Why vaccination is important- or why doctors don’t recognize previously common childhood diseases

Let’s make this clear- I am a physician and believe without a doubt that vaccines are a good thing.  I have not yet fired any patient for refusal to vaccinate, and if a parent is willing to vaccinate but to do it under an alternate schedule, I am willing to work with them.  I think there is little value in alienating someone who is not anti-vaccine, but maybe can we decrease the shots in one setting.  While I am fully going to discuss the reasoning for the shots, the potential complications, and the risks and complications of each vaccine, those who merely want to space vaccines, and they are keeping their child out of the public area, well maybe it is worth working with them.  

However, I fully believe that the risk from the polio vaccine is substantially less than the risk of catching polio itself.  However, because of the decreased risk, of polio in this country we have changed from the more effective but more potential side effects of the oral polio vaccine to the injection which is slightly less effective and definitely safer.

I have read the study which was manipulated to link autism to the MMR vaccine, and more specifically the thiorisal that was a preservative, and I know the difference between ethyl mercury and methyl mercury, and find that tuna fish is much more risky, and the incidence of autism really increased not due to the vaccine but more likely due to the widening of inclusion criteria.  And I have a son who was showing the signs before he ever received a vaccine, much as I tried to both ignore it and deny it at the time.

And yet, the last 2 weeks, I have seen three cases of chicken pox.  And unlike MRSA, it took me longer than an instant to identify it.  The kids seen have either been vaccinated or too young to be vaccinated.  So these are not faults of their parents, but of society.  The one vaccinated, well had a mild case, the one too young, well it is a wait and see.  I had it as a baby, and don’t remember it.  The previous case that I saw was 18 months ago, in a child that had received his booster less than 2 weeks prior.  While not expected, not uncommon, but these not so much.

The recent outbreak of measles in Indianapolis, those opposed to vaccines point to it being a harmless childhood disease, but when does a harmless disease have the potential to deafen a child.  And mumps is worse, since it can leave a male sterile.  And unfortunately it may take longer to diagnose due to most of the current crop of young physicians have not seen a case in real life.  As the vaccination rate of MMR continues to drop farther down, (we have never reached projected herd immunity rate of 90-95%), chances of a measles epidemic continues to increase.  And what caring parent wants to see their child suffer, and many of those who did suffer from measles remember it as being painful and definitely uncomfortable.

A couple of years ago there was a shortage of Heamophilus Influenzae B vaccine, and the incidence increased tremendously in babies, which made it difficult for children to breath several children did die due to lack of vaccination, and unfortunately that is probably what is going to be required for some parents to realize just how harmful measles can potentially be.  There has been an increase in incidence in whooping cough, which has led to a recommendation for adults and adolescence to receive a TDaP instead of the previously recommended Td.  Why?  Because the CDC realized if you could remove the carrier state from adolescents, parents and grandparents, maybe transmission would decrease to the most vulnerable among us.  And isn’t that possibly the most important reason any parent could have for vaccination, protection of their youth and the future generation.  As an adult whooping cough is annoying, a cough that lasts about 100 days, as a baby it is sad and heart breaking.  

There are legitimate reasons to not vaccinate some children.  Some have conditions, that would make it dangerous to vaccinate.  Some that have to rely on herd immunity, so much for protecting the vulnerable.  While I realize it is up to every parent to look at the risks and decide what is best for their child, you must understand that the risks are small, 1 in 1,000,000, 1 in 100,000, and while if you are that 1 none of those ratios matter, for the vast majority, there is little to no risk for vaccination.  Occasionally, there is infiltration of the injection site, there are fevers and there are occasionally allergic reactions.  And all of these risks are there, but infiltration of the injection site is mild, and fevers occur throughout childhood.  But they are not and should not be used as excuses to not protect your children and even more important those with congenital heart defects, those too young for vaccinations, and others with legitimate reasons preventing their vaccines.

Vaccinations help save lives.  The success of vaccines have led to their biggest challenges, people don’t see these diseases as threats anymore and therefore undervalue the vaccines.  This has led to increase in diseases that aren’t seen anymore, and physicians, who no longer see these diseases regularly, have to go and look again, and remember what was only supposed to be a text book picture.    So protect yourself, protect your baby, and protect those that cannot vaccinate.  Follow immunization schedules and keep our most precious safe and healthy

 

Yesterday, I almost kicked my computer out the window

In my 2 month long saga (of which I was only aware of for a month) of not getting paid, I continued to do my job, and provide the best care for my patients that I could.  I was still seeing between 25 and 35 patients a day, and trying to get them referred to specialists, and watch their lab, ordered MRIs, XRays, mammograms, and CTs as indicated, and tried to adjust medication.  All fairly ordinary in a day’s work for me. I became frustrated with some patients and specialists, and others were easy and pleasant to see and talk to.  Still fairly routine.

However, the one thing that was constant, is that I was still using a computer through it all to track everything.  On Tuesday afternoon, the internet went down.  Don’t know why, but we were still able to work on our internal network.  No internet, made things harder like checking eligibility, taking credit card payments, and other tasks, but life was not impossible  However, that evening, my software started popping up that our licenses were not active and that further use of the software might result in errors and damage.  What!  I paid my yearly contract in August, and well it is February.  The day finished, and we noticed updates had not been installed on the server, so thinking that might have been one of the internet problems, my husband restarted and installed the updates.  During this time I wrote an angry email to my EHR vendor, pretty much expressing in it all of the frustrations we have had with them in the last 6 months, and especially the last month and a half.  Not expecting a response until morning, as it was 5 pm when I sent it, I was really surprised at the first response in 10 minutes, followed by another 4 in over the next 20 minutes.  I guess threatening to find a new vendor (which can be pricy, mine cost around $30,000 for two physicians 6 years ago) is enough to warrant prompt attention.

Anyway, there was only so much that could be done that night, with the server updating, I don’t know how many updates that night.  So I went on with my night, and yesterday morning, still the same error message and my tablet (which I take room to room) would not connect onto the network.  Actually none of the computers that were on the wireless would connect.  So we followed the directions to fix the licensing issue, pulled out our paper charts that we have for an emergency, and started the day.  However, we got to one step that said, clicking yes will disconnect you from your system.  And the directions clearly said to click yes. Oh my.  Did we want to do this?  At this point, I am definitely ready to throw my computer out the window and look into new lines of work.  Not sure what I am qualified for, but they surely pay better (since I am not getting paid) and probably 100% less stress. 

At this point, the wireless connection was reset and the tablet was working, so we were electing to not fixing the error, because despite the error messages, we could at least access the chart.  But how frustrating.  Though somewhere during the first hour of patients, apparently my office manager had gotten ahold of support, who said there would be no effect to the rest of the system when pressing those buttons, and had fixed the licensing issue.  So if I would log out and log back in, I would not longer be bothered by the annoying error message that I had not active licenses.  Finally, some good news.  Anyway, we were finally able to finish the morning, but the right off the back frustration makes me wonder, do computers make it easier or more difficult?  It is hard to decide.

A light at the end of the tunnel (OH I do hope it is not a train)

Finally after 8 weeks of not getting paid by Medicare, and 6 weeks of not getting paid by Medicaid, maybe there is hope.  Talking to my fellow physicians have helped.  Sadly the fact that knowing I am not alone and the biggest idiot with regards to payment ever has comforted me. For the first time in my life the expresssion, misery loves company actually does apply.  Not that I wanted them to have any difficulties, but for a bit, I thought maybe I was alone.  Being alone, would mean that it was all my fault, having company means there must be something in the system that is tragecially wrong.

Anyway, the new company that we had contracted took over the Medicaid billing immediately, and did get us some cash, unfortunately the Oklahoma Medicaid site crashed on Friday, and was not back up until Wednesday.  It still is not fully functional, but at least claims can be inputted back in.  (Probably due to all the desperate physicians in the state who had been using a clearinghouse to submit claims jumping on in droves desperate for some cash flow, that is just my opinion, but it is as likely as anything else.)

And Thursday morning, we were told that all of the updates from both the EHR vendor and the interface were finally complete.  (These are updates that have been released since the first of the year, and probably since the date we found out there was a problem, not due to any negligence on my part.)  And we were free to resubmit all claims.  Which means we get to go through and find all of the claims that we have submitted since December 19, and start all over again.  What fun will that be!

I spent Friday with the company that we had hired to start doing our billing (because we had a problem before the 5010 conversion almost bankrupted me, it only made it worse).  We were showing them the ins and outs of our system, and while showing them how to do somethings, we were able to understand some of the issues that we have been having.  Unfortunately the person who was responsible for inputing payment in never brought that issue to our attention.  But it will be fixed immediately.

As for our Clearinghouse, I understand that you were probably overwhelmed, but seriously, couldn’t you have given at least a heads up.  Some of us were in the middle of a Medicaid audit so it took a little longer to realize the problem.  You should have posted something immediately.  You were only too happy to take my money.  And the email you sent me saying you were looking into the issue, still has yet to address any of the concerns we have.  And your customer service response of “well look at our website.”  Which we had already looked at, and it said nothing, left much to be desired.  So any thoughts we had about retaining your services have been removed.  We will probably convert from you over the next month, after being a customer for almost 6 years now.

To my elected officials, I will keep you lack of response in mind when it comes to your re-election campaigns.  I received one confirmatory email which the senator will try to respond in the next month.  I guess you all were too concerned about issues of birth control (both state and nationwide) to think about whether physicians would even still be in practice in 3 months to prescribe the pills.

For all of you with your kind words of support, thank you.  I do appreciate it, and send happy thoughts back to you.  This year, so far has not been the one that I would like to repeat so far.  This conversion has really opened my eyes about future conversions.  I am not worried about ICD-10 for the coding issue, but for the computer conversion issue.  IF this is a taste of what is to come when that happens, well I am not sure that I have the desire to continue.

For all of my friends in the medical field that are having similar problems like I am. Thank you to echobillingsolution for bringing this blog to my attention

Medical Account Solutions Blog

As a Medical Practice, you are aware of the impact that our industry is facing as of 01.01.2012…conversion of Electronic Files from the 4010 to the 5010 formats.  The American Medical Association is aware that this is creating many denials and issues with 5010 and therefore has put out documentation on what you can do if you are experiencing claims processing issues.  Please read below:

Since the deadline on January 1, 2012 to convert to the Health Insurance Portability and Accountability Act (HIPAA) Version 5010 transactions, some physicians have been experiencing issues with their claims processing, resulting in lack of payments.

The AMA is aware of issues with claims processing related to the 5010 transition and is addressing these issues directly with the Centers for Medicare and Medicaid Services (CMS). Please inform the AMA and CMS of your issues:

• Report the problems you are having to the AMA with this form…

View original post 226 more words

To all my friends in the medical field

Dear friends-

This blog is for you.  while there is no difficulty in others reading it, this one concerns you all directly.  Well at least those of you who accept Medicare, Medicaid and TriCare.  (If there is a federally funded carrier that I missed, I apologize, and advise you to check on them as well).  Look and see if any of your Medicare claims submitted after December 19, have been received, paid or rejected.  And then look at your Medicaid claims and see it they have been paid.  (In Oklahoma, look after December 28).  If the answer is yes, well then never mind.  If not well, it is your attention that I am seeking.

I understand this does not affect physicians that work at the VA, many of the Indian Clinics, and possibly those that are federally funded, but for the rest of you, this absolutely affects you, whether in practice for yourself, a small group, or those employed by a hospital.  CMS has installed firewalls blocking claims from getting through.  This is not just for providers who are not 5010 compliant.  I went through all the steps required to be compliant, and my payments have been blocked.  This is not just the 2 week delay we were told to anticipate for the 5010 conversion.  This is a complete block that appears to not be vendor specific nor clearing house specific.  

After checking those of you who have found this to be true that you have not been paid by those under the umbrella of CMS, I am asking for your help.  I have attempted to contact CMS and cannot get through.  Their email addresses are only for those who wish to report fraud either on themselves or someone else.  I am asking you to take the time to write your Senators and Congressmen/women, in order to get this situation fixed.  If not, many of us in smaller clinics have only a small amount of time left.  

This is not about greed, this is about getting paid for services you provided.  Last week, I had to pay my staff’s payroll partially out of my own bank account.  If you want to write it off as bad business decisions that is fine.  I have made some, but realize that if you are not getting reimbursed, at some point you will find that you also are unable to practice medicine.  I am not asking for money that is not mine, only what I have earned.  I cannot continue practicing without income coming in.  My practice is 45% Medicaid and 25% Medicare.  How long could any of you go without receiving payment from 70% of your patients?  

And for those of you who accept neither, ask yourself what will happen if Medicare and Medicaid are allowed to get away without paying?  What will happen to the rates to your private insurance payments?  And those in the Emergency Rooms- where do you think that those patients that can no longer see their physician will end up?  I am just asking that you write your Senators and Congress for help to end this block so that we as physicians can get paid for what we have done.  I have not committed fraud, and I have followed the rules.  And following the rules has led to me being within two weeks of being forced to close my office, because that is the reality.  I cannot afford to bankroll my staff any longer than that.  They say you should find a career you would do for free, I have been doing that since the end of December, I cannot see myself paying to do this for long.

Thank you for your time and any effort you put towards my cause, and for many of you, your own cause. 

Dear Center for Medicare and Medicaid Services

Dear Center for Medicare and Medicaid Services.

Dear Center for Medicare and Medicaid Services

This is an email that I would send to the Center for Medicare and Medicaid Services, but since they don’t have an email address for themselves, unless I want to report fraud on either myself or another, well I will have to make do.

 

Dear CMS-

I would say that you don’t know who I am, but you have used my picture for the last year advertising your EHR Incentive program as the first clinic to receive the Incentive Bonus from Medicaid.  So you must at least have an idea of who I am.  That being said, you probably don’t care, but at least you know that I have tried to play by your rules in order to win that honor.

Couple that with the calls a couple times a month from the Office of the Inspector General looking for the physician whom we  agreed to become custodian of record for, well you have talked to at the very least my office staff.  And we have given you all of the information we have.  OR have at least indicated just let us know what you want, we believe that she left the country, given you the email addresses we have, but we don’t have what you are looking for.  Well other than the patients version of what she did.  But otherwise you have not had many dealings with me.

I have a practice of 45% Medicaid and 25% Medicare.  So all together about 70% of my practice is receiving “insurance” from your office.  Over the past year, we have done all of your recommendations for 5010 conversion, and per you and our systems passed them all.  We have performed the required updates, installed the needed hardware, software, implemented the required training, all that you have indicated as necessary.  So based on those, we were ready for the conversion January 1, despite the delay to March 1, 2012.  However, you decided to implement the conversion on December 19, 2011 and installed a firewall.  This firewall blocking all new claims from going through.  We didn’t notice it right away, due to a 2 week to 45 days delay from date filed to date paid.  So we didn’t notice.  Add to that the notification that claims would be delayed about 2 weeks, well it took a little while.  25% is a large chunk of income, but it would have been ok, for a short period of time.

On December 28, the firewall went up for Medicaid.  Again there was a slight delay in noticing, since the turn around is two weeks, plus we were told that there would be a two week delay.  However, this was somewhat more painful.  Added to that the insurance companies have all installed required firewalls, however, after three weeks, we are finally through and getting paid.  So we are receiving payment for 30% of the work that we do.  That does not even cover my staff or overhead.

My understanding is that I am not alone in this problem.  It is neither EHR vendor specific nor clearinghouse specific.  The only constant is that they are plans paid for under your umbrella, Medicare, Medicaid and Tricare.  And one message received was that I was fortunate, at least my problems only started in mid-December, not early November like some physicians.  Whatever.  I have not taken a paycheck since the middle of December.  That is no paycheck for either my husband (also a physician) and me.  Still had to make payroll for the staff of eight that I employ.  Well currently seven, due to a recent death.  But even she received a paycheck this last pay period.  So I have had enough to pay 8 people, well up until this week.  This week, I had to pay some staff out of personal accounts.  So now, not only am I working for free, I am paying for the privilege to deal with government regulations and bureaucracy.

Oh and did I mention that I experienced the privilege of an audit by Oklahoma Medicaid during this time, which other than a few minor problems, I passed.  One of those being something that I have no control over, being specialists not sending their consult notes to go with the referral that they got paid for, but somehow that is my deficiency, DESPITE CALLING AND ASKING FOR A NOTE!!

So anyway back to the point of this message that you will neither read, nor receive, but maybe someone out there will hear me.  I paid for the pleasure of working last week, PERSONALLY!!  And I wonder why I constantly have a headache, and the gnawing of an ulcer in my belly.  I own my clinic, and am personally responsible for the debt to go into business.  I don’t have a big corporation that can afford a short period of time to cover not being paid.  My clinic sees 68 patients on average a day, so I should not have a negative balance sheet, but I do because for 70% of them, I have not seen a dime since December 28, maybe a few more due to the small amount of TriCare that I also see.

I know that I am not the only one who is experiencing this, since this week we were 2017 in line when calling to see where the problem was.  (We were 1700 last week, and that ended with 7 and a half hours on hold, only to be told to check online for solutions, WHICH WERE NOT THERE!!!)

I scraped enough for payroll this week.  In two weeks, I may be able to do it again, even without payment.  But after that I will be done, I will have no choice but to close my doors.  I understand the theory that you should love what you are doing so much that you would do it for free, but I did that the first 18 months in practice, and 6 months in 2010, and an occasional pay period here and there.  But I cannot afford to do that for much longer.  And I definitely cannot afford to do it and pay to do so.  Currently I have $120,000 in Medicaid Accounts Receivable since December 28, and another $60,000 in Medicare. (that is not what I will receive, only what I am billing)  And if by some miracle that were to come through tomorrow, I now have back bills and creditors who would also like to be paid, so even if you were to fix it tomorrow, I will be working for free until May or June.  So my husband will have to spend more time away from his boys, and work more shifts in the ER so we will survive.

I know to some, this is what I deserve being a greedy doctor, though I have yet to make over $100,000 personally since graduating residency.  (My declared income is higher only because of my husband working in the Emergency Room)  I have bills to pay, and cannot afford to continue floating the payroll for the clinic.  So I am asking CMS to look at their firewall, and attempt to fix it, or the looming doctor crises will come in about 2 or 3 months instead of the 3-5 years that is currently anticipated.

 

P.S. If this is your plan to save Medicare, it is a really crappy thing to do.  You should look closer at where your biggest incidences of fraud occur, and not cause those who are playing by the rules to become financially ruined.

CMS blocks payments to providers through firewall

The Centers for Medicare and Medicaid services have found a way to save money.  They simply installed a firewall which blocked claims submission from providers who have complied with the 5010 conversion by January 1, 2012, which was their initial deadline.  And the best part, most providers did not realize the problem until the end of January.  In what has been one of the worst weeks in my life at the office, we received a phone call on Tuesday, from another office who used the same EHR and the same interface processing claims asking if we had been paid this month from either Medicare or Medicaid.  The answer was, yes.  Well initially it was yes.  Followed by “Well only by Medicaid.”  Followed by, “Well outside of our medical home payment about $18.22.”

WHAT!

Throughout this month, I have been watching the income come in.  And until about the middle of the month, it was about the same as last year, maybe even a little more.  And while I was not thrilled with that considering there was more patients 45 days before than there had been a year ago, money was still coming in.  And we had already found that there was a problem with a glitch in our billing and were attempting to locate it.  So I was already not taking a paycheck this month.  So at least my salary was not affecting the outgoing.

However, as the month went on, that number seemed to not change the way that it was supposed to.  Well, we are looking for it on the one hand, but last Thursday, we underwent an audit from Medicaid, so much of our effort went to preparing for that.  Making sure that all of our i’s were dotted and our t’s were crossed.  Knowing that no matter what they would find something wrong.  Realizing too late, that after our last COLA inspection, our CLIA certificate seemed to not be put back in the same place, and was currently MIA.  Which is not great news, especially since a computer glitch at CLIA has not allowed them to send new certificates out, and we are still waiting today for the request submitted two weeks ago.

So anyway, while the numbers were concerning, they were not in the front of our mind, until Tuesday.  When a call partner called, and we looked.  And then discovered.  We had not heard anything from our clearing house all month regarding claims.  So we examined further, and that $18.22 was from Medicaid secondary payment which was submitted to Medicare prior to January 1.

So we called our interface to find out what happened.  “You are currently 1,746 in line.  Approximate wait time is 7 hours 32 minutes.  Did you know that you can check wait times online visit www….”

Well that sounds, uh promising.  After utilizing a phone line for the entire day, we found out, that there was the problem, they were contacting our EHR, and no they don’t know when it will be fixed.  That was tuesday.

Wednesday, we found out that it was not just our EHR having problems.  It was multiple EHRs.  And we started looking for a new way.  We had recently hired a new billing company, who was in the process of creating tunnels and whatever else is required for them to extract our data over the internet and bill for us, would they be able to take our Medicaid claims and submit them an alternative way?  The answer was maybe, if we can figure out how to extract them from the mess, we currently were in.  (Then tragedy struck our office Wednesday afternoon, and to be honest, we just tried to finish our day)

Thursday morning, numb and still in shock, we checked by on the Gateway.  Still no payment, but there was something that had not been there in a month.  A screen of rejections.  We don’t know if that is a good sign or not, but it was something new.  Still no payment.  But a new screen.  And the interface was still working on the problem.  (However, this did not prevent them from drafting my account for payment earlier in the month)

Finally, Friday morning came some answers.  Calls to Medicaid to make sure that we would not get hit with a penalty for attempting to file claims multiple ways, which received a probably not, also had some news.  Apparently the day before, they received 18 electronic batches through interfaces.  While they did not know if they were ours, they said it was promising only because they had not received anything the entire month of January.  Nice.  And you could not have said anything to your providers?

And Friday morning, also provided word from our clearing house.  Apparently the 5010 conversion had caused this.  Despite providers, software vendors and electronic interfaces having had successful tests from the previous year, January 1, conversion did not go as planned.  A firewall at CMS enacted for this event, did not recognized claims that were in compliance or not.  It did not recognize NPI numbers, ICD-9 codes, or CLIA numbers.  In an essence, those who complied with the rules by the initial deadline were penalized and just not paid.  This included all federal government programs Medicare, Medicaid, and Tricare.  Well actually Tricare was worse, their firewall had been blocking claims since November.  And our situation could have been worse, there were Medicare providers who had not been paid since November.  And this is for those that comply with their rules.

Unfortunately for me, 45% of my income is from Medicaid, 20% from Medicare, and Tricare <1%.  So you can imagine what this is doing to us.  The only thing good with regards to Medicare is that we collected their deductibles up front, so we did get some of that.  Though there were also glitches with Blue Cross Blue Shield which is our 3rd biggest payor, which has a percentage close to that of Medicare.  So I guess that I am lucky that I am sitting at half of the number that I should be.  Next month figures to be worse, when you consider a 45 day wait time for Medicare on average.  If we can get claims through under Medicaid, I should get paid in as quick as a week after submission.

So the month of January, I have worked for free.  February, I will also not be taking home a paycheck, and I imagine it will be close to May, since March and April will require me to catch up on bills not paid this month due to the CMS firewall.  Which means more shifts in the ER for the hubby, so that we can survive at home, since my bills won’t stop.

So those of you who think physicians are just greedy, and should be willing to take a 27% cut in pay from Medicare (which would result in similar cuts from other insurances) consider this.  My overhead does not decrease, it increases.  I still have to pay my staff, rent, electric, water, etc.  And following this incident for being in compliance… it is no wonder that physicians don’t trust CMS.  I have not committed fraud, and have played by the rules.  But situations like this sometimes makes you wonder why you bother.

So before any of you call your physician greedy or just in it for the money, think about this.  Those that are self employed didn’t get paid this last month at all, and will probably not get paid this month (take home pay).  The fact that they don’t trust CMS results from issues such as this.  And that is not even looking at the cluster that is ObamaCare.  So I worked last month seeing patients for free, will next month as well.  Sometimes you have to wonder if that time wouldn’t have been spent better elsewhere.

So I guess CMS has come up with an ingenious plan to save money.  Just block physician claims from going through at all.  That way, their money is able to stay in their account and draw interest, and well unless providers close their doors overnight, their patients are still being seen at least temporarily.  So if you look at the numbers for January for CMS, I am sure they look the best in a decade.  Thanks CMS.

Unexpected loss

As a physician, I always thought that the hardest part of my job was to tell someone that they probably have cancer, or some other potentially fatal disease.  Or to tell a family that their loved one is not going to make it.  Well, yesterday, I found out that is not correct.

Yesterday afternoon, one of my staff died suddenly, unexpectantly.  That is probably the most difficult thing.  Except I think that my husband had it worse.  He was actually in the Emergency Room as they were coding her.  I was only at the office pretending that it was just an ordinary patient that he had run over to take care of, trying not to let the staff know, that one of their friends and collegues was over there.  (we would have told them after work, but didn’t want to make their day impossible)  Was that the wrong decision?  I don’t know.  It was the one that seemed best at the time.  But when he came back, he didn’t say anything, he merely had tears in his eyes, and shook his head.  One of my other employees had already heard from the husband of the previously mentioned staff member.

Well there was no getting around it at that point. We now had to let everyone know the cause of the tears, but they already knew why.  They had known that she had called in sick that morning, and they had known that she had been sent to the ER at lunch time.  So they knew.  Through the tears we made it through the day.  Didn’t know what else to do.  It was a horrible afternoon.

And this is the worst part of being a doctor.  Last night,  I spend my whole night thinking about the night before, wondering if I had missed something, but could not find anything.  And I didn’t.  And that is not healthy.  And today, we are here back at work.  There is less laughter, we are all a little sad.  But we have to go on living. 

The worst part was seeing the spot where she parked, and knowing she would not be there.  People who could have parked closer haven’t.  But we are going through our day, not knowing what else to do.  Right now, we are trying to decide how to move forward.  But it is sad, knowing that she will not be greeting people at the front window.  She won’t be there everyday with a smile.  Knowing that we could not have done anything to save her.  That is the hardest part.