Woo Hoo!

I passed my final exam…..only the presentation of my project is left.

I suppose I will have to change the blog title soon to “Trials and Tribulations of a New NP”. I have found a position with a group of GI physicians, this ought to be interesting! It is not easy to find a position when you are a new grad, I was lucky to get more than one offer, of which this one worked out the best.

The cool part is, I get to hang out in the cushy doctor’s lounge in the hospital between patients. 🙂 If I have time to hang out that is… Will keep you all posted.

 

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Presenting complaint, or how a cough medication was prescribed for foot pain.

One thing I have learned is that the presenting complaint is never what you think it is.

Foot pain: An elderly lady came in complaining of foot pain. She had told the nurse it was bothering her a lot and wanted to know what to do about it. On examination there appreared to be a crusty area between the last two toes of one of her feet. She points out “It was pretty swollen up for a while”. I try to gently clean away some of the crusty stuff and just see a little bit of a macerated area. I questioned her if she had a podiatrist as she was diabetic and she said she did.

 “He operated on that toe a while back, and the nurse came and dressed it and they took out the stitches last week”. Okay……..Well, I advised her if it was still sore she should check with the podiatrist. She agreed that was a good idea, she denied any other issues when I asked if there was anything else she wanted to talk about.

I left to give my report to my preceptor, the good doctor….he agreed the patient should return to the podiatrist to have it checked.

We go back in the room. “So,” he says, ” I hear you are having some trouble with your foot, but that you are going to get the podiatrist who operated on it to check it out.”

“That’s right”, she says, “But that’s not why I came in today, I wanted to talk about my cough.”

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Being of two minds…

I consider myself a caring and nice person, after all I went into nursing for the usual reason, “to help people”. Many years were spent helping people, starting as a volunteer EMT with my local rural fire department, then on to diploma school to become a registered nurse. I chose the three- year diploma program over the four-year BSN, not to save time, but because I liked the hands-on curriculum. (I have worked with BSN-prepared RN’s who had never actually inserted a Foley catheter while in school). Ten years later I got my BSN, and now another ten years later, my Master’s. (Does this show a trend? Will I be working on my DNP when I am in my sixty’s?).

Most of my career was in home health, psych and hospice. It was tough but rewarding to help people with their chronic issues, wounds and all the stuff that goes with home health. It was even tougher and more rewarding to have the privilege of helping the dying and their families. And the psych patients could be difficult. It was so sad, their problems aren’t fixable, all we could do is try to control symptoms and help them and their families cope.

So, as I said, I consider myself a nice, understanding and compassionate person. So what do I mean about being of two minds, and why did I try to prove my niceness?

Well, I am finding that I don’t like some of what I am seeing in the Health Department clinic. This facility is there to help the “underserved”, those without insurance or money. And those on Medicaid. It is beginning to seem like it ought to be called Medifraud.

My experience of the place, which is of course limited to the last 4 weeks, shows that a large percentage of the people coming in are stealing resources from our community. That is a harsh thing to say, and I am sure I am going to get a s**t-storm of backlash, but I can only say what I see. Here are examples:

• The family that arrives for their free appointment in a late-model BMW sedan
• The young and able-bodied man who arrives in a uniform from a large company, wanting a  referral to a volunteer dentist for a bad tooth. He informed us that his wife got him and his whole family on Medicaid (“I don’t know how she managed it!”), and he wants to get as much out of it before his new health insurance from work starts in a few weeks. The tooth has been long neglected and is not an emergency. He would have a copay on his new insurance, you see.
• The young woman who has beautifully manicured and pedicured nails, lots of gold jewelry and designer clothes who wants a prescription for loratadine (a cheap over the counter antihistamine) so that Medicaid will pay for it. She won’t buy it herself.
• The woman who comes in for a follow-up after an emergency room visit last week for bronchitis. ER visit paid by Medicaid, of course. On getting her history, we discover she has asthma, uses her rescue inhaler four times a day, smokes a pack a day, and never “got around to” sending in the paper which the nurses here had helped her fill out to get her prescribed steroid inhaler for free from the pharmaceutical company’s assistance program. The cost of a stamp and the effort of putting the envelope in the mail was too much. The bronchitis was caused by her not controlling the asthma by taking all of her medications, and the smoking (at $5 a pack, $150 a month…).
• I was cursed at for not refilling an antibiotic for bronchitis by another patient coming in for follow-up after an emergency room visit for bronchitis. His lungs were clear, he had a slight residual cough and we were about to write a script for an anti-tussive, when he became angry, beligerant and threatening to me and the rest of the staff. He knew he still had bronchitis and no stupid bitch was going to tell him he was fine and did not need more antibiotics…
• A young person who was prescribed iron for anemia, came in for follow-up, was found to still be anemic, went through a battery of expensive tests, only to find out she never bothered to take the iron. She came in for the follow-up visit because she ran out of birth control pills and wanted her free supply.
• The teen who was brought in by mom for a refill of her acne medicine prescribed by another doctor. The kid had mild-moderate acne, and the script was for benzoyl peroxide pads. The pharmacist had informed me the pads were rarely used anymore and cost well over a hundred dollars! She suggested simple OTC benzoyl peroxide wash instead, it costs a few dollars. Mom refused, “Medicaid pays for the pads”.

The attitude of entitlement and thoughtlessness about money (other people’s money, MY tax money) in a large portion of the people coming in the clinic is appalling to me. The reckless disregard for their own health, ignoring treatment plans and then expecting society to pay for the inevitable consequences is just unbelievable. The country is drowning in government debt and these people, who don’t take resposibility for themselves in any meaningful way that I can see, seem to think that they are owed everything.

I did see a few people who wanted to pay their own way. One patient needed surgery for a treatable cancer and only wanted us to help her find a hospital which would give her payment terms. She had already struck a bargain with the surgeon. I made a call and got her a hospital who would help her with that. She didn’t want “charity”, only the chance to do what was needed and what was right.

So, there you have it. I have changed from a nice caring person into an angry one. I really don’t think my original idea of helping those “poor, underserved people who have no access to healthcare” is my career choice anymore. I would much rather help those who are willing to take responsibility, and realize that everything costs money and someone has to pay. Those who don’t expect someone else to pay their way for them. People with self respect, not self esteem.

Sorry if I sound not-nice, but I am not expecting anything out of anyone that I don’t do myself, and I was not born rich. I started poor and I am still not wealthy by any means. I absolutely know what it means to be poor in money. But I have self respect, and I don’t steal from others.

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Saving your own healthcare

In light of all the political garbage recently purporting to save American healthcare, I propose that we have the power to save ourselves. Being only partially employed while I go to school, I have no employer backed health insurance, and even when I did, the insurance was still expensive and left a lot to be desired. It started me thinking.

Health insurance should be like other types of insurance, it only covers the disasters. Does your car insurance cover oil changes and windshield wiper fluid? Would you want to pay a higher premium to cover those types of expenses? I would think not. Does your homeowner’s insurance pay for cleaning supplies and new lightbulbs? Of course not. So why do we expect health insurance to cover the little dribs and drabs of regular healthcare?

I have bought insurance through one of the major companies with a $1000 copay, and coverage for hospitalization, and emergency room care that involves a procedure like splinting or admission to the hospital. It costs me about $133 dollars a month, though I am sure that is going to go up when the health care “reform” starts to take effect. I did however, have similar coverage before with another company and when they raised the rate to $180 per month, I switched. Granted, I have no major health problems, even at my age of fifty+. However, I do take care of my health, I don’t smoke, try to maintain my weight at a reasonable amount, and don’t use any chemical substances as happiness substitutes (Alcohol included. My consumption of a glass of wine at a holiday dinner constitutes my drinking).

So, people I talk to say, “Oh my goodness, how terrible, you don’t have access to regular healthcare!”.  What CRAP that is! Of course I do. It’s called patient managed healthcare, or PMH. This is how it works.

I wake up one morning and I have a pain in my right side, bad pain. It doesn’t go away for a couple of days. Okay, this needs to be taken care of. I call my family doctor’s office. Note: I did NOT go to the emergency room. Emergency rooms are for emergencies, like gushing arterial bleeding, heart attacks, strokes, knife sticking out of your back. Stuff like that. Not diarrhea, the flu, a pimple on your butt, a cut on your finger, or a headache. Getting back to the story. I call my family doctor’s office, make an appointment for later in the day.

Some people will say, I don’t have a family doctor, or my doctor would never get me in the same day. This is where the PMH comes in. Several years ago, when I first moved here, I asked around for a recommended MD in the area. I went to the one suggested, tried him for a while, didn’t like him, fired him. Next, I asked nurses where I worked for a recommended doctor. (Nurses are the best ones to ask…) A couple of names came up. I called the offices of those doctors and asked to interview the doctor before I signed on with them, one refused, the other agreed. This doctor let me come in that day over his lunch break to talk. Definitely a good sign..we talked for quite a while, negotiated our health care agreement and Bingo, I had a family doctor. The negotiations included the fact that I am a bit stubborn, like to do things a certain way (as few drugs as possible for example, and I like vitamins, etc.) and am not the type to blindly follow directions. He, bless his heart, was good with that and agreed to discuss options with me for every problem, and let me do it my way if it was within his parameters of feasible care, and we would switch to his way if mine didn’t work. I LOVE this doctor. Over the years, I have stopped arguing with him and I trust him now completely. I pay him a reasonable fee for a visit depending on the length of the visit, usually around $50-60. He also has open scheduling so that there is always an opening if I am ill and need to be seen that day. All good.

So, I go to my appointment, he listens to my presenting complaint and history of current illness. A physical exam follows. The differential diagnosis includes the possibility of a kidney stone. The normal route for a kidney stone is a urinalysis, a CBC and a CT scan. The urinalysis is done in the office. The CBC is important since it will tell us if there is an infection somewhere, so that is a must.

The CT scan is expensive, but in the negotiation, we decide the CT can wait, the CBC can’t. The urinalysis did not show blood, which decreased the chance of the kidney stone, but does not rule it out. I went to the lab across the way and got the CBC, it cost me $23.85.  I went home with a strainer and some samples of a med to help the ureters relax to help pass the stone. If the stone didn’t pass, or the pain got worse, then we would have to do the CT scan.

Luckily, the pain passed, and if the stone did, it was very small and I didn’t catch it. The total cost for this illness, including the lab, was around $125. If it had been done the usual way, it would have been thousands in ER costs, CTs, etc. Since I was in charge of it all in partnership with my own physician who knows me, the cost was minimal.

The bottom line: each individual should have a HSA where they put, say, 1-2% of their income from day one, have insurance only for catastrophies, and have a family physician or family nurse practitioner that they have a good working relationship with, and a sense of responsibility for their own health and health care. The price of medical care would drop like a stone. If labs, hospitals and imaging places knew everyone was shopping around and paying CASH, good old capitalism and market influences would do their magic. The other bonus is the large reduction in costs for the physicians, with the massive reduction in paperwork.

Oh, and get the fricken lawyers out of healthcare: TORT REFORM. Please! I know that this isn’t the total answer, but it would be a starting point. Some other people are getting the same idea though, see  http://www.faircaremd.com/about_us    http://www.patmosemergiclinic.com/     

There just has to be a better answer than the monstrosity the government is trying to foist on us. My mother just moved back to Europe, the model of socialized medicine we are supposed to emulate, and told me she could not get her colonoscopy or other screening tests there because “they don’t do those screenings for people over 70 years old. They save that kind of stuff for the younger people, because there isn’t enough money.” My mom is over 70, what happens if she gets sick? I shudder to think.

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