“Thank you, young lady.” She started taking off her coat and scarf.
Tobi walked into Mrs. Cappione’s room a few minutes later. “Good morning. How can I help you today?”
Mrs. Cappione explained that three weeks ago, she had been cooking her pasta fagiole, and her hand had slipped on the pot handle. It spilled, overturning the pot onto her right thumb. Luckily, the stovetop had barely warmed up, so she didn’t have any burns (although, she complained it made an awful mess), but her thumb had been hurting ever since.
“First, I saw my primary care doctor at The Center, and he sent me for x-rays. Then he made me go to an orthopedist, and then I had to go back for an MRI.”
She did not have the results of either of these tests, and she was almost in tears.
“They told me I have ‘osteoporosis,’ and they want me to go for occupational therapy, but I can’t get involved with all that. It’s too complicated to get car service, and have to keep going out … who’s going to take me? Last night it hurt so bad! Can’t you help me? I tried icing it, but it only made it worse. Maybe it’s an infection. Can you give me an antibiotic?”
Tobi looked at the electronic chart. Mrs. Cappione had come to their urgent care a week ago, and Ellie had seen her and given her a thumb spica splint to wear, which extended from the tip of her thumb to the mid shaft of her forearm. Then Ellie sent Mrs. Cappione back to the doctors who were already caring for her. Ellie hadn’t ordered any imaging because the patient reported it had already been done. It was unlikely she had been given a diagnosis of osteoporosis, since that would only cause pain if it resulted in a fracture, and it didn’t appear that she was being treated for one. When old ladies broke their hands, they usually required a cast or solid splint, and moreover, the injury she was describing didn’t sound like it was of sufficient force to cause a break. There was, of course, a much more likely diagnosis.
Tobi examined Mrs. Cappione’s thumb. It looked like the gnarled branch of an ancient tree. She could almost see right through the skin to the misshapen, arthritic bones. But there was no wound or evidence of infection, not even a healed scratch.
“It looks more like severe arthritis,” Tobi told her. “Maybe the splint is making it stiff now, even though it might have been helpful earlier. Would it be okay if I took another x-ray now, since you don’t have the results of the last one, just so I can get a look at what’s going on in there?”
Mrs. Cappione clasped Tobi’s hand in hers and looked up gratefully with rheumy eyes. “Oh, thank you, Doctor, you can do it right here? Please take a picture. They told me it was osteoporosis, but I think it’s an infection, it just hurts so much!”
The radiographs were enough to make anyone cringe. The joint spaces were gone; it was all bone on bone, and there were sharp, spicule calcifications jutting out from every joint in her poor hand. Her skeleton was so disfigured, it almost looked like it belonged to an alien. Nothing was broken, though, and the bone density looked pretty much normal for a ninety-one-year-old.
Tobi winced. She was not sure what she could do for Mrs. Cappione’s pain, since she certainly couldn’t throw narcotics at an unsteady, elderly patient. And since she was on blood thinners for her heart, the patient couldn’t even take ibuprofen without risk of bleeding.
Tobi went back into Mrs. Cappione’s exam room. She took the patient’s hand in hers and raised her voice slightly, but spoke gently. “It’s not osteoporosis, Mrs. Cappione, it’s osteoarthritis, and it’s very advanced. That’s why it hurts so much.”
Mrs. Cappione looked like she might cry. Tobi continued, “I want you to try using heat instead of ice, to loosen up the joints a little. Do you have a heating pad at home?” Mrs. Cappione nodded, her eyes wide.
“And stop using the splint now, I think it’s making you sore. You can take Tylenol Extra Strength, or the generic acetaminophen, every six hours, and I’m going to send you a prescription for a lidocaine patch. It’s a medicine you put on like a bandage, and it should numb the pain—if you can get it. I see you have Medicare; do you have a secondary insurance for prescriptions?”
“I have that ‘harp’ thing, so my medicines don’t cost as much. They still cost me a bundle, though,” Mrs. Cappione looked distraught.
“AARP?”
“Yes, that’s it.” Mrs. Cappione nodded.
“Okay, good. I’m going to send the prescription straight to your pharmacy. Also, please call your primary care doctor on Monday and schedule that occupational therapy. You might only need a couple of sessions to see what it’s about, and then perhaps you can do the exercises at home, all on your own. Many people do. I’m going to write all of this down for you.”
Mrs. Cappione scowled. “I don’t like my doctor. I tried every doctor at The Center, and none of them ever make me better. I’m ninety-one years old. They can’t fix anything that’s wrong with me.”
Tobi nodded sympathetically. “That’s what my Baba used to tell me, she’d say ‘don’t get old’; but I used to ask her, ‘What’s the alternative?’”
Mrs. Cappione agreed. “Getting old is the worst—but if you don’t get old, you have to die young.” She sighed heavily, took the CD that was her x-ray copy, and made her way deliberately out to the waiting room. She thanked everyone for seeing her.
Tobi watched her go, feeling demoralized for having so little to offer. The pharmacy might not fill the Lidoderm for her without a prior authorization, Tobi thought. It was a topical anesthetic and only minimally absorbed, so it was safe in the elderly, but it was expensive, so the insurance companies often wouldn’t pay for it unless someone spent forty-five minutes on the phone with them to get it authorized, and they were not even available on Saturdays. She had no idea whether AARP covered it, and even if it had last month, that didn’t mean it would be covered today.
Tobi groaned at the futility of it all. Primary care offices had secretaries dedicated to getting approvals from insurance companies for medications, imaging, and procedures, which would not be paid for otherwise. It was an extra expense for the practice just to be able to treat patients, and most urgent care offices did not have such a luxury. Theirs certainly did not, especially since they were cutting her staff. There was no one to spend that kind of time on the phone.
It was going to be a very busy day. There were seven people signed in before they had been open an hour. At a quarter to ten, a family of three had arrived: a mother and her two small children, Amara, age five, and Jonna, age seven. Mom had developed a scratchy throat the night before, and Jonna had completed treatment for strep two weeks ago, so Mom had wanted to make sure he was completely recovered, even though he felt fine. While they were there, she asked if Amara could be checked as well, who, by the way, had no symptoms at all.
Tobi walked into their room at five minutes to ten. Both children felt completely well, but Mom demanded strep tests on both, as well as for herself. All three had completely normal exams, no history of fever, and with the exception of Mom’s scratchy throat and slight post nasal drip for less than a day, no one had any symptoms. The encounters and documentation took twenty-five minutes and included triaging three patients, taking three histories, swabbing three throats, and doing three examinations. Everything had to be charted separately in the EMR for each patient.
All three swabs were negative for strep, so three cultures were sent to the lab. The three visits were sent to the insurance company for payment, and the outside lab would bill the same insurance company for the three strep cultures. Mom had to be reassured at length that if the rapid strep tests had missed anything, the cultures would find it, and that they did not require antibiotics in the meantime “just in case.” As for their insurance, it was a form of Medicaid, so they had no copays, and they left the office without spending a dime out-of-pocket. Tobi couldn’t help thinking that the unnecessary cost could have funded at least a month of Lidoderm patches for Mrs. Cappione.
Jorge said, “That’s not even unusual. Last week, we had a couple in here who felt absolutely fine, but the father-in-law had a stomach virus, so they wanted to be ‘checked out.’ They had no symptoms of anything!”
He turned to Tobi. “What do you think, Dr. L, is it just because they don’t have to pay for it? Are they really worried they’re sick? Why do people waste their time and our time like that?”
“The couple from last week wasn’t Medicaid, they each had to pay a thirty-dollar copay, but it’s still costly to the insurance company, and it’s a waste of our resources,” Tobi said. “Some people definitely do work the system, but what’s to gain from this? Except to assuage their angst.”
“What’s ‘angst’?” Esther asked.
“It means free-floating anxiety, like an underlying uneasiness that you can’t quite put your finger on but that permeates your life.”
“Oh, like working at B. Healthy,” Esther said.
“Yeah, kind of,” Tobi said. “It’s not completely unfounded, you know. People worry about losing their jobs if they can’t go to work. How many flu patients do we have to argue with to stay home, and they often don’t anyway? They’ll get better much more quickly if they’d just rest, and they wouldn’t infect the rest of their coworkers. But they say their bosses won’t understand, or they don’t have sick time. Our culture doesn’t support sick people—other than to try to make money off them.” She looked pointedly around the office.
“And the media doesn’t help, either,” Jorge said. “When I’m feeding little Jeremy at night, he falls asleep and I don’t want to get up because I’ll wake him, so I watch TV. All the commercials are about drugs.”
“I know,” Esther said. “It’s like pills are supposed to cure everything. They play sweet, peaceful music, and you see families at barbeques together or walking on the beach, so you don’t pay any attention to the awful side effects they’re listing in the background. Some of them are horrible. You can even die!”
“The problem is, people expect life to be easy and for things to just be handed to them,” Patty said, chiming in. “I never had nothing handed to me, but I managed and my kids grew up just fine.”
“Better than fine, I expect,” Tobi said. “Your kids know how to bounce back from hard times. Do you remember Mrs. McCleary from last month? She came in three times in less than one week with the same uncomfortable flu symptoms, even though I explained to her each time that her symptoms would last seven to ten days. We need to teach people how to be strong so they can deal with problems, instead of giving them pills so they feel like they don’t have to. There will always be some hurdle that can’t be overcome. We have to help people find a way to accept that and move on without falling apart.”
Esther nodded. “When I worked for the IRS, I didn’t like it at all, but all my friends told me I shouldn’t give up all those benefits. I think I was depressed. It was hard to go to work each day, and I felt like there was something wrong with me. But then my abuelo sat with me and told me my friends didn’t have to live my life, and I have to be happy. He made me feel so much better, and now I am a medical assistant. I help people instead of pestering them.” Esther smiled.
“But the extended family is becoming a thing of the past,” Patty said. “Remember the Lenmans? They didn’t even feel welcome in their kids’ home. And children don’t get as much time with their grandparents nowadays, they’re so busy playing sports and video games or hanging out on social media. And everyone lives so far apart.”
“And don’t forget, there’s no money to be made off our elders’ wisdom, so our society doesn’t value it,” Tobi said. “You have to be able to package something if you want it to be promoted. Biggest mistake in medicine was letting pharmaceutical companies advertise on television. Now all ‘cures’ come in a bottle—and they have to be profitable. Did you know the United States and New Zealand are the only countries in the world that allow the advertisement of drugs in the media?”
“Aren’t we lucky?” Jorge asked, rolling his eyes. “That means we are the only countries whose health values are driven by capitalism.”
“Health values and health care,” Tobi said. “It’s a swindle.”
Chapter 14
Mannford was seething when he stepped off his jet at Zhuliany Airport in Kiev. That squirrel Sokowsky had evaded him for nineteen years! That punk must have been the hacker gathering info on them, so it was anybody’s guess into whose head he’d been funneling all that intel. Strange that there had been no repercussions, unless his “heart attack” three weeks ago had been rigged. Something in his coffee cup? The Project did have some “clients” in Queensland as well as the US and Europe, powerful men who had contracted some nefarious sexually transmitted diseases they’d prefer their family and constituents didn’t find out about. Keeping that dirt under wraps cost those men on a regular basis, and padded Mannfort’s pockets nicely, but if the Project were to be exposed, it would not bode well for their clientele, and they knew it. If Sokowsky had made the mistake of going to the authorities with incriminating information, he might have been squashed out of hand.
Kazimir was driving toward him as he exited the airport doors, and Mannfort hopped in the car.
“This could be a problem, Kazi. I’m positive Sokowsky was the hacker—this guy had a dive shop named Tobi’s! We have to trace his communications—check every email that he sent. The nerve! To be out there digging in our stuff. He had to have planned to use what he found, or why else would he bother?”
“You think he was sending information to someone? Maybe he was waiting until there was enough evidence to bury us, so he could come out of hiding, but it took him long enough to try that. Why start now?”
“I have no idea,” Mannfort said. “I think we have to go to New York and check on this sister. Maybe question her before we get rid of her. What did you learn about her employment? Can we get to her from there?”
“Oh, dah! The sister works at B. Healthy, LLC. We have a toad there, some Turkish guy.”
“Good. Tell him we will need additional information on her or we will have to make him a personal acquaintance.”
Chapter 15
Ismar was sitting on his lounge chair in front of the fire, listening to a recording of tanbur music with his eyes closed. The minor harmonic scale and peppy rhythm mixed with the lingering smell of zaatar made him feel like he was back home. Except, of course, when his wife Jennie kept pestering him to take out the trash and change the outside light bulb. These were definitely things a woman should be able to handle, and it was cold outside; he had no interest in walking down the long driveway dragging a garbage can. He had provided her with an enormous house and even paid for a servant to come and clean it once a week, something Jennie should have been able to manage on her own, especially since she no longer needed to work. She should not be bothering him with little nuisances.
“Ismar, pretty please …?” Jennie crooned in his ear and stroked him under his chin just where he liked it. Next thing, she had her hand on his chest and was rustling the hair under his shirt.
This woman really knew how to work him! And he never learned, because by the time he finished doing whatever she asked of him, she would be on the phone with one of her girlfriends and would stay there for the rest of the night and then beg fatigue, or she’d pretend to be fast asleep when he came upstairs. He would have to insist and get rough with her, and then she would be angry and distant for the rest of the week. Blasted American women.
Ismar got up and put his shoes and coat on and took out the trash, despising himself for turning into a weak Western man, and wished again that he hadn’t had to leave Turkey and his life there. Damn Russians. They had ruined his life. He didn’t know who he hated more, the Americans or the R
ussian oligarchs, who were just slightly better than the neo-Bolsheviks; they all detested Muslims. America was supposed to be the “land of opportunity,” but he was sure that giving him the post as lead physician was only B. Healthy’s way of satisfying affirmative action, or whatever they called it these days. He didn’t believe the company cared about him at all, and yet, he couldn’t really complain. They had no idea that the position they had given him helped him gather information for the Project, which, in turn, paid him ten times what he earned in his day job.
Ismar’s phone buzzed, telling him to log on to the encrypted server for additional instructions. As he read it, he felt the customary sweaty palms and racing heart that he always got when he was contacted by his benefactors. One day, he promised himself, he would pay off his debt and go back home as a rich man.
And he’d teach Jennie to cover up when she walked outside!
Chapter 16
Dr. Andy Corbet was cleaning out his office. After forty years, retirement felt bittersweet. He’d left much of his active practice behind three years ago, but he had stayed on in the American Medical Association because, as they’d said to him, who else would continue to chair the Council on Constitution and Bylaws? It was a tedious job, with a lot of infighting. He hated playing referee, but he was good at it, so they’d kept electing him year after year, and he’d never been very good at saying no.
Now it was over. He was done. Andy and his wife had bought a little chalet in the Swiss Alps and he wanted to spend his time between there and Big Sky, Montana, where his grandchildren were growing up in what was left of the clean air regions of the United States. He did not think he would miss Chicago, even after all this time, and he was passing his post on to a younger, more enthusiastic—if less conservative—doc, Zack Pryor.
Were his files all complete? He thought he had left everything fairly organized and orderly. He fingered the file containing the anonymous emails; all of them were agitated requests that the AMA look into the patterns and practices of a certain insurance company. He had been getting them for years, and never had decided what to do about them since they seemed to come from multiple addresses, but they never identified the sender. The recent emails had a few names and diagnoses, and one even included a Trojan Horse that could unravel the insurance company in question, or so that email said. There were strict instructions on how to—and how not to—use the subversive device, with warnings that once it was initiated, it would of necessity, violate HIPAA laws, but it would also expose the origins of the insurance company and would shut it down. The email cautioned to perform the virus only under the specified, controlled conditions. To Andy, the whole proposition sounded incredulous. Who could possibly write such a complicated program like that? More likely, it was a ploy that would destroy their own software instead.
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