We serve Medicaid patients. Always have. It was fairly traditional in our area to start a practice with Medicaid patients and gradually withdraw as the private patients built up. We took a different tack and just kept them and added practitioners. It fit our social responsibility agenda, and I don't think we lost money on it. I think we still manage a very modest margin.
Part of what we do is give vaccines. There, we really lose money. There is no mark up on the Vaccines For Children program "free" vaccines, and the immunization administration fee is only $9.50. By contrast, for private patients we have a markup on the vaccines of a certain percent that covers our overhead for ordering, storing, keeping track of temperature, etc. etc. It's considerable work, and for the Medicaid patients, we get nada for this. The official Medicare values for vaccine administration would be $25 for most vaccines. So giving our Medicaid vaccines is a considerable loser for us.
The problem with government is that you agree to treat Medicaid patients at a very reduced fee and they treat you like a criminal. We just got a notice on Monday that the Inspector General - must be the Feds, I don't yet know for sure - will be coming to our office on Thursday and has a list of 24 policies, temperature logs, etc., that they want on a CD to give to them.
"Will be coming," no "May I." No explanation. No niceties. No nothing. It's a wham-bam without the "thank you, M'am."
The Feds! I'm going to tell them to visit the land where the sun don't shine. Twenty-four items! For the privilege of losing money.
Honest to God. These people.
Budd Shenkin
Wednesday, May 11, 2011
Sunday, May 8, 2011
The Best Ride to the Maui Airport
Sometimes things just pop out of the ground, it seems like. Our friends the Moes were going to take us to the airport to go home from Maui, but we told them the wrong time to pick us up, so we improvised and walked across the street to the Kia Lani Hotel to catch a cab.
Boy, did we catch a cab. Our cabbie, Jack, was an older guy with white hair in a ponytail and a droopy white mustache. He told us as we left that he liked driving a taxi and was doing it on this Saturday so he be off next Saturday to watch an NBA playoffs double header.
His accent seemed familiar, so I asked him where he came from.
“Outside Philadelphia,” he said.
“Where?” I asked.
“Havertown,” he said.
“Where did you go to high school?” I asked.
“Haverford High,” he said.
“I went to Lower Merion,” I said.
Jack observed that Kobe had gone to Lower Merion, and I assured him that Kobe had learned that crossover move as a legacy from yours truly.
So here we were, 5,000 miles from our mutual original homes, running into each other by chance and finding we went to adjoining, rival high schools. And it seemed that we were both basketball fans, which is not so strange if you come from Philadelphia. (One of my college roommates from Braintree, Massachusetts, didn’t believe us about Philadelphia basketball mania until he came to Philly for a holiday and saw a hoop behind each house and kids walking down the street bouncing a basketball. He capitulated.)
So we had the best time ever talking Philadelphia basketball to each other, Ann watching and listening bemusedly. What is reminiscing about basketball? It’s really a panoply of names, each conveying the physical image, the moves, sometime the games, and an intensity of feeling. Plus personal encounters if they occurred. Talk to me about Philadelphia basketball and it won’t be long until I mention the great Guy Rogers, my hero. How I loved Guy Rogers from the time he was a sophomore at Temple, and then into the pros with the Warriors! God, I thought, I wished, I truly believed he was better than Bob Cousy!! I wrote my greatest freshman year paper “Mr. Basketball, or Why I Hate Bob Cousy” and to this day am convinced that Cousy was ordinary, and that adding Russell to the Celtics was the crucial move, and other guards could have done what Cousy did.
But I digress. I did not leave out in my conversation with Jack that I was in a car on a pretty summer day with Larry Ring when Guy Rogers came off the court at Narberth Playground and said to us, “I want to buy that car!” My God, I said, that’s Guy Rogers! A signature moment of my life. And Jack knew about Narberth Playground, he had played there, and it was just three blocks down the hill from my house.
First Jack and I covered the pros – names, names. Arizin, Johnston, Wilt of course, even Joe Fulks. He passed my test – he knew who Fulks was, and knew he had a jumper. We hit the Big Five college names, every one. Temple, Penn, LaSalle, Villanova, St. Joe’s. Rogers, Lear, Van Patten. Ernie Beck, Sid Amira, McCloskey. Tom Gola. Walli Jones. Goukas and Dr. Jack. Stories, moves, years.
We even hit high school. The Chester teams – he said “Jerry,” I said “Foster, and his brother Billy.” Granville Lash and Emerson Baynard. I told him how we beat Chester when Bob Campbell hit 8 of 10 outside shots before he got a concussion. Mark Dumars from Western Pennsylvania and the 1958 high school state finals.
And then the unbelievable finale. His late ex-wife came from Reading. “Reading,” I said, “Home of my first girlfriend, and the home of beer, pretzels, vice, and Albright College.” “Actually,” I said, “The guard on our high school team went to Albright and played ball, Norman Ruttenberg.” Now, this is the most obscure fact in the known world. But Jack responded, “Ah, Dr. Norm!”
So, as I say, 5,000 miles from home, two very different guys, him from Lackawanna College after a year on an oil tanker to make some money, me a Harvard doctor, and here we were, best friends. We did sneak in some personal stuff. My tenure with the Harvard JV’s and our 23-0 junior year when we beat our own varsity three out of four times. His basketball scholarship to Penn if only he could have qualified academically. Not to mention that he lived in an apartment house a floor down from Billy Cunningham and would run with them if they were a man short. His two artificial knees that are working great. My three knee operations and artificial hip. Hey, the ravages of war.
We reached the airport and he said how short the trip had been, and he said it was the best ride he’s ever had. I said “Me, too.” We took his card. I’ll call him. Maybe we can go to the Maui Invitational together. It would be real fun.
I knew Ann loved it. So I asked her, “What were you thinking while we were talking.”
She said, “I was thinking, when is Budd going to stop talking with taxi drivers?”
She’s so funny.
Budd Shenkin
Boy, did we catch a cab. Our cabbie, Jack, was an older guy with white hair in a ponytail and a droopy white mustache. He told us as we left that he liked driving a taxi and was doing it on this Saturday so he be off next Saturday to watch an NBA playoffs double header.
His accent seemed familiar, so I asked him where he came from.
“Outside Philadelphia,” he said.
“Where?” I asked.
“Havertown,” he said.
“Where did you go to high school?” I asked.
“Haverford High,” he said.
“I went to Lower Merion,” I said.
Jack observed that Kobe had gone to Lower Merion, and I assured him that Kobe had learned that crossover move as a legacy from yours truly.
So here we were, 5,000 miles from our mutual original homes, running into each other by chance and finding we went to adjoining, rival high schools. And it seemed that we were both basketball fans, which is not so strange if you come from Philadelphia. (One of my college roommates from Braintree, Massachusetts, didn’t believe us about Philadelphia basketball mania until he came to Philly for a holiday and saw a hoop behind each house and kids walking down the street bouncing a basketball. He capitulated.)
So we had the best time ever talking Philadelphia basketball to each other, Ann watching and listening bemusedly. What is reminiscing about basketball? It’s really a panoply of names, each conveying the physical image, the moves, sometime the games, and an intensity of feeling. Plus personal encounters if they occurred. Talk to me about Philadelphia basketball and it won’t be long until I mention the great Guy Rogers, my hero. How I loved Guy Rogers from the time he was a sophomore at Temple, and then into the pros with the Warriors! God, I thought, I wished, I truly believed he was better than Bob Cousy!! I wrote my greatest freshman year paper “Mr. Basketball, or Why I Hate Bob Cousy” and to this day am convinced that Cousy was ordinary, and that adding Russell to the Celtics was the crucial move, and other guards could have done what Cousy did.
But I digress. I did not leave out in my conversation with Jack that I was in a car on a pretty summer day with Larry Ring when Guy Rogers came off the court at Narberth Playground and said to us, “I want to buy that car!” My God, I said, that’s Guy Rogers! A signature moment of my life. And Jack knew about Narberth Playground, he had played there, and it was just three blocks down the hill from my house.
First Jack and I covered the pros – names, names. Arizin, Johnston, Wilt of course, even Joe Fulks. He passed my test – he knew who Fulks was, and knew he had a jumper. We hit the Big Five college names, every one. Temple, Penn, LaSalle, Villanova, St. Joe’s. Rogers, Lear, Van Patten. Ernie Beck, Sid Amira, McCloskey. Tom Gola. Walli Jones. Goukas and Dr. Jack. Stories, moves, years.
We even hit high school. The Chester teams – he said “Jerry,” I said “Foster, and his brother Billy.” Granville Lash and Emerson Baynard. I told him how we beat Chester when Bob Campbell hit 8 of 10 outside shots before he got a concussion. Mark Dumars from Western Pennsylvania and the 1958 high school state finals.
And then the unbelievable finale. His late ex-wife came from Reading. “Reading,” I said, “Home of my first girlfriend, and the home of beer, pretzels, vice, and Albright College.” “Actually,” I said, “The guard on our high school team went to Albright and played ball, Norman Ruttenberg.” Now, this is the most obscure fact in the known world. But Jack responded, “Ah, Dr. Norm!”
So, as I say, 5,000 miles from home, two very different guys, him from Lackawanna College after a year on an oil tanker to make some money, me a Harvard doctor, and here we were, best friends. We did sneak in some personal stuff. My tenure with the Harvard JV’s and our 23-0 junior year when we beat our own varsity three out of four times. His basketball scholarship to Penn if only he could have qualified academically. Not to mention that he lived in an apartment house a floor down from Billy Cunningham and would run with them if they were a man short. His two artificial knees that are working great. My three knee operations and artificial hip. Hey, the ravages of war.
We reached the airport and he said how short the trip had been, and he said it was the best ride he’s ever had. I said “Me, too.” We took his card. I’ll call him. Maybe we can go to the Maui Invitational together. It would be real fun.
I knew Ann loved it. So I asked her, “What were you thinking while we were talking.”
She said, “I was thinking, when is Budd going to stop talking with taxi drivers?”
She’s so funny.
Budd Shenkin
Saturday, April 30, 2011
Was Hank a Dinosaur?
I have to say I'm absolutely struck by the heartfelt comments on my post about Hank. So I'm wondering, was Hank a dinosaur?
That is, he was in private solo practice. He was with a couple of groups before he went solo - don't know what the story was there, but he finally found himself in a small office by himself and had never been happier. Nothing between him and his patients, except insurance, but he didn't grouse about that.
Medical sociology, mostly Eliot Friedson in his great tome Profession of Medicine, looked at groups of doctors, mostly large groups in New York. He said that the more you are in a group, the more you look for consensual validation from your peers - that is, other doctors - and the less you look to your patients to validate your work and you as a person. I would imagine that the more administration there is, the more you look for validation from the administrators, the more you want to be like them (every doctor I know thinks that administrators have a sweet deal - little do they know). So with larger institutions patients are less patients and the more customers or even consumers.
Maybe I'm wrong. Maybe when a Kaiser doctor leaves the scene for whatever reason, patients feel bereft. Or maybe they shouldn't feel bereft, so personally deserted. Maybe they should feel that there is another one just behind him or her, waiting to take their place. I remember in Sweden when I would talk to people about the impersonality of the polyclinics, some of them said, but isn't that what you want, objective opinions?
But for myself I can't think that medicine should be anything but a real person to person enterprise. Our group, Bayside, is large by Bay Area standards - about 35 clinicians in 10 offices. But the offices are small, intentionally, not one stop shopping but rather pearls on a string. I think my job is to make sure we retain the ideals that Hank personified. We'll see if it's possible - I think it is. The culture comes from the top, they say, and I think everyone knows where I stand. With the dinosaurs.
Budd Shenkin
That is, he was in private solo practice. He was with a couple of groups before he went solo - don't know what the story was there, but he finally found himself in a small office by himself and had never been happier. Nothing between him and his patients, except insurance, but he didn't grouse about that.
Medical sociology, mostly Eliot Friedson in his great tome Profession of Medicine, looked at groups of doctors, mostly large groups in New York. He said that the more you are in a group, the more you look for consensual validation from your peers - that is, other doctors - and the less you look to your patients to validate your work and you as a person. I would imagine that the more administration there is, the more you look for validation from the administrators, the more you want to be like them (every doctor I know thinks that administrators have a sweet deal - little do they know). So with larger institutions patients are less patients and the more customers or even consumers.
Maybe I'm wrong. Maybe when a Kaiser doctor leaves the scene for whatever reason, patients feel bereft. Or maybe they shouldn't feel bereft, so personally deserted. Maybe they should feel that there is another one just behind him or her, waiting to take their place. I remember in Sweden when I would talk to people about the impersonality of the polyclinics, some of them said, but isn't that what you want, objective opinions?
But for myself I can't think that medicine should be anything but a real person to person enterprise. Our group, Bayside, is large by Bay Area standards - about 35 clinicians in 10 offices. But the offices are small, intentionally, not one stop shopping but rather pearls on a string. I think my job is to make sure we retain the ideals that Hank personified. We'll see if it's possible - I think it is. The culture comes from the top, they say, and I think everyone knows where I stand. With the dinosaurs.
Budd Shenkin
Monday, April 11, 2011
Welcome Back Budd
I have been neglecting my readers, and myself, by not posting lo these many weeks. Unlike a columnist, I don't have to churn them out and can lay fallow at times. I hope that's what I've been doing, fallowing. I've been distracted. Two trips to Chicago for AAP meetings, losing my wallet (and having it found) on one trip, losing my favorite belt in the scanning machine when I forgot it and discovered the fact too late when my pants were falling down. Many activities at the Goldman School of Public Policy where we hosted former Senator Bob Graham last week, and then health economist and Obama advisor David Cutler - first time I met him. Losing my Kindle. Worrying about good friend Bob with two heart attacks, my good friend and neighbor obstetrician Hank, who delivered my step-granddaughter with a midnight house call, with recurrent melanoma. As my friend Michael says, as you get older, there is no Yellow Brick Road, you just keep doing what you have always done, coping. Sigh.
Also, there is the tyranny of success. I have been so pleased to get positive responses about my blog from people I respect that I don't want to pollute my product with mediocre posts. Easy enough to do. It can be a killer. One of our employees, after years of underproduction, met with our new Administrator and began to do really well. They then went out with anxiety, and their stupid doctor recommended rest - like a pill, rest. Idiot! The employee finally does well and collapses with anxiety? What about some counseling to make it possible for them to continue to do well, and not worry if they can keep it up? Doctors. Kaiser. Idiots.
OK, so with this prolonged intro, here's my post on health care, my now and forever topic.
Our system of health care sucks. Everyone knows that. Here is another detailed complaint from a primary care doc at the Mass General (sine she is at Mecca, anything that happens must be someone else’s fault.) Then a comment from my friend pediatrician Jon Caine, and finally trenchant comments from me.
A Waste of Money
By Katharine Treadway
Last week, a patient I have known for several years called my office and spoke to my nurse. She said that while she was driving, her vision had gone blank for one second and then she was fine. My schedule was already overbooked: almost all of the slots were filled with patients with the usual array of multiple chronic medical problems for follow up and management of what were, for the most part, stable conditions. Thus my nurse sent her to Urgent Care, a unit set up so that patients can be seen quickly for acute medical problems rather than being sent to the emergency room. The necessity for such a system has developed gradually as the burden of prevention, chronic care, documentation, and paperwork has eroded the flexibility of many internists to squeeze in the extra patient who has an acute problem. The result of this system is that paradoxically, I see my patients when they are well or stable and urgent care sees them when they are sick; the reverse of what should happen. The cost of such a system can be significant, as this story illustrates.
The nurse practitioner who saw my patient in Urgent Care sent her to the emergency room for evaluation of a transient ischemic attack (TIA, characterized by passing stroke-like symptoms) despite the fact that a symptom lasting 1-2 seconds does not fit any definition of a TIA. Once in the emergency room, she was seen by the medical service and then the neurology service who, not surprisingly, ordered magnetic resonance imaging tests which, also not surprisingly, were entirely normal. She was sent home after several hours with instructions to follow up with her primary care physician.
I saw her a few days later and carefully reviewed her history which confirmed the story of a 1-2 second white-out of her entire visual field bilaterally which resolved with complete visual clarity in the time it took to blink. She had no preceding symptoms: no heart palpitations, no lightheadedness, no other focal neurological symptoms. Except for a burst of anxiety, she felt entirely well after the episode and has remained so.
I thought about the close to $10,000 that had been spent ruling out a serious cause of her symptoms. If I had been able to see her, would it have made a difference in her management? I believe it would have for two reasons. After listening to her story in detail, I was confident this was not a significant neurologic event. Because she knows and trusts me, I was able to reassure her with my opinion (which interestingly the normal scans had not been able to accomplish). But equally importantly, because I knew her well, I was willing to take responsibility for my decision. One of the hallmarks of being a primary care physician is to be comfortable with uncertainty. We learn to trust our clinical judgment and not jump to ordering expensive tests “just to be sure.” It is hard to accept the responsibility of decisions when the patient is unknown to you.
It is clear that we need to redesign primary care so that we can see our patients when they are sick, not just when they are well. The medical home is one such model and there are undoubtedly others but whatever the design, it cannot be assumed that medical personnel are interchangeable. The knowledge of a patient gained over years coupled with the trust such a relationship builds for both the doctor and the patient are essential components of cost-effective medical care.
Katharine Treadway, MD is a primary care physician at Massachusetts General Hospital who teaches at Harvard Medical School.
---------------------
Jonathan Caine MD says:
The sequence of events you describe was completely predictable once you made the decision to “turf” the patient to the Urgent Care Center. What your patient experienced was a sequence of defensive medicine decisions. First, the NP was not able to correctly diagnose the patient was not having a TIA. (Those bureaucrats who believe that NPs will save the “system” money because they are paid less for providing services, please take note.) She in turn “turfed” the patient to the ED, who then “turfed” her to neurology. Neurology did what neurology consultants do, that is, order MRIs (and occasionally EEGs). The fact is no one gets sued for ordering too many tests. The number one cause of malpractice suits these days – failure to diagnose. Would the medical home model have prevented this as you surmised? Doubtful. You could have had the highest level of NCQA Certified Medical Home, but if you were fully booked and couldn’t see the patient that day the same outcome would have occurred. If you were truly confident in your impression that she did not have a TIA, you never would have referred her to the Urgent Care Center in the first place. So, your decision was defensive medicine as well. Until we have legitimate tort reform in this state these types of cases will continue to occur on a daily basis in Massachusetts.
Jonathan Caine MD, Pediatrician
• Kate Treadway says:
You are absolutely correct about the problem of defensive decision making and that is the point of my blog – that, as primary care doctors who know our patients, we are much more willing to accept responsibility for these types of decisions. My nurse sent the patient to urgent care without my input so I was not part of that decison making process. However, I also heartily agree that tort reform is absolutely necessary if we are to change medical care and medical costs. Thanks so much
And now, breathless reader, my own comments:
She thinks the problem is "the system," a vague designation. You, Jon, think the problem is defensive medicine. I agree. But although both are correct, I think we should look further.
First, let's not forget incompetence. Was the NP generically over-matched -- that is, no NP could make this diagnosis, and only a doctor could -- or was she as a professional not up to the job?
Then the ER - why could they not deal with this? Not sharp enough?
Then the neurologist. Is the primary care doc smarter than the neurologist in his or her own specialty? Or were they mindless?
So, yes, certainly defensive medicine and the fear of lawsuits pressure all of us in practice. But then there is competence or the lack thereof and courage of convictions.
However -- having said that -- the "system" will not reward any of these professionals who saw the patient for their abstemiousness. No way. So why try if your only reward will be your own knowledge of what you have done? It's not enough.
But then, why has this primary care doctor so overbooked her day that she does not have the capacity to see an acutely ill patient? Why has she set up her practice this way? She blames others, but why? We have the same mix of pre-scheduled and acute patients in pediatrics, and we make sure we have enough capacity every day to see anyone who calls in.
Perhaps the issue is payment. Because we build in the capacity to see patients who might or might not call, we sometimes have unused capacity. We therefore make less money than we might otherwise. If primary care adult doctors had higher payments and thus had more money to play with, perhaps they could do the same thing.
But one still has to ask, why is her practice set up this way, with an urgent care center somewhere else? Wouldn't it make sense for her to have a group practice where they had an urgent care center right on their premises? Wouldn't it make sense for her to employ some nurse practitioners or physician assistants to see some of her regular patients for some of their visits, allowing her to see some of the more difficult patients -- our patient in question -- when warranted? It would be better medicine, and the partners in the practice would make a little more money.
Our physician corps does have many entrepreneurial members, and being entrepreneurs, they often look for the biggest payoff, which is available in areas other than primary care. The entrepreneurs thrive in areas with surgical interventions, or radiological interventions, or some such -- that's what our system pays for. But still, our primary care physicians can build systems that serve patients better and make themselves a little bit of money in the process.
So, yes, it's the system. But this primary care doc let's herself off too easily. Better to ask, "Why have I not set up my practice so that I can serve my patients better?"
And finally from Jon:
“I agree completely that the problem lies with the doctor herself and the way she is scheduling her office visits. I sort of implied that with the term "turf". I didn't want to continue to bash her so as not be accused of assault.”
Budd Shenkin
Also, there is the tyranny of success. I have been so pleased to get positive responses about my blog from people I respect that I don't want to pollute my product with mediocre posts. Easy enough to do. It can be a killer. One of our employees, after years of underproduction, met with our new Administrator and began to do really well. They then went out with anxiety, and their stupid doctor recommended rest - like a pill, rest. Idiot! The employee finally does well and collapses with anxiety? What about some counseling to make it possible for them to continue to do well, and not worry if they can keep it up? Doctors. Kaiser. Idiots.
OK, so with this prolonged intro, here's my post on health care, my now and forever topic.
Our system of health care sucks. Everyone knows that. Here is another detailed complaint from a primary care doc at the Mass General (sine she is at Mecca, anything that happens must be someone else’s fault.) Then a comment from my friend pediatrician Jon Caine, and finally trenchant comments from me.
A Waste of Money
By Katharine Treadway
Last week, a patient I have known for several years called my office and spoke to my nurse. She said that while she was driving, her vision had gone blank for one second and then she was fine. My schedule was already overbooked: almost all of the slots were filled with patients with the usual array of multiple chronic medical problems for follow up and management of what were, for the most part, stable conditions. Thus my nurse sent her to Urgent Care, a unit set up so that patients can be seen quickly for acute medical problems rather than being sent to the emergency room. The necessity for such a system has developed gradually as the burden of prevention, chronic care, documentation, and paperwork has eroded the flexibility of many internists to squeeze in the extra patient who has an acute problem. The result of this system is that paradoxically, I see my patients when they are well or stable and urgent care sees them when they are sick; the reverse of what should happen. The cost of such a system can be significant, as this story illustrates.
The nurse practitioner who saw my patient in Urgent Care sent her to the emergency room for evaluation of a transient ischemic attack (TIA, characterized by passing stroke-like symptoms) despite the fact that a symptom lasting 1-2 seconds does not fit any definition of a TIA. Once in the emergency room, she was seen by the medical service and then the neurology service who, not surprisingly, ordered magnetic resonance imaging tests which, also not surprisingly, were entirely normal. She was sent home after several hours with instructions to follow up with her primary care physician.
I saw her a few days later and carefully reviewed her history which confirmed the story of a 1-2 second white-out of her entire visual field bilaterally which resolved with complete visual clarity in the time it took to blink. She had no preceding symptoms: no heart palpitations, no lightheadedness, no other focal neurological symptoms. Except for a burst of anxiety, she felt entirely well after the episode and has remained so.
I thought about the close to $10,000 that had been spent ruling out a serious cause of her symptoms. If I had been able to see her, would it have made a difference in her management? I believe it would have for two reasons. After listening to her story in detail, I was confident this was not a significant neurologic event. Because she knows and trusts me, I was able to reassure her with my opinion (which interestingly the normal scans had not been able to accomplish). But equally importantly, because I knew her well, I was willing to take responsibility for my decision. One of the hallmarks of being a primary care physician is to be comfortable with uncertainty. We learn to trust our clinical judgment and not jump to ordering expensive tests “just to be sure.” It is hard to accept the responsibility of decisions when the patient is unknown to you.
It is clear that we need to redesign primary care so that we can see our patients when they are sick, not just when they are well. The medical home is one such model and there are undoubtedly others but whatever the design, it cannot be assumed that medical personnel are interchangeable. The knowledge of a patient gained over years coupled with the trust such a relationship builds for both the doctor and the patient are essential components of cost-effective medical care.
Katharine Treadway, MD is a primary care physician at Massachusetts General Hospital who teaches at Harvard Medical School.
---------------------
Jonathan Caine MD says:
The sequence of events you describe was completely predictable once you made the decision to “turf” the patient to the Urgent Care Center. What your patient experienced was a sequence of defensive medicine decisions. First, the NP was not able to correctly diagnose the patient was not having a TIA. (Those bureaucrats who believe that NPs will save the “system” money because they are paid less for providing services, please take note.) She in turn “turfed” the patient to the ED, who then “turfed” her to neurology. Neurology did what neurology consultants do, that is, order MRIs (and occasionally EEGs). The fact is no one gets sued for ordering too many tests. The number one cause of malpractice suits these days – failure to diagnose. Would the medical home model have prevented this as you surmised? Doubtful. You could have had the highest level of NCQA Certified Medical Home, but if you were fully booked and couldn’t see the patient that day the same outcome would have occurred. If you were truly confident in your impression that she did not have a TIA, you never would have referred her to the Urgent Care Center in the first place. So, your decision was defensive medicine as well. Until we have legitimate tort reform in this state these types of cases will continue to occur on a daily basis in Massachusetts.
Jonathan Caine MD, Pediatrician
• Kate Treadway says:
You are absolutely correct about the problem of defensive decision making and that is the point of my blog – that, as primary care doctors who know our patients, we are much more willing to accept responsibility for these types of decisions. My nurse sent the patient to urgent care without my input so I was not part of that decison making process. However, I also heartily agree that tort reform is absolutely necessary if we are to change medical care and medical costs. Thanks so much
And now, breathless reader, my own comments:
She thinks the problem is "the system," a vague designation. You, Jon, think the problem is defensive medicine. I agree. But although both are correct, I think we should look further.
First, let's not forget incompetence. Was the NP generically over-matched -- that is, no NP could make this diagnosis, and only a doctor could -- or was she as a professional not up to the job?
Then the ER - why could they not deal with this? Not sharp enough?
Then the neurologist. Is the primary care doc smarter than the neurologist in his or her own specialty? Or were they mindless?
So, yes, certainly defensive medicine and the fear of lawsuits pressure all of us in practice. But then there is competence or the lack thereof and courage of convictions.
However -- having said that -- the "system" will not reward any of these professionals who saw the patient for their abstemiousness. No way. So why try if your only reward will be your own knowledge of what you have done? It's not enough.
But then, why has this primary care doctor so overbooked her day that she does not have the capacity to see an acutely ill patient? Why has she set up her practice this way? She blames others, but why? We have the same mix of pre-scheduled and acute patients in pediatrics, and we make sure we have enough capacity every day to see anyone who calls in.
Perhaps the issue is payment. Because we build in the capacity to see patients who might or might not call, we sometimes have unused capacity. We therefore make less money than we might otherwise. If primary care adult doctors had higher payments and thus had more money to play with, perhaps they could do the same thing.
But one still has to ask, why is her practice set up this way, with an urgent care center somewhere else? Wouldn't it make sense for her to have a group practice where they had an urgent care center right on their premises? Wouldn't it make sense for her to employ some nurse practitioners or physician assistants to see some of her regular patients for some of their visits, allowing her to see some of the more difficult patients -- our patient in question -- when warranted? It would be better medicine, and the partners in the practice would make a little more money.
Our physician corps does have many entrepreneurial members, and being entrepreneurs, they often look for the biggest payoff, which is available in areas other than primary care. The entrepreneurs thrive in areas with surgical interventions, or radiological interventions, or some such -- that's what our system pays for. But still, our primary care physicians can build systems that serve patients better and make themselves a little bit of money in the process.
So, yes, it's the system. But this primary care doc let's herself off too easily. Better to ask, "Why have I not set up my practice so that I can serve my patients better?"
And finally from Jon:
“I agree completely that the problem lies with the doctor herself and the way she is scheduling her office visits. I sort of implied that with the term "turf". I didn't want to continue to bash her so as not be accused of assault.”
Budd Shenkin
Sunday, February 13, 2011
Dcotors and Nurse Practitioners
There is a vigorous discussion in medical care organization policy circles on the role of physicians, and the role of “advanced practice nurses” and physician assistants. How much can the role of the doctor be played by these so-called midlevel practitioners? In practices headed by physicians, midlevels already thrive. But the recent ACA legislation has succumbed to the nursing lobby and granted money for independent nurse practitioner clinics where physicians would not be present.
I present here a discussion from our American Academy of Pediatrics administrative listserve that I found interesting. You can’t make these arguments persuasively without looking closely at what actually happens, and what people in the field find. In this listserve exchange we hear first from Seth Kaplan, pediatrician in Texas, on his day where he had to exercise a great deal of his physician prowess. What would a nurse practitioner have done with these patients? Jon Caine of Massachusetts answers puckishly. Finally, David Horowitz of North Carolina makes the case (which I have shortened) that some docs couldn’t have handled this case load as well as Seth did, but that some nurse practitioners could have given it a pretty good shot. David points out, rightly, that a person is not totally defined by his or her training.
First, Seth:
There's been a lot of talk on the listserv about the possibility of mid-level providers replacing general pediatricians over time. I'm sure most of you have had similar days, but this is a synopsis of my day today:
The normal well checks and sick checks, dominated by gastro and a febrile illness without much of a source, with fevers to 103-104 lasting 4 to 6 days.
A 4 month well check with a very depressed mom.
A new sick patient with fever, who, oh by the way, has adrenal insufficiency, growth hormone deficiency, thyroid dysfunction, and some unidentified underlying disorder.
One of the kids with high fever for several days who had some small lymph nodes and mom has been convinced he must have cancer and will no leave without getting a cbc done and the cbc has an ANC of 700 (probable viral suppression - kid otherwise looks good, but we will be rechecking counts).
An 11 year old with poorly controlled asthma due to parental non-compliance and poor understanding who I ended up having to admit.
A well 7 year old with the "oh, by the way, I'm concerned about inattentive ADD".
A teen brought in for concerns about weight loss, "not looking well for 3 months, does he have diabetes?"
A child with arthyrogryposis with growth patterns that are difficult to make heads or tails of.
The sick kid with gastro amongst many who only came in because they wanted Zofran, but their exam sure seemed a lot more like appendicitis and it took 20 minutes to convince the mom that we really did need to image, check labs and get a surgical consult despite the fact in would involve a needle stick and maybe an IV, because "if she doesn't have appendicitis, I don't want her unnecessarily stuck"
The new well visit with an adopted kid who is a victim of sexual abuse both by her birth parents and multiple foster families, who exhibits signs of PTSD and major behavioral problems.
One of the kids with the high fever thing whose mom took him to Minute Clinic after school 3 days ago because "it was right next door" and the NP told them that "she was going to stop taking the temperature because it went up every time they took it and if it is above 103, we have to refer him out."
All of this in ONE DAY. Would love to see a "mid-level provider" handle it all.
Don't really have a question, just venting and thinking that we do is awfully challenging. We should be proud to be general pediatricians and continue to fight for our role in the healthcare system.
Seth D. Kaplan, MD, FAAP
Frisco, TX
Now, Jon’s reflection on Seth’s day (note the increased costs the nurse practitioner’s actions would entail):
No one is saying that PNPs will be effective or even cost-effective replacements for pediatricians. But, as long as Scope of Practice laws continue to be passed allowing independent practice in states where the politicians "think" they will save money, it will continue to progress. How would a PNP in independent practice handle your day?
1. Normal well/sick visits - Piece of cake
2. Depressed Mom - Refer to psych
3. Multiple Endo Pt - Refer to Endo
4. Neutropenia - Turf to Tertiary Children's Hospital ED for workup
5. Asthma Exacerbation - Turf to Local Hospitalist or Children's Tertiary
6. ?ADD - Refer to Pedi Neuro - 4-6 month waiting list
7. Teen with weight loss - Back to Children's Hospital ED
8. Arthrogryposis - Refer to Genetics & Endo
9. R/O Appendicitis - Give Zofran. "If pain worsens go to ED".
10. PTSD - "Call your insurance plan for psychiatrist who is participating in their closed panel".
11. Minute Clinic kid with fever and shockingly no antibiotics - Rx: Antibiotics
12. Lunch Break
Jon Caine MD
Tongue somewhat firmly in cheek.
A quick note from Jeff Couchman of Arizona:
Actually, I think many of the people who are changing scope of practice laws actually ARE saying the PNPs will be effective and cost-effective replacements for pediatricians…
Jeff Couchman, MD
And finally, from David Horowitz (edited):
I have worked with a PNP who could handle all (all right, most) of those kids appropriately. I have worked with real board certified pediatricians who would have handled this list the same way listed (by Jon), or even worse, attempted to treat the complicated kids and do it wrong. IMHO, one of the key attributes of being a good doctor or provider of health care is to know what you don’t know but know where to find the answer to those questions you don’t know. The bad docs I’ve worked with didn’t know that they were doing the wrong thing for their patients. All of the NPs I have hired have freely come to me with questions when they didn’t know the answers and asked very appropriate questions. That is because the structure I provided in my office meant that the NP was never there alone.
The question of the role of NPs is a lot more complicated than “should they replace us”. The first PNP I hired was one of the smartest people I’ve ever met. She was competent enough to work sick call on evening hours by herself and I never felt uncomfortable because I new she would call me if there were issues. She did more work in the running of the office than many hired doctors I have had. On the other hand, I have had an FNP work in my office who I felt I had to look at every ear to confirm if it was a real otitis or not.
…(It is important to note that) not all NPs are created equal and there are several training tracks: Pediatric, Adult, Family, and Neonatal. …There is no doubt in my mind that the ONLY qualified NPs to do any serious pediatric work are PNPs. Adult NPs have no training in kids at all, and FNPs are similar to Family Practice doctors in their training, and I see little to no role for them in seeing quantities of children.
(But) as good as some PNPs are, they are not doctor replacements, they are doctor extenders. While the laws may be structured so that the doctor doesn’t have to be physically present in the building to provide supervision (I am thinking of rural health centers here, not Minute Clinics), there MUST be a supervising pediatrician immediately available by phone. I am against totally independent practice without any MD supervision and this aspect is one area to focus our attention on legislation. I can also see different rules for rural health clinics where there is a lack of other qualified pediatrician services as defined by the government, and Minute Clinics, which are totally different in purpose and orientation.
David Horowitz
I present here a discussion from our American Academy of Pediatrics administrative listserve that I found interesting. You can’t make these arguments persuasively without looking closely at what actually happens, and what people in the field find. In this listserve exchange we hear first from Seth Kaplan, pediatrician in Texas, on his day where he had to exercise a great deal of his physician prowess. What would a nurse practitioner have done with these patients? Jon Caine of Massachusetts answers puckishly. Finally, David Horowitz of North Carolina makes the case (which I have shortened) that some docs couldn’t have handled this case load as well as Seth did, but that some nurse practitioners could have given it a pretty good shot. David points out, rightly, that a person is not totally defined by his or her training.
First, Seth:
There's been a lot of talk on the listserv about the possibility of mid-level providers replacing general pediatricians over time. I'm sure most of you have had similar days, but this is a synopsis of my day today:
The normal well checks and sick checks, dominated by gastro and a febrile illness without much of a source, with fevers to 103-104 lasting 4 to 6 days.
A 4 month well check with a very depressed mom.
A new sick patient with fever, who, oh by the way, has adrenal insufficiency, growth hormone deficiency, thyroid dysfunction, and some unidentified underlying disorder.
One of the kids with high fever for several days who had some small lymph nodes and mom has been convinced he must have cancer and will no leave without getting a cbc done and the cbc has an ANC of 700 (probable viral suppression - kid otherwise looks good, but we will be rechecking counts).
An 11 year old with poorly controlled asthma due to parental non-compliance and poor understanding who I ended up having to admit.
A well 7 year old with the "oh, by the way, I'm concerned about inattentive ADD".
A teen brought in for concerns about weight loss, "not looking well for 3 months, does he have diabetes?"
A child with arthyrogryposis with growth patterns that are difficult to make heads or tails of.
The sick kid with gastro amongst many who only came in because they wanted Zofran, but their exam sure seemed a lot more like appendicitis and it took 20 minutes to convince the mom that we really did need to image, check labs and get a surgical consult despite the fact in would involve a needle stick and maybe an IV, because "if she doesn't have appendicitis, I don't want her unnecessarily stuck"
The new well visit with an adopted kid who is a victim of sexual abuse both by her birth parents and multiple foster families, who exhibits signs of PTSD and major behavioral problems.
One of the kids with the high fever thing whose mom took him to Minute Clinic after school 3 days ago because "it was right next door" and the NP told them that "she was going to stop taking the temperature because it went up every time they took it and if it is above 103, we have to refer him out."
All of this in ONE DAY. Would love to see a "mid-level provider" handle it all.
Don't really have a question, just venting and thinking that we do is awfully challenging. We should be proud to be general pediatricians and continue to fight for our role in the healthcare system.
Seth D. Kaplan, MD, FAAP
Frisco, TX
Now, Jon’s reflection on Seth’s day (note the increased costs the nurse practitioner’s actions would entail):
No one is saying that PNPs will be effective or even cost-effective replacements for pediatricians. But, as long as Scope of Practice laws continue to be passed allowing independent practice in states where the politicians "think" they will save money, it will continue to progress. How would a PNP in independent practice handle your day?
1. Normal well/sick visits - Piece of cake
2. Depressed Mom - Refer to psych
3. Multiple Endo Pt - Refer to Endo
4. Neutropenia - Turf to Tertiary Children's Hospital ED for workup
5. Asthma Exacerbation - Turf to Local Hospitalist or Children's Tertiary
6. ?ADD - Refer to Pedi Neuro - 4-6 month waiting list
7. Teen with weight loss - Back to Children's Hospital ED
8. Arthrogryposis - Refer to Genetics & Endo
9. R/O Appendicitis - Give Zofran. "If pain worsens go to ED".
10. PTSD - "Call your insurance plan for psychiatrist who is participating in their closed panel".
11. Minute Clinic kid with fever and shockingly no antibiotics - Rx: Antibiotics
12. Lunch Break
Jon Caine MD
Tongue somewhat firmly in cheek.
A quick note from Jeff Couchman of Arizona:
Actually, I think many of the people who are changing scope of practice laws actually ARE saying the PNPs will be effective and cost-effective replacements for pediatricians…
Jeff Couchman, MD
And finally, from David Horowitz (edited):
I have worked with a PNP who could handle all (all right, most) of those kids appropriately. I have worked with real board certified pediatricians who would have handled this list the same way listed (by Jon), or even worse, attempted to treat the complicated kids and do it wrong. IMHO, one of the key attributes of being a good doctor or provider of health care is to know what you don’t know but know where to find the answer to those questions you don’t know. The bad docs I’ve worked with didn’t know that they were doing the wrong thing for their patients. All of the NPs I have hired have freely come to me with questions when they didn’t know the answers and asked very appropriate questions. That is because the structure I provided in my office meant that the NP was never there alone.
The question of the role of NPs is a lot more complicated than “should they replace us”. The first PNP I hired was one of the smartest people I’ve ever met. She was competent enough to work sick call on evening hours by herself and I never felt uncomfortable because I new she would call me if there were issues. She did more work in the running of the office than many hired doctors I have had. On the other hand, I have had an FNP work in my office who I felt I had to look at every ear to confirm if it was a real otitis or not.
…(It is important to note that) not all NPs are created equal and there are several training tracks: Pediatric, Adult, Family, and Neonatal. …There is no doubt in my mind that the ONLY qualified NPs to do any serious pediatric work are PNPs. Adult NPs have no training in kids at all, and FNPs are similar to Family Practice doctors in their training, and I see little to no role for them in seeing quantities of children.
(But) as good as some PNPs are, they are not doctor replacements, they are doctor extenders. While the laws may be structured so that the doctor doesn’t have to be physically present in the building to provide supervision (I am thinking of rural health centers here, not Minute Clinics), there MUST be a supervising pediatrician immediately available by phone. I am against totally independent practice without any MD supervision and this aspect is one area to focus our attention on legislation. I can also see different rules for rural health clinics where there is a lack of other qualified pediatrician services as defined by the government, and Minute Clinics, which are totally different in purpose and orientation.
David Horowitz
Tuesday, February 8, 2011
My Son Peter - A Reminiscence
When Peter was small, he was really small. He was born small at 35 weeks gestation when Ann had HELPP Syndrome, which had yet to be described in the literature, so as her blood didn’t clot and her BP was up and her liver enzymes were up and she was very sick and went into labor at 35 weeks, we all weren’t sure what was happening. It turned out all right and Peter more than survived. But he was small. Today he is just a bit shorter than I am and all muscle and very athletic, but when he was younger he was small.
But smart and with an emotional IQ of 150 from the day he was born. Here he would be, about three feet tall, standing by the door and looking straight up at our friends and say, “How was your vacation?” People would say, is that a little kid, or is that a midget? And they would leave saying, “That kid is going to be President.”
But before that, Pete was small and very verbal as a three year old. Having older sibs was a big help because he acculturated readily, and made the expressions of others his own. He taught himself to read by taking baseball cards and finding out where they belonged in the scrap-book by comparing letters in the names. He had no hesitation in parroting. One day he turned over the telephone (let’s all date ourselves), saw the symbol and said, “AT&T – The Right Choice!” Big mouth, my parents would say.
So Ann had passed the bar, worked for a firm she didn’t particularly like, then went to work for a small firm she did like, and we invited the youngest partner and his wife over for dinner, and some lawyer patients of mine that I liked, and we had dinner. It was a nice time, and we were on our good behavior, as one would be in that circumstance. A nice dinner and nice talk as Ann and I tried to find ourselves in our new lives as young professionals.
As the dinner came to an end, who would provide the coup de grace? Peter, of course. So down the stairs he came, our little verbal cherub, as the dinner broke up and we all headed for the door. “Here’s Peter!” we exclaimed, and started to introduce him.
Pete walked down the stairs and surveyed the situation with his 150 emotional IQ. We were so proud, he was so darling. Then he spied in our front hall – we had five kids, after all – a parked bicycle. Well, that happens. But Pete was no doubt conscious of how this violated the image of the young lawyers. His visage clouded over, he became incensed, he approached the bike head on, he glared, he kicked the front tire, and with the impassioned heat of a violated host pronounced: “I told Brian to keep his fucking bike out of the hallway!”
I’m still laughing at Peter – and, I guess, at our little pretensions. I guess I could have sent it in to Reader’s Digest if it were a little less of a family magazine.
Budd Shenkin
But smart and with an emotional IQ of 150 from the day he was born. Here he would be, about three feet tall, standing by the door and looking straight up at our friends and say, “How was your vacation?” People would say, is that a little kid, or is that a midget? And they would leave saying, “That kid is going to be President.”
But before that, Pete was small and very verbal as a three year old. Having older sibs was a big help because he acculturated readily, and made the expressions of others his own. He taught himself to read by taking baseball cards and finding out where they belonged in the scrap-book by comparing letters in the names. He had no hesitation in parroting. One day he turned over the telephone (let’s all date ourselves), saw the symbol and said, “AT&T – The Right Choice!” Big mouth, my parents would say.
So Ann had passed the bar, worked for a firm she didn’t particularly like, then went to work for a small firm she did like, and we invited the youngest partner and his wife over for dinner, and some lawyer patients of mine that I liked, and we had dinner. It was a nice time, and we were on our good behavior, as one would be in that circumstance. A nice dinner and nice talk as Ann and I tried to find ourselves in our new lives as young professionals.
As the dinner came to an end, who would provide the coup de grace? Peter, of course. So down the stairs he came, our little verbal cherub, as the dinner broke up and we all headed for the door. “Here’s Peter!” we exclaimed, and started to introduce him.
Pete walked down the stairs and surveyed the situation with his 150 emotional IQ. We were so proud, he was so darling. Then he spied in our front hall – we had five kids, after all – a parked bicycle. Well, that happens. But Pete was no doubt conscious of how this violated the image of the young lawyers. His visage clouded over, he became incensed, he approached the bike head on, he glared, he kicked the front tire, and with the impassioned heat of a violated host pronounced: “I told Brian to keep his fucking bike out of the hallway!”
I’m still laughing at Peter – and, I guess, at our little pretensions. I guess I could have sent it in to Reader’s Digest if it were a little less of a family magazine.
Budd Shenkin
Sunday, January 16, 2011
The Great Steve Martin
I’ve always liked Steve Martin a lot, maybe loved him, not exactly putting me in a minority. Remember when he started? Everyone had a beard and was scruffy, but Martin looked like a regular button down guy with prematurely gray hair. “Why do you dress like that?” he was asked. “To be different,” he said, truthfully, with his trademark subtle irony, since of course the first scruffy guys wanted to be different, and then everyone else figured that was the way to do it. He was great, as everyone knew, that wild and crazy guy. My special favorite, the Christmas wishes monologue: (http://www.hulu.com/watch/116204/saturday-night-live-steve-martin-introduces-his-christmas-wish).
I had read some of this New Yorker articles. He could write! Then I read his autobiographical Born Standing Up. Great writing -- direct, vivid, truthful, excellent writing. The picture of him growing up seemed so authentic. He had worked so hard starting at the bottom. I particularly liked how he was different from me, since I was on the track of Ivy League, med school, etc., not just trying something you liked with no guarantee at all. Then I remember especially his recounting his triumphant one-man tour when every event was completely sold out. He trooped people out the door all together as part of the act at one point, amazingly. Then one day, he saw it. Way, way in the back of the balcony, there was an empty seat. He wondered if it would be filled a little later, but no, there was an empty seat. So I knew it was coming to an end, he said. His writing is so intimate that I felt I was his friend. That’s hard to do.
So, I just read his new novel, An Object of Beauty, which I think is just great. I’m prejudiced by loving him, but still, I think the book is great. Surprisingly to me, it reminds me of Richard Ford’s Independence Day, in which Ford’s protagonist, Frank Bascombe, is doing real estate, and the picture of the real estate business makes you understand what it’s like to be in that world. Ford said he hung around with real estate people a lot, just found himself doing it, before he wrote the book.
That’s what Steve does for the art-collecting world in New York. As an art collector himself he clearly knows the people and the business. As with the real estate business after reading Independence Day, I think I know a little something about the art-collecting world now, too.
I like the story, featuring Lucy Yeager, a very pretty girl who becomes upwardly mobile first at Sotheby’s, then with her own gallery, and who is not really likable at all. I read this the same week we saw The Social Network, which we liked, and which doesn’t have many if any likable characters at all. I found shades of sympathy with most of An Object of Beauty’s characters, but still, there was something in common with Social Network. Lust pervades both, money and sex, and at least in the book, beauty. The narrator, a guy who is a friend of Lacey’s and who becomes an art writer, is sympathetic. Some are more and some less sympathetic, and all are real, at least those in the constant trade winds of the art world. They either lust after art, or they are in the business of servicing those who have that lust. You will have noticed that the title is a double entendre, some lusting after art, some after Lacey, many after both. And maybe that’s almost the same thing.
What’s it like to be lusted after all your life, to be an object of beauty? That’s Lacey. She knows she is lusted after by most men she meets – that’s us, men! – so she uses it, and has contempt for those who continue to be used by it. Boy, does she use it. When she rides her bike with a halter top and shorts, she listens behind her for the metal clank of bikes crashing as, she imagines, boys and men are looking at her. I guess this is what many beautiful and sexy women deal with – it’s probably hard to do, to figure out who loves you and who is simply lusting for you. Most people probably feel, as with great wealth, I know there are problems, but I wouldn’t mind that challenge. At the end she has a long affair with an FBI agent, the only one she knows below her station, who she always calls “Agent,” and who she loves because he never tells her he loves her.
It’s interesting that Steve has this agent look at a painting he likes – his line is not art appreciation but following art theft, so if he likes something it’s from a very unprofessional view – and he tells Lacey it might be symbolic, explains what symbolic is (thank you, says Lacey), and then says the sea is reality, the sky is the dream, and art is trying to connect one to the other. Sounds like Steve to me.
Steve writes really good sentences. He writes with structure. We hear it referred to that Lacey came into money, and we think, she did? Did I miss exactly how that happened? But it pops up later. The story doesn’t bog down for a minute, and I like his short chapters. I didn’t want the book to end, but still, when I would look ahead and see that it was only a couple of pages, especially since I’m having some trouble with my eyes, it would be a relief. Steve might have started as a showman, but he is a writer, in every good sense of the word. He is a very good writer, and I’m so glad he is.
All of which reminded me of my brush with the art world. It was 1970 and I was in graduate school at Berkeley, my first wife Mary Jane was an undergrad at Mills College, and we lived at the corner of Arch and Hilgard, just a few blocks walk for me to school. She brought home a fellow student one day who lived just a block up the hill from us, a young lady who dressed in a peasant-type dress, I guess it was, and whose chest was very alluring. I was 29 years old and had as much testosterone as most guys that age, probably at the higher end of normal. Truthfully, I just couldn’t get over her chest just below the scoop neckline as we stood there. She was recently married to a guy who I met probably a few days later, it’s hard to remember the details, but I do remember it was hard to think of anything beyond this young woman’s chest, very hard. Anyway, I guess she and her young husband wanted to be friends. He was a nice enough guy on the small side. He was called Dicken, which in German meant little Dick, because he was junior to his father, whose name was Richard.
So, as part of getting to know each other, they said that Dicken’s father was an artist and did I want to meet him and see his studio? I pictured walking up to his house nearby, looking at the studio, who knows what boring stuff I would be faced with. So I demurred, we never became friends with this young couple, life went on, I never met the father. Face it, I was distracted.
And so it was that I never met Richard Diebencorn.
I am such an asshole.
Budd Shenkin
I had read some of this New Yorker articles. He could write! Then I read his autobiographical Born Standing Up. Great writing -- direct, vivid, truthful, excellent writing. The picture of him growing up seemed so authentic. He had worked so hard starting at the bottom. I particularly liked how he was different from me, since I was on the track of Ivy League, med school, etc., not just trying something you liked with no guarantee at all. Then I remember especially his recounting his triumphant one-man tour when every event was completely sold out. He trooped people out the door all together as part of the act at one point, amazingly. Then one day, he saw it. Way, way in the back of the balcony, there was an empty seat. He wondered if it would be filled a little later, but no, there was an empty seat. So I knew it was coming to an end, he said. His writing is so intimate that I felt I was his friend. That’s hard to do.
So, I just read his new novel, An Object of Beauty, which I think is just great. I’m prejudiced by loving him, but still, I think the book is great. Surprisingly to me, it reminds me of Richard Ford’s Independence Day, in which Ford’s protagonist, Frank Bascombe, is doing real estate, and the picture of the real estate business makes you understand what it’s like to be in that world. Ford said he hung around with real estate people a lot, just found himself doing it, before he wrote the book.
That’s what Steve does for the art-collecting world in New York. As an art collector himself he clearly knows the people and the business. As with the real estate business after reading Independence Day, I think I know a little something about the art-collecting world now, too.
I like the story, featuring Lucy Yeager, a very pretty girl who becomes upwardly mobile first at Sotheby’s, then with her own gallery, and who is not really likable at all. I read this the same week we saw The Social Network, which we liked, and which doesn’t have many if any likable characters at all. I found shades of sympathy with most of An Object of Beauty’s characters, but still, there was something in common with Social Network. Lust pervades both, money and sex, and at least in the book, beauty. The narrator, a guy who is a friend of Lacey’s and who becomes an art writer, is sympathetic. Some are more and some less sympathetic, and all are real, at least those in the constant trade winds of the art world. They either lust after art, or they are in the business of servicing those who have that lust. You will have noticed that the title is a double entendre, some lusting after art, some after Lacey, many after both. And maybe that’s almost the same thing.
What’s it like to be lusted after all your life, to be an object of beauty? That’s Lacey. She knows she is lusted after by most men she meets – that’s us, men! – so she uses it, and has contempt for those who continue to be used by it. Boy, does she use it. When she rides her bike with a halter top and shorts, she listens behind her for the metal clank of bikes crashing as, she imagines, boys and men are looking at her. I guess this is what many beautiful and sexy women deal with – it’s probably hard to do, to figure out who loves you and who is simply lusting for you. Most people probably feel, as with great wealth, I know there are problems, but I wouldn’t mind that challenge. At the end she has a long affair with an FBI agent, the only one she knows below her station, who she always calls “Agent,” and who she loves because he never tells her he loves her.
It’s interesting that Steve has this agent look at a painting he likes – his line is not art appreciation but following art theft, so if he likes something it’s from a very unprofessional view – and he tells Lacey it might be symbolic, explains what symbolic is (thank you, says Lacey), and then says the sea is reality, the sky is the dream, and art is trying to connect one to the other. Sounds like Steve to me.
Steve writes really good sentences. He writes with structure. We hear it referred to that Lacey came into money, and we think, she did? Did I miss exactly how that happened? But it pops up later. The story doesn’t bog down for a minute, and I like his short chapters. I didn’t want the book to end, but still, when I would look ahead and see that it was only a couple of pages, especially since I’m having some trouble with my eyes, it would be a relief. Steve might have started as a showman, but he is a writer, in every good sense of the word. He is a very good writer, and I’m so glad he is.
All of which reminded me of my brush with the art world. It was 1970 and I was in graduate school at Berkeley, my first wife Mary Jane was an undergrad at Mills College, and we lived at the corner of Arch and Hilgard, just a few blocks walk for me to school. She brought home a fellow student one day who lived just a block up the hill from us, a young lady who dressed in a peasant-type dress, I guess it was, and whose chest was very alluring. I was 29 years old and had as much testosterone as most guys that age, probably at the higher end of normal. Truthfully, I just couldn’t get over her chest just below the scoop neckline as we stood there. She was recently married to a guy who I met probably a few days later, it’s hard to remember the details, but I do remember it was hard to think of anything beyond this young woman’s chest, very hard. Anyway, I guess she and her young husband wanted to be friends. He was a nice enough guy on the small side. He was called Dicken, which in German meant little Dick, because he was junior to his father, whose name was Richard.
So, as part of getting to know each other, they said that Dicken’s father was an artist and did I want to meet him and see his studio? I pictured walking up to his house nearby, looking at the studio, who knows what boring stuff I would be faced with. So I demurred, we never became friends with this young couple, life went on, I never met the father. Face it, I was distracted.
And so it was that I never met Richard Diebencorn.
I am such an asshole.
Budd Shenkin
Subscribe to:
Posts (Atom)
