24 December 2012

Mixed Emotions—A Christmas Story

When I'm in the kitchen, nothing else exists. There's no stress, no deadlines, no illness, no worry. I commune with pot and spoon and liken my seasoning and stirring to an indoor form of gardening—cheaper than therapy and resulting in good things to eat.

Unlike therapy, when my soul calls out in the dark hours, cooking and gardening don't keep office hours. There's an old R.E.M. song that I can't help but sing when I'm out pulling weeds by the light of the moon, "Though all the feelings that broke through that door/ Just didn't seem to be too real/ The yard is nothing but a fence, the sun just hurts my eyes/ Somewhere it must be time for penitence... Gardening at night..." Brutal cold and whipping winds made gardening impossible Friday night, so instead, I set about baking. Three runs of scones came together as amalgamations of flour, sugar, and half and half. I used my grandmother's cookie cutters to give them shape—candied ginger and coconut diamonds, lemon and cranberry trees, and spicy fruited hearts.

Adorned with a dusting flour—it was after all all-purpose—I curled up on the couch while my scones cooled. The house was warm and smelled of sweetness as the Christmas tree twinkled and the dog on his bed twitched with muffled dreaming barks. It was about this time three years ago that an interventional radiologist was noodling around in my brain's vasculature, weaving a tiny basket of platinum wire into each of three aneurysms. I remember being in the neuro ICU and the nurses there enjoying having an interactive patient—apparently most in the neuro ICU aren't quite so awake and cognizant. I remember having a bit of headache for which they offered me some Tylenol, which didn't quite cut it, so they gave me Vicodin. I remember needing to pee, which given my mobility presented a bit of a quandary as nothing about my glass-walled room's toilet was private, thus a well-placed hovering mom helped to at least moderately preserve my dignity. I remember being given something to eat, which Mom helped feed a tiring me.

Days slipped past, and the next thing I remember is Christmas Eve. My husband and I held Christmas Eve dinner at our new home the first two years we were there. Per tradition from my father's Polish-Czech family, Christmas Eve was the time to gather for a multi-course meal including pea soup, pierogi, and kraut. We cracked walnuts to determine the disposition of the coming year, and all the women were dotted with honey on their forehead to keep them sweet all year long. Though we weren't overly fussy about it, the gathering was still a major to do that brought my family and my husband's family together with two tables for the adults in the dining room and one for the kids in the adjacent living room. I had broken out the inherited family silver, donned an apron, and pan-fried six dozen pierogi. I relished having been transferred the role of kitchen matriarch.

The third year—the aneurysm year—the role was stripped away, as I was allowed to do little post-surgery. There was no large family gathering. There was no formal dinner. My mother and father came over to our house to visit. I sat on the floor by our Christmas tree and scooted presents to Mom, Dad, and my husband. I'd asked for a simple gemstone bracelet, a request which my husband had obliged. There was a book and a CD and a few things from Mom and Dad. And though thankful simply to be alive, I was self-conscious when I noticed a feeling of deflation, of disappointment. What I wanted...what I'd hinted at to the point of being absolutely annoying... what even my friends had nagged my husband about... was a KitchenAid stand mixer. But there were the facts of the matter... the mixers were expensive, and we'd had a less than stellar financial year. And while the KitchenAid made my heart go pitter patter, I had told my husband that we needed to be reasonable, that I knew he would give me anything and everything in the world if he could. I didn't expect to be so disheartened when he actually listened to me.

My husband apologized that I didn't have more gifts to open and then walked away. I continued to sit on the floor and tried not to dwell on my feelings of missing Christmas magic—the surgery, the family dinner foregone, and the predicament of getting—and thereby not getting—exactly what I'd asked for. My mom crumpled up scattered wrapping paper. I heard a door open and close. The wooden floorboards squeaked as they always did as my husband walked back into the living room. He was carrying a big rectangle box and grinning. I blinked, shook my head, and smiled bemusedly. My husband put the box on the floor and said softly, "I think you know what this is." Still blinking, I cocked my head, looked at the wrapped box, and back up at him. He grinned again. I peeled off the paper to find what I'd been coveting—and it was shiny, and it was red. 

I was at once thrilled and embarrassed. "Travis...," I said in a small voice thankful yet admonishing. He raised his eyebrows slightly. "I got it on sale the day after Thanksgiving," he said. It turned out that my friend who had done the most cajoling on my behalf actually knew my husband's plan all along. The ruse was a team effort. And it worked. I wasn't allowed to do any cooking yet, so I could only admire my mixer from afar. Yet it was with my husband that I was truly impressed. My husband hadn't just given me a "thing." He had given me something to remember.

It's funny how life is so circular. This Christmas' candied ginger and coconut diamonds, lemon and cranberry trees, and spicy fruited hearts were made based on a recipe from a favorite holiday cookbook I was gifted years before I was married and mixed with the sturdy beater of the stand mixer that never leaves my kitchen counter. So many times that mixer has beaten back bad feelings as well as it beats eggs, but the best reward is the old-fashioned way of finding my way to my husband's heart through his stomach. 

This holiday season, I wish everyone joy. I wish everyone magic. I wish everyone a shiny red KitchenAid mixer. But most of all, I wish everyone love.

04 December 2012

No, You Kiss My...

According to the results of 10 patient surveys conducted by HealthGrades.com, Dr. Larry M. Greenbaum's patient satisfaction marks are below the national average. A board-certified rheumatologist who graduated from SUNY Downstate Medical Center in 1984 and did both his internship and residency at Winthrop University, Greenbaum has been with Indiana Internal Medicine Consultants in Greenwood, IN since 1993.

His practice's office staff seems fine enough. For the ease of appointment scheduling, office environment and office friendliness the survey indicates that patients find these services to be "good" or, just marginally, "very good." But when it comes to wait time, things don't look so good. HealthGrades.com shows that patients are reporting a 16 to 30 minute wait while the national average is 10 to 15.

Perhaps patients spend this extra time waiting doing a bit of personal reflecting. Rather than reading old magazines, cleaning out their purses or checking their voicemail, the patients dwell on persistently aching hips, a recurring rash or the crippling joint pain of rheumatoid arthritis.

One such patient was a 75-year-old man in for his first appointment. Diagnosed with rheumatoid arthritis for about a year and half, the man was struggling to adjust to his treatment's side effects. Greenbaum describes the case in his article "Kiss My ...," which appeared online in Rheumatology News on Nov. 30, 2012.

"When his treatment commenced with 20 mg of prednisone a day, he felt like 'Superman,' but by the time he was down to 2 mg a day, he felt as if he had been 'hit by a truck'," Greenbaum writes. "He claimed that an arthrocentesis by his first rheumatologist caused his left index finger MCP joint to permanently dislocate the day after the procedure. 'He took too much out,' he complained. He was on methotrexate, but he was dreadfully worried about dire side effects. A recent string of sinus infections were clearly due to his medications, in his opinion. He didn’t think that his long history of smoking could possibly have contributed to his problems."

Greenbaum's condescension is clear as he mocks the man's attempts to describe his condition and its effects on his life. The man—like most patients—did not use medical terminology. He spoke in the manner to which he was accustomed. He related his story from his perspective, illustrating the tenant of cognitive behavior therapy that an event does not cause our emotions, rather how we perceive an event and what meaning we give to it thereby defines it.

Greenbaum defines his own philosophy of care. "Trying to keep the mood light, I used one of my favorite quips: 'If all else fails, examine the patient,'" he writes.

Greenbaum's "quip" is not amusing; however, it is certainly enlightening—only when lab results and a headful of institutional knowledge fail to produce a solution, should a doctor deign to rely on information given by the patient—the person—who actually has experience living with the condition and living with the condition under the specific circumstances of being himself. It's a belief as antiquated as using a mallet to the head for anesthesia. It is an affront to the concept of patient-centered care. It is a failure to care at all. 

Of course, caring doesn't seem to be what Greenbaum's in it for. 

"If your practice is like mine, you probably don’t bill for 'consult level 5' very often," Greenbaum writes. "That is the most expensive level of care on our office superbill, and I usually reserve it for patients with huge volumes of records, patients who take an inordinate amount of time, or patients who annoy me in some other extraordinary fashion.

The 75-year-old man with rheumatoid arthritis whom I’m describing, didn’t bring many records, but I spent a very memorable hour with him. I charged him level 5 for taking so much of my time, for bad-mouthing his previous doctors, and for incessant whining."

Assuming the patient is enrolled in Medicare, Greenbaum's indication of a "consult level 5" reflects code 99205. E/M University is run by Peter R. Jensen, MD, CPC a practicing physician and certified professional coder who practices in Connecticut and is Director of E/M Compliance for the Yale-New Haven Hospitalist Service. E/M University refers to code 99205 as such: "This is the big daddy. The 99205 represents the highest level of care for new patients seen in the office... The reimbursement for this level of care is approximately $197, which is pretty good. Usually the problems are of moderate to high severity." In 2011, code 99205 was $154.98 more than the most basic new patient office visit code 99201, according to the American College of Rheumatology's National Medicare Fee Schedule. Three sources of documentation are required for this code 99205—comprehensive history, comprehensive exam, and high complexity medical-decision making—or 60 minutes of time spent face-to-face, with proper documentation. Therein lies the loophole that allows Greenbaum, and doctors like him, to apply this code to those patients whose worst offense is to require a doctor's time or, as Greenbaum puts it, "patients who annoy me in some other extraordinary fashion." 

Other patients who have seen Greenbaum may have in turn been equally annoyed as HealthGrades.com's 10 patient surveys score the doctor well below the national average with a solid "not sure" in response to all of the following questions: "Do you trust your provider to make decisions / recommendations that are in your best interests? Does the provider help you understand your medical condition(s)? Does the provider listen to you and answer your questions? Do you feel the provider spends an appropriate amount of time with you?" And finally, "Would you recommend Dr. Greenbaum to family and friends?"

I am sure. Even though I've never been one of Dr. Greenbaum's patients, I also never will be.

__________

Look for RA patient and health advocate HurtBlogger's post regarding Dr. Larry M. Greenbaum's article "Kiss My ..." later this week for which Greenbaum has been contacted. Visit www.thehurtblogger.com