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Monday, July 12, 2010

Insurance companies

They are the bane of everyone's existance. I know.

But an evil thing that exists is this form called prior authorizations. You need it for procedures, medications, shots etc.

A doctor writes a prescription and the patient gladly goes to the pharmacy thinking "oh boy! I have drugs!" or "Oh boy, I will no longer be in so much pain that I want to kill myself". Whatever the case may be, the doctor deems a certain treatment plan will help the patient.

The insurance company will sometimes tell the pharmacist to tell us that we need a "prior authorization" that can either be approved or denied. It is basically a form stating a medical necessity. As if the prescription itself wasn't proof enough.

So the doctor and I fill out this stupid form and fax it back and sometimes, just SOMETIMES it gets approved.

I just wonder, however, why not prescribe a different drug? The thing I see most often is MassHealth patients being denied for a simple Lidoderm patch that is a topical pain reliever. Maybe there is no substitute, I don't know, I don't have an M.D. yet. But I've only been working here since late September and I know that MH and lidoderm never gets approved. So why would you prescribe this if you know the patient has masshealth. I write their insurance information on the person's chart when they come in. I don't understand.

Another instance is approving MRI's. I know that doctors order unnecessary costly tests now-a-days. We are a department full of specialists so these patients are here because a) people don't know what to do with them b) they are drugies and other departments won't appease them any longer c)they truly are in horendous amounts of pain. If they need an MRI they aren't fucking around. They need to see a patient's insides because old MRI films are out of date. The situation could change.

A person with a slipped disk could get worse and the doctor needs to know how much worse. When we screw around with Prior Authorizations, it takes up everyone's time. It takes 24 hours sometimes to get approval or more depending on lots of beaurocratic bullshit factors. If you've ever had a pinched nerve you'll know that waiting for that approval seems like eternity.

Second: shots and procedures. This is the one that boggles my mind the most. Fine, medications we'll proove to you that this patient needs it and you'll pay for it like a good little insurance company. Sometimes they will approve a botox injection procedure but not the botox medication itself. This is not for cosmetic purposes, the chief of this department gives botox shots to cerebral palsy, and muscular dystrophy patients to calm their muscle spasms. They are bound to a wheelchair and need 24 hour care, their quality of life depends on this medication.

How is it that an insurance company can approve the procedure and not the medication? It's not like the patient has a secondary insurance plan, it's all the same. The doctor might as well shoot a placebo into the patient.

If insurance companies are there for sick people and aren't helping the people that need coverage the most, what is the point? I don't know if this adds to the healthcare debate going on right now with this new bill, I haven't looked into it. I should.

Patients

The most fulfilling interactions with patients at my job are those where they never come back.

They no longer need appointments, they are no longer sick, and they are not on narcotic drugs.

But most of them don't get there. I've only been working at Tufts since late September and the majority suffer from chronic back, neck, hip, ass pain.

Also there are those patients with muscular dystrophy, stroke victims, cerebral palsy sufferers. They will always need our department and we can help; most of the time.

Their demeanor changes drastically from the time they enter the clinic to the time they leave. They are at ease even though they can't say it themselves.

This sounds cliche, I'm sure. I just see patients lost in the maze of this huge hospital and they've been re-directed by the operator, the nurse, the PA, the medical assistant. It is nice to find them the correct department, the right doctor, and obviously a successful treatment plan.

The parts of the job I hate the most are of course the bullshit, the paper pushing, the needles spats over mis-communication. Also misplaced anger. Most often this anger is directed at me, the person on the other end of the phone. I was not directly responsible for their incorrect dose on their prescription, I did not write down the wrong time of their MRI in their planner for them and most certainly I did not cancel their appointments.

I hate it when I see doctors fighting over the biggest room in which to see patients. There are practical concerns here, if all of the patients coming in are CP, MD patients then of course the biggest room is necessary for wheelchair accessibility. Otherwise, I laugh with my co-workers at how juvenile doctors behave.

Most of all I hate it when interdepartmental cooperation does not happen and a patient does not get their appointment. I am waiting on an appointment from a different department. It's a routine test to rule out a nerve problem and it hasn't been made. One would think that because I work in a hospital I would not get "the run around". But I do, and that's fine as long as shit gets done.

When shit doesn't get done I hear it from both the doctors and patients and I just don't have enough ears. Or patience.

I should write stuff down. Blog about my inane job. I may learn more from this position by reflecting on it rather than plowing through the week, begging for the weekend.

I am going to say something that is not humble, nor is it becoming. I use 1/8 of my brain at this job. That is another thing I absolutely hate. It is not that I am better than my co-workers. They are skilled caring women and they are efficient. They know the TMC system far better than I ever will. But I simply don't belong here.

New book, new ideas

So I have finished reading the Poisonwood Bible. It was a struggle for me because it is a slow book that boils and develops over hundreds of pages. But since when have I been scared off by prodigious texts that tempt their readers to loose themselves in the countless words that are fixed on crisp, soft pages?

I struggled to find common ground with the many characters, to learn about a country that I knew absolutely nothing about (starting with the fact that the Congo and Zaire are not two different countries). And of course today there is the Democratic Republic of the Congo and the Republic of the Congo. Like the character Leah in Kingsolver's book, I re-learn the simple fact that the political maps on walls and inside books have arbitrary lines that shift with the will of the people that reside within those physical places. Simple, I know, but it's illustrated very artfully, if not in an epic manner, meandering way in the novel. The tale spans the 1960-late 80's.

And though I am learning and engaging my mind in ways besides my chosen scientific profession I realize that I am driven to distraction, putting off the incredibly intimidating task of readying myself for the next step in life: grad school/med school.

I realize this tonight because within this tale there is a girl who is an outcast that overcomes her demons to become a doctor/researcher of tropical viruses, Adah. I have never been "disabled" like her but everyone is an outsider to a certain extent for some period in their lives. It's tied to our unique fingerprints, our DNA that controls our personalities (to some degree).

She is a part of the team that contributes to the field of Public Health. The very school of Harvard that signs my paychecks, so to speak. Africa has not been on my radar ever, even now having completed this saga of a family undone while living in the "Dark continent" but public health seems appealing to me now.

But we come back again to the heart of the matter which is my dreams. It is safer to be on this side looking down at the potential energy rather than taking the plunge converting it into useful kinetic energy. Ha ha. I made a pun much like my dear boyfriend.

In all seriousness though, in order to reach anywhere near "public health" or "medicine" or "researecher" I need to conquer this one, huge weakness of mine. This standardized test that I can't even book. My type A personality is dying to organize this endeavor but my will continues to fight it.

I sound self-indulgent, unlike my suck it up and deal self (when it comes to academic matters anyway) but I have to reflect right now in order to move forward.

I choose now to read aboutt Zaire/Dem. Rep. of the Congo who was basically ransacked by America and it's CIA operatives that raped and pilaged this nation for its wealth. Things that the natives themselves did not appreciate, did not reap the benefits of. I choose to think about atrocities against human kind, disease, family dynamics within these fictional characters' lives; themes in the book that circle around Biblical imagery, botanical imagery, the idea of the Patriarch failing to burgeon within a savage land where only the women thrive, the inability of man to tame nature and how the African bush reclaims whatever people try to take from her, how the fury of floods wipe out villages, crops, people's hopes, the insignificance of one family in the backdrop of turmoil, the use to languages to unify and divide groups of people, definition of morals, justice, rights and wrongs; people's attitudes towards the unknown, mother daughter relationships, father daughter relationship, interracial relationships, wealth, what it means to be a white minority ruling over a black majority; the true evil between Communism and Capitalism, choosing between hunger or political views.

A book so rich in themes that I failed to appreciate until the very end. And it still drives me to further distraction because there is a helpful bibliography that will tell me more about the injustices committed by white men in stuffy offices against poor starving people in Africa. Like with Howard Zinn I am trying to learn a little more about an area of human nature I've either dutifully ignored, or was forced to ignore because I had no more white or gray matter left to devote to anything other than surviving Simmons Biochemistry (though I did dip my little brown fingers in various departments around the CAS).

I will give into this distraction, for now. But I will have to take the plunge soon.

When, I cannot say because like before my life is still in transition. And I do not think this will cease until I'm well into my 30s. Realistically. So since I'm so bad at transitions I need to learn to deal. Because this type A is not gonna get her cake and eat it too on her road to becoming "whatever".

When I was young I thought myself too dumb to become a physician. I would hate to not become one on account of being a coward and afraid of a small room with a computer screen, a woman out there that reads my finger print every time I finish a section of a test that will determine my future, and bunch of passages that bust my metaphorical balls.

Perhaps later I will write more about the book itself. But tonight I was a little overwhelmed with these ideas rushing to my head.

Relevant Quotes from A Farewell to Arms

So in an attempt to draft a paper comparing the writing styles of Jhumpa Lahiri and Ernest Hemingway I am making a list of relevant quotes from one of my favorite novels.

Possible themes: Spaces, the passage of time seen in a novel vs. a short story, loss/death/rebirth (the usual suspects).
I found this phrase entertaining: "the Austrians seemed to want to come back to the town some time, if the war should end, because they did not bombard it to destroy it but only a little in a military way" (11).

"This was a game, like bridge, in which you said things instead of playing cards. Like bridge you had to pretend you were playing for money or playing for some stakes. Nobody had mentioned what the stakes were. It was all right with me" (34).

"I wish that I was with the British. It would have been much simpler. Still I would probably have been killed. Not in this ambulance business. Yes, even in teh ambulance business. British ambulance drivers were killed sometimes. Well, I knew I would not be killed. Not in this war. It did not have anything to do with me. It seemed no more dangerous to me myself than war in the movies" (39).

"I put my Saint Anthony back in the capsule, spilled the thin gold chain together and put it all in my breast pocket" (45). (relate this to Hema's bracelet from her grandmother? Maybe?)

"I felt him in his metal box against my chest while we drove. Then I forgot about him. After I was wounded I never found him" (45).

Rinaldi says to Henry: "Now you see. Underneath we are the same. We are war brothers. Kiss my good-by" (66).

Similarity in observational style between Lahiri and Hemingway: "He waved from the doorway, his mustaches went straight up, his brown face was smilin. There was a star in a box on his sleeve because he was a major" (95).

Banter is always fun:

"Come back then now."
"No," she said. "I have to do the chart, darling, and fix you up."
"You don't really love me or you'd come back again."
"You're such a silly boy." She kissed me. "That's all right for the chart. Your temperature's always normal. You've such a lovely temperature."
"You've got a lovely everything."
"Oh no. You have the lovely temperature. I'm awfully proud of your temperature."
"Maybe all out children will have fine temperatures."
"Our children will probably have beastly temperatures." (97).

"I was always embarrassed by the words sacred, glorious, and sacrifice and the expression in vain. We had heard them...had read them...now for a long time, and I had seen nothing sacred, and the things that were glorious had no glory and the sacrifices were like the stockyards at Chicago if nothing was done with the meat except to bury it...Abstract words such as glory, honor, courage, or hallow were obscene beside the concrete names of villages, the number of roads, the names of rivers, the numbers of regiments and the dates" (169).

"The wounded were coming into the post, some were carried on stretchers, some walking and some were brought on the back of men that came across the field. They were wet to the skin and all were scared" (170).

The two disobedient sergeants. Bonello "he walked down to where the sergeant of engineers lay face down across the road. Bonello leaned over, put the pistol against the man's head and pulled the trigger...he cocked it and fired twice" (186).

"Bonello...was looking through thep ockets of the sergeant's coat" (187).

"You certainly shot that sergeant, Tenente," Piani said. We were walking fast.
"I killed him," Bonello said. "I never killed anybody in this war, and all my life I've wanted to kill a sergeant."
"You killed him on the sit all right," Piani said. "He wasn't flying very fast when you killed him."
"Never mind. That's one thing I Can always remember. I killed that ---of a sergeant."
"What will you say in confession?" Aymo asked.
"I'll say, 'Bless me, father, I killed a sergeant.'"
They all laughed (189).

Egyptian Adventures Day 3

Coptic Cairo

Tidbits: Part of Old Cairo made up of the Babylon Fortress, the Coptic Museum, the Hanging Church, the Greek Church of St. George and many other Coptic churches.

The Holy Family is said to have visited this area and stayed at Saints Sergius and Bacchus Church (Abu Serga).

So we went a little late in the day and the church of St. George was closed. But we walked around the area and took in the sights anyway. Especially the graveyard.

We were joined on this day by an old friend Thalia who lives in my home town. She studied Arabic with Daniel and will be living in Cairo for a year. Just as with any place, but especially a city like Cairo which is very different form the U.S., she felt it was nice to see familiar faces. I could not imagine living in Cairo for a year. I am just not used to the modes of transportation there, the heat, the language of course. But having lived in the U.S. for so long the idea of being a woman alone in Cairo makes me a little scared. I don't know if it's because I heard from Thalia that it's hard getting around alone and you get harassed a ton or that...it just reminds me of Dhaka and I haven't been there in so long. And even when I was in Dhaka I never had to fend for myself, I was always under the protection of my family.

Everything else about Cairo I'm sure I could get used to. I wasn't surprised to see Zamalek and Maadi the areas where Westerners frequent. There are signs in English, mini-supermarkets where you can shop much like here in the U.S. Actually on a trip to such a supermarket I met a former classmate, Monika, who took Arabic with me last year. It was so strange seeing a piece of Simmons right in the middle of a supermarket in Cairo. Of course I knew the IR professor was organizing a trip to Egypt and I knew that some of the girls would stay on. But it was quite a surprise to see her there. We did not plan it because the trips didn't totally overlap.

So here are some pictures from our day in Coptic Cairo.

The church we could not enter:


A family plot with pictures of the deceased on the tombstone.


An older part of the graveyard


The "Muslim" girl standing in front of a door full 'o crosses


A decrepit door


Daniel took this shot. It looks pretty cool because they were burning detritus and the smoke from the small fires gave the graveyard an eerie feel.

Egyptian Adventures Day 2

The Citadel and the Ibn Tulun Mosque

History Lesson:
Citadel: the air smelled great here and there were great views of the city.The Ayyubid ruler Salah al-Din (Saladin)fortified it between 1176 and 1183 AD, to protect it from the Crusaders.

The Citadel was completed in 1183-1184.

Ibn Tulun: The oldest mosque in the city surviving in its original form. The largest mosque in Cairo.

Commissioned by Ahmad ibn Ţūlūn, the Abbassid governor of Egypt from 868–884.

Intended as the focal point of Ibn Ţūlūn's capital, al-Qatta'i, which served as the center of administration for the Tulunid dynasty.


Architectural style: Samarran (common with Abbassid constructions). Constructed around a courtyard, one covered hall on each of the four sides.

On the outskirts of Cairo there is the Citadel which sits near a large patch of green (a botanical garden of some sort that we never got a chance to explore. The drive to the citadel is on an incline and it overlooks the city. The air here, like I said, smelled much better because there were trees here, lots of them. The mosque nearby, within the citadel is surrounded by gardens and people are always seen watering the plants. It almost smells like suburbia on the weekends, water, fertilizer, cut grass.
After climbing up to a patio-type area this was the view of Cairo.
I read somewhere that Cairo out-pollutes LA. From this view I can believe it.

We could see two mosques that unfortunately you had to pay a fee to enter. One of these is the Sultan Hussein mosque, the one Obama visited on his trip to Cairo.


We entered the mosque of Muhammad Ali which is contained inside the citadel.
It looks like the Turkish mosques that Daniel brought back photos of. It has beautiful ceilings.


A short cab-ride away was the Ibn Tulun mosque. It was easy to walk to this mosque but the day had become very hot and I was feeling lethargic. The only relief we felt from the constant sunshine beating down on us was on top of minarets and inside mosques where there were always breezes.

In Ibn Tulun especially I noticed the calm and relief from the city's chaos and odors. It was a peaceful place to visit that felt very imposing because it was built in centuries past and was still standing. People did not use this place to pray anymore, but I am sure in the past they did. I wonder if much has changed since the time that men would crowd the courtyard to perform their ablutions in preparation for jumma prayers.







Egyptian Adventures Day 1

Daniel and I arrived in Cairo at night to a bustling, hot, crowded terminal and waited in the passport control line. There were a lot of families in line, anxious old ladies that shifted their weight from leg to leg, men with varying degrees of facial hair and of course all of them had different levels of body odor. The family behind us in line had two little girls with their hair in pig tails and the same yellow dress with pink flowers on. They seemed very well behaved despite the chaos around them.

The line moved slowly enough but we were at the security point talking to a nice guy wearing the white Egyptian army uniform. He was very friendly but realized we did not buy a visa. At this point Dan started to sputter with frustration and I walked along with him like a zombie to the Bank of Masr (Bank of Egypt) kiosk to get the $15 useless visa. It took no application, no justification just give them the money and they put a sticker in your passport.


So we went back in line and waited yet again to go through passport control. It was simple enough, but it would've helped if there was a sign that clearly said "get your visa first at this random bank of Egypt kiosk and then get in line". But that's not how Egypt works. Ever.


Leaving the arrivals area we were inundated with cab drivers offering rides at very inflated prices. Dan spent some time speaking in Arabic to them and haggling. I didn't understand a lot of it seeing as I've only taken one semester of the language and he's lived in Cairo for a semester etc. Finally we got this man that took us to his cab in the lot and told us to wait while he tries to get one more passenger.


Dan and I waited in the cab but the driver didn't show. We took our stuff out and were about to get another cab when we saw the driver running towards us. So we stayed with the same driver but got jipped in the end of the price because we didn't have exact change. Driving down the highways I felt like I was in Dhaka again because there were no traffic laws. The lines on the road were mere suggestions, people used their horns to just say "hey I'm coming up on your right/left and you better accommodate me 'cause I'm not stopping."


We stayed in a multi-purpose building with a hotel on the 9th floor. It was really an office building of some sort but it was very clean and in the center of Cairo. The two men who worked there spoke English and someone was on duty all night or all day. I was just glad that it was clean and the toilets were the regular sit-down ones and not the squatting ones. The showers were great too to get all the dirt from the city off your tortured pores. The city really was an assault on all the senses.


Day 1: Bab Zuwayla

Daniel, our friend Nick and I did a lot of walking this day. We walked from Cairo's Medan Tahrir to old Cairo. We saw this old gate called Zuwayla and the surrounding mosques.
The gates were erected around the Fatimid dynasty. To read more about the history.




For a small fee we were able to go up into the gates and see the view of Cairo from above.
We could see the Citadel and the Al Azar mosque through the lovely Cairean haze.


We would visit the Citadel the following day.

There was this one house/apartment that actually had goats on their decrepit rooftops.


The best part about the gates was this sign:




While exploring these old fortifications we stumbled upon some minarets with small, dark entrances. There were no signs saying we could not climb up these tall, narrow, elaborate structures so we did. When we stepped into one it was not cooler than the outside temperature as one would imagine. The stairs were very small and the passageway narrow. The stairs were not much bigger than my size-five feet. I wondered how Nick was doing climbing up behind me.




This picture was taken on our way up the minaret I believe. We could not go to the very top because it turned into very unstable, iron bars that served as a ladder. How a man could climb up one of these and then deliver an adhan I'll never know. The view was amazing though and the breeze refreshing after all the walking, sweating, and trekking through Cairo on foot. But of course the best way to get to know a city is on foot.

Nearby there was the Al-Muyyad mosque that we had to visit. This was the first step towards our eventual mosque overload. All the mosques we saw are beautiful works of architecture but I did end up getting kind of overwhelmed with the number of mosques I saw. And I was brought up Muslim.

We stopped by the Khan el-Khalili one of the oldest markets in the world. I found a site that has a great video with a guide talking about the Khan. Here I bought my mother and aunt some pretty prayer beads. We did most of our shopping on this day for friends and family back home. We also bought our shisha.

The three of us walked up and down the narrow streets, repeatedly refusing offers for goods that poor Egyptians tried to sell us. Things that we clearly did not want or need.
We took a short breather at Fushowi's an old ahwa where Daniel and I shared a shisha and Nick sipped some tea. We sat in a private area with intricate dark woodwork, mirrors that look like someone stole them our of Versailles, and of course the kittens that infest the city. There are so many cats in the city because they are considered holy, I think. But they are almost as bad as rats. But of course if there weren't so many cats the city would be infested with rodents so I'd much rather have a surplus of "fury, cute disease vectors".