Unthinking Limpet

The following was sent to me by an anonymous Ph.D.  See if you notice a trend in our healthcare system:

I’m a psychologist, although I no longer have a clinical practice. My 27-year-old son is no longer covered by our insurance. He’s between jobs, so he has MediCal, California’s version of Medicaid. He’s been living with us, waiting for the federal government’s hiring freeze to be over so that he can accept the job he’d been offered by the Department of Justice.

He had nausea and vomiting for 24 hours. No other flu-like symptoms. No abdominal tenderness and the like. My wife and I thought it was likely some food poisoning, but because of his medical history we wanted to make sure we were doing the right thing. We brought him to a local urgent care center. They informed us that since he was on MediCal, they couldn’t accept him. We offered to pay cash for the visit, but they said that since he was on MediCal, they couldn’t accept cash since MediCal means that he doesn’t have the income to pay—even though we, his parents, were paying. They said that we could bring him to an ER or we could call the hotline run by the insurance program.

Since this had not yet risen to the level of a true emergency, and bringing him there would result in a long wait and a large bill, we decided to go with the hotline. My son was feeling really miserable. We called the hotline. After he attested to the person answering the phone that he had given me permission to speak for him, I was transferred to what I presume was an R.N. who clearly had a series of algorithms on a computer screen in front of her. To save time (or so I thought), I quickly ran the case for her. Our conversation went something like this.

ME: “I’m the father of Philip R., who’s asked me to convey his symptoms and history to you. He’s a 27-year-old man with a 10-year history of Type 1 Diabetes that’s generally under control. He’s on an insulin pump and uses a continuous glucose monitor. His serum glucose levels are currently within normal limits. He’s had nausea and vomiting for the past 24 hours. He currently can’t keep any food or liquids down, even water. He has no other flu-like symptoms, no pains, no headache, and no abdominal tenderness. The one thing that he ate that my wife and I did not were some blackberries yesterday afternoon. He’s wondering if there’s anything else he should be doing other than replacing water and electrolytes.”

NURSE: “Does he have any chronic illnesses?”

ME: “YES. He has Type 1 diabetes. He’s had it for 10 years. It’s generally under control.”

NURSE: “So he has Type 2 diabetes….”

ME: “No, he has Type 1 diabetes. It’s a completely different disease.”

I began to feel like I was in the middle of the old Bob and Ray Komodo Dragon routine.

We went over the details of his symptoms. She was clearly checking off boxes on an algorithm without thinking about what I was saying.

NURSE: “Does he have any problems with his immune system?”

ME: “YES! HE HAS TYPE 1 DIABETES! It’s an autoimmune disorder. He’s had it for 10 years.”

The bottom line was that she recommended that we give him a teaspoon of water every few minutes to see if he could hold that down.

He was fine 24 hours later, so it likely was food poisoning of some sort. But I was really struck by the disconnect between what I was saying to the nurse offering the triage/advice and her desire to stick to the written algorithms like an unthinking limpet.

I also believe “Unthinking Limpet” would be a pretty good name for a band.


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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  7 comments for “Unthinking Limpet

  1. Dr Mom
    September 2, 2017 at 11:54 am

    Assume you are talking to a nurse? They are developing computer menus so a high school drop out can click boxes. Then the patient themselves.

  2. Pat
    September 2, 2017 at 11:17 am

    For readers who want to move to a single payer system: THIS is what you want.

    • politovski
      September 4, 2017 at 11:23 pm

      and we will have insurance folks making the same decisions, except for a profit motive, as the logical conclusion of our current system….

    • Bridget Reidy
      September 12, 2017 at 7:18 pm

      No, this type of care was invented in the US, not in a single payer system.

  3. Perry
    September 2, 2017 at 9:42 am

    Circling the drain…

  4. Stephen O'
    September 2, 2017 at 9:37 am

    There is nothing subtle to this; it is simple collective economics. Meat in the old Soviet Union was cheap, but you couldn’t get it. If something is unavailable, it has no value. Therefore, the price can be set at any level.
    Also – excellence is defined as the best that you CAN get. THE BEST means the highest-quality product that is actually in the store. In the story, this patient received the best that modern American healthcare had to offer. The BEST.
    People can’t wait until there is an iPhone app for medical care. All this will do is take away the living but unthinking algorithm-reader on the other end of the telephone. And we will still have THE BEST medical care in the world.

  5. William E Green III MD
    September 2, 2017 at 8:31 am

    Welcome to the “future” of American Healthcare. Reminds me of SO MANY times in the past when I had to call insurers/ HMO’s to have someone “preauthorized” for a hospital admission. Typical Call:
    Me: on hold for 10-15 minutes, finally get my third “real person”,
    Me: “She’s a 42 y.o. BF with Psychotic Major Depression who has developed severe suicidality over the last 24 hours. She attempted suicide once previously, nearly dying from a severe Overdose 2 years ago”
    Insurer: “How severe is her sucidality, has she actually ever attempted to harm herself?”
    Me: “Yes, her husband had to wrestle a pistol away from her today, before she was brought to the ER by police/ EMS. She is hearing voices telling her she’s worthless and to kill herself. She is too delusional to interact rationally.”
    Insurer: “You did NOT answer my question, has she ever tried to harm herself before?”
    Me: “Yes I did answer your question, she had a severe overdose two years ago, and spent four days in the ICU. Your company has all the information, as she was covered by you. Your company refused to pay for several months, and we finally were payed after appeals.”
    Insurer: “Can’t she just contract for safety and her family just watch her at home? I’m afraid we can only approve her for 12 hours in observation status, and then you can call us back”.
    Etc., etc.

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