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Those who feel entitled to our time and attention (article)
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southernbubby




 
 
    
 

Post Mon, Feb 23 2015, 9:18 am
She is always a difficult admission. The long chart review. The vague complaints. The entitled attitude. The misdirection. These are expected. As is the cake at her bedside after a diabetic crisis. The two-liter soda after an emergent fluid dialysis. The urine toxicology was positive for cocaine. The staff knows her well. I know her well. I give her the attention, kindness and empathy that I give to every patient. In abundance. But admitting her overnight on an ICU shift was especially unpleasant.


After she settled in, I went to interview her. She grimaced. She told me about her abdominal pain and her headache. She told me about the dizziness and the shortness of breath. And, of course, the chest pain. I listened with my usual attentiveness. Where did I get all the extra fluid in my lungs? I don’t drink any liquids. I know I’m not supposed to. I never miss dialysis. I take my medications. Where did all the water come from? She looked surprised.

After some time though, I saw something different in that hospital bed. Instead of a scared, vulnerable patient I saw a hospital bill. The sum and future cost of her medical care. The countless nights of medical and ICU beds. The CT scans and catheterizations. Dialysis. The endless list society knows nothing about, yet foots the bill. At that moment, I saw it all. The draining of resources. The exploitation of welfare. All on Medicaid. All on the taxpayer. The mythical free lunch. I am not and would never vote for a Republican, but for a moment I thought like one: a moocher and a taker. It was a difficult admission.

It’s natural to take care of those stricken by an unfortunate illness, those who are gracious, or those who comply with doctor’s orders. They are easy. The attention. The kindness. The empathy. They flow from a doctor like saliva from Pavlov’s dog. We are conditioned since medical school to have boundless patience and limitless compassion. We are an engine, and the motor is always running.

And then there are those like my overnight ICU admission. My patient. Our patient. She eats ****, sending her diabetes out of control. She drinks gallons of soda, making dialysis a moving target. She skips medications, driving her heart failure over the edge. She uses cocaine. Yet somehow, on every admission, she receives all the gifts of medicine: a precious hospital bed, a team of nurses, state of the art care, the attention, the kindness, the empathy. I wonder how we do it. How do we find the energy?

I am proud of us. Our society. We provide care to everyone, regardless of station. We do it with the same voracity at all times. No one wants to be on welfare or Medicaid. They do their best with what they have. They don’t want to burden society. But some may be regarded as exceptions. They seem to believe that society owes them. They have no obvious graciousness and no remorse for consuming limited resources. This is how I perceived my ICU patient that night.

And yet, she is our strength. Caring for her defines us. Because it is hard. At the very limits of our attention and kindness and empathy. When we finally stop to ask: Why do we still care for this person? Why do we still give her all that we are? We continue to provide. All the care. All the energy. This is a sign of a society that cares for its people. All of them. I am proud of us.

Michael Joel Pottash is a medicine resident, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY. He blogs at Better | A Healthcare Blog.
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Fox




 
 
    
 

Post Mon, Feb 23 2015, 2:19 pm
A very cute article. I don't know how old Dr. Pottash is, but I'm assuming he's in his mid- to late-20s, since he's identfied as a medical resident.

The phenomenon he's describing is known as the "80/20 rule" -- 20 percent of your patients, customers, clients, students, etc., will take up 80 percent of your time, effort, energy, and resources.

What Dr. Pottash probably hasn't experienced or developed insight into just yet is that *he* is (or will be) part of somebody else's 20 percent.

Will his accountant despair of his haphazard bookkeeping if he's someday in private practice? Will pharmacists groan when they see handwritten prescriptions from him that they must decipher? Will contractors swear to themselves when he insists on certain building features without understanding the technical difficulties?

Somewhere, in some context, Dr. Pottash is part of the 20 percent that gives somebody headaches.

I do understand what he's saying, but I think he's perhaps a little too impressed by the importance medical care plays in our lives. In fact, *most* of us go through each day, just like Dr. Pottash and his colleagues, helping the 20 percent that make us crazy.
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sequoia




 
 
    
 

Post Mon, Feb 23 2015, 2:22 pm
Yep. My thoughts exactly.

Each of us, in our profession, has clients like that.
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Barbara




 
 
    
 

Post Mon, Feb 23 2015, 2:28 pm
sequoia wrote:
Yep. My thoughts exactly.

Each of us, in our profession, has clients like that.


Yes.

But our complaints are a bit less distasteful than his. He borders on suggesting that it would be a good idea to just let people like her die, to save our society money.
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saw50st8




 
 
    
 

Post Mon, Feb 23 2015, 2:52 pm
Barbara wrote:
Yes.

But our complaints are a bit less distasteful than his. He borders on suggesting that it would be a good idea to just let people like her die, to save our society money.


That's a little too simplistic.

Would you do a lung transplant for an active smoker? Would you sacrifice care that could be giving to another struggling patient for someone who is actively harming themselves and won't actually fix the problem?

What about the fact that when you compound this one individual's astronomical bills (paid in large part by other people's insurance premium), this skyrockets the cost of health care and often puts other people out of reach of paying for health care?

Medical ethics are rarely simple. We triage in hospitals all the time and he's just asking for a little triage introspection.
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southernbubby




 
 
    
 

Post Mon, Feb 23 2015, 3:39 pm
I saw something else in his article. There are people who are so manipulative, demanding and difficult that they burn out anyone that tries to help them. Eventually, you tell yourself that you are not going to let them take over your life but you still want to help them to the extent that you are capable, even though they feel entitled to more. So you give, what you can give, while they keep saying that it isn't enough.
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Fox




 
 
    
 

Post Mon, Feb 23 2015, 3:40 pm
saw50st8 wrote:
Would you do a lung transplant for an active smoker? Would you sacrifice care that could be giving to another struggling patient for someone who is actively harming themselves and won't actually fix the problem?


Yes, there's a sense justice in spending medical resources on the nice, cooperative patients who try their best to follow conventional wisdom and medical advice rather than on patients who "are actively harming themselves and won't actually fix the problem."

My difficulty with that, however, is that it supposes that we can easily measure and determine who is trying his/her best to fix the problem; who isn't intellectually capable of fixing the problem; who has psychological impediments to fixing the problem; who just doesn't care; and who we're giving bad advice to because we just don't know any better.

Here's a perfect example from the medical world: one of the biggest advances in both Type I and Type II diabetes management is the pump that automatically dispenses insulin as needed. There are also nasal inhalers that are somewhere in the development pipeline. Why? Because researchers discovered that a lot of "non-compliance" occurred because people were fearful and anxious about needles and injections. Now, you can argue all day that someone should grow up and learn to give himself insulin shots, but if people are genuinely uncomfortable with it, their compliance is going to be spotty, at best.

The triage paradigm also presumes that compliance with medical advice is a bell curve, with some people being extraordinarily compliant and an approximately equal number being almost entirely non-compliant. In fact, it probably more of a power curve, with a small minority of people being the most non-compliant. Malcolm Gladwell addressed this in "Million-Dollar Murray," an essay about solving versus managing social problems with limited resources.

Obviously, medical care grabs our attention, but is it really so different from any other resource? We have to analyze why it's hyper-expensive and what role the identified "problem" plays in that. While I have not doubt that non-compliant patients are aggravating and frustrating, flagrant non-compliance isn't really what drives medical costs through the roof. Dr. Pottash would gain more insight examining the tort system and what happens when the government sets prices.
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Fox




 
 
    
 

Post Mon, Feb 23 2015, 3:46 pm
southernbubby wrote:
I saw something else in his article. There are people who are so manipulative, demanding and difficult that they burn out anyone that tries to help them. Eventually, you tell yourself that you are not going to let them take over your life but you still want to help them to the extent that you are capable, even though they feel entitled to more. So you give, what you can give, while they keep saying that it isn't enough.


Yes, there's that. I'll again recommend "Million-Dollar Murray," by Malcolm Gladwell. His example focuses on homelessness with a additional illustrative topics. He points out that the most demonstratably effective solution to homelessness is unpopular with both liberals and conservatives: it is neither "fair" nor does it reward good behavior.

The question that we are left with, when discussing people who seem to have persistent overwhelming difficulties, is whether we want to actually solve the problem or simply keep it in a holding pattern. Most of us would like to say, "Solve the problem," but we don't always like what that entails.
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southernbubby




 
 
    
 

Post Mon, Feb 23 2015, 3:57 pm
Fox wrote:
Yes, there's that. I'll again recommend "Million-Dollar Murray," by Malcolm Gladwell. His example focuses on homelessness with a additional illustrative topics. He points out that the most demonstratably effective solution to homelessness is unpopular with both liberals and conservatives: it is neither "fair" nor does it reward good behavior.

The question that we are left with, when discussing people who seem to have persistent overwhelming difficulties, is whether we want to actually solve the problem or simply keep it in a holding pattern. Most of us would like to say, "Solve the problem," but we don't always like what that entails.


When I see those people like the woman in Dr Pottash's article, I see that they abuse their health and then come to a place where others will take care of them. The homeless who stand on the streets and beg feel cared for each time someone hands them another dollar. It is though they spend their entire lives so hungry for love and attention and were so deprived of it at some critical point in their lives that they will suck the life out of everyone around them trying to get that love and care. The solution of simply throwing taxpayer's money at it is like putting a band aid on a huge incision. They could be given a home but they want someone to care.
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Fox




 
 
    
 

Post Mon, Feb 23 2015, 4:17 pm
southernbubby wrote:
It is though they spend their entire lives so hungry for love and attention and were so deprived of it at some critical point in their lives that they will suck the life out of everyone around them trying to get that love and care.


Yup. That solution that Gladwell pointed to that *does* work with the chronically homeless are semi-shared living quarters and daily contact and intervention with social workers and other caregivers.

The thesis of his essay is that, expensive as that kind of intervention is, there is simply a certain percentage of people in society who simply can't take care of themselves within normal parameters, and giving them the kind of daily interaction they need to stay on track is less expensive than all the medical care we provide.
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ora_43




 
 
    
 

Post Mon, Feb 23 2015, 5:46 pm
sequoia wrote:
Yep. My thoughts exactly.

Each of us, in our profession, has clients like that.

Most people get paid by their "clients like that." But a certain set of professionals (mostly people in healthcare and social services) don't.

I also disagree that most of us have clients like that. Difficult clients? Sure. Clients who lack the ability to care for themselves on the most basic level, to get through the day sober, or even to perceive reality with a reasonable degree of accuracy? No. I'm not saying it never happens, but people in that position usually aren't hiring accountants or web designers or lawyers in private practice or math tutors or what have you. They deal with cops, paramedics, hospital staff, and maybe social workers.
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ora_43




 
 
    
 

Post Mon, Feb 23 2015, 5:48 pm
Barbara wrote:
Yes.

But our complaints are a bit less distasteful than his. He borders on suggesting that it would be a good idea to just let people like her die, to save our society money.

Did we read different articles or something? I saw him saying the exact opposite of that. He's saying that our society is defined by how well we treat such people.
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saw50st8




 
 
    
 

Post Tue, Feb 24 2015, 7:18 am
Fox wrote:
Yes, there's a sense justice in spending medical resources on the nice, cooperative patients who try their best to follow conventional wisdom and medical advice rather than on patients who "are actively harming themselves and won't actually fix the problem."

My difficulty with that, however, is that it supposes that we can easily measure and determine who is trying his/her best to fix the problem; who isn't intellectually capable of fixing the problem; who has psychological impediments to fixing the problem; who just doesn't care; and who we're giving bad advice to because we just don't know any better.

Here's a perfect example from the medical world: one of the biggest advances in both Type I and Type II diabetes management is the pump that automatically dispenses insulin as needed. There are also nasal inhalers that are somewhere in the development pipeline. Why? Because researchers discovered that a lot of "non-compliance" occurred because people were fearful and anxious about needles and injections. Now, you can argue all day that someone should grow up and learn to give himself insulin shots, but if people are genuinely uncomfortable with it, their compliance is going to be spotty, at best.

The triage paradigm also presumes that compliance with medical advice is a bell curve, with some people being extraordinarily compliant and an approximately equal number being almost entirely non-compliant. In fact, it probably more of a power curve, with a small minority of people being the most non-compliant. Malcolm Gladwell addressed this in "Million-Dollar Murray," an essay about solving versus managing social problems with limited resources.

Obviously, medical care grabs our attention, but is it really so different from any other resource? We have to analyze why it's hyper-expensive and what role the identified "problem" plays in that. While I have not doubt that non-compliant patients are aggravating and frustrating, flagrant non-compliance isn't really what drives medical costs through the roof. Dr. Pottash would gain more insight examining the tort system and what happens when the government sets prices.


I agree that it's hard to measure who is actually doing their best. But I'm not even talking about your best - if you are an active alcoholic or an active smoker, please save the precious donated organs for someone who won't continue to destroy them!

Human Performance is a huge factor in many accidents and problems. You will never make that go away, although you can limit the issues. Kids with diabetes for example benefit tremendously from a pump.

Yes, medical care is different from other resources. Medical care is both private and communal. A doctor can only treat so many patients at a time.

I am thankful that as a country we do treat everyone, but that doesn't mean we shouldn't examine the benefits of the treatment.
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disneyland




 
 
    
 

Post Tue, Feb 24 2015, 7:57 am
I think it is really great that here in America everyone is taken care of no matter what their situation is. We don't know how great a person really is and who deserves to live more. Everyone should take care of themselves because that's a mitzvah but it's great that people can get the help they need. (just devils advocate, you may not agree with me, it seems like a really complex situation)
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amother


 

Post Tue, Feb 24 2015, 12:23 pm
And because the woman drank while on dialysis, used drugs, didn't take her meds, ate junk while diabetic (ALL CHOICES) my relative who was in a terrible accident had to wait 10 hours in an ER, 7 after they decided to admit. No beds. (First 3 were running tests, x rays, CT etc). And they couldn't get enough pain meds because they weren't in a room yet. Surgery was postponed because of the wait.
My relative didn't do anything reckless. An accident. Clean (of drugs), sober, compliant. Taking all prescribed meds and could tell you which ones. But screaming in pain. So bad that the most they would give in the ER brought it down to a 9 out of 10. Who has a high pain tolerance.

Anon because it was recent and a lot of people know this story IRL. Otherwise I would use my sn.
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southernbubby




 
 
    
 

Post Tue, Feb 24 2015, 1:16 pm
amother wrote:
And because the woman drank while on dialysis, used drugs, didn't take her meds, ate junk while diabetic (ALL CHOICES) my relative who was in a terrible accident had to wait 10 hours in an ER, 7 after they decided to admit. No beds. (First 3 were running tests, x rays, CT etc). And they couldn't get enough pain meds because they weren't in a room yet. Surgery was postponed because of the wait.
My relative didn't do anything reckless. An accident. Clean (of drugs), sober, compliant. Taking all prescribed meds and could tell you which ones. But screaming in pain. So bad that the most they would give in the ER brought it down to a 9 out of 10. Who has a high pain tolerance.

Anon because it was recent and a lot of people know this story IRL. Otherwise I would use my sn.


I think that what this Dr Pottash is saying is that his first reaction is to feel the same thoughts that you have expressed; that there are those who usurp all of the medical resources and all the while don't really value their lives or their health, while those who do try to stay healthy are denied care because it all goes to people like his patient. Then he thinks about it again and decides that he must view all patients of equally deserving of those resources because it is not up to us to decide who is valuable and who is not.
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notshanarishona




 
 
    
 

Post Tue, Feb 24 2015, 1:58 pm
I don't think you can decide who is "valuable". I do think there should be a penalty for compliance I.e. Medicaid should only cover treatment for people if they are also undergoing counseling and a stop smoking program, etc.
I think people should have to pay out of pocket if they are abusing the system but they should still be treated (just not on tax dollars).
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southernbubby




 
 
    
 

Post Tue, Feb 24 2015, 2:05 pm
notshanarishona wrote:
I don't think you can decide who is "valuable". I do think there should be a penalty for compliance I.e. Medicaid should only cover treatment for people if they are also undergoing counseling and a stop smoking program, etc.
I think people should have to pay out of pocket if they are abusing the system but they should still be treated (just not on tax dollars).


Where do we draw the line, however, on compliance? My doctor just prescribed Prolia for osteoporosis. The possible side effects could be incapacitating and many have spent months in bed due to a bad reaction to Prolia. I don't want to take it. Am I non-compliant? Does the insurance have to cover me for osteoporosis related problems if I don't take it?

Most insurers jack up the price for smokers and for the obese.
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Fox




 
 
    
 

Post Tue, Feb 24 2015, 3:36 pm
In a lot of ways, I think these are artificial dilemmas created by a broken medical care system.

Linking health insurance directly to employment is one problem. The undermining of the free market system by Medicare is another. The effect of the tort system on caregivers is also at play.

The reason that health care is so expensive and resources often so scarce is *not* primarily because of a small minority of significantly non-compliant patients. The problem is much, much bigger:

* Linking health insurance to employment is a historical development and has become ineffective as rates have risen. While I'm not a particular fan of our President, there has to be *some* mechanism for allowing people to purchase insurance not linked to their employers at affordable rates.

* With most goods and services, the value of an item is based on the cost of manufacture, transportation, and a reasonable profit to all those involved. If a pair of scissors, for example, costs $2 to manufacture, $.50 to ship, and all parties involve take a profit of $2, the retail cost will reflect $4.50 plus any taxes.

The unexpected consequence of Medicare (and to a lesser extent, Medicaid) is that a bureaucrat decides what the reimbursement rate will be, and this sets the value. If Medicare decides that a pair of bandage scissors will be reimbursed at a rate of $7, then that becomes the price for everyone. It leads to a surreal environment in which there is little relationship between production costs and price.

* Why do ER visits involve such long waits? Not because of non-compliant patients. Rather, because physicians order all kinds of tests and treatments that are medically questionnable but can be used in a lawsuit defense. This happens not just in ERs, but in virtually any medical environment. Reforming malpractice claims would save enough money to adequately care for the most irresponsible bums -- but personal injury lawyers lobby hard against it.

Arguing over who should get priority in treatment is simply rearranging the deck chairs on the Titanic. It keeps us sniping away at one another while the real underlying problems fester and undo any progress we make.
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amother


 

Post Tue, Feb 24 2015, 3:44 pm
southernbubby wrote:
Where do we draw the line, however, on compliance? My doctor just prescribed Prolia for osteoporosis. The possible side effects could be incapacitating and many have spent months in bed due to a bad reaction to Prolia. I don't want to take it. Am I non-compliant? Does the insurance have to cover me for osteoporosis related problems if I don't take it?

Most insurers jack up the price for smokers and for the obese.


Ahh, not when your insurance is Uncle Sam and the tax payers.
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