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The Last Word: The Troll

“The mass of men lead lives of quiet desperation.”
-Henry David Thoreau – Walden

by Tom Black, MD – Publications Committee

As I reflect upon the thousands of patients with whom I had contact during my general surgery residency training, one stands out as perhaps the most important, at least in the sense that she is the one from whom I learned the most profound lesson.

I can see Sara Hardin in my mind’s eye. She occupied bed space 15, the middle bed of the three just to the left of the 2nd floor nurses’ desk, facing south. Sara was 49 years old, but she appeared to be at least 70. She was thin and bent. Her wrinkled and leathery skin spoke of a life none of us could hope to understand, undoubtedly spent out of doors and working hard. Her teeth were gone and she either didn’t bother putting in her dentures or didn’t own any. Her unkempt short gray hair and the dirt under her nails contributed to her derelict appearance. Sara was admitted to the county hospital for evaluation of intestinal bleeding. 

No one came to visit Sara, at least, no one that I was ever aware of. Whenever I saw her, she was generally napping or staring out the window. I don’t recall that she ever said a word to us as we rounded each morning and evening, but then again, I don’t recall ever saying much to her either.   

Once, when I was a senior resident, a new second year resident was assigned to our surgical service. We had never worked with each other and I knew nothing of him aside from the expensive watch he wore. I always thought it was in poor taste, if not ill advised, to flaunt something of such value in front of so many people who themselves had so little. One day during rounds at Sara’s beside, this new resident concluded his introductory remarks with the words, “She’s your typical troll.” All present nodded knowingly.

   “Troll” was Ben Taub Hospital parlance for a homeless individual, and the term carried with it, as one might imagine, a terribly negative connotation. It comes, I’m sure, from the Norwegian folktale of the ugly ogre who lived under the bridge that the Three Billy Goats Gruff had to cross. In Houston, as in many other cities, many homeless people live under the shelter of bridges and overpasses.

I am quite embarrassed now to admit that I neither said nor did anything at the time to set the young man straight regarding his opinion of someone of whose situation he was ignorant. But the label stuck in my mind, and it troubled me. In retrospect I can only hope that Sara either did not overhear that young man’s comment or did not understand his insinuation.

I suppose I had fallen, as do most students and residents, into the depersonalizing mindset of those who say, “the appendix in room five,” or “I admitted a head injury last night.” Most physicians-in-training are much more focused on the task of developing clinical acumen and less on humanity, but that’s a poor excuse. Nurses are often guilty, as they tend to report, “Four fifty-seven needs some pain medication.” HIPAA has greatly exacerbated the problem by disallowing the use of names in favor of initials or anonymous room numbers. But it’s a leap beyond depersonalization into cruelty to demean and denigrate another individual, particularly when he or she is in a debilitated condition and worse yet, when he or she is dependent upon you for assistance. 

What right did I have to do anything other than to exhibit the utmost respect for everyone as unique individuals of worth, while administering to them
the best possible care?

A day or two after the episode, I stopped by Sara’s bed. She was sleeping, which allowed me the opportunity to observe and to learn a bit about her. A book lay on the bedside table. It was a well-worn copy of the Bible. The bookmark and the pair of scratched and repaired eyeglasses nearby indicated that the book was read often and was of significance to her. A cross hanging next to her bed showed her personal devotion. Although she wore no jewelry, the proximal phalanx of her left ring finger was noticeably narrower than the same area of her other fingers, indicating that a ring had once held a longstanding position of importance there. Perhaps she had been recently widowed; who knew? And who even asked? I studied the lines on her face. They indicated that she had spent much more of her life smiling than frowning and spoke of happier and perhaps more secure days now past. Taped to the side of the bedside table, in such a manner as to be easily visible by her, but nearly invisible to casual visitors, was a simple crayon drawing with a crudely scrawled caption that read, “I love you Gramma.” Next to that was a small photograph of the type taken annually in public schools, of a little girl aged five or six years. I was even more ashamed of the callous attitude my colleague had displayed toward one of our fellow human beings and of myself for having remained silent. 

I may have been as guilty as others of depersonalization, but never of cruelty, and having witnessed that appalling lack of compassion was a wakeup call for me to reassess my own values. I began to appreciate the people who passed through the hospital in a new light and as being more than “clinical material” who existed for my benefit. Each became an individual. Each old man was someone’s father, and if not father or grandfather, then at least someone’s son. Each elderly woman was someone’s daughter and, as in Sara’s case, likely to be loved by someone. There were experiences etched into the wrinkles of each of Sara’s hand that I could not even begin to understand. What right did I have to do anything other than to exhibit the utmost respect for everyone as unique individuals of worth, while administering to them the best possible care?

Several days later, in a different location but similar circumstance, I heard the term “troll” again used in a similarly insensitive manner. This time I was determined not to allow the opportunity to pass.

“Stop right there. Everyone remember from this moment on that the word you just used is not acceptable on this service, at least as long as I’m here.” I paused to collect my thoughts, although I had mentally rehearsed my comments many times. 

I addressed the speaker. “When you applied to medical school, you were probably asked why you wanted to become a doctor, and you probably said ‘Because I want to help people.’ Well, either you meant it or you didn’t, but if you were honest and you do want to help others, start by treating everyone as a fellow human being. You wouldn’t appreciate someone speaking that way about your mother or grandmother.” There was some resentment after that over the reprimand, but I heard no more “troll” comments.

On the evening of the day Sara was discharged, the team assembled at the nurses’ station for rounds. “Dr. Black,” the charge nurse said. “This was left for you.” It was an orange mailing envelope with Sara’s name on it. Opening it, I pulled out a nice greeting card addressed to our team. I read the card aloud to the members present. “Dear Blue Surgery team. Thank you all so much for the kindness and care you gave to our mother and grandmother while she was recovering in the hospital.” I was gratified to see that the irony of the message had wounded a few egos. 

A few months ago, an essay by medical student Sneha Sudanagunta appeared in this journal. In it, Ms. Sudanagunta concluded that medical schools must do a better job teaching what she called “humanism,” (an ambiguous word for which I suggest “compassion” may be a more apt term). While I applaud her passion for this important topic, it is disconcerting that Ms. Sudanagunta felt compelled at all to implore physicians to teach more compassion. My experience leads me to believe that her observations represent an exception rather than the rule among practicing physicians. 

I suppose medical students and residents are much the same as they were forty years ago. Sometime between acceptance to medical school and the completion of medical training, one must resolve one’s personal standards regarding the treatment of others and the sanctity of human life. Of course, cruelty must be categorically opposed and compassion fostered just as strongly. While I am doubtful that compassion can be taught, per se, I am quite certain that it can be effectively modeled, and a receptive individual can be influenced to change his or her own behavior. 

I am convinced that we are surrounded by compassionate physicians; their names are in the TCMS directory. It is who we are, or at least, who we want to be. Nevertheless, it is wise for us to recall from time to time the wisdom of the Dalai Lama: “Be kind whenever possible. It is always possible.” We need to show Ms. Sudanagunta that whatever she experienced was the exception, not the rule.

The Last Word – December 2019

By Hujefa Vora

I want to close out this year talking about change.  How much have your practices changed in the past year?  How much have your lives changed over the past year?  You’ll notice that I use the terms practice and life interchangeably.  Unbeknownst to our patients, our clients, our friends, and sometimes even our own families, these terms are equivalents.  One cannot achieve the title of physician without accepting this fact.  Our work defines us as human beings.  There is no other way to make an accounting of all the time we spend caring for others while neglecting our personal responsibilities.  This year, I missed my daughter’s first gymnastics meet because I had a patient attempting to code in the hospital.  Life changes.  Practices change.  When the government rolls out new regulations governing how we practice medicine, it changes not only our interactions with our patients and their insurance companies, but also the relationships we have nurtured over the years.

So how has my practice changed?  I recall a time just 10 years ago when I could easily see 20 patients a day in my office.  Comfortably.  I remember being able to do my documentation while I sat in front of the patient.  Prescriptions were sent off with a click or two of my mouse.  Follow ups were scheduled and the patient was satisfied. I started my practice 13 years ago with the exact same electronic medical records system that I am using today.  That has not changed, though there have been many updates to the system over the years.  What has changed quite dramatically now is how I use this system.  Practice with the same system for more than a decade, and users build a higher level of proficiency and efficiency.  It would make sense that I would be faster with the system, that my proficiency would make it easier to navigate the windows and the electronic maze of my patient’s chart.  Changes over the years in the rules behind coding and documentation have not made us more efficient though.  Let me give you my most cumbersome example of change in my practice pattern brought on by changes in rules and regulations brought about Medicare.  I am an internist by trade, but the vast majority of my patients are diabetics, so I fancy myself a closet endocrinologist most days.  When I first started practicing, I routinely ordered glycosylated hemoglobin (a1C) levels to gauge the degree of control my patients had over their diabetes.  My staff would order the test for the patient to have drawn at a local lab.  We would get the results back and I would call the patient a week later, provided the patient went to get their blood work in the first place.  Based on the results of that test and the discussion with the patient, I would call in any medication changes.  Then, we would follow up with the patient in a month or two and see if the medication adjustment worked by rechecking the levels.  This worked for a few years, until Medicare and the insurance companies decided that a1C levels would only be paid for if they were drawn three months apart.  Patients would get angry at me and my staff when they started getting bills for the a1Cs I was ordering.  We were forced to move away from this really good method of tracking diabetic

Patients would get angry at me and my staff when they started getting bills for the a1Cs I was ordering.

control.  I started bringing my diabetics into the office every three or four months.  My supply salesman introduced me to a machine that we could use in the office to check a1C levels. The catch here was that regulations dictated that because I was not

running a certified lab, the insurance companies would not always pay for the a1Cs we drew in the office.  Thus, only some of my patients got everything done at the point of care.  It was easily noticeable with my patients that those who had their a1Cs checked at the time of visit had better overall long-term outcomes in relation to their diabetic care.  Medicare eventually took notice of the importance of measuring glycosylated hemoglobin levels and started asking us to track these levels more routinely.  With the advent of Medicare’s quality initiatives several years ago, tracking a1C levels became a key quality indicator for diabetes control.  It is only recently that they started paying for this test if it was done in the office.  Reporting of quality metrics has been the ultimate gamechanger.  As every insurance company begins to incorporate the reporting of these quality metrics, the process has become even more cumbersome.  I decided that the easiest way to tackle this issue was to measure all a1Cs in-house.  If the insurance company would not pay, then my practice would eat the cost, not pass it along to the patient.  Every company we have worked with on this particular metric has a different way that they want these values reported to them.  Medicare has codes for the different ranges of the a1C that have to be coded into the note at the time of care, so whether or not they paid for the test became irrelevant.  A patient with no reported glycosylated hemoglobin level was just as bad as an uncontrolled diabetic in terms of the scoring of the quality of care being provided by the physician.  Ultimately, a lower quality score means a significant drop in revenue.  Most insurance companies would not allow us to simply document the level in the chart.  Medicare would not allow an a1C to be reported without proper documentation that the test was done in-house.  We are now required to document the value of the test, followed by phrases stating that the test was “drawn, collected, and performed in office, in-house, today <today’s date>, at <time>.”

My patient volume has not increased substantially, but the amount of time required to see each patient has made it impossible to continue to do this on my own.

Understand that Medicare has primary care physicians tracking over 30 different quality metrics for every patient we see.  Also understand that what Medicare does in terms of regulations trickles down to every commercial insurance plan eventually.  So how has my practice changed?  I am a five-star rated doctor for Medicare.  That means that because I am truly obsessive-compulsive about most of these details and metrics, my staff and I keep track of all of these metrics for all of our patients at all of their visits all of the time.  First and foremost, we do our best to provide the ultimate in good service and care to our patients.  Then, we spend the rest of our time buffing and polishing the patients’ charts so that we can stay in business and continue to serve our patients.  A typical visit of 10 minutes of face-to-face time with the patient requires about 20 minutes of documentation, insurance processing, and quality reporting.  A simple follow-up visit takes a minimum of 30 minutes.  A new patient may have taken 30 minutes when I first started my practice, but we typically give an hour of my time for these visits now.  And I had to hire a second nurse practitioner to keep up with the flow of patients.  My patient volume has not increased substantially, but the amount of time required to see each patient has made it impossible to continue to do this on my own.

And so, the practice of medicine continues to change.  Our lives continue to change.  I hate to be a pessimist, but not much of the change feels positive right now.  The optimist in me says the next year will be better.  I just hope that I don’t miss too many more gymnastics meets.  No one twirls quite so beautifully, or awkwardly, as my little girl.  That too will change.  My name is Hujefa Vora, and this is the Last Word.

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