Little pieces of RK

RK died this morning. He just fell down and his heart stopped. I took care of him for myasthenia gravis. He had a terribly challenging myasthenia. He didn't have the usual findings, because his blood tests (antibodies) for myasthenia were negative. His chest CT scan was also negative. He was very difficult to treat because the medicines didn't work very well. He did well with plasma exchange, but that didn't last very long. I did send him over to Mayo for a second opinion. I'm not really sure that they helped. I tried to send them over to a friend of mine who I think is a really smart neurologist for a second second opinion, but he and his wife didn't want to go. I tried treating him with a few different things, but none of them really helped until we came up with plasma exchange. I really expected him to do well and gain his strength back. I was totally wrong, though. I don't think he died from anything I did wrong. I reviewed his chart and I think I did OK at treating his illness. The only thing I can think of is that he could have had a pulmonary embolus which is a clot in your legs that then goes to your lungs that then causes a low oxygen in the blood which leads to an irregular heart rhythm. He didn't show any signs of a blood clot in his legs, though. Also, he still walked a lot (with a walker) which means that it wouldn't have been sensible to put him on a blood thinner to prevent that. So if that's what happened, then I couldn't have really treated it. He could have died from an aspiration which is when your weak swallowing muscles (which he had) mess up and your saliva blocks up your airways. I was trying to get him strong enough to avoid that, though. I had a pulmonary doctor helping me with his breathing at night, but that doesn't prevent this issue. He could have died from something I don't even realize that is related to his illness also.
He might have died from an unseen heart condition - his death may have been unrelated to the myasthenia gravis that he had. He was fairly young, but he was overweight. I wasn't treating his cholesterol levels or his heart. Sudden heart attacks are very tricky. We're lousy at predicting them, especially the ones that start off with a rhythm problem.
RK was definitely one of the best patients that I've had in my practice. I'm not sure that people think very much about how much the patients give the physicians. I know that a lot of the doctors that I know don't really think about it very much. I think they give the doctors as much or more than the doctors give them. I'm not talking about the money part of the practice: patients (and their insurance companies as a proxy for them) pay for services. That's business. I'm talking about the other part: the people getting together with people and "giving" each other some of themselves. We give people little pieces of us, and they give us little pieces of them. That's what happens when we "socialize". Socialization changes people in this way. It causes "group behavior". I and many of my colleagues work very hard to avoid taking the pieces of our patients that they have to offer; the offered pieces contain so much of the negative and draining parts of us that they aren't really good to "take". It's really nice when there are patients who come in and make up for that by giving us the pieces that are good. Those pieces can sometimes be a truly wonderful gift. Those are the little pieces that make people happy as doctors. Without those, it clearly isn't worth it at all.

What are things worth?

AM didn't come today. He had a confirmed appointment. However, his wife came without him to his appointment just to talk with me about his condition. This is a sensible idea, and it's good care. AM has dementia and there isn't really that much that I need to see him for. Mostly I need to help his wife to take good care of him. However, this is a medicare issue. Medicare doesn't allow billing for "family conference" with outpatient care. That's a silly thing, but that's what they do. So people have to pay for that themselves. I don't mind the conferences, but I mind not being paid for things, so I tell people that they'll have to pay for it without medicare. Usually, they don't want to have the conference if they have to pay for it. Of course, that's what Mrs.M chose to do. She "can't do that". The charge for that service is $80. This is a little less than what medicare pays for a patient visit. It is $10 less than what I am charged to clean out my dryer vent once a year. I'm not sure how we can fix a "broken health care system" under these circumstances. If the patient's wife "can't do that" (spend $80 for a consultation about how to take care of her husband) when that costs less than what most people who smoke spend on cigarettes, then we have a problem. There is a huge difference between what people are willing to TAKE and what people are willing to SPEND in terms of health care. I don't think that the service in question is worthless. However, my thoughts on the matter are irrelevant. Things are only worth whatever the market will bear. If no one will pay for whatever it is then whatever it is isn't actually worth anything, regardless of what your thoughts are on the matter. My new dog needs hip surgery (dysplasia). The vet said it would be about $500. To me, it's worth more. I don't know how he came up with his fee schedule for that procedure, but I'm very happy to pay what he's asking (I'd pay more, but I didn't offer that to him). Since I'm willing to pay him what he wants it's worth $500. On the other hand, if he were charging $2,000 (which I think a lot of Vets do) then (in my case) it would be worth $2,000. Of course, he'd do less operations (some people just "can't do that") so he could end up making less.
Next year, medicare will pay $150 for a new patient visit for a physician (it's $225 this year). That means that a new patient visit will be "worth" $150 next year. How did that visit lose all of this value this year? It's worth whatever medicare says it's worth as long as I continue to take medicare. I take medicare because if I don't I can't practice in this town and I don't want to leave. I take medicare because right now, I still make more than I could doing something else with my training. However, that is very rapidly changing. Soon, I will be able to make more by working at Publix. At that point, it will become more difficult to explain to my family why I am doing what I am doing. Next year, a lot of physicians will stop practicing because it isn't "worth it". I will still do it, but I still like being a doctor very much. I haven't had to cut down my patient visits to five minutes and see forty people a day yet. The guys who have already done that just don't have any more cushion left. They also don't like being doctors anymore.
Worth is very funny, and very complicated.