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Unfolding Nature Shop: Unfolding Nature: Being in the Implicate Order

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Offlinemorrowasted
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A modern RN's field guide to navigating the US medical system/AMA about my experiences etc.
    #28329396 - 05/22/23 12:30 AM (8 months, 3 days ago)

Background:

Once upon a time, people had nearly unwavering respect for doctors. Even to this day, when Americans are polled, they say they trust nurses more on average than any other kind of professional. Nevertheless, I’m sure you’ve sensed that respect for doctors and trust in nurses has recently been on a rapid decline.

We in the West have set a high bar for medicine- maybe too high- as with essentially everything we have expectations about (easy accessibility/affordability of food etc.). The average American, consciously or not, simply expects a functioning medical safety net to exist. And for many decades following WW2, it arguably did exist. That safety net is now riddled with holes/cracks and looking less and less safe by the hour.

A lot of people suddenly and often unexpectedly find themselves struggling to hang on and not fall through the numerous cracks. Inevitably many do fall through them.

Ever since COVID changed... everything... people don’t who don't fall right through the cracks immediately find themselves feeling unsafe in that net. To cut the metaphor, patients too often feel trapped- ignored, confused, and taken advantage of.

Having been hospitalized many times myself, I completely empathize. Even if all doctors and nurses were good people who always tried their hardest to do right by the world, it make little difference.

You see, back in that Once Upon a Time epoch, your post-op rehab nurse had 3 other patients. Today, they have 6- sometimes even more.

A nurse with 4 patients had 15mins per hour to accomplish all tasks for each of them- assessments and vital signs monitoring (including heart rhythm if patient is being monitored for dysrhythmias), giving meds- not just pills, but pushes like cefepime that require you to stand there for several minutes** and primary fluids and usually secondary medicine that has to be primed/plugged/programmed, drawing blood and taking it to the lab and checking in periodically for clinically relevant results that the doctor needs to be made aware of, (re)placing IVs/Foleys/NGs/etc as needed, physically answering call bells (to discover 50% of the time the pt rolled over onto the button sleeping), trying to get the attention of their doctors when shit comes up or the doctor makes a mistake, helping CNAs reposition them and/or assist them to the bathroom if needed, assisting with transport to radiology etc as needed, performing any necessary wound care and/or routine cleaning of lines/catheters... And oh did I mention paperwork? Shitloads of it, most of which only exists to protect the hospital from lawsuits. We haven't even factored in any time for the nurse to piss or eat.

Sound like a tall order? Now realize the nurse has to do all of those same tasks but only has 10 minutes per hour to get them done.

I say that to illustrate that any following advice here is not intended to stir up anti nurse or doctor sentiment, and certainly not to encourage frivolous lawsuits, which are themselves a major contributor to the very problems we just went over. Some nurses and doctors are selfish pieces of shit who should have their licensed removed, but much or most of what you may perceive as being ignored and confused is systemic in nature, and in no way personal..most doctors and nurses would love to reappropriate all the time they spend on the computer actually with the patient. But admins say legal team and quality assurance (none of whom, incidentally, are actually involved in patient care) say "not a chance".

So. The system is fundamentally too weak to give you optimal or even acceptable care. The purpose of this thread is to help you protect yourself against the system without throwing the wrong people under the bus. See next post.


Edited by morrowasted (05/22/23 01:30 AM)


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Offlinemorrowasted
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Re: A modern RN's field guide to navigating the US medical system/AMA about my experiences etc. [Re: morrowasted]
    #28329403 - 05/22/23 12:51 AM (8 months, 3 days ago)

A) you are going to roll your eyes at this, but the first and easiest way to advocate for yourself is to know what healthy behaviors are and do them and to know what risky behaviors are and to avoid them. This will reduce your need to be involved with medics to begin with. Now you can't pretend all medics are in on a grift to keep you dependent. We would like you off our caseload and at home.

For outpatient visits (GP, psychiatry, whatever):

A.2) If you keep any copies of prior physical medical records, bring them with you.
A.3) If you have a specific purpose for going, a working hypothesis diagnosis for yourself, and a treatment plan developed based on your own experience and research, write down exactly what you want to say and just read it to them- hell, bring them a copy to read along and keep. Say for example your doc has diagnosed you with depression cuz you report feeling sleepy, unmotivated, lethargic, and hopeless that things will improve, and put you on Prozac. But after a little poking around you have come to suspect that your primary diagnosis is actually autoimmune thyroid deficiency and that those symptoms were misinterpreted as depression. Write it all down. What you found, your experience/rationale. Make sure they order t3/4/tsh labs.

A.4) Take a recording device with you to any doctor visits. Preferably audiovisual, with a timestamp. Activate it during your session but attempt to keep it secret. In 39 of the US states, it is legal for you as the patient to record your own appointment without the consent of the doctor, or anyone else present, unless there are other HIPAA protected patients in the recording. More on this later..

To be continued below


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Offlinemorrowasted
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Re: A modern RN's field guide to navigating the US medical system/AMA about my experiences etc. [Re: morrowasted]
    #28329414 - 05/22/23 01:11 AM (8 months, 3 days ago)

For outpatient visits continued

B) If you are ‘systemically stuck’ with a doctor you feel isn't right for you- or hell, anyone at all- either because they’re committing fraud, neglecting patients, or simply because they lack the needed knowledge to practice medicine safely- both prepare your schpeal from A.3 and your device of choice from A.4, go to your visit, give your schpeal, voice any additional concerns you may have based on how they response, but otherwise appear satisfied.

Now. Return just before the clinic closes, when the doctor and everyone else are most anxious to just leave and go home,, and submit a formal written request for your electronic medical record, in both written and pdf format, noting again by videorecording the time they receive the request. Do not appear to be upset. State that you just want to keep it in your personal files 'because you're a compulsive organizer like that' (or whatever)- regardless,  they will be legally obligated to give you a version of your medical record containing the progress note from your visit.

When you receive it, make sure you note the last time that doctor explicitly states it was updated. Then check the actual file properties and notice the “Last Updated” time. A lot can happen from here. If the file was updated after your request, implying that the doctor edited some of it upon discovering you were going to read it, submit a new formal request specifically for the earliest (or even All) version(s) of the doctors’ progress note of your visit. If you end up with ‘two different documents’, obviously you're going to be scrutinizing any discrepancies between the two. Let's say you find one. At the end of progress notes doctors always have to annotate how much time was spent on the patient's care, mostly for insurance billing reasons. It's given in a total amount, and it's also supposed to be divided up into face time and non-face time. Say you notice the original note claims that the doctor spent 5 mins with you in person and 10mins reviewing/ updating your EMR, but the newer version of the note claims 10 minutes in person and 5 updating the EMR. Say your recording device proves that they spent 3 face-minutes with you. Doesn't matter which version of the document you refer to, they're both technically falsified and potentially even fraudulent. Or Say your recording device proves that they spent 5 face-minutes with you- Doc claimed 10 in the updated version (which is the one that would be used for insurance billing purposes). Fraud.

At this point you have some choices.
- Perhaps the most obvious is to  'become a snitch'. I know most of us don’t like doing that, myself included. I'm not going to encourage you to snitch. I'm just trying to even the balance of power between you and doctors.
- Rather than snitching on said doctor, I would essentially fight fire with fire: don't outright say 'I have evidence of fraud and or malpractice so if you wanna void a huge pain in the ass just do what I say'. Merely allude to the fact that you had recorded the session, stating something like 'Oh I just record everything lol just in case I forget something important so that I don't have to call over and bother y'all with questions'. If the doctor remembers you or reviewed your prior progress note before seeing you, as they should, they will know you already procured all potentially legally relevant documents. The dynamic should shift between you.

Upcoming: how to protect and advocate for yourself in an inpatient setting, how to protect yourself from corner-cutting nurses, cnas, PT/OT/ RTs, and other non-doctor members of your care time, and maybe more


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Unfolding Nature Shop: Unfolding Nature: Being in the Implicate Order


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