshing and inspiring to attend an open house this evening for a new Infectious Disease (ID) practice in our city of employment. In the last 25 years, the role of the ID provider has greatly expanded, taking center stage in the fight against AIDS. This particular physician, having emigrated from Puerto Rico to attend medical and public health graduate school here in the US, was struck by the disparities being experienced by her own ethnic community. This realization led her to pursue a specialization in infectious diseases, taking up the gauntlet of HIV/AIDS treatment and the stemming of the waters engulfing the Latino community.

In her presentation, the director of this organization drove home the point that disparities in healthcare vis-a-vis the care of ethnic minorities is an area requiring the utmost attention and sensitivity.The centerpiece of the presentation, other than introducing her staff, revolved around the notion that the target population—mostly HIV- and Hepatitis C-infected low-income Latinos—need culturally competent and flexible healthcare which caters to their special needs and challenges, not only medically, but also within the psychosocial and socioeconomic realms.

Low-income patients face many challenges in terms of childcare, transportation, financial constraints, social stigma, as well as disempowerment and disenfrachisement from the society at large. Complex multi-generational family structures, chronic illness, and other challenges complicate the pursuit of care for diseases as complex as Hepatitis and AIDS, and this particular provider clearly stated that her practice strives to be flexible to the patients’ life circumstances which may inhibit or challenge care. Flexible visit times, allowances for late arrivals, and asistance with transportation, childcare and other psychosocial issues all pay dividends in terms of the potential for successful treatment.

As we have learned in our practice, flexibility and understanding go a long way towards fostering positive relationships between provider and patient, and it is upon that foundation that successful treatment is achieved. If a patient does not feel seen, understood, and welcomed as they are, the ability to provide holistic and comprehensive treatment is immediately handicapped and may eventually backfire. It is clear that other practices are pursuing the same laudable goals to which we also aspire, and when I feel that another provider is singing my song and walking the same path, that is indeed a heartening experience which I do not take for granted.

deus ex machina: an agent who appears unexpectedly to solve an apparently insoluble difficulty.

Healthcare in this country is in crisis. Rising drug costs, millions of uninsured Americans, bankrupt hospitals, Big Pharma run amok—the most powerful and influential nation in the world still cannot care well enough for all of its citizens. While Senators and members of Congress have health coverage to die for (pun intended), so many of the working poor are denied even the most minimal of coverage. Seniors are forced to choose between paying for prescriptions or groceries, and insurance companies continue to deny certain types of care as costs skyrocket out of control.

Enter the deus ex machina, or at least the hope for some solution which will fall out of the sky and save us. Is it Canadian-style universal healthcare? Is it a market system? (Oh wait, that already failed miserably, right?) Where will we find our panacea of preventive medicine and cost containment?

In Massachusetts and California, governors and legislatures grapple with critical universal coverage mandates which could break the bank, but may just be one answer which could be followed by other states around the country if they succeed. I would never have imagined that Arnold Schwarzenegger, that movie-star playing a politician, would be the one who could actually pull it off. If he does, I’ll gladly eat my hat. And here in New England, in Massachusetts specifically, perhaps Deval Patrick—the first African-American governor of that state, and only the second in all of U.S. history—is also poised to tackle universal healthcare which is mandated by law to swing into action on July 1st of this year. And who knows, maybe Nancy Pelosi will perform the miraculous, only to be thwarted by a cantankerous and staid Senate. (Talk about The Bride Stripped Bare By Her Bachelors, even.)

My patients are relatively lucky, receiving the benefits of a cutting-edge program which provides that with high quality care, timely follow-up, and personalized service. Still, drugs are denied, certain procedures and equipment are not covered, and certain specialties are becoming almost impossible to refer patients to as those provider groups stop accepting Medicaid all together. Something has to give, and usually the first thing to go is quality and equality.

So is there a deus ex machina? Will someone or something save us? Will Arnold’s proclamations bear fruit, his iconic super-hero status actually managing to be the springboard to bring healthcare to the disenfranchised? Or will Deval Patrick, a descendant of the disenfranchised himself, turn a tide that has been carrying the poor out to sea for decades? Both of these scenarios are possible, and still others are yet to be born, or are now being hatched in minds around the country. But the rest of us cannot necessarily sit on our laurels and wait for others to solve the dilemma. Letters to the editor, calls to legislators, op-ed pieces, dreams and meditations, or even water-cooler chat—all are potential places for the birth of a kernel of an idea that could turn the tide. So, where is the deus ex machina? Apparently it is us.

Healthcare is riddled—no, saddled—no, ruled and regulated—-by bureaucracy. From visiting nurse agencies to hospitals to private practices, bureaucracy with both a capital “B” and lower-case “b” own the airwaves and pocketbooks of the healthcare system. Whether it be fiduciary or surgical, top-down bureaucracy rears its ugly head like a rabid marsupial. You know, all marsupials have deep pockets for the protection and nurturance of the young, and the only “young” spawned of the healthcare system is money, or its popular euphemisms, market-share and capital. And don’t be fooled by a hospital that’s a not-for-profit. Those wolves in sheep’s clothing can devour weaker competitors for lunch and regurgitate a new “satellite” branch for dinner. But I digress.

Today, I was informed by a visiting nurse—in whom I place my complete trust and confidence, by the way—that a mutual patient of ours is in need of a wheeled walker. This patient, of undisclosed race, gender or age, has long-standing AIDS with various complications including dementia and mental status changes, a newly-discovered bone spur in the lumbar spine, worsening depression, newly manifested self-mutilating tendencies, hypertension, hypothyroidism, Hepatitis C which failed treatment with Interferon and Ribavarin (the standard of care for the “cure” of chronic Hep C), and chronic pain of unknown etiology. S/he has had several precipitous declines towards disability or death, and several subsequent and equally noteworthy recoveries, like a magical phoenix rising from the ashes of a recalcitrant body’s failure to thrive.

Now, having gone from fully ambulatory to walking with a cane and then progressing to a manual wheelchair, this patient is beginning to regain some of his/her strength, and with assistance and perseverance—and despite massive depression, suicidal ideation, and self-inflicted cigarette burns on both hands—this courageous individual is in need of a walker to facilitate movement from the wheelchair to a standing position, the cane not being enough to support such a transfer.

I happily obtained the necessary paperwork from the medical supply company—paperwork which is, I must say, meticulously designed to comply with the bureaucratic hungers of both Medicare and Medicaid. Discussing this newly arisen need for equipment with the primary doctor, I rapidly obtained his signature, completed the paperwork with the necessary “Medicare-ese” needed in such delicate situations, and faxed said paperwork to the supply company forthwith, content to move on to other pressing matters, satisfied that my patient would then, through the miracles of modern communication technology and computerized billing, receive a home delivery of said device within 48 hours, as is the customary turnaround time with this particular company with whom we have a chummy (and somewhat bureaucratic) working relationship.

Ten minutes later, I received a call from the above-mentioned company to inform me that the doctor had not dated the form where he had signed it, so could I please add the date to the form and re-send it? (Couldn’t the person on the other end fill in the date? Oh no, the uppity ones at Medicare would examine the signature and date with a magnifying glass, and a handwriting specialist would determine if they were both written by the same person!) Feeling more and more like this was a scene from Terry Gilliam’s Brazil, I filled in the date—using the same color ink as the doctor, of course—and re-faxed the form, putting the original in an envelope to be mailed, since Medicare (read: “the bureaucrats”) wants an original on file.

Again satisfied that I had done my nursely duty, I moved on to other (now even more pressing) tasks, and was interrupted by yet another telephone call from the medical supply company approximately an hour later. Was I aware that the patient already had a manual wheelchair? Yes, indeed. Was I also aware that the patient has Medicare as his/her primary insurance with Medicaid as secondary? Of course. Was I also aware that Medicare will not pay for a walker for a patient who already has a wheelchair?

I stared into space, noting all of the varied colors and relative positions of the push-pins on my bulletin board. Dissociation can be helpful in times of stress (as can Prozac).

“Do you mean to say that, even if my patient needs a walker to get up out of his wheelchair, he doesn’t qualify?” I asked incredulously. The answer was affirmative. “Do you also mean,” I continued, “that a patient who improves and becomes more ambulatory should therefore remain confined to a wheelchair because Medicare feels the paltry cost of a walker is just too much to provide for this person’s improved quality of life and mobility?” I was informed that yes, in Medicare’s eyes, he should stay in the wheelchair. I hung up the phone and put my face in my hands.

Big sigh.

So, yet another bureaucratic fight for this nurse to wage? So many other battles are pending, like the patient who lives in an apartment with severely sloping floors which the housing authority claims is fine, even for a patient with severe arthritis. Oh! the humanity (or lack thereof).

What bureaucratic nightmare will I encounter tomorrow? You can rest assured that one will most likely make its presence known sooner than later. And what is a lowly nurse, a mere cog in the healthcare wheel, to do? Yell? Scream? Rage against the machine? Abuse beer and benzodiazepines? Take your pick. Til then, let’s hope no faceless bureaucrat in a cheap suit is sitting in some cubicle at Medicare scheming up even more insidious ways to save money and diminish the quality of life of its recipients. Then again, that’s probably an apt job description for someone with no healthcare experience who is at this moment burning the midnight oil and doing just that. He probably has a boss who told him to stay until he could figure out how to screw one more Medicare recipient out of $50 this week. (And that boss probably gets a $100 raise for every $50 saved. Go figure.) So, let’s just hope he has one too many tonight after work as he drowns his guilt with cheap gin at a local bar and calls in sick tomorrow. Maybe then I’ll be able to get something done after all.

All healthcare providers eventually have their turn as patients, even if it means just a routine physical. Even though we providers spend most of our time on the professional side of the exam table, there comes a time when we also must be seated on that table ourselves.

In this regard, I’ve had a modest share of experience, more often than not with chiropractors and acupuncturists, although I have seen my share of MDs, psychotherapists, psychiatrists, physical therapists, and Nurse Practitioners. My two hospitalizations were for a spontaneous pneumothorax (collapsed lung) at age 22, and an overnight stay to rule out cardiac problems (must have been gas) at age 25.

It always seems slightly odd to be waiting to have my blood pressure taken, or to step onto the scale and have an overly friendly medical assistant yell my weight out loud for all to hear. These experiences, among others, feed my compassion for my own patients and underscore for me the need to be vigilantly conscientious as a provider of medical care.

These days, my medical appointments center around back pain: spinal injections, physical therapy, and previously an enormous number of chiropractic adjustments over the last 20 years or so. Hesitant to take pain medications, I now have a TENS unit, a device which provides electrical stimulation to my muscles, essentially fatiguing the muscles into relaxation. Coupled with moist heat, stretching, and mental coaxing, I now shock my poor muscles into surrender. Still, my follow-up with the physiatrist will most likely result in another corticosteroid injection to my lower spine, or perhaps a series of lidocaine “trigger point” injections directly into the offending muscles. Woe unto the muscle that does not submit to such ministrations.

The humility of being a patient, of being on the receiving end of healthcare, is a frequent reminder of just how much better healthcare can be, and how I can be an integral part of that movement. It is also a reminder of just how vulnerable patients can feel, and we healthcare providers all need reminders of just how it feels to wear that proverbial johnny.

Detail management is the name of the game when faced with the daunting task of keeping track of so many individual lives. I often wonder if I’m doing enough, and whether my processes for managing such information is useful and efficient. They didn’t really teach us such things in nursing school, so creative seat-of-the-pants creativity is often the modus operandi.

On a daily basis, I use a printed spreadsheet to track my contacts with each of my 80-some-odd patients, whether it be an office visit, home visit, or telephone call. This list, which I carry in my bag, gives me a snapshot of who’s in touch, who’s on the ouskirts of my orbit, and who is apparently MIA. I also have another spreadsheet which tracks whether I have had contact with each patient on a monthly basis. When I see several blank spaces in a row for a particular patient, I know that a few months have passed my by without my having lay eyes on that person, or at least checked in by telephone. I am not expected to see every patient every month, but I’m expected to make attempts at contact, and document each attempt accordingly for the patient’s chart. As all nurses have drummed into their heads during nursing school, “if you don’t write it down, it never happened”. So, I record every disconnected telephone number reached, unanswered call made, or other attempt at finding the ones who got away.

Looking at these crude devices which I have devised for my own obsessive-compulsive purposes, I can see in a glance who the freqent flyers are, who is avoiding me, who might be dead, or who perhaps is just under the radar. Unfortunately, there are a few who have a string of blank spaces on my log, demonstrating the fact that if they truly are out there, they just cannot be found without hiring a detective. Perhaps they like it that way. Perhaps they don’t care.

Just recently, I learned that one patient who I have never met is now in jail. Over many months of trying to find her, I ran into dead end after dead end. (Did I say this would take a private eye?) When I would check the hospital computer system periodically, I would learn that she had been in the ER, and I would consequently scour the electronic medical record for an updated address or telephone number with which I might contact her. These leads would generally fail, but one eventually led me to this patient’s grandmother, who informed me that her poor misguided grandchild finally ended up in jail. “At least we know where ______is. S/he’s fed, clothed, and taken care of medically”, she said. I empathized with her and promised to contact the jail (where our doctors run the show) and follow up on her family member’s condition. At least I found him/her and my colleagues over at the “Big House” can check in.

Trying to follow eighty people relatively closely and keep them straight in my mind is a challenge. Of course, there are a number of patients with whom I have worked for more than five years, and these are especially well-known to me from the salad days of our organization when we had the luxury of miniscule caseloads of thirty. What luxury that was! We had the time to really build relationships then, holding our patients’ hands through every twist and turn of the healthcare rollercoaster. Now, in our current iteration, I still do my best to provide personalized care, but there is just not enough time to do it justice. As much as I liked my old way of practicing, it just is not sustainable. The up side of such a change is that more responsibility is put on the patients’ shoulders where it really should be, although many simply fall under the weight of their own myriad needs. How to find that balance of empowerment and assistance? A good question to which I have no answer.

So, this very tired and overworked nurse tries his best against long odds, and I watch my colleagues do the same. We go to extraordinary lengths—often disappointed, manipulated, and otherwise thwarted, but some rewarding moments sneak through almost daily. The chaos is sometimes overwhelming, as is the chaos of having 19 clinicians in a relatively small space all talking on phones, sending faxes, emailing, dashing for medical records, and catapulting in and out the door to and from home and office visits to our hundreds of patients. It is a perplexing exercise, often quite frustrating, and I often long for simplicity and quiet, something which is rarely seen and would probably feel somewhat pedestrian and boring compared to the general maelstrom with which I’m acquainted.

It’s 8:30pm, I just finished my notes after having dinner with Mary, and now I write about my work to exorcise it from my mind so that I can move on with a relatively clear head to the rest of my evening. This is a frequent practice, the office frequently being a place where paperwork just cannot be finished in peace. I look forward to moving on to laundry, bills, perhaps some reading, some emails, and then the big reward—seven or eight hours of sleep—which will allow me to get up and do it all again. With “retirement”(is that even possible these days?) perhaps several decades away, most likely, I know that a change of pace will be needed soon. Such ongoing stress takes its toll, and there will come a day when it will be time to leave this harried rat-race behind. Til then, this rat will get back up on that wheel tomorrow, nose to the healthcare grindstone.