Still Life and Non-Sense

It's snowing in Seattle and after risking frostbite, waiting for the never-appearing bus, listening to the traffic report, or falling on icy asphalt, everyone is now sitting at home watching the snow. Seattle closes down when it snows. Schools were closed yesterday and again today. Even worse, Seattle uses some kind of ecology-minded salting mix for the roads, where they bother to salt, which has not stood up well to the below freezing temperatures, causing ice-on-ice . I had my snow tires placed on my all-wheel drive Subaru yesterday, but I'm sitting it out too. Too many people here have no idea how to drive in snow, much less on ice. If you recall, I've had my share of sliding and falling on ice. I'm happy for an unexpected day at home in a warm house, with a silly cat, good music, snow drifting down and kids outside having a ball.

In this lovely free time, I'm making corn chowder and trying to learn about vent weaning and dialysis. Our service is now doing consults for a kidney dialysis center and a vent-weaning facility. My understanding of ventilator settings and prognosis for weaning is kind of sketchy. Good excuse to hang out on Amazon.com and buy more expensive medical books. I also finished reading Death Foretold: Prophecy and Prognosis in Medical Care by Nicholas Christakis, which I highly recommend whether you work in the field of medicine or not. Christakis is, by the way, one of the authors on the recent BMJ paper about happiness. <http://www.bmj.com/cgi/reprint/337/dec04_2/a2338> The funny thing about this study (which basically found that if your friends, or your friends' friends are happy, you are more likely to be happy) is that these effects did not show up in co-workers. I wonder what that means for those of us that spend so much of our daily lives immersed in work?

I know that I was unhappy in my last job and I'm pretty darn happy so far in the new one. Of course, true to my melancholic personality, I don't expect happiness to last. I used to say, when I somehow landed on a small island of pleasure, that I was "between depressions." But in terms of my work-life, the greater contentedness seems to me to be entirely related to differences in the two systems. I'm thinking about levels of systems: the teams' practices and processes, the hospitals' climate and culture, the regulations governing nurse-practitioner autonomy (or lack thereof), the communities we serve.

So not to get too personal, here's a thought. I was reading Supportive Care for the Renal Patient (Chambers, Germain, Brown, eds., 2004, Oxford Press) when I came across this sentence: "In the U.S. there can be barriers to hospice care particularly for the patient who chooses to continue dialysis." So this means, in contrast to in the U.K., where apparently being on dialysis is not a barrier to hospice care. And of course, the difference isn't in the cost of dialysis, or the philosophy of palliative care, it's in the structure of payment. In the US, the renal patient who wants both hospice care and to continue dialysis (the nerve!!) puts hospice in the position of having to pay for dialysis out of the hospice pot of funding. After all, it's all Medicare funds, but just in different pots. This is the essence of fragmentation. Hospices get blamed for this, or worse, hospice comes to accept an artificial divide between disease management and comfort care. Now keep in mind, for the unacquainted, that the dialysis patient who stops dialysis will die in an average of 7-10 days. That's 7-10 days of hospice, in the US book. Now I ask with honest incredulity, does this make sense to you?

Closer to home: In Pennsylvania, a nurse practitioner has to have a supervising physician in order to practice and prescribe medications, in Washington state, there are no such requirements, NPs can practice and prescribe without any relationship to a physician. In both states (all states, because it is a Medicare policy) an NP get 80% of the reimbursement that a doctor gets for providing the same service. In the former job, the palliative care service was embedded in Home Care. Speaking Medicare regulations again. What a mess. In the current job, we are a medical service. Like any other medical service, say Cardiology or Infectious Diseases. So there are minimal barriers to providing care in multiple settings, home, hospice, nursing home, hospital, dialysis center, vent-weaning hospital. But in both places, decision algorithms are designed for billing, not for providers. Providers spend a enormous amount of time just learning the rules.

Does any of this make sense? I can't make enough sense of it to even begin to know how to criticize the system or how to make it better. Although I guess all of us (patients, parents, partners, doctors, nurses, etc.) should let Mr. Obama know how we feel about it.

Now, I'm going to sit on the couch with a blanket, cat in lap, cup of coffee in hand and read another book, this one just for pleasure, Magic Mountain, by Thomas Mann. Thinking about Susan Sontag last week reminded me that this is one of the classics that I've somehow missed.