Managing the Flamingo


photo by Chris Duppenthaler
Lewis Carroll Illustration
Lewis Carroll Illustration

The chief difficulty Alice found at first was in managing her flamingo: she succeeded in getting its body tucked away, comfortably enough, under her arm, with its legs hanging down, but generally, just as she had got its neck nicely straightened out, and was going to give the hedgehog a blow with its head, it would twist itself round and look up in her face, with such a puzzled expression that she could not help bursting out laughing: and when she had got its head down, and was going to begin again, it was very provoking to find that the hedgehog had unrolled itself, and was in the act of crawling away…. Alice soon came to the conclusion that it was a very difficult game indeed. ~Lewis Carroll from Alice in Wonderland

Navigating the U.S. health care system these days reminds me of Alice’s dreamscape game of Wonderland croquet.  A physician is given a flamingo mallet and a hedgehog ball and ordered — by the Queen at the risk of having one’s head lopped off — to go play, but the mallet won’t cooperate and the ball keeps unrolling itself and crawling away.  Just like any day in a medical clinic, a doctor’s time is spent trying to manage their flamingo and the patient gets tired of waiting,  so gets up and leaves.  At least Alice gets a good giggle out of it, but the reality in health care causes more tears than laughter.   We are playing a very difficult game of changing rules and equipment.

The flamingo in the doctor’s hands could represent the increasingly time-consuming requirement now to search over 68,000 ICD-10 diagnosis codes rather than the previous 14,000 ICD-9 codes.  Or the requirement to search for a 10 digit NDC number for any prescription medicine sent electronically to a pharmacy.  Or the “meaningful use” criteria that regulate mandatory data collection and reportage on patients to the Federal Government in order to receive full payment for Medicare or Medicaid billings.  Or the newly updated HIPAA and HITECH electronic security requirements to ensure privacy.  Or the obligations to the new Accountable Care Organization that your employer has joined.  Or the Maintenance of Certification hoops to jump through in order to continue to practice medicine.   The exasperated and uncooperative “managed” flamingo keeps curling itself around and looking at us with a puzzled expression:  just what is it you were supposed to be trained to do?    is there actually a patient to pay attention to in all this morass of mandates?

And the poor hapless hedgehog patient is just rolled up in a ball waiting for the blow that never comes, for something, anything that might look like health care is about to happen.  Instead there are unread Notices of Patient Privacy to sign, as well as releases to share medical information to sign, agreements to pay today’s co-pay and tomorrow’s deductible and whatever is left unpaid by Affordable Care Act insurance, passwords to choose for patient portals, insurance portals, lab portals and  It might be easier and less painful to just crawl away and hide from that bumbling physician who can’t seem to get her act together.

I wish I were laughing, but I’m not.  As both physician and patient, it’s getting harder and harder to play the game that is no game at all.  The threat of losing credentialing in an insurance plan, or getting poor ratings on anonymous online physician grading sites, or being inexplicably dropped from a provider list, or too unproductive to remain in an employer medical group, or losing/forgoing board certification is like a professional beheading.  We keep trying to juggle the flamingo motivated by those threats, all the while ineptly managing the managed care system, and hoping the patient won’t walk away out of sheer frustration.

It’s hard to remember why I’m in the game at all. I think, at least I hope,  I wanted to take care of people, heal their illnesses and help them cope with life if they can’t be healed.  I wanted to provide compassionate care.

It is enough to make a doctor cry.  At least we can meet our patients at the Kleenex box and compare notes, and maybe, just maybe, we’ll find enough common ground to even share a laugh or two.



photo by Chris Duppenthaler
photo by Chris Duppenthaler

6 thoughts on “Managing the Flamingo

  1. Thank you for sharing this perspective which usually never gets to the patients or the media! I hope this whole healthcare experiment doesn’t completely fall apart….who knows where Alice will go to find a cure for her common cold (code)… bless you, Doctor Emily!


  2. Thank you, Emily:
    for being the nurturing, compassionate healer that you are and for having the courage to stand up and be counted among those voices crying out in warning about the status of the failing, fractured medical/health delivery system in our country. You truly are a beautiful woman in every sense of the word.
    Alice LaChapelle, Albany NY

    Liked by 1 person

  3. Frightening reality setting in all around us. There were those who cried warning a few decades ago when the Feds first started getting their fingers into the pie, I think in the early, mid-60’s ?
    We don’t get to be a turtle and crawl into our shell to ignore life either.
    Thanks for revealing more of reality.


  4. I had never looked at it from the doctors’ real point of view — only my perceived one. Wow… I had no idea. I’ve often heard nurses say that they miss nursing (it’s mostly paperwork/computer), and we aides get assigned more nursing so that nurses can hold up the bureaucratic end — and that was even before the ACA malarkey. I myself am blessed enough to be able to forego doctors of every kind, and I feel really unnerved about when that will have to change. Thank you for expanding upon it all. Who knew?


  5. Emily,
    Jessica H referred me to your blog. Keep your chin up! Physicians like you keep the “heart” in medicine which is so sorely needed as so many forces ‘asail’ against the patient-physician relationship. Our challenge is to navigate these hazardous times well. You are navigating with ‘eyes wide open’. Thanks for sharing!


    Tripp Bradd, MD
    Skyline Family Practice
    Front Royal, VA


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