OBAD (The Dark Side of Doctoring) -Rule Number Four
OBAD stands for Official Begging Armistice Day. I’m sure that will require some explanation.
If ‘The Mandolin Case’ sells more than four books, I have a sequel planned. It is called ‘Acquisition Syndrome; the Doctoring Business.’ As far as what it’s about, legal advises me all I can tell you at this time is this: A wise patient of mine, a farmer, told my nurse Lynn O’Carroll, “Dr. B knows something and he ain’t talking.” But the gist of the saga is that along the way Dr. B learned a few tricks of the trade and figured out ways to get people taken care of even if some fool does their best to stonewall the process. It happens more often than you might think. To their dismay, over time I am gonna tell what I know.
Fifteen years ago if I wanted to get a CT head scan Lynn O’Carroll would call and say, “Dr B. needs a CT today.”
And they’d say, “Sure sweetie, what time?”
It is no longer that way. Now mind you I’ve never been one to order a CT on every headache patient. A history will usually do it. But if there is even one ‘red flag’ warning sign I’m on the warpath and will not be denied.
When you have a lady who has fallen in the last month and has a new headache like she’s never had, and you run into some insurance guru who finds a scan unnecessary, I always ask what he would want done if it was his mama. If he doesn’t want to rule out a subdural hematoma then there are only a few logical conclusions. Either he is poorly trained, doesn’t care, is more interested in money than truth, or hates his mama. None of them are good.
The idea of ‘managed care’ is if you make the Doc jump through enough hoops he’ll stop hopping and take a few chances. Sorry, I made an A+ in Hoop Jumping 101. Nowadays a Doc not only has to care, read like a wild man to ace his Boards (O.K. I’m gonna brag on my 94th percentile) and work hard, but he also has have an iron will to force the system to do right when it has created more inertia than a barge that lost it’s tugboat.
I call it OBAD. Official Begging Armistice Day. I never beg anyone for help. If they aren’t willing, I proceed to plan B, go to door number two and lumber on in anyway. It is the power of the lessons of Acquisition Syndrome; the 80/20 rule. (Rule number four) 80% of the time people will do right because they want to. The other 20% have to be positioned where they have no choice but to do right.
I can’t tell you the details of this week’s case. It is too fresh. Even if I fictionalized it, it would be recognizable and a breach of patient privacy. So instead I have to make it into a parable. But as I told Julius; “if they won’t do right make ’em.”
On our flight this week, I was the pilot and Julius was my co-pilot. On Tuesday we hit some awful turbulence.
“Hey pal, my rudder is balky and she don’t wanna trim out. We’re losing oil pressure on the right engine. We’re gonna have to feather the starboard side and put her down in a cow pasture. I know one we can get to from here.”
“If anyone knows Harvey County, it’s you, Doc.”
“Go back there and get approval. Tell that arm chair QB it’s an emergency.”
Julius was back in a minute. “He’s say his computer simulation says it’s doesn’t meet the criteria. Procedure denied.”
“Tell him to look out the window. The dadburn engine is on fire.”
“I did. He said they have to go by protocol.”
I tossed Julius a chute. “Take this to him. Tell him he can jump if he wants to, but I gotta get this dude on the ground.”
“O.K., boss.” Julius turned to head for the back of the plane.
“Hey, kid. Tell him one more thing.”
“What’s that Doc?”
“He might as well take his computer too. It’s no good to us here. He might want to play some video games at least if he survives the fall.”
“Yes sir.”
“By the way, tell him I’ll go ahead and call in my dictation. If this thing doesn’t make it I’m gonna document the fact he got in the way here. Legal will tell him not to worry too much. It’s only one passenger. She’s just some country lady and I know he doesn’t think she’s that important. I know the husband. He thinks right much of her, but he’s reasonable. My guess is five mill will cut the gig.”
Julius smiled. “I expect that man in a suit and tie in a Harvey County courtroom would have a hard go.”
“Yeah, remind him a dead Dr. B is gonna be a difficult opponent. You don’t diss dead people. Tell him it’s against the law.”
Julius did just that. The man froze. He was scared to go against us. When it’s your own life on the line, people see it in a different light, and besides the guy was tighter than Jack Benny.
We got her down, got the lady off the plane, and put out the fire. I told the little regulator man I believe I’d get some new software for his simulator. One of these days he was gonna convince someone more naive than me to go along with him when he’d never laid eyes on the patient. When he does he’ll have to hope I remain as obscure a writer as I am now. By the way, he admitted he’d never flown a plane. I wasn’t surprised.
The patient did fine, and I wasn’t scared until it was over. Then I cried. Medicine made me tough as a pine knot, but it ain’t gonna make me mean. I’m gonna go play some music.
I’m glad I did not spend my life as some insurance chart jockey. As hard as it was, I’d rather be Doc, even if the pay wasn’t as good as those executive guys. l’ll close with a favorite quote. It is from Sir William Osler, the father of modern medicine.
“Seeing patients without reading books is like going to sea without a compass, but reading books without seeing patients is like not going to sea at all.”
I love books, but I love patients more. Some things and people are forever. Osler was, but I assure you all those little regulatory guys will be lost to history. (as they should be) They are nothing but a nuisance to be thwarted, but I have learned to do it well. I’ll probably be lost to history too, but at least I tried to do right.
Dr. B
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Dr. Tom Bibey: Stories of the Bluegrass Music Road 
July 31, 2009 at 8:58 am
“tough as a pine knot”
Damm good that sums up what I have seen in every salt-of-the-earth human. Esp if you have ever tried to whittle at one.
Good work.
July 31, 2009 at 9:14 am
Thanks Billy,
I have found most truck drivers are tough as a pine knot too.
Dr. B
July 31, 2009 at 3:59 pm
Not ever been a doctor, but trusted myself and my children to doctors who were “tough as a pine knot” when necessary. One of them, a pediatrician I grew up with told me a story very similar to yours. One of many he said he could tell.
A ten-year old boy came in for a follow-up, and my friend’s partner was not in the office. The boy had come in with a considerable mastoid infection. The partner had written up the degree of swelling, the history of the infection from the mother, and given an antibiotic injection and prescribed pills. Set up the follow-up for a week, with the notation for the patient to be brought in sooner if things got worse. The mother came in a day early, and my friend was alarmed at the swelling he saw, so much worse than what his partner had observed. He did not doubt his partner’s description, and the treatment was exactly what he would have prescribed. Evidently the infection was stronger than what they would have expected.
Friend Doc immediately had the boy admitted to Children’s Hospital for intensive treatment, and the story ended well for the child, who recovered with no ill effects.
A few days after, the insurance folks called up my friend and questioned Friend Doc most severely, pointing out that the “protocols” specified outpatient treatment. Holding onto his temper, the Doc described the history, and the clerk began to repeat the “protocol,” only to be cut off with a curt question as to which medical school the clerk attended.
My friend eventually won that argument.
I trusted my children to that friend, and never doubted his judgment.
July 31, 2009 at 4:55 pm
Felix,
You make the point well. You have to put the patient first. I don’t care if I make some people mad in the process.
If the plane goes down I’m going with it, and I ain’t gonna bail out on ’em.
Dr. B
August 1, 2009 at 5:34 am
Dr. B, you should teach a seminar so that all doctors would know how to get the treatment and checkups they need when they need it. With the whole stupid insurance system in the US [don’t even get my started on this, it makes me so mad] it seems to me just too easy to deny patients the checkups they need.
I wish all docs were as stubborn and caring as you are, Dr. B.
August 1, 2009 at 8:02 am
msslightly,
I have had a number of medical people tell me that along the way. If the other party is hell-bent on doing wrong, all you have to is figure out what motivates them and strike there. With the insurance companies, it is usually money. Once they understand you will support the patients’s rights and they stand to be out significant dollars if something goes wrong, they usually yield.
I have a good friend who is a high powered lawyer, and he is set to go with class action litigation should things go bad for one of my people over this obstructionism. He would be happy to see if he could establish a new legal precedent of insurance companies being responsible for the individual patient decisions they try to force on Docs, and I am more than willing to oblige him.
But, I play fair. I tell them up front they can bring all the people they want to Harvey County and try to convince folks I ain’t telling the truth, but I also advise them ahead of time it is not a strategy I recommend.
One of the key points in my life was to figure out my faults and try to channel them into something positive. I have a bad tendency to be stubborn, but it can come in handy. (Sometimes I like to think I am relentless, but it was born out of pure old stubborn!)
Dr. B
August 1, 2009 at 4:20 pm
Doc…
Doing the right thing is not always easy. But..it is always the best. Some times we have to have a “come to Jesus” meeting with others to get them to see what the “right thing” is.
Glad you are one of the good ones that God has put here to help us find our way.
August 1, 2009 at 6:26 pm
newt 221,
Your comment reminds me of one of my favorite sayings. “In this society if you want to do wrong, you will be afforded considerable latitude. If you want to do right you can expect a very hard time.”
You sure do have to figure out your fight strategy to do right, esp as a Doc.
Dr. B