America the Fat

Time Magazine recently reported in their 6/23/08 issue, p.67, "In the 1950's kids had three cups of milk for every cup of soda. Today that ratio is reversed, (three cups of soda for every cup of milk) meaning they get all the calories and none of the nutrients."

When I was growing up back in the 50's, kids were expected to drink a glass of milk with their breakfast and again at dinner. In the school cafeteria we were handed a carton of whole milk with our nutritionally balanced lunch and we drank it dutifully. Every kid did it because we were instilled from a very young age with a personal responsibility to eat right and exercise in order to be healthy. Just as we implicitly accepted our polio vaccine on sugar cubes, as kids we were obligated to ourselves, our family, our community, and our country to drink our milk. It was a national duty. And during the Kennedy administration, we believed milk was some sort of perfect super food and our best defense in keeping us out of the doctor's office; a prophylaxis against illness. And healthy kids meant a healthy future for America.

But soda? I was 12 years old when I tasted my first Coke. In those days, Coke was a treat, and treats were taken seriously, forboden save for special occasions which were few and far between, like cake on a birthday or turkey on Thanksgiving. They were anticipated with excitement, savored, and appreciated; not indulged in at whim as they are today. A fat kid was an oxymoron.

Today one third of American children are obese. Not only is this group endemic with Type II Diabetes, but the American Academy of Pediatrics now endorses the use of statins such as Lipitor for these kids to control their dangerously high cholesterol levels and avert the heart disease which can lead to heart attacks.

Many of the senior patients we see at the clinic also struggle with these same diseases. Some have spent their adult lives indulging in poor life style choices and now they're suffering the consequences. How ironic that these patients will find their own pre-adolescent grandchildren struggling along side them with the same life-threatening, preventable maladies.

Remember the 900-pound man seen on the Discovery Channel or Dr. Phil who is bedridden from obesity? Every day his mother still serves him the liters of soda and high-calorie foods that she fed him as a child. Now as an adult, he is so profoundly addicted that despite his agony, he still demands more of the same. And the mother, despite her son's morbidity, accommodates him.

Obese kids who regularly drink soda, eat high-fat fast-foods, and are sedentary lack basic health education and a supportive environment to reinforce it. Blame is rampant, but irregardless, our youth are our future and they must once again become a national priority in this country. We should vote for a President who will genuinely advance the mental and physical health of our children...from birth through early adulthood. Surely this will require extraordinary changes in our society and an extraordinary leader to bring them about.

Obama or McCain?

Blossom

A professional songwriter friend of mine and I launch a volunteer after school mentoring program and Blossom is referred to us by social services. She is 12-years old. One evening as the kids are singing, I notice she is staring at the lyrics handout. She hides it well, but something is wrong. This American-born girl can't read.

When it is time for the kids to be picked up, I tell Blossom to ask her mother to come to the music room. I need to talk to this woman whom I have never seen before and know nothing about. And she comes in, eyeing me nervously with four little children in tow. We sit facing each other, mother to mother. I speak softly and gently, "Why can't Blossom read?", I ask. And as if a dam breaks open, she responds in a sudden, frantic torrent of broken English with a thick accent. "I ask for help! I talk to the teachers! I try and try! No one will listen to me! No one will help her," she wails.

"A 12-year old girl who can't read?", I think to myself. "How is this possible? How humiliating for this beautiful young lady about to start middle school."

I look over at Blossom crying in shame. I look into her mother's eyes. "I will help her," I hear myself say. "Bring her to my home every Sunday for 2 hours. I will teach her to read."

As I sit on their living room couch, I learn the family is Muslim, the mother from Nazareth, Israel, the father from Syria. I tell them I am Jewish lest this will somehow alter their desire for me to tutor their daughter. To my surprise, they are happy with this disclosure and express their gratitude with cups of tea and a plate of homemade baklava.

I take Blossom to the library for books. I assess her reading. I am appalled. I call the school and arrange a formal meeting with Blossom's teachers. "How can this happen?", I challenge them. They tell me that in the third grade, Blossom was determined to have an auditory learning disability. I am told that reading isn't taught after 3rd grade, so since she couldn't keep up with the other children, she was placed in a special education tract. And, as I see it, essentially forgotten. Here she is, entering 6th grade, and she is unsure of how to sound out vowels. I can hardly believe it. It's pitiful. But Blossom is hungry...ravenous...to learn.

That was three years ago. My involvement in the after school program has long since ended, but my mentoring Blossom continues today. She is 15 now and wears a hijab unlike the other women of her family. In a high school rampant with teenage pregnancies, her head covering is her unspoken declaration of modesty and self-assuredness. In my home, her learning extends beyond books. She delights in frying perfect latkes and shares in the lighting of Chanukah candles with three generations of my family. Her mother pays me in tabbouleh with fresh mint and stuffed grape leaves with rice.

And Blossom reads abundantly..at about a sixth grade level right now. In spite of her challenges, she has a fierce determination to keep practicing and improving. She calls me on the phone five or six evenings each week and we go over lists of vocabulary words together.

And as long as Blossom works hard, I will continue to push her and encourage her...and be there for her.

Some day I hope to dance at her wedding.

08-08-08 0lympics 洪水 0h My!

I'm tantalized by Planet China.

Ever since my university independent study on the Sino-Soviet conflict, Mao Tse-tung, and the Cultural Revolution, ever since the table-tennis match and Nixon's visit, I've been fascinated with that Quiet Giant composing one-fifth of the world's population. I disdain the communistic thought control yet I am in awe of the culture and the physical beauty of the country. I worry about China's emergence as a powerful leader into the world market buying up U.S. Treasury Bonds as we sink deeper into debt.

But, hey, TGIF! The Olympic opening ceremonies are on TV tonight. I've been looking forward to these for months...years. The Olympics are incredible enough, but from China? It's probably one of the most significant events in the history of human civilization. I am exhausted and stressed from work and I want to get home and watch the extravaganza!

I can't wait!

And there it is on the big screen! Beijing and the massive architectural wonder of a Bird's Nest where ninety thousand athletes, dignitaries and spectators from every country in the world are converging in 65% humidity as a statement of global unity! The promise of the future of mankind! I am transfixed. Only fire, flood, or pestilence will steal me from this pleasure! Bring it on!

An hour later, I haven't blinked. I am mesmerized by the performers, the children, the costumes, the colors, the faces. I am watching George W and Vladimir Putin on camera 'yuckin it up in their stadium seats. Suddenly I hear blaring alarms. The TV screen goes black and a bold message appears across it. "What's this?!" I think to myself. "Am I witnessing the Chinese censoring of American television?"

Not so lucky! It's a Civil Defense weather warning. "A dangerous storm is passing over certain parts of the city." "FLOODING IS IMMINENT!", it yells at me.

"Is it raining?" I'm downstairs totally unaware. And within seconds, Niagara Falls breaks through the windows and water is pouring into the basement! "HELP ME!", I scream. The family bursts into action. Buckets, mops, towels, fans. My husband is outside in the torrential rain looking like a sailor bailing out his ship to keep it from sinking.

Another hour later the storm passes and the flooding is over. And so are my Olympic opening ceremonies. I'm exhausted from sopping up gallons of water and running up and down the stairs.

But, hey! Ninety thousand people may be sweatin' the big stuff in the Beijing humidity, but I ain't sweatin' the small stuff here in the States. What's so bad about a couple of rooms with soaking wet carpeting that already smell of mildew? Through the wonders of cable video, the hoopla has been magically recorded and I can still watch it, tomorrow, commercial free, with the push of a button.

And...I can't wait!

Oxycodone Known

Since our State Board of Pharmacy recently published an on-line prescription history database for doctors, we've verified that some of our patients who we suspected were abusers, are abusers. They're addicted to oxycodone and other narcotics, and they've been going from doctor to doctor, making up stories, and getting multiple prescriptions filled. Now we have the ability to screen new patients carefully for prescription drug abuse and while we're on the phone setting up the appointment, I can download the entire prescription history in 3 minutes.

Some of the patients genuinely need oxycodone like the patient with the shredded rotator cuff which was verified by an MRI. But sometimes we have to remind ourselves not be suspicious all the time, that is, ever since we met Mr. Kidder (sic). He walked into the office unexpectedly one morning, stating he had fallen in the shower and hurt his tailbone. "Could he see a doctor?", he pleaded sincerely.

One look at the patient and Dr. Richard informed me that he believed Mr. Kidder to be a drug-seeker. To prove his point, and squelch any doubts among the staff, the kind doctor gently conducted his physical examination which, due to the nature of the so-called injury, included a rectal digitation. In that, according to Dr. Richard, the patient didn't flinch, the coccyx was determined to be not fractured, and Extra-Strength Tylenol was prescribed for the professed discomfort. The patient, upon realizing that he would not conclude his visit with the desired oxycodone prescription in hand, discreetly departed the premises in a state of profound consternation.

He left behind a balance due, his bogus address and phone number, and a lengthy narcotic abuse report, freshly downloaded and printed.

Mr. Kidder, indeed.

InSecure Horizons

My mother calls me. Her dearest friend, 93-year old Miss Bessie, wants to know if I will look at her bills from the rehab facility she stayed in two years ago. The balance due is over $5,000 and Bessie can't understand the paperwork.

Miss Bessie is no frail, old lady suffering from dementia. Far from it. When I visited her in the rehab facility where she was recovering from a broken shoulder, she was sitting in a chair with a new Apple laptop shooting off emails to her family. She's a retired librarian and sharp as a tack. She may be 93, but she looks and acts 20 years younger.

So, at my mother's request, I, being the good daughter that I am, dutifully drive to the assisted living center where Bessie now lives and pick up her plastic grocery bag full of bills and health insurance policy documentation. I adore Bessie, but I dread this. It's like doing a jigsaw puzzle with 500 pieces and no distinct picture. It's so anxiety provoking that I make up my mind that I will not even attempt it until which time I am fully rested, calm, and in a good mood. And most importantly, when I have a window of opportunity to tackle this at work. I'm thinking in about 5 years.

It takes me about a week to psych myself up. The bag is sitting on my desk next to the laser printer. I pick it up, look inside, see all the puzzle pieces, and spread them out on my desk. I open up a new excel spreadsheet on my computer screen to enter and track the charges and I start with the rehab facility bills. ("No wonder Bessie couldn't understand these," I think to myself. "This is ridiculous!") Then I comb through the Secure Horizons contract. Then I call Secure Horizons who refuses to talk to me until I tell them I'm with a doctor's office and give them all the secret information that allows me to get past their HIPPA gatekeepers and convince them that we can discuss Bessie's billing problems behind her back. I challenge their reimbursements to the rehab facility and point out their mistakes. It turns out that Secure Horizons reimbursed the rehab facility at a different daily rate than was on Bessie's contract. There was a $800 error in Bessie's favor.

I call the rehab facility, email them the excel spreadsheet with all the reconciliation detail and wait. Three weeks later Secure Horizons sends a check to the rehab facility, but not for the full $800. I have to call them again, B.S. my way through their umpteen layers of HIPPA security and once again point out the error of their ways. And finally they pay up. Bessie gets her bill reduced by $800. She's elated. Probably more from the peace of mind knowing that she wasn't taken advantage by the rehab facility and Secure Horizons than the money itself. She pays off the rehab facility. She's smiling her beautiful smile again.

Now, you tell me, how in the heck was Bessie suppose to do this herself? What about all the other hundreds of thousands of other seniors receiving bloated bills from rehab facilities, hospitals, and doctors? There is no possible way these innocent, naive, trusting people will ever know they're overpaying. The bills are nearly impossible to understand and so difficult to dissect that I'm sure most never are.

Bessie's health insurance, Secure Horizons, is one of dozens of the Medicare Advantage Plans, marketed to seniors with the promise of giving them an advantage over straight Medicare and a supplemental plan. An advantage?

In our office, we call most of them Medicare disadvantage plans.

"Hi, Ray Charles!"

Charles wasn't really his last name, but Ray was really his first name and he had been a patient in this practice for 25 years. I only knew him for the last two. Ray suffered from schizoid disorder. He lived in a group home. A social worker brought him to our office every six weeks to monitor his delicate health issues. One thing I noticed was that when Ray came in, the staff got excited. They treated him like he was a member of their own family. They took care of him with so much tender loving care that I couldn't help loving him too, even though he was quiet and not particularly communicative, and he didn't really know me. Ray was tall, refined, and always wore his gold chains. He walked with a cane.

One day, Ray called and I answered the phone. The deep, monotone voice said, "This is Ray." And, I, in an impetuous moment responded enthusiastically, "Hi, Ray Charles!" And Ray cracked up laughing.

And then I did it every time he called and every time he came in and it always broke through his depression, even for a few seconds.

On Monday, Louise the social worker brought Ray to the office. He was AMA from the hospital (Against Medical Advise) for a GI bleed and only wanted to come to our clinic. I walked into the exam room and saw him sitting there waiting solummly, and exclaimed, "Hi Ray Charles!" He and Louise both cracked up laughing.

Yesterday, Louise called and said that Ray had been readmitted to the hospital. He'd had a very successful GI surgery. But something had gone wrong. She was still trying to find out.

And Ray had passed away.

I hung up the phone, sank into my chair, and wept. I informed the staff.

"Goodbye, Ray Charles." I thought.

"Thank you for all those times you made me smile. You never knew how much they meant to me."

Paper Travail

I'm experiencing the reality of something I read in a Time magazine article a long time ago. Something in the article was so profound that it resonated with me then on a personal level and it's resonating with me now on a professional level... years later. Usually when I read something that truly impresses me, I want to save it. I tear it out of the magazine or save the magazine or copy the article. But in this case I didn't and I regret it because the gnawing feeling is bugging me.

Today, with the patient chatter in the front office particularly subdued, I search for the Time magazine archive website and search...and search. What key words should I use? I try this and that and this again. I concentrate on staying calm as I maneuver through thousands of articles. I focus. And low and behold, Eureka! I find it!

It's the cover story, "10 Ways to Cure the Health Care Mess", from the November 25, 1991 issue by Janice Castro.

Here's the quote I'm looking for: "The U.S. has more than 1,500 different health-insurance programs, each one with its own marketing department, complex forms and regulations. Doctors, nurses and clerks are buried in the paperwork needed to keep track of whom to bill for every aspirin tablet. It's a massive waste of time. U.S. health-care providers will spend as much as $90 billion this year on record keeping, according to a Harvard study."

And that was written nearly 17 years ago!

Today, amidst the ever increasing absurdity of having to keep track of every single patient's individual insurance company (of which I count 60 companies among our records) and specific plan (of which there are too many to count), which by the way the patient frequently changes from year to year, (and we have to keep track of that too or we don't get paid) or if they're on Medicare, to bill to Medicare first and then bill again to their supplemental insurance plan (if they have one) and bill to each private insurance company separately, and recognizing that when we do eventually get paid, a sizable chunk of it will go to the billing company who slogs through this mess for us, and don't forget we must also keep track of each patient's network of specialists when trying to refer because they don't have a clue how to navigate the system themselves (how could they?) and, oh, keeping track of that plan's medication formulary because Plan A doesn't cover this drug or that drug and requires a physician's letter to document the justification, and while your fighting that battle with the insurance company and they're stone-walling you as long as possible, the patient dies and then the issue goes away on it's own...

Stop the insanity! Yes, Janice Castro articulated the situation perfectly, "It all is a massive waste of time." And the waste has grown exponentially since 1991.

What have we created? A health care system that forces our doctors to spend a substantial portion of their 24-hour day coping with a bungling administrative quagmire constructed by a billion dollar profit-focused insurance industry instead of allowing them to spend most of their time, attention, energies, and advanced education on what is important - practicing medicine.

Oh, and by the way, many of our best and brightest minds are opting out of medicine altogether because they can no longer stand dealing with this "Health Care Mess".

It's shameful.