Another Observation From the Bedside on Health Care Reform

       My colleagues and I don’t discuss Health Care Reform at work much, out of respect for one another’s views.  Like most of the public, none of us is well versed in any of the issues under debate.

   I had a patient the other day (isn’t this how most nurses begin a story? “I had a patient….”) who has not met the specialist writing her treatment orders. Her previous specialist contracted with another health care system, and was no longer covered under my patient’s insurance plan. So she randomly picked a new one from a list of specialists who are covered by her plan. She has an office visit scheduled with her new physician a month from now. Her insurance provider told her who her physician couldn’t be, and she accepted this as part of her life as a patient.

     My point is, patients are already told who they can and can’t go to for medical care.

     Yes, I have the choice of choosing my own physician, from my insurance company’s preferred providers list, but I will pay a much larger deductible if I choose a physician not on the list. I don’t think this concept will change under Health Care Reform. Doctors set their fee schedules, then contract with insurance carriers. If the carrier and the doctor can’t agree on a  fee schedule, both look for other partners. If the doctor of my choice and my insurance carrier don’t agree on how much my doctor will be paid for services and procedures, I have to find another doctor. This has been going on for years, so I’m surprised when I hear people yelling at town hall meetings that they don’t want to be told who they can go to for their medical care. It makes me wonder if the people who are yelling this have ever been patients.

     Again, I don’t claim to be an expert on Health Care Reform. This is simply a personal observation from the bedside.

Mother Mary and Me

Mother Mary Comes to Me photo J.Paradisi 2009

Mother Mary Comes to Me photo J.Paradisi 2009

     Yesterday I walked out the door of the clinic where parked alongside the curb was this turqouise Galaxie with its backseat passenger. I recognized her immediately and snapped a picture. I love Significant Coincidence and I am passing it along to you.

Let it Be
When I find myself in times of trouble
Mother Mary comes to me
Speaking words of wisdom, let it be
And in my hour of darkness
She is standing right in front of me
Speaking words of wisdom, let it be.
Let it be, let it be.
Whisper words of wisdom, let it be.
And when the broken hearted people
Living in the world agree,
There will be an answer, let it be.
For though they may be parted there is
Still a chance that they will see
There will be an answer, let it be.
Let it be, let it be, Yeah
There will be an answer, let it be.
And when the night is cloudy,
There is still a light that shines on me,
Shine on until tomorrow, let it be.
I wake up to the sound of music
Mother Mary comes to me
Speaking words of wisdom, let it be.
Let it be, let it be.
There will be an answer, let it be.
Whisper words of wisdom, let it be.


Follow Up : A Personal Response to Moral Distress in Health Care


detail from Goldsmith Artists collaborative project 2008

detail from Goldsmith Artists collaborative project 2008


In  my post

A Personal Response to Moral Distress in Health Care (Feb. 7, 2009), I describe events leading to an uninsured, homeless man’s admission to an emergency department.

From there he was admitted into the hospital.

I was off for a couple of days after that event. When I came back to work, I was told that the man called our clinic from his hospital bed “just to check in” and to thank us, “his nurses.”

He will discharge soon, and I will see him again in the clinic. There are no indications that his lifestyle has changed. No miracle has occurred.

But I can’t keep from smiling about his phone call to us and my awareness that a simple human connection was made that day. It makes me feel hopeful. It helps me continue advocating for the voiceless.

I am reminded of an adage I heard some where:

If you want to change the way you feel about someone, change the way you treat them.


I Wish I’d Said It

Ring the bells that still can ring

Forget that perfect offering

There is a crack in everything

That’s how the light gets in.

                                                    Leonard Cohen,  Anthem

A Personal Response to Moral Distress in Health Care

oil on wood 2008 J.Paradisi

oil on wood 2008 J.Paradisi

This morning I visited Pauline Chen MD’s Well blog at the NY Times on-line to read comments posted to her Moral Distress article. There were many, mostly from MDs, a few by nurses, and one from a patient, who’s life was saved when an ICU nurse challenged the doctors treating him.  The strong emotions reveal the virulence of the topic.

The article resonated for me. I read it after returning home from a particularly busy shift. In the clinic, I saw a patient and knew something had changed since our last encounter. The tension of his muscles indicated pain, but he didn’t ask for medication for it. He knew better. Let’s just say that his track record of lifestyle choices make him a less than stellar patient. The package of cigarettes in his shirt pocket is his least dangerous vice and negates the purpose of the medication his doctor prescribes for his asthma. Still, something was clearly wrong with the man, and my job is to be his advocate, not his judge.

So, I looked closer, to see if I could spot the problem causing the change. I found it: his calves were swollen to twice their normal size above his ankles; his soiled socks acted as  compression wraps, so his ankles were deceptively normal. Taking a stethoscope to his chest, I heard the anticipated expiratory wheezes, but otherwise muffled breath sounds. CHF, congestive heart failure. We were treating him for another condition, unrelated to his heart, but CHF added itself to his problem list anyway. He needed treatment.

I paged the doctor who ordered his care. The doctor called me back from the  ICU, where he was treating a seriously ill patient, hopefully a compliant one. He patiently explained to me he was no longer treating my patient. He had only been brought in as a consult to begin with, and my patient was not following instructions, and missed appointments. He had sick patients who were trying to get well needing his care. He doesn’t have the time or resources to continue treating a patient who thwarts all efforts to improve his condition. I heard what he was saying, and I understood.

Choices have to be made. Still, I was the one looking at a human being and watching him struggle to breathe.  I called another health care provider familiar with this patient, and he was sympathetic, but my patient wasn’t under his care either. I would guess this provider has fifty to one hundred patients just like this one whom he is committed to caring for; I cannot accuse him of a lack of compassion.

The patient in front of me was now wheezing audibly. Never particularly conversant,  now he  only responded to my questions in monosyllables.

I had to make a decision. I seated him in a wheel chair, and walked him to the emergency department. It was a particularly busy day there, but the triage RN was very kind, and efficient. We both knew this noncompliant, substance abusing, uninsured, suffering, frightened patient was very ill and would be admitted to an expensive, and hard to come by hospital bed. But what was our choice? In the face of economic crisis, outpatient resources are cut by the minute, leaving emergency departments and inpatient care the only avenues available for the uninsured.

And lately,the faces of the uninsured are morphing in front of me. They aren’t always dressed in dirty socks and flannel shirts. Now I see unfunded patients with expensive college degrees who used to have jobs, and they are parents of a child or two, as lay- offs create a new kind of uninsured patient.  Will I be asked to choose which kind of unfunded patient gets care, as hospital funding dries up, and administrators have to decide where to make more cuts in order to keep the hospital solvent?  This is the moral monster underneath the bed I fear, and even with the lights turned on,  it’s not my imagination.