Tuesday, January 22, 2013


"Alas poor Yorick, I knew him…"

There are days of reflection, where the past looks crystal clear and the future dull and pasty. Is it my bias that reigns in these events? Is it the longing for the days gone by, when things were simpler? Is it?


But perhaps it is more than that. Maybe there is a locked door to the past that opens up when the door that you see in front seems barricaded. Maybe the longing for the past is a simultaneous event, when faced with adversity that forges a benign memory of the days gone by.

Yet people say that when adversity aligns in the stars there are opportunities. My question is for whom?

And there is where we lay our scene…

I met a former fellow physician the other day. We talked about life. You know the kind of things physicians talk about. “I had this horrendous aortic aneurysm, the other day…” And so the stories went. One after another the cautionary tale of the human frailty laid itself bare.

Somewhere in that conversation his demeanor changed. “In the good old days, we worked hard and we had something to show for it; patient’s gratitude, a reasonable compensation for the surgery performed and a few winks of sleep and an hour or two with the family,” He shrugged his head, “but now it is expected without any gratitude, minimal compensation after weeks of haggling with the insurers, and fewer winks and almost total isolation from the family due to lack of hours in a day.”

There was a pregnant pause, pregnant with thought and frustration. I looked at him and unable to contain the urge, he went on to reveal his inner fear, “I don’t know that I can do it much longer.”

“You are a good surgeon,” I looked at him in all sincerity, “your work is needed in the community.”

“No there is no loyalty anymore. If I leave tomorrow others are there to fill in, in my shoes.” He looked at his hands clutched tight on the table between us. “We put everything into a patient, our thoughts, our fears, our desires, our years of knowledge and experience before and during our management of their disease and all we get is, ‘how bad doctors are.’ We are maligned for doing too many tests, we are castigated for earning too much, which by the way is a fantasy created by the media. I barely made $150,000 last year after working 70-hour weeks. Besides the medical malpractice risks, the onerous regulatory compliance and the daily drumbeat of new demands placed on me, what’s the point?”

Ah the slings and arrows...

What is the point I thought? He was right in his thinking. How had we come to this?

“And to think I paid $35,000 for the new EMR system in the office and Medicare denied me the promised reimbursements because of lack of “meaningful use.” I spoke with other docs and they told me they had to hire a Medicare certified company, another middle man earning big bucks, to send in their papers. All the dots had to be in the right boxes, otherwise the computer spits them out.”

There was nothing more to say. I looked at my hands and hey too were clutched with the knuckles all white. A thought came to me…

“Why don’t you join or create an ACO?”

“I looked into that. That is another clever way to cut into physician reimbursement. The ACOs contract for a capitated fee and over time the insurers will pit one ACO against another to reduce payments.” He thought for a moment and then said, “Wouldn’t that make it so convenient for the insurers? One swipe and an x-amount of doctors, or providers as they call us, will be knocked down in reimbursement. More profits for their shareholders.” The revulsion in his face was obvious. “What a concept?”

“But in the meantime, you will have saved yourself a lot of headaches.” I replied.

“Not sure, that I will.” It will be another hamster wheel!”

“I don’t…don’t know what to say.” I stammered.

He looked up and a spark came into his eyes. “Maybe I can go back to fee for service, like in the old days.”

Yes Maybe…

As Hamlet looks at Yorick’s skull and contemplates those glory days spent, with his father’s court jester, when life was full of promise and compares it to now, where he sees the same world through a different lens, colored by the whips and scorns of experience. The world has lost its enchantment. As in all wonderful notions of implied easement of human sufferings, eventually the creators of such phantoms of false mirth reach the same wanton act of chivalry, as when their skulls that had a tongue in them once, are nothing more than a means to block a gaping hole to steel against the raw winds of time.

There is a blank anonymity in death!

Remember the skull, it will be yours, one day! Great powers and fortunes in all hands will leave. Emptiness will reign. So think well of those whose labors you wish to demean.

Should one fight or lay down against a sea of troubles?

"To be or not to be, that is the question."

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