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

When the Wind Blows Hard

photo by Starla Smit
photo by Starla Smit

Let us not be surprised when we have to face difficulties.
When the wind blows hard on a tree,
the roots stretch and grow the stronger,
Let it be so with us.
Let us not be weaklings,
yielding to every wind that blows,
but strong in spirit to resist.
~Amy Carmichael

And so the government and its people are at an impasse–the winds of change are pummeling us all and everyone has entrenched more deeply in order to stay upright.

As a U.S. health care provider who has worked for over 30 years as a salaried physician, in non-fee-for-service health care settings providing patient care that meets the need when need arises without profit motive, I am flummoxed by this impasse.  Policy makers could not come up with a more simplistic solution than what is contained in 2000+ pages of complex regulations that are already creating bureaucratic havoc in all health care settings, distracting health care providers with electronic and telephone paperwork that pulls us away from the bedside. The patient and the provider no longer partner together without a dozen other entities dictating the choreography of their dance.

A potential solution to the problem of affordable access to all who need it already exists in the form of the Public Health Service Commissioned Corps with incentive scholarships for medical and nursing training in exchange for work in under-served areas.   An expansion of such a system, requiring funding at a much lower cost than the billions of dollars required by the current health care reform act,  would address the challenges of the uninsured and the uninsurable.

As a medical student in training, I  spent many months providing patient care in Seattle’s exemplary Public Health Hospital and its associated clinics.  Patients traveled hundreds of miles to see the specialists who worked there; the best and the brightest clinicians saw the poorest of the poor inside those walls, but there were a number of physicians and their families I knew who received their care there as well because they knew the people who worked there were devoted to the patient, not to profit.

When the Executive, Judicial and Legislative branches of government refuse themselves to participate in a health care system they have constructed for the people, then it is not created of the people, by the people, for the people for they are people who get sick and injured just like the rest of us.  What is best for them must be best for us all.

All citizens, and non-citizens inside our borders for whatever reason, should have easy access to affordable health care.   All health care providers should have opportunity to work off the costs of their training to keep the debt load from crushing them for decades to come.

I am grieved that health care has come to this impasse, with government now in a take-no-prisoners mode that clear-cuts us all down to the bare roots.
We need to lean in together for support and quit the fighting that only creates more injury.

We need look no farther than our own commissioned corps of health care officers.  It is an idea whose time has come.