Virestorm Chapter 8

Chapter 8

Ann Arbor

Alex awoke with a start. She could hear a knocking on her door. At first she was disoriented. She started to raise up and realized she was unable to. As the fog in her mind began to clear she could hear Stephanie in the background calling to her over the music playing. She reached up and remembered she was still in the tanning  booth. “Oh shit” she thought to herself, how long had she been there? She raised the clamshell top and pulled out the earbuds.

“Stephanie I’m fine, I fell asleep. Sorry”

“That’s ok Alex, it happens all the time.” Stephanie rolled her eyes and backed away from her door and returned to her desk.

Alex grabbed her watch. Uh oh, it was already nine o’clock. How could she have slept for an hour on that bed? She could feel the sticky sweat in the small of her back. She grabbed a towel, wiped the bed down and a with a fresh towel wiped her back arms and legs. She must look like a disaster. She pulled on her panties and bra and went over to the mirror. She brushed her hair, applied make up and then put the rest of her clothes on. Paula was going to kill her. If she decided to stand up and do her routine she would have been first up like all of the newbie first time performers. Alex headed out the door and into the main room. Stephanie looked up at her.

“Alex, you owe for an hour and you only paid for 30 minutes.”

Alex rolled her eyes, reached into her purse and pulled out the punch card. “Fine, just punch it I’ve gotta go!”

“Fine, not like it’s my fault you passed out in there you know. Maybe you should be getting your sleep at home.”

Alex was perturbed by this latest comment, partly because it was rude but partly because she really wasn’t sleeping well at night and Stephanie’s comment hit a chord. Alex headed down the narrow wooden staircase and bounded out onto South University Street. She speed walked down the side walk toward State Street. She passed the undergraduate library, better known as the “Ugly” from the old days before they replaced the 1950’s boring brick structure with the new modern glass and brick structure. She saw the undergraduates heading in and out with their back packs full starting their Spring term studies. She made it to Main Street and headed up the steps to the Union building.

The Union building is a red brick structure with peaking roofs and a traditional old school East Coast appearance. Built in the early 1900’s for men only the building is now used for all sorts of University student functions and is very popular for its lounge with frequent band performances and on nights like tonight amateur comedy hour.

Alex entered the heavy wooden doors and went up the hallway to the lounge. She could hear the tail end of laughter followed by applause. She headed through the crowd and could see a table just in front of the stage where Paula’s boyfriend Malcolm was sitting and next to him two empty chairs. She walked up and looked up at the stage. Paula was bowing to the audience and waved and said thank you. She caught Alex’s eye and raised her eyebrows quizically. Alex sat down next to Malcolm. He looked over at her. His ice blue eyes cut straight through her.

“I can’t believe you Alex, you’re her best friend and you missed her entire act.”

“I know Malcolm, look I feel like a total shit ok? I didn’t plan on missing her debut. Today was crazy, I raced over here and I know I blew it, but I didn’t mean to. I wanted to see her too you know.”

“Well, she did great, and you better make her feel like you were here even if you weren’t. She’s been behind you through all of your issues and you owe her more than this. Oh, here she is.” Paula ambled up, she was smiling although her lips were a little tight. When she leaned over to give Malcolm a kiss Alex could see that she was shaking.

“I hope I didn’t make a complete ass of myself.”

“No babe, you were great. We were all laughing. You totally had us. Great job. Didn’t you think she did great Alex?” He gave her a kick under the table.

“Oh yeah, great job. I missed some of it but you totally had everyone eating out of the palm of your hand.”

“Really?” Paula was starting to relax, her tremor in her voice began to settle down. “I wasn’t sure if the joke about Bush nuking the “liberal country of Hawaii” carried well. You know how everyone’s so sensitive.”

Alex didn’t know what to say but Malcolm stepped in and saved her, “You nailed it right on. Maybe the junior national guard didn’t quite get it but everyone else was totally with you. You did great. Do you want to stick around for the other acts or go out for a beer?”

“I could really use something a bit stronger. Let’s head to the Full Moon and get some chili fries and drinks. I’m starving, I never ate, I was way too anxious.” She reached over and gave Alex a hug. “I’m so glad you caught part of the act. I was so pissed I thought you missed the whole thing but you must have been out of my sight. Those bright lights distort, like, everything. Come on guys, let’s get out of here.”

They headed out of the club and turned onto State Street and again on South University.  Students were heading out of their dormitories, apartments and houses and heading in loosely amalgamated groups toward the various bars in town. A few were heading out with stuffed backpacks to pull all night study sessions at one of the several libraries but since the term had just started most students remained in party mode. As they navigated the streets Alex struggled to keep up with Paula and Malcolm. She could over hear the two of them dissecting the monologue to refine and improve it. Even though Alex could practically recite the routine herself she didn’t feel she was invited to contribute.

Eventually the streets became quieter and they reached Main Street. This area was more of a graduate level group of students who tended to be more serious. Evening festivities tended to be less noisy and more intellectual. Branching off Main Street were a number of establishments catering to this crowd for several decades. Most of the bars and restaurants maintained their early twentieth century architectural style with tin ceiling tiles, old wooden floors, and brass railings.

They turned into the Full Moon restaurant. At the entrance outside was an iron gate enclosure and behind it were several tables. Sitting at one of the tables was a thin guy with thin light blonde hair. He was surrounded by a couple of other guys and girls who looked to be graduate students and at least ten years younger. They were watching the thin blonde guy closely and he was gesturing with his left hand which was holding a partially burned cigarette, the right was holding a pint of a dark beer. He looked over to Alex, Paula and Malcolm as they entered.

“Hi Alex, how are ya doing tonight?” He opened his arms and Alex leaned in to give him a kiss on the cheek. One of the woman who was sitting across the table looked Alex up and down and not with a look of approval.

“I’m doing pretty good Vince. They totally bombed me in the lab today. Nine specimens to process from Pakistan, well really only eight arrived. Tomorrow will be marathon part two so I hope you don’t have too many plans for tomorrow.”

“No problem, we’ve been light lately. Hey, you want me to get you a beer?” Now the girl sitting with Vince was really glaring.

“No, it’s okay, I’m going to help Paula and Malcolm celebrate her debut at the Union, but I’ll catch you up tomorrow.” She headed in after Malcolm and Paula who had already navigated past the narrow bar area to an available table. As they walked through more than one of the men at the bar turned to look at Alex. Her near hip length blonde hair was always a potent visual stimulus and was a source of both good and bad fortune depending upon your perspective. Paula caught several of the visual shakedowns in mid view and projected one of her “concerned friend” looks to Alex who was happily sashaying in the midst of the attention.

“Oh, don’t worry, I haven’t anytime for games tonight. With the work load I have tomorrow I only have just enough time for a basket of chili cheese fries and a beer. I still don’t get why you guys just blow past Vince every time we see him.”

Paula rolled her large brown eyes to the ceiling, shrugged, and shook her head a little. She probably understood Alex’s need for masculine attention better than Alex did and she wasn’t convinced that Vince was a “good friend” like Alex was always saying. Paula didn’t really think it took a Ph.D. in psychology to recognize that Alex was eventually going to have to discover a better method of dealing with her father’s absence in her life. Because of this she gave Alex a lot of free space and support. She knew deep down Alex would eventually confront these demons, a few weeks ago after a night of copious alcohol consumption Alex began to discuss her dad. But, the discussion was just the tip of a very deep iceberg.

“Look Alex, he plays this Mayor thing every night. He closes the place down, surrounded by his disciples and the rest of his “city council”. You’d think he’d grow up by now. These girls he dates are like at least fifteen years younger than him. Anyway, I’m not so sure his intentions are true with you.”

“Oh Paula come on, we work together sometimes but besides that he’s totally harmless.  It’s not like I’m going to sleep with him or something.” Just as Alex said this Malcolm walked up.

“Hey ladies I got a pitcher of the draft  weissbeer.” After Malcolm poured three tall glasses he raised his to Paula, “To your triumph at the Union, may we all laugh until our buttons pop and our trousers rip,” with that they all crashed their glasses together in unison.

Moments later Malcolm and Paula were dream talking about her great future career of physician by day and comedienne by night. Alex’s mind slowly wandered to the day’s work and the inconsistencies in the lab specimens. Paula reached over and punched Alex in the shoulder busting her out of her thoughts.

“Oww, what was that for?”

“Well, for like ten minute Alex we’ve been asking you what’s going on in your head and you haven’t responded. Malcolm was ready to call the paramedics.”

“Ha ha. Today was just very strange. There was another flu outbreak, this time in Pakistan. Looks like nine people died but they only sent eight specimens. Anyways, tomorrow I have to process everything. Looks like the weekend might even be burned. We’ll just have to wait and see.”

“Bummer, I was hoping we could take a canoe out on the Huron River together. This will be one of my last weekends for a while since clinical rotations have us doing Saturday Grand Rounds and Sundays we have to work. Let me know if you end up getting any free time.”

Just then the food arrived. Alex hadn’t even thought about eating today, with the frantic work pace she just realized the last thing she ate was that cinnamon raisin French toast at breakfast. She voraciously dug into the fries and half of Paula’s blue cheese bacon burger.

“Wow Alex, I’m glad you didn’t mistake any of my digits for a fry or I would be ruling out surgery as a specialty. I think your enthusiasm for the meal scared away half the single guys at the bar who’ve been eyeing you all night. Of course the other half are wondering if you could do that to a burger, hmmm.”

Alex made a limp chuckle. Her eating habits were a common topic of humor to Paula and admittedly there had been some pretty funny times but she didn’t always like being the butt end of some of Paula’s humor. Anyways, right now it didn’t really matter, she was tired and she knew she better head home and catch up on her sleep, tomorrow was going to be a very long day. Alex broadened her lips into a smile leaned over and gave Paula a hug and a peck on the cheek for Malcolm.

“With that, I must go. Those of us who work for a living get few chances for rest. Ciao guys.” Alex quickly headed for the door, no sashay this time, only one brief eye contact with an attractive twenty-something long light haired guy in a tie-dyed shirt, and out into the Spring night.

Bin laden and me, the doctor

I woke up and turned on NPR and discovered the world's most wanted criminal was dead. I listened as they talked about celebrations at Ground Zero and in Washington, D.C.. I didn't have the drive to celebrate, but rather to reflect. For me that fateful day led to the end of my first marriage. I know, that sounds impossible, but I am quite certain it was true.

My wife at the time and I watched those towers fall and the ensuing chaos. We didn't say much. I'm pretty sure that like the rest of the world we were in shock. I felt true fear that some great force was trying to create an overthrow of our government. The whole thing was practically right out of a Tom Clancy novel. I guess it's strange but when the terror stopped that day and we later on found out it was perpetrated by this man and his acolytes from training camps in Afghanistan I felt relieved.

I know that the real terror that was committed wasn't the death of all of those people. The real terror is how each of us dealt with the tragedy. For me I immersed more intensely in work. For my wife, she reevaluated her life and decided I wasn't going to be a part of it. For the past 11 years I have dealt with that terror, the disruption and destruction of my original family unit.

That day in 2001 and the ones that followed were interesting in the office. Either nothing was said about the disaster  or people needed someone to talk to . Most were quiet. A few needed me to sit and listen. They asked me questions that were mostly about the future. Future of healthcare, government, our lives. I would reassure them that our country was strong, our people were good, and somehow we as a nation and world would end up stronger and better from this.

Fast forward to the last couple of days. I could sense a change in the office and in people's attitudes but I couldn't exactly identify it. Two of my older patients wanted to talk. Interestingly, they both had similar viewpoints. They didn't feel celebratory. They even thought that we were kind of gloating as a nation about the death of this terrorist. And neither of them felt it would make a significant change in the grand scheme of things.

Once again, I listened, I talked about how disturbing it was that Pakistan was probably not the ideal partner. But, mostly I talked about how this showed that we as a nation were growing and maturing in some ways and in others we were still like children. All this time, in the back of my mind was the havoc that was wreaked on my life from that fateful day.

But, also in my mind was the wonderful change my life had taken. For now I have the most beautiful and wonderful wife who loves me and cares for me. We have an absolutely phenomenal child who is bright, beautiful and a joy to be with. And, my relationship with my eldest daughter is now stronger than I can remember.

So, in retrospect, I cannot celebrate the death of this monster for I have very mixed feelings from what he did to me and my country and my world. But, I do know that I and we are stronger and better than we were.

Slaying the beast

In my last article I introduced you to "the hidden beast" in health care which is the fact that we lack enough physicians in our country to handle our growing and aging population. I may be a bit pretentious in claiming that I have ideas on how to slay the beast but I do have some very specific ideas. These ideas will require patients, physicians and the various insurance companies to undergo a dramatic shift in how we interact.

First, we must accept that there is no way we can create enough healthcare providers to meet our upcoming demands. How do I know this? Training a physician takes approximately twelve years after high school on average. If we start today, and we should, encouraging kids in junior high and high school to begin thinking about medicine and mentoring them through the education process and simultaneously expanding medical school enrollment to allow for this influx, under the best of circumstances we will begin to bring these young doctors to you in 2025. Now, these kids are pretty bright and I think they probably read the same articles I do that Medicare will go bankrupt somewhere around 2018. I wonder how many of them are interested in being professional physician volunteers. By the way, they will probably owe somewhere in the neighborhood of $500,000 for this privilege.

Ok, so that idea may not work. Well, we could just make the existing doctors work harder. We can continue dropping reimbursements so they will be incentivized to work harder and see more patients. Oh, wait, that's what Medicare has been doing for the last 10 years and it hasn't worked. On top of this, I hear patients everyday complaining their doctor has no time for them and how can an office visit last only five to ten minutes. I guess people might be even more disappointed if the visit lasted one to three.

Perhaps we need to think a little "outside the box". I suggest we try to make our doctors more efficient and incentivize this efficiency. For example, attorneys, accountants, and countless other professionals are compensated for services that are not face to face. Did you know that insurance companies have created reimbursement codes for a doctors phone calls or emails to a patient? But, here's the zinger, they pay zero dollars for this service. Every physician deals with this issue differently. The majority will not provide any significant treatment or planning over the phone or by email but rather require face to face contact. Many will notify patients of lab results and x-rays by phone, or at least have their office staff do it. Some will require a return appointment to discuss results. I suspect it really depends on how busy they are.

Furthermore, the forward thinking members of our congress created the Health Information Portability and Accounting Act of 1996, better known as HIPAA. Part of this legislation prevents your doctor from emailing you if either email company does not use encrypted secure servers. If your medical information makes it into the wrong hands the fines for your doctor can be tens of thousands of dollars. I suspect this may represent a bit of a disincentive to your doctor as well.

I suggest that compensation for non face to face care be established and that the government "encourage" email companies such as Google and Hotmail to have special servers that are for the delicate transfer of this information. Just by enabling me to email a patient that his x-ray was fine would be a huge improvement in efficiency.

Now let's get a little bit controversial. Many of you are thinking what about a greater use of physician's assistants (PA's) and nurse practitioners (NPs)? I think that this is a great idea, but, we have to recognize the skill levels that each of us has. PA's and NPs typically have two years of training beyond their undergraduate degree. They are very well suited to managing routine health issues including annual check ups, uncomplicated diabetes and hypertension care, treatment of routine respiratory infections, etc.. Unfortunately, many doctors use these vital assistants as substitute physicians and place responsibilities on them that are inconsistent with their experience and training. On the other hand, I think that it is a terrible waste of resources to use highly trained physician's to do these activities.

In fact, I find it ironic that over the last twenty years there has been a huge push for physicians to become primary care providers. We are taking our best and brightest and encouraging them to focus on the least complex care. In fact, if your doctor sees you for five minutes to tell you that you have a viral upper respiratory infection he is paid practically the same amount  as if you come in coughing, and wheezing with pneumonia. Yet the two situations result in a very different amount of complexity and time required.

I would suggest we establish clear expectations on patients with appropriate incentives in the way of copays and deductibles that pushes them toward PA's and NPs for routine care and incentivizes the doctor to pick up the most complex patients they can. In fact, I suggest that we push more of our doctors to specialize. There is far too much information for someone to handle in a general way. When I was in medical school there were about five commonly used blood pressure medications. Now there are twenty categories each having dozens of medications. In fact, many doctors trained in primary care fields have left their practices to become hospitalists. Hospitalists get to focus on hospitalized patients, i.e. those that are the most ill, because the care is rewarding, the hours are structured, and once cured the patients return to their original practitioner. This model could be expanded with a far better structure for reimbursements.

In the ideal world easy routine care could be provided by a PA or NP. Those who don't respond would see a physician and in some situations one who has specialized in the area of concern and get placed on appropriate care. Once cured or on a treatment plan the patient would then return to their original caregiver, freeing up the physician/specialist to move on to the next complicated case. In addition, the PA or NP would have lower level assistants reporting to them who routinely communicate with patients to make sure that they are taking their medications as well as setting up even lower level visits for just checks on those issues that need chronic monitoring.

The entire health care system would be changed from it's current design which is flat and wide to a pyramid with the doctor at the top and all of the other caregivers below. By doing this we could successfully do more with less. And, I suspect, we may even save a few dollars. I know that what I suggest is radically different from what we are used to. In fact, some people may feel offended at my assessment. But, that is why I have established this blog. I encourage anyone to help come up with better ideas. And perhaps if we are very lucky we can help change this situation.

Best of luck to us all in slaying the beast!

Return on Wednesday and I will post the first chapter of "Virestorm". I am hoping to provide an interactive entertaining way to share a story that I have been working on in pieces for the past year. I will use your input to help steer the characters and action to a hopefully exciting finale.

The hidden beast

Watching and listening to the news lately one would think that all of the troubles in healthcare can be solved either by having everyone purchase insurance coverage or finding a funding source and giving it to them. I find it remarkable that the most "brilliant" economists keep on missing one of the most important factors in health care delivery. Who is going to provide the care to all of the newly expanded health care rolls? They somehow have the mistaken belief that if one has a health insurance card all will be well.

Unfortunately, they have forgotten one very important factor. While our population ages and shifts into a larger and larger number of people who require ever greater care we have not had any significant growth in physicians in decades. There was a bump in medical school enrollment in the 80's but that group, which I am part of, is established and unlikely to significantly increase it's workload.

For the past 20 years the best and brightest have chosen fields like investment banking and computer engineering. These fields have had dramatically greater compensation growth. In fact in the past 10 years physician compensation has had virtually zero increase so relative to inflation the income has gone backwards. This insight has not been lost on the young men and women in college. So, while our population grows our number of graduating medical professionals are hardly keeping up.

I predict that in the next 3 to 5 years this issue will hit a break point. Those with an existing physician will start off doing fine but if you don't have a doctor caring for you it may be near impossible to find one. This has already started happening in the primary care fields but it will extend to specialty care as well. In addition, there is a large number of doctors 60 to 70 years old who have delayed retirement the last 5 years. But, as the economy rebounds the doctors who are near retirement will see their retirement investments grow and become large enough to allow them to retire. This will put a further strain on an already highly stressed system.

In fact, as this group of doctors goes in to retirement a large number of people will be looking to establish relationships with new physicians. But they will be in direct competition with a younger group of the aging population as well as newly insured. I predict that this will create a very interesting dynamic that hasn't occurred in the country in generations. We won't need to worry about death panels or insurance denials of care because a large number of people won't be able to make it into an office.

In fact, we will see a huge shift to using the emergency room as a site of primary care. This has already occurred for the uninsured and under insured population but this will become typical for most everyone. I predict that insurance companies will begin to aggressively recruit doctors to their panels. They will require exclusive agreements and will give special packages to the doctors to recruit them in. This will likely shift another segment of the population into the ER. These will be patients who no longer can see their doctor because he is a provider for only a finite number of insurances.

The state and federal governments will be faced with an unprecedented issue. How to provide care for literally millions of people. We might look to recruiting doctors from overseas but as the economies in Asia begin to grow I suspect the doctors will sense opportunities for success in their homelands and will choose to avoid the chaos here.

Is there an answer? I doubt that there will be any easy way to solve this but I will begin to offer some ideas in my next blog "Slaying the Beast".

Time to share

Today begins my journey to share with you my thoughts and feelings about health and healthcare and how it relates to each and every one of us. For several years I have had patients, friends and family ask about my opinion regarding health policies and health care. Often times they are scared about something they read in the newspaper or heard on the radio or television. I'm not surprised about the fear and confusion since most of what is presented is slanted in one angle or another.

In fact, more than once a patient has turned to me with tears in their eyes and asked what will happen to their insurance or whether I will be available to help them after new changes occur. Usually, these are the moments I slow everything down and take the time to explain from my perspective how I think events will play out. Each time this happens I wonder how many others are out there scared and confused and wanting an answer from someone they trust who is impartial and understanding.

So that leads to why I am writing this post today and why I am going to continue doing this into the future. My plan is to make commentaries about various aspects of what is occurring in both the macro national and world environment as well as the micro personal environment of myself. I hope to relate to my readers and to share stories and anecdotes about success as well as some of the scariest and even strangest moments I have experienced.

Each time you look at one of my new posts I hope to share with you a new idea or thought. I hope that if my comments move you that you will share that with me. I also look forward to you asking questions for me to ponder and answer. Together I hope we can all grow and learn together.