Atrial fibrillation Health Care Health Care Reform

A good plan denied…

Smart doctors will take help from wherever it lurks.

Today, advice on doctoring came from an unlikely and well-camouflaged source. (I always ask: “where are you talking to me from?”)

He was advising me from a warm cubicle in Milwaukee, Wisconsin.  It was a paternalistic male voice—another doctor, he said. Obviously, he was savvy, disguising himself to an unsuspecting medical assistant as a doctor who needed my expertise.

I was in a patient’s room, when, in the middle of discussing a complex treatment plan with an anxious patient, a flustered assistant poked her head in to say: “this Dr (with a very long name that I don’t recognize) is on the phone…and he says he has been on hold for more than 5 minutes.”

Ooh, I thought, it’s bad to keep a busy referring doctor on hold. Hurry.  Line 1.

Was it a patient in his office with a problem?

Was it a patient of mine having problems while out of town?

Maybe it was a doctor calling to tell me he liked my blog.


It was any cardiologist’s pal: a cubicle-doctor from an insurance company.

Last week, one of our schedulers had told me that an admission for anti-arrhythmic drug initiation was denied. They would only approve one day (of the three-day FDA-mandated inpatient monitoring.)  In my mind, I had dismissed their dismissal last week—on the grounds that it was utter nonsense. But dismissing a dismissal isn’t easy.

…”This is Dr [with the long name]… I am calling you about your patient, Mr X.”

That was it.


I knew.  And I was mad. The cardiology in me came roaring out–like a start of a CX race.  The inflammatory system fired—as my head flushed, voice lifted, and temperature rose, I could almost feel the platelets get stickier and the endothelium crunchier. Meet aggravation with reciprocal aggravation is how a lot of cardiologist’s roll.  (For the record: this is a heart unhealthy behavior, but nobody’s perfect.)

“How you can approve only one day of a three day admission? …Give me a break, you deceived my medical assistant, and got me out of a room with an anxious patient for this?

Usually, when these confrontations get inflamed, the voice on the other line backs off a bit. The tone gets slightly deferential, calm, as if they are saying, “look Doc, I don’t like this any more than you, but I ain’t 65 yet, and I need health insurance, so I took this job in the cubicle.”

But not today, this guy must have been a cardiologist before choosing his new regulatory role.  And like a Burger King manager, he seemed to like his power too much.

It turns out that my plan for medical treatment was just fine.   It was the vocabulary that was amiss.  (I was never very good at vocab.)  It wasn’t an “admission.”  [This week] Insurance company X stipulated that this three-day hospital stay should be called an “observation.”

Geez, John.  Were you asleep that day in medical school when they discussed observation and admission?

Although, I knew it was in vain, I told him:  “Admission.  Observation.  It’s the same bed, the same monitors and the same daily rounds and QT monitoring.  And you all change the rules every month.  Next month it will be an admission.”

…”John (apparently, we were now friendly enough to be on a first name basis),  it’s the cost…Observation costs much less.”

Of course.

But, the piece de resistance was summed up by his concluding advice:

“Doctor Mandrola, your day (and your week) will get better when you learn that this (our conversation) is where medicine is going.”

Maybe so, but not without some inflammation along the way.


Epilogue: Twenty minutes later, another medical assistant tells me:  “Dr M, this is a first for me…That insurance doctor called back to apologize for the conversation.  He said he approved your plan.”