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 over the last decade or so 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. The patient, tired of waiting for weeks for an appointment, then stuck in an urgent care center or emergency waiting room– 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 technology.
The flamingo in the doctor’s hands could represent the increasingly time-consuming requirement to search over 70,000 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 updated HIPAA and HITECH electronic security requirements to ensure privacy and the requirement for patient access to their chart.
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 awaiting a contact that never comes – for something, anything that might look like health care is about to happen.
Instead, for the patient, there are many electronic forms to sign:
Notice of Patient Privacy,
Notice of Patient Rights and Responsibilities,
releases to share medical information,
agreements to pay today’s co-pay and tomorrow’s deductible and whatever is left unpaid by insurance,
agreement to have an AI app record and then transcribe the healthcare interaction,
passwords to choose for each electronic patient portal: the chart, insurance, health savings account, lab and X-ray results and healthcare.gov.
It might be easier and less painful to just crawl away and hide from that bumbling health care provider who can’t seem to get their act together.
I wish I were laughing, but I’m not. As a once-practicing physician and now a patient, it’s getting harder and harder to play the game that is no game at all.
There is always a threat to the physician of a professional beheading:
losing credentialing in an insurance plan,
getting poor ratings on anonymous online physician grading sites, being inexplicably dropped from a provider list,
keeping up with 50 hours of approved continuing education annually,
being too unproductive to remain in an employer medical group,
losing/forgoing board certification.
We keep trying to juggle the flamingo motivated by those threats,
all the while ineptly managing the managed care system,
knowing the patient might get up and walk away out of sheer frustration.
Thankfully, I didn’t ever see patients in a fee-for-service clinic setting,
so I have sympathy for those who have no other option.
I think, at least I hope, I focused on taking care of people, trying to heal their illnesses and help them cope with life if they can’t be healed.
I wanted to provide compassionate care without all the fol-de-rol.
These are absurd times for humans and hedgehogs.
It is enough to make a doctor cry. At least we meet our patients over the Kleenex box and compare notes, and maybe, just maybe, we’ll find enough common ground to even share a giggle or two.
