The Prior Authorization

The Prior Authorization

Another day at the office, that I am a physician in a small town. It is Monday morning and I am running late. My nurse herds me quickly towards my first patient.


The patient is a 42 year old man with a history of Diabetes. He lost his job as a construction worker 3 years ago and consequently lost his insurance. He recently got a new job and regained insurance and has come to see me. He has completely neglected his Diabetes in those years. He is married and a devoted father to two young children.


My nurse comes to me to tell me that his hemoglobin A1C is 9.6%. This is a test that we do in the office that gives us an average of his sugars over the last 3 months. Normal is 6.5% or less.


I have several medications available to me. Each on average can reduce his hemoglobinA1C by 1%. Appropriate diet can add another 1%. Thus for a 3% drop, I will need two medications and an appropriate diet.


One medication is the generic Metformin which is usually the first medication tried on Diabetics. There are also several newer medications that get at the root cause of Diabetes, but these are not generic. They are available in combination with the Metformin (which is included at no additional cost). At random I pick one that will be one pill once a day. I give him all this information on Diabetes and the proper diet to follow and send him on his way.


An hour later, my nurse tells me that the pharmacy has called and this drug requires a ‘prior authorization’. A ‘prior authorization’ is used by insurance companies to keep costs in control, by trying to restrict some of the newer and more expensive drugs. Now the nurse has to get on the phone with the insurance company to try to get this approved. 


It takes 45 minutes to get someone on the phone. Usually it is someone with no medical training, who follows the insurance company’s standard algorithm. ‘Has he had a trial of Metformin alone for at least a month’ they ask? No, the doctor feels that he will need more than just Metformin answers the nurse. They said that they will send their decision in two days. We get a letter the next day that the request has been denied and he needs a trial of generic Metformin alone first.


Many thoughts come to my mind. How is it that an insurance company is legally able to alter a physician’s medical decision? Interestingly if the patient has a poor outcome, it is almost impossible to legally sue the insurance company.


So I put my patient on Metformin alone, knowing that it probably will not be sufficient.  My nurse wasted 45 minutes yesterday, and will waste another 45 minutes next month. The insurance company will save on the cost of the medication for about a month.  One study assessed that prior authorizations cost US doctors approximately $ 31 billion a year.


I wish there was a better way!

The Battered Child

The Battered Child

It was another busy day at the clinic. One of the patients being seen is an HIV patient in his late twenties. I had first seen him several years ago. At that time he was not doing well. He was first diagnosed with HIV at age 17, but because of multiple reasons, did not start treatment.


Five years later he was admitted to the local hospital. The HIV had destroyed his kidneys and he was put on dialysis. His immune system was destroyed to the point that he had no detectable T cells (normal is greater than 1,000).


I did an HIV resistance test on him and with the help of our HIV pharmacist, came up with a regimen of medications that was not only effective, but was also dosed appropriately for his renal failure.


He made steady progress, and within a few months his T cells had recovered to well above the 200 AIDS threshold. During this time, he continued on dialysis and was generally doing quite well. 


A few months ago he told me that he was on the waiting list for a renal transplant. I subsequently got a call from a doctor at our nearby teaching hospital, that he had received his kidney transplant. 


His entire regimen had to be changed as he was on anti rejection medications which interact with a lot of HIV medications. The dosages also needed to be adjusted as his new kidneys started functioning. Of course we would also have to keep in mind his original resistance test.


He did very well. His new kidneys started working and his new HIV regimen kept his virus undetectable and also his T cells remained good, despite the anti rejection drugs that can reduce the T cell counts. He is now in college and working part time as well.


At his appointment, I asked him if he knew where his kidneys came from.  ‘It was a baby’ he said. I was taken aback!


It was a battered baby he explained further. Her parents had battered her so badly as to cause brain death. Her grandparents had then made the painful decision to donate her organs. 


Her kidneys came to my patient. Her heart went to someone else as did her corneas and so on. Because she was an 18 month old baby, it took some time for those kidneys to grow in my patient until they became fully functional.


As this information sunk in, I asked my patient how he felt about this. He said when he first found out about the baby, he cried. He has talked to the grandparents via teleconference arranged by the hospital, and he told me that they are happy to see him doing well.


After the visit, I felt incredibly sad that this child’s life was ended so soon, in such a sad way, and yet feel a sense of gratitude to her for making such a difference to so many people.

Kidney ready for transplant

The Prayer

The Prayer

I was a third year resident in Internal Medicine at a large Teaching Hospital. I was in the middle of my Medical Intensive Care Unit rotation. This was one of the toughest rotations in our residency. It involved working in the intensive care unit with many critical and seriously ill patients.


I had a wonderful team. They were four young interns, and a fellow senior resident. This was an awesome team. Everyone was dedicated, hard working and extremely smart. It was fun to work with them, and my life was easy. We had excellent attending physicians as well.


One morning we were rounding on a very ill elderly obese woman. Her blood pressure had dropped to very low levels, to the point that she had become dependent on dopamine, a medication that maintained her blood pressure. However the reasons for this were not clear.


We need to put in a Swan Ganz catheter, our attending pulmonologist said. This is a special catheter that is put all the way into the heart and can tell us if her low pressures are coming from her heart or other reasons. The process of putting it is technically demanding.


My intern on that day was a smart young woman. She was a very hard working and dedicated person. We determined that while the patient had a triple lumen central line in place - in order to put in the Swan Ganz, we would have to change the access to a ‘port’ that will allow both the Swan Ganz as well as the central line. This was going to be tricky, as the patient was dependent on the access we had to maintain her blood pressure.


The attending told us to change the line to a port over a wire. In this process a thin wire is put in through the old line, then the line is withdrawn and the new port is placed over the line. This would be accurate and hopefully quick. The patient had no other intravenous access, and attempts to place another line had failed previously. Since changing a line over a wire is considered a fairly simple procedure, our attending left to see another patient. He would be back in 10 minutes to help us put the Swan Ganz in.


We put on our gloves and gowns, and stopped the dopamine drip. My intern carefully threaded the wire through the existing central line. The patient’s blood pressure started dropping immediately. We had a very experienced completely unflappable nurse assisting us. She started reporting the blood pressure as it dropped. 90, 85, 80.


The wire was in and I instructed the intern to pull out the line. She says to me – I don’t think this is right. The wire does not feel like it is properly placed. Please pull the line I reply. We don’t have much time. She pulls the line out and out comes the wire too!


This was a disaster. I had made the mistake of using a wire that was designed for the shorter port and not the longer central line that the patient had. Suddenly we had lost all intravenous access. 75, intones the nurse as the blood pressure continues to drop.  She raises the foot of the bed to try to maintain the blood pressure.


At this point, I said some colorful words under my breath and asked for another kit for a new line. My intern looked at me disapprovingly. Getting a new line can be difficult in normal circumstances, but in this situation seemed almost impossible. My intern hands me a new kit and says to me, it will be okay. She looks absolutely calm and I can see her silently saying a prayer. I am not a very religious person, but I felt an instant sense of calm.


I make the first stick and am immediately rewarded by a return of dark red blood indicating a successful attempt. I quickly thread the new port in and the nurse resumes the dopamine. The blood pressure which had dropped to 60 gradually starts climbing back again.


At this point our attending shows up. Oh good he says, you have the port in place, oblivious to the drama we just went through. He subsequently guided the intern in putting in the Swan Ganz catheter. I do not recall the eventual outcome of that patient, but we had stabilized her in the acute setting.


Afterwards, I marveled at the fact that we got the line back in so quickly. My intern said to me, “that is the power of prayer”. Now many people do not believe in prayer, but I have no doubt that her prayer at that time made a difference.


On that day, I learnt the immense power of prayer. I thanked my intern deeply.

Swan Ganz catheter

The Mother

The Mother

It was many years ago, and I was a second year resident in Internal Medicine. Our hospital was a large teaching hospital that often received transfers of sick patients from nearby smaller hospitals.

I was on call one night in late summer.  Our attending physician called me. He told me that he had accepted a transfer from a smaller hospital and the patient was being brought in to be admitted directly to our service.

She was a young woman in her early twenties, who was two months pregnant. She was also a type 1 diabetic with very erratic blood sugars. Getting pregnant had been a challenge for her because of her Diabetes. Once she did get pregnant, her sugars became ever more unstable.

On that fateful day, she had awakened, and saw her husband off to work. Soon after, her sugars dropped to very low levels and she went into a coma. Type 1 diabetics often have fluctuating blood sugars, but pregnancy makes this worse. Added to that is the pressure of keeping the sugars tightly controlled to prevent complications for the baby. Her husband came home several hours later to find her still in a coma and called Emergency Medical Services.

At the local hospital she could not be aroused and it was determined that her prolonged time with low sugars had damaged her brain. The medical term for this was hypoglycemic encephalopathy.

After she arrived at our hospital, she was admitted to the intermediate medical service (one step above a general bed), because her sugars were so difficult to control. I was given instructions to consult both Endocrinology and Gynecology when she got in.

She was petite and dark haired. She was unconscious and could not be aroused when she arrived. The Endocrinology fellow showed up that night to see her. Normally Endocrine fellows rarely have to come in on call, but this was no ordinary case. The fellow wrote very detailed orders on her. She was on an insulin drip along with a dextrose drip and sugars were to be checked every hour.

 The Gynecologists saw her and said that the baby was ok for now. I spoke to her husband, who was very concerned for his wife. He also told me that she had really wanted this baby.

Over the next few days, we struggled with controlling her sugars. Despite the close monitoring and the drips and the frequent labs, her blood sugars would swing wildly from one extreme to the next. The Endocrinologists would spend hours with her every day. The Gynecologists were concerned about the health of the baby.

We all came to the conclusion that continuing the pregnancy was risking the life of this young woman, who by the way was still in a coma. This led to a family conference, and I can never forget her husband saying to us; "Do what you have to, but please save her. I want my wife back".

An elective abortion was planned. On the morning this was scheduled, the Gynecology resident called and told me that they had to cancel the procedure. Apparently someone from the hospital staff had complained to the hospital ethics board that this was an inappropriate abortion.

For the next two days we struggled with controlling this woman's sugars, while the hospital ethics folks evaluated the situation. They finally gave the go ahead for the procedure and an elective abortion was done on her.

The effect on her sugars was dramatic, and they stabilized rapidly. A day later, she woke up and gradually started talking and eating. We were able to discharge her to a rehabilitation facility soon afterwards.

I have often thought of this young woman when I see the abortion debates today.  I think we did the right thing for this young lady, although there may be some that disagree. I hope that she is doing well today.

The Noble Maggots

      The Noble Maggots

It was July 1993, a warm summer night in the small Northern Nigerian town of Zaria. I was a resident in Trauma and Orthopedic Surgery at the local Teaching hospital and was on call that night. I had been born in Pakistan, but had grown up in this West African town as my dad taught at the local university.

I had gone to medical school here and started my training in Orthopedics. However after two years, I had become tired of dealing with the surgical lifestyle and had been accepted for further studies in the United States. It was my last night on call.

I received a message that a new patient had been brought in. It was a gunshot wound. This was very unusual. Guns were very rare in Zaria. I quickly went to see this patient. He was 24 years old. Apparently he was a member of a local gang. He had gotten into a confrontation with the police, and was shot in the leg. In the ensuing chaos, he managed to crawl into the bushes and lay there for two days until the police found him.

His leg was a mess. Gangrene had set in and it was infested with maggots. The dangerous signs of gas formation in the leg had started. I knew that gas gangrene was lethal and can kill rapidly. He needed an urgent amputation.

I spoke to his family and got the anesthetist on call to prepare for an emergent amputation. The police had handcuffed his good leg to the bed. The constable had to get permission from his senior Inspector to release the cuffs, and we got ready for Surgery.

Suddenly, I heard a commotion outside. A crowd of young men had gathered, maybe 10 to 15, some armed with machetes. They were his friends and fellow gang members. Apparently one of them had heard the Police Inspector telling another policeman that he will tell the doctor not to save the leg as he would prefer this gang leader to be handicapped. Of course no such conversation occurred, but the crowd was adamant that they will not allow the amputation. The Police constable had disappeared.

This was scary. I walked straight up to the crowd and told them that this was the only way to save his life, but since they objected, I will not do the surgery. I took off my gloves for good effect and walked out of the operating room, right through the crowd. It was the bravest thing I have ever done. Thankfully, the crowd parted and let me through. I had given orders for the patient to be put on strong antibiotics, but was not sure he would survive the night.

However, he did survive the night. The maggots in his leg probably saved his life. This was a fact known in the pre antibiotic era that wounds infected with maggots often did better as maggots would remove the dead tissue. He was still very sick, but alive the next morning.

It was at this point that his father came to me and asked me to please do the amputation and save his son’s life. He assured me that the gang members will not interfere. I called the anesthetist and we got ready for emergency surgery.

I did that amputation that day. It was quick and involved a lot of debridement of dead tissue. His wound was packed and antibiotics were continued.

The next day, I came to see him in the ward before leaving for the United States. He was sitting up and eating. The police had released him on bail. I had handed over his care to another colleague. This was the last Surgery I was involved in.

I came to the United States and started a new career in Infectious Diseases and Internal Medicine. I never entered an operating room as a surgeon again.

I have no doubt that his life was saved in part because of the maggots. It was interesting to see something I had only read about in history books.

I thought often about this patient and how his life would be with one leg. I hope he is doing well and has kept out of trouble from the Police.

Asif Zia
Zaria, Nigeria, July 1993.