Tuesday, September 8, 2009

An Ode to Freedom

“O’ Horrible, O’ Horrible, Most Horrible.” The ghostly echo rises from the slain Dane reaching across centuries to cry the injustice of times. There is a time to mark and it is now.
Darkness enshrouds. Trees and bushes conjure images of ghosts and goblins. The sleepy, creepy fog floats, caressing the foliage. It’s tongue licking nature’s bounty. Not a stirring this late hour can be heard, except the lone headlights of the car coursing its way on a highway. This exterior is bottled outside from the inner sanctums of the car where the lilting, lolling, cadence of Beethoven’s 9th. confronts the anger, happiness, resignation and finally acceptance of life is playing center stage. “Ode to Freedom” that it is, is the essence of the violins. Life expressed in D minor. The cold and mocking air outside slams and presses against the doors but cannot find a way inside this musical realm. It is a winter’s night. Humanity is calling for help and neither cold nor dark will win.
The muted hum of the Operating Room with its bright lights and day-like ambience caters to the needs of the unfortunate. The two nurses with their slightly wrinkled uniforms are chatting, trying to find equilibrium. Their eyes speak volumes. The clarity that brought them in is disjointed by the grief of the day. And there is always a teaspoonful of that elixir to swallow on a daily basis. Human suffering is never a timely event.
“Haven’t seen you in a while?” The statement morphs into a question with the raised decibel at the end.
“Yeah. It is every other weekend and every third week on coverage.”
“Not bad. This place is a second home for me.” He says twisting the ends of the paper overalls he is wearing. His eyes are screwed into a mess of wrinkles with deep pockets of circles accentuating the lower eyelids. The scorn and fear combine to create the unflattering troubled image in the face of a healthy thirty-five year old.
“Not quite, I still have the paper work to finish and speak to the family outside.” He said with a hint of exasperation.
“Hey, did you watch the game last night. It was unbelievable.”
“No, I fell asleep on the couch. I was tired. I am beginning to see that I am not a whole lot of fun these days.” His hands open in total resignation.
“Catch the next one then.”
“Yeah.” He says again his head bobs a little in muted defiance against the gods.
“Everything okay?”
“Long story.”
“I have time. My case is delayed pending approval.”
“That is exactly what I am talking about!” he slaps his hands on the bench besides him. The color of his face reemerges. The frustration boils the anger out in bubbles of expression.
“What about?”
“Those approvals!”
“What about them?”
“What the hell are we doing here? I get called on an emergent appendicitis. I am scrubbing and they tell me that the approvals are not authorized yet. So finish scrubbing and get gowned and ready and the company wants to talk with me. What the hell!” Disbelief in his eyes tells the tale. The face is contorted with muscles contracted in different phases give him an eerie look. His voice takes on a higher pitch. “ What do they think, I am doing, performing an appendectomy on a normal appendix at 2 AM for fun?”
“Its getting tough.”
“I did the case anyway. The patient was prepped and ready. The appendix was blown up like a balloon ready to burst. It was a mess in there.” His hands clasping and unclasping, “Now the admin tells me that they are not going to get paid because of the pre-approval issue.”
“Did you speak to the company?”
“Not yet, but I will. You know how much time it takes to get to their doctors. The last one wasn’t even a surgeon who had to give the approval for a lysis of adhesion. He was embarrassed himself for taking on the approval issue.”
“The whole concept is wrong.”
“It is!” He cries.
“The problem is that the whole medical industry is a 1.9 trillion dollar enterprise. It forms 16% of the GDP so the insurers are trying to figure out cuts where ever they can.”
“That would be so if they were not paying astronomical compensations. Like that CEO of United Health Care Company got 2 billion dollars in stock and options. That is obscene.” He shakes his head with frustration.
“It is, especially when they vilify the doctors and deny compensation. I am a supply side person. If the demand is there the supply must command the right to charge for the service. It is the way of our country. If you change the model then universality of choice is lost and mediocrity of performance is gained. Tit–for-Tat. There are no free lunches.”
“You know if I did not love what I do, I would have done what my friend did.” He launches into an argument inside his head.
“What’s that?”
“He started a small chicken and egg business in Seattle. He is happy dong that. He has hung his shingle up for good after only five years in practice and is happier now then he ever was the past 14 years learning medicine and doctoring.” He stops thinks about it for a moment. “That may not be a bad idea.”
“What, setting up a chick and egg business?”
“No something other then medicine.” He betrays his soul.
“But you are so good at it.”
“Good for what? Being questioned on my decisions, my judgment, my knowledge and understanding of the disease. No! based on the questioning, I am good for nothing!”
“Easy there. This just a bad night and you are tired. The day will bring a different perspective after you have had some sleep.”
“Oh, this might help. An excerpt from my fourteen year-olds’ essay. Even the kids know the score.”
“Well, they see us haggard always saying no to their demands and complaining about a work that once was pleasure now with every bureaucratic finger in the pot it has become a nightmare.” He opens the folded paper and reads.
Somewhere in that conversation the cries of humanity are being stifled, they will rise and command the theater one day.
The lined paper unfolded trembles in his hands.
When tough choices become tougher. The social, peer and legal pressures continue to burden the system. The latter is where the prospective judgment of the physician is questioned by retrospective reviews. The public and peer pressure to use the new technology and then to deride the physicians or even impose penalties against them for using these tools is lunacy at best. There is a steep cost of excellence in medical care, but this cost is self-imposed. We sing praises for the newest accomplishments, cures, latest biotechnological products, tools such as the use of CT scans, MRI and PET scanner machines. But we cry foul when the cost of using this technology has to be borne. The duality of thought has to be reprocessed. One cannot have it both ways. These impositions have allowed their pressures to mount over the past decade and now the regulatory concepts are framing the same argument. As if paperwork leads to excellence in human care. Stitching a sentence of demand and then to devilishly imbue it with the scent of purity of purpose is not the genius of sanity nor does it guarantee safety of the patient. It is the human intellect, experience and knowledge that guides the domain of caring. ‘Feeling’ is an emotion expressed by the outsiders, the lookers-on and the rubbernecking crowd. That is not who helps the person in need. No amount of on-lookers on the highway can help the accident victim. It is the police, the paramedics at the scene and the physician and his team of experts in the waiting hospital. All others are wearing the pretend white lab coats of observers. Let experience prevail. The messages of clarity from yesterday are no longer understood in the precincts of this dubious realm of today. Failure was not an option then. Now success is decried.

The fading echoes from the ghostly apparition smother the morning sun. The dew shall not form on the dry leaves and the spiders shall not spin their magic into a web. The birds chirp their dissonant chirps and the instructive words of the imagined past echo again.
“Pity me not, but lend thy serious hearing.”

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