31: Pay Now or Pay Later

Eight states require insurance plans to cover in-vitro fertilization (IVF). Costly decision? Well, maybe not. Couples who pay per cycle (about $10,000) demand implantation of multiple embryos with each cycle, in order to lower total costs. While this may lesson the number of cycles necessary for a successful pregnancy, it also means more twins, triplets, etc., And that means millions more spent in neonatal intensive care units. The average cost of triplets is $300,000. These eight states have significantly fewer IVF multiple births.

30. Have You Thought About...

...going to Haiti? Yes, but my assumption has been that the need is for providers who have experience dealing with acute trauma, and that there have been more volunteers than the infrastructure can handle. To wit, the following comes from an email sent by a rehabilitation psychologist:

"Hi everyone. Just back from Haiti and I wanted to put forth a few thoughts to those of you who would like to volunteer… It is absolutely key and essential that ONLY people who have had large-scale and severe disaster experience go over at this point. Many of you know that I have been to Sichuan--have had many experiences with large hurricanes, Katrina, etc., but I cannot tell you how horrendous and very different this situation is right now… We were doing surgeries almost 24 hours a day....mostly amputations. Unfortunately many of the people who have had amputations have already become infected within a day or two of the surgery (remember essentially no aftercare)... The docs I flew back with came to the consensus that if 30% of the people they operated on survive, they will be lucky... Even the tsunami was in a country where you could find some infrastructure...somewhere. Here--there is nothing. For the first time in my life I truly had to consider [my own] survival …"

Other sources estimate tens of thousands of amputees, which will burden Haiti's health care for decades.

29. Foreign Bodies

T., a 29-yr old exotic dancer, doesn't want to have any more kids. She has three and thinks that's enough.

She tried an IUD, a T-shaped piece of plastic about an inch long that is placed inside the uterus. But then had it removed after several months because "it bugged me having something foreign like that inside of me." I restrain from making the observation that her breast implants aren't exactly natural.


So we decided on a tubal ligation, a day surgery.

"How long," she asks, "do I have to stay off of pot before the surgery?"
"Don't really know," I say, "how does 48 hours sound?."
"Good, that's what my boss says too"

Smart lady, getting lots of opinions before making a decision

28: Pulmonary Embolism

After several years of menopausal quiescence, Mrs. J's 60 yr old uterus erupted a few days before Christmas. What was the stimulant--stress hormones? More likely estrogen produced by adipose cells, of which Mrs. J has in excess. Whatever the source, too much stimulus can cause cancer, necessitating a biopsy, obtained last week.

Tonight I called her to explain the results: hyperplasia with atypia, just one stop short of cancer. I needed to tell her about my referral to a local gyn oncologist who will certainly recommend major surgery. Her husband answered, and I asked for Mrs. J. He paused and then slowly and quietly explained that she had gone to the ER last night, short of breath. And then died there. In the ER.

27. Zero-Sum Game

Ironic that tonight, while a sizable segment of America is salivating at the thought of defeat of health care reform, I'm on call for the ER. Two patients without insurance. One will have a shorter life because of delayed diagnosis of cancer. She couldn't afford a doctor despite telltale symptoms for several months. The other bleeds half of every month, receiving periodic transfusions in the ER, just enough to get her on her feet and out the door. Why does America think that health care is a zero-sum game: every benefit given to one means less benefit for another?

26: Ah, Now I Understand

Yes, I was annoyed when Dr. A called me on Sunday, asking me to come in to see a patient Monday morning (with the unspoken understanding that I would assume care for her). T. delivered six weeks ago (by Dr M), with a rare complication that required two subsequent minor procedures, one by Dr. M, the other by Dr L. She was later re-admitted by Dr J, and followed by Drs W., M, and A in the hospital. So why call me? Well, it seems that the patient made that request, having met me during antepartum visits. Well, of course--my unimpeachable bedside manner. But doesn't Dr A (or any of the others) have the communication skills to establish a relationship with patients in whatever setting? To make plans and carry them out? Whatever.

So we go to surgery, this time more of a final approach, gratefully not as difficult as predicted, and her uterus remains intact. Meeting her mother in the waiting room afterwards, I noticed a book peeking out of her handbag. Glenn Beck. Dr. A is black. It's not my bedside manner, it's the color of my skin.

25: the Token

Received an email last week advising me that I would shortly be receiving "The Token," and that I should carefully read the attached instructions.

Wow, am I being inducted into a secret society? Will it help me find the Holy Grail, or open the back door to Hogwarts?



No, it's just a security upgrade. My "remote access" allows me to review all of my organizations medical records, for its 500,000 current members plus several hundred thousand former members. So yeh, I understand the need for security. So when I log on, I'll need not only my personal password (which I have to change every 60 days or so) but also the token's 6-digit number, which I assume changes much more frequently.