Insurance

Who doesn’t have an insurance nowadays? Yet, how many people can say I know what I’m doing? Even for Dr. Chu, a rehab doctor with twenty-five years of clinical experience, insurance is still her blind spot. She isn’t alone; most of her colleagues choose their own insurance according to the premiums. What are their choices, but to bet on the you get what you pay for saying?

Not understanding insurance is common among doctors; after all, they didn’t go to medical school for that. Nowadays, hospitals have case managers and billing experts who take care of the business aspects, so doctors don’t need to. In fact, this arrangement suits Dr. Chu well. By the time a patient meets her, all necessary paperwork such as insurance, privacy and treatment agreements are signed, and doctors can then “put patients first”— literally a slogan printed in gold, framed and hung on the wall facing the main entrance of the hospital.

For Dr. Chu, insurances of all kinds, including car, home, life and healthcare, are like a huge maze. She is one of those people who have no sense of direction and has never been good at getting out of a cornfield ever since she was young; therefore, having a case manager as smart as Michelle is a blessing. Michelle, on the other hand, is quick and witty. She is thirty-five and has more than ten years of case management experience. She has two kids and juggles family duties and work day in and day out, so busy that oftentimes, she comes to work with her hair still wet. Yet, Michelle is seldom late. Having raised two children of her own, Dr. Chu knows what it is like to balance family life and work. She tries to accommodate her schedule by letting her come and leave early. In this way, Michelle can pick up her kids from school in the afternoon, while her husband drops them off early in the morning. In fact, her early start is a win-win situation for the rehab unit, since typically the inpatient medical team starts early. The time frame from seven to eight o’clock in the morning is crucial to affirm if a patient is or isn’t stable enough to be transferred to the rehab unit. And the earlier a patient is on the rehab unit, the earlier therapy can begin, often on the same day of the admission. As far as insurance is concerned, that’s one day saved.

*

The rehab center is adjacent to the main hospital; many rehab patients are from the center, and their transfers are typically early in the day. The teams on either side have established a cohesive protocol for smooth patient handover over the years. And, of course, there isn’t traffic to consider.

This Monday morning, Michelle opens her computer as usual and sees a message from the discharge coordinator from the main hospital. It confirms that Mr. Silva is ready to be sent to the rehab unit. Ah, someone is up earlier than she is, she thinks.

Michelle knows that Dr. Chu and Mr. Silva’s cardiologist discussed the case on the previous Friday and decided to let him stay on the cardiac unit under observation over the weekend and admit him to the rehab unit on Monday if he remains stable. Michelle writes an encrypted email to Dr. Chu, “Doctor, Mr. Silva, 85, S/P (status post) heart failure. He’s ready to come for cardiac rehab today.” Her email is concise, more like a heads-up, since she is well aware Dr. Chu always reviews the patient e-chart for recent updates.

“Got it. Will review and see him as soon as he arrives. Thanks,” the doctor emails back. She too is an early bird, one of her longtime habits dating from her residency training. She likes to use the quiet morning time to go over patient test results and nursing notes from the previous day before a busy day begins.

At eight-thirty, a nurse on the rehab unit texts Dr. Chu on her pager: “Mr. Silva is here.”

Dr. Chu gives the patient about thirty minutes to settle down. In the meantime, she reviews the patient’s medical record, including vital signs, medication list, and blood and imaging test results. When she is done, she feels satisfied.

Then, she heads to the unit to meet Mr. Silva. As she approaches his room, she hears Michelle’s voice in the room. “Ah, your doctor is here, I’ll leave you for now and come back tomorrow to talk to you. I just want to introduce myself to you. And it’s a pleasure meeting you again.” Michelle can tell it is Dr. Chu from her distinct fast-paced clicking steps. She usually tries not to have the doctor wait, so as soon as she notices Dr. Chu is here, she leaves. The goal of her first encounter with a patient is straightforward: introducing herself, verifying the insurance and the support system, and handing out her business card to the patient.

On her way out, she passes the doctor at the door. She gives her a one-eye wink and a positive nod. Dr. Chu recognizes this as either a good insurance or an easy discharge plan and nods back in appreciation.

Sure enough, the moment Dr. Chu enters the room, she understands what Michelle means. A woman, perhaps in her forties, sits by the patient’s bedside. So, Mr. Silva likely has a family member or at least a friend. That’s what Michelle calls a real insurance. With a support system in place, half the battle is done for a discharge plan. Plus, from the doctor’s perspective, when a patient has support, he or she is more likely to be motivated to work with the therapists.

At the sight of the doctor, the woman stands up and introduces herself. “Nice to meet you, Doctor. I’m Jessica. This is my dad.”

Jessica is slender and wears a color-coordinated cashmere sweater and skirt. She has shoulder-length brown curly hair and an oval-shaped face.

“Pleased to meet you too,” Dr. Chu says warmly, sounding upbeat.

Over the years, Dr. Chu has witnessed many changes: not only medical, or technological, but cultural and social. Her patients are getting older, and fewer of them have family support; the support that they have tend to be their elder counterparts, such as spouse, friends, or partners.  Michelle is right again, she tells herself.

When she turns her gaze to Mr. Silva to greet him, she is taken aback. Before her eyes is an old man with sunken eyes, hollowed cheeks, wrinkle-mapped face, and protruded collar bones. His tree-branch-like arms extend into twig-shaped hands and fingers that are laced and lie on the top of his body covered with a white blanket. He looks like a ghost. The only sign of life is the soundless, barely perceivable rising and falling motion of his chest. Even though this isn’t the first time she sees a patient this frail, every time she does, her heart sinks. She can’t help but wonder, what makes him hold on to his life like this?

For a moment, the doctor questions why she accepted this patient into the rehab program here, rather than referring him to a lower level one at a nursing home? She is aware that their bed-occupancy rate has been lower lately, but that has never lasted long, and usually the pace picks up quickly in one to two weeks. It’s always been like that, like waves. She shouldn’t take sick patients like this one or ‘anyone who has a pulse’ to fill up the beds, regardless of their rehab potentials. But her doubt lasts only a split second. After all, the facility slogan is Put Patients First, and this is one way to interpret it, isn’t it? Plus, Dr. Chu has to admit that she has seen a few very sick patients who have done well and even gone home after the rehab despite their initial feeble looks. Maybe Mr. Silva will be one of them, especially since he has family support?

Thinking about this, Dr. Chu reconciles with herself. She has three days to follow up on Mr. Silva’s progress and can decide a discharge plan later. There is no need to worry on day one. So, she greets the patient softly. “How are you, Mr. Silva?”

The patient opens his eyes, then closes them as if his eyelids were too heavy.

Dr. Chu says, “I’m sorry, Mr. Silva. You must be tired. I don’t want to bother you too much. May I examine you quickly?”

He nods.

Good. A nice man. Dr. Chu appreciates his collaborative manner. She puts on a pair of latex-free rubber gloves, tears open an alcohol package, and wipes the head of her stethoscope with an alcohol pad. Then, she leans over to listen to his heart, lungs, and abdomen. Afterward, she palpates his belly from one corner to the next until she covers the whole abdomen. Finally, she asks him to lift his limbs and push and pull against her own hand. After she’s done, she straightens up her back and says, “Very good. You’re pretty strong.”

The patient doesn’t say a word. Maybe he knows that the word “strong” is a relative term, especially when it’s used by a doctor. It depends on her expectation, which, obviously, is low.

Mr. Silva’s silence makes the doctor believe that he must be tired, so she turns to the daughter. “Jessica, you know your dad’s diagnosis is heart failure, right?”

“Yes.”

“He looks frail, but he actually isn’t as weak as he appears, and all his blood test results are stable. I think after one or two weeks of rehab, he should be strong enough to go home.”

“You think so?” Jessica’s tone sounds more doubtful than exhilarated.

Noticing her concerned expression, Dr. Chu explains, “Yes. We’ve had patients like him before, some were even in worse conditions. As you can see, your dad is no longer in heart failure. His lungs are clear, and his legs are not swollen. The nursing report showed he had good urinary output. He was up in a chair when he was at the cardiac unit in the main hospital. And, he’s able to move his limbs smoothly. What he needs now is to be mobilized further. He can begin by sitting up in a chair three times a day for meals, starting today. Tomorrow, perhaps he can sit longer and even walk to the washroom with a nurse or a therapist. Gradually, he’ll be stronger.”

“I hope so. But I don’t want to push him too hard. He is eighty-five,” Jessica says, sounding more like a plea.

“I understand. Don’t worry. We won’t pressure him. By the way, may I ask who lived with him at home?”

“He lived alone.”

“I see. How did he do before he came here?”

“He used to walk without a cane.”

Dr. Chu widens her eyes. “I see, that’s great.” The fact that he walked without an assistive device prior to his hospitalization is actually an extra point added to his rehab potential. “How about cooking?”

“I cooked for him.”

“Every day?”

“Yes.”

“Wow, he’s a lucky man! In this way, you can check on him every day.”

“Yes,” Jessica nods.

 Dr. Chu feels more confident now, so she continues. “Speaking of food, since he’s had heart failure, he needs to be on a low-sodium diet. This is very important. If you’d like, I can ask our dietitian to go over his diet with you.”

“Oh, no. I know that. I’m a dietitian.” Jessica waves a no need gesture.

Elated by this new information, Dr. Chu says, “Well, that’s even better.” It’s strange that the word, dietitian, makes Dr. Chu glance at Jessica one more time, and somehow the classy pearl necklace catches her eye. On the spur of the moment, the doctor remarks, “Your necklace looks very beautiful.”

Jessica’s blushes. She touches the pink pearls of the necklace with her long fingers and says nostalgically, “Dad bought this on my eighteenth birthday. He had spent years of his savings on it. That’s many years ago, but it’s still my favorite.”

Moved by her words, Dr. Chu says, “You’re precious to him. And I have to say that he has good taste too.” She watches Mr. Silva to see if he is cheered up by her compliment, but Mr. Silva remains silent with his eyes cast down. Dr. Chu assumes that he’s either too tired or too moved to talk.

Maybe embarrassed by her father’s lack of response, Jessica shakes her head and gives the doctor a smile that conveys both gratitude and apology.

Dr. Chu smiles back and gives Jessica an I don’t mind gaze. Suddenly, for an instant, an idea flickers in her mind, why did he get into heart failure if he had a dietitian at home? Of course, she can’t tell for sure, but there is only one possibility. So, she raises her voice towards him. “Mr. Silva, since your daughter is a dietitian, I have no doubt that you have a healthy diet at home. I want to emphasize that please do not add extra salt or eat too much takeout food. Takeout tends to be salty and fatty. You understand?”

Mr. Silva nods slightly without opening his eyes. He probably has heard this numerous times. Naturally, he admits it’s been his own fault.

Dr. Chu understands that Mr. Silva has had a long day: the early transfer, the settling down, a meeting with Michelle, and now a physical examination—-all of this can exhaust an old man. So, she turns to the daughter. “Jessica, I can’t ask for a better situation than his at home. I don’t want to sound like a broken record, but a healthy diet is the most important step to prevent heart failure. I know it’s hard to change one’s lifestyle, but since you’re an expert yourself, you can remind him about it later.”

Dr. Chu notices dark circles under Jessica’s eyes. She suspects that Jessica must be worn out too. It isn’t easy to take care of her dad and go to work at the same time, and now she has to come to the hospital to visit him. The doctor decides to leave them alone and says, “I see you’re both tired. I’m going to put in medication and therapy orders for him. In the meantime, I hope you can take a short break and have some quiet time before therapy begins.”

Afterward, Dr. Chu visits the other patients on the unit.

Because most of the patients’ doors are left open on the rehab unit for the nurses’ convenience to distribute medications and attend the patients’ needs, the doctor and nursing staff can see Jessica and Mr. Silva when they pass by. They notice Jessica seems to be very attentive. She doesn’t read or watch TV but just looks at her dad as if she’s afraid he might stop breathing if she doesn’t watch. She stays with him for two to three hours before she goes to work.

Dr. Chu passes by Mr. Silva’s room a couple more times that morning. Somehow, the sight of father and daughter together, reminds her of an oil painting that she saw at a museum, although the painter’s name escapes her. The image evokes an unspeakable emotion in her: The daughter’s mere presence, even in silence, must give the father a sense of togetherness and comfort. There is the answer to her earlier question: Jessica is what keeps him going. She says to herself, not many men are as lucky as Mr. Silva.

The next morning, Dr. Chu receives an email from Michelle, telling her that she checked with nursing staff and that Mr. Silva didn’t get out of bed yesterday.

“Noted. Will follow. Thank you,” the doctor replies.

Per insurance policy, a rehab patient must participate in therapy and make progress, as minimal as sitting up at the bedside; otherwise, doctors can’t justify the rehab stay, and the insurance won’t pay someone who only lies around. Michelle’s email is her way of alerting the doctor that the first day of rehab is gone and the clock is ticking.

Dr. Chu tries to reason why Mr. Silva didn’t sit up in his chair yesterday. Given her examination yesterday, she saw that he was frail but he didn’t show heart failure. With his daughter at his side, she expected him to be more motivated and sit up at least once. He might be tired in the morning, but he still had time in the afternoon, or perhaps at dinner time. On the other hand, he is eight-five and yesterday was his first day, Dr. Chu tells herself. She plans to evaluate him again and go from there.

Before eight o’clock, she arrives at Mr. Silva’s room and sees that he is shaved and his white hair is combed neatly. According to the rehab staff routine, they usually make patients ready early in the morning so that they have time for breakfast and participate in therapy later in the day. Now for some reason, Mr. Silva isn’t up. He lies in the bed, his body covered with a clean white sheet and a blanket, and his eyes are shut.

“Good morning, Mr. Silva, how are you?” she speaks softly, trying not to startle him.

Mr. Silva doesn’t reply.

Dr. Chu raises her voice a little. “Mr. Silva, how come you’re not out of bed? Remember we talked about sitting up in a chair for meals?”

No response. The doctor can see his eyeballs move under his eyelids.

Dr. Chu bends down slightly and continues, “Mr. Silva, you want to get better, so that you can go home, right?”

“Yes,” he replies.

“You know it’s not good to stay in the bed all day without moving. You may develop blood clots and get even weaker.”

He raises his eyelids.

“Don’t you want to get better and to go home with Jessica?”

Mr. Silva gives her a blank look.

“Do you want to get up now? The breakfast will be here at any moment. I can help you.” Dr. Chu reaches out her arms to gesture that she is strong enough to assist him herself: a trick of hers—the white coat authority, which she’s had successes using quite a few times.

Mr. Silva shakes his head and says, “I’ll get up later.”

Dr. Chu remembers Jessica’s plea. “I don’t want to push him too hard.” Maybe he isn’t ready? The doctor knows that for some patients the simple task of grooming can be exhausting. Maybe he didn’t sleep well, especially since it’s his first night here. She decides to leave him alone for a moment. Before she goes to see other patients, she reminds the nurse, “Please help Mr. Silva to get up for lunch and dinner.”

“Will do,” the nurse promises.

That afternoon, Dr. Chu is busy with two patients to be discharged from the facility and two new patients to be admitted. By the end of the day, she doesn’t have time to see Mr. Silva and the time for therapy is over. Since nobody paged her about Mr. Silva, she assumes that he is stable and doing well.

On Wednesday morning, Michelle emails Dr. Chu early again. “Mr. Silva hasn’t been out of bed. I see that he refused PT and OT yesterday.” Then ends her email with an unhappy face.

Hmm, two days in a roll? Hasn’t sat up even once? Dr. Chu writes back right away, “Will see him the first thing in the morning.”

While walking toward his room, Dr. Chu double-checks her pager and sees no overnight messages. So, at least he isn’t sick, she thinks. When she arrives at Mr. Silva’s room, she is  disappointed to see the patient lying in bed with his eyes closed just like the day before, and the breakfast tray is on the bedside table, untouched.

“Good morning, Mr. Silva,” she greets him, unable to hide a stiffer tone.

The patient opens his eyes, then shuts them.

When he doesn’t reply, Dr, Chu says, “Why are you not out of bed, Mr. Silva? Your breakfast is here and is getting cold.”

Still no response.

“Mr. Silva, you know that you can’t get better if you don’t move.”

“I have pain,” he replies.

“Pain?” Dr. Chu knows that Mr. Silva has pain medications around the clock, but he hasn’t complained of pain until now. To make sure, she puts on gloves and re-examines him from head to toe. She sees no swelling, no redness and no painful reactions on palpation. When she moves his limbs, she doesn’t see him grimace. Even his breathing and heart rate aren’t fast, which would be unusual if someone is in pain. She frowns and asks cautiously, “Mr. Silva, where is your pain?”

Unexpectedly, her question triggers a burst of anger from the patient and he cries out, “Everywhere!”

Startled first, then, she thinks, at least he talks now. She inquires, “I see. So, how bad is your pain on a scale of one to ten?”

“Ten!” Mr. Silva’s body jerks as he speaks, and whoever who invented this one-to-ten scale should have heard him.

“But...did you ask for more pain medications?”

“No. I was on oxycodone every four hours. Now, the nurse told me that you’ve changed it to every six.” He turns his face away.

“I see. Yes, Mr. Silva, I lowered your medication frequency yesterday because when I examined you last time, you didn’t seem to be in pain. I want to reduce the dosage to make sure that you don’t overuse it. At your age, it’s dangerous to take too many narcotics because it makes the mind muddy and can cause constipation too,” she explains patiently.

“I need it.” He interrupts her rudely.

“I understand. That’s why I also ordered as needed medications. In case you have more pain in between two scheduled doses, you can ask the nurse for an extra one.”

“I don’t like to ask.”

“But this is the best way for me to figure out exactly how much you need.”

“Other doctors have that figured out already.”

“That’s true. But if you get up and move around with the therapist, your pain and stiffness can get better, and you’ll need fewer pain pills.”

“I only know that I’m in pain.” He shuts his eyes again, refusing to say another word.

“Mr. Silva, if you need pain pills now, I’ll tell the nurse to give you an extra dose.” Dr. Chu concedes and leaves the room to find a nurse. She figures the priority now is to let him out of the bed. By giving him what he wants, maybe he’ll be willing to move. As she steps out of the room, she hears Mr. Silva’s voice again, “My daughter wants to talk to you.”

She replies, “No problem. I’ll let the nurse know so that they can page me when Jessica comes, or if she wants to wait, I’ll be back at noon.”

As Dr. Chu leaves the room, she realizes why Jessica looks so exhausted. Her dad is stubborn and behaves like a three-year-old child. It has to be his way or the highway. He has lost two days on the rehab unit. If he doesn’t move today, he’ll need placement and have to leave tomorrow.

Knowing that today is critical, Dr. Chu decides to see other patients, order necessary tests for them, and review potential new admissions in the morning and return to Mr. Silva at lunchtime. She’s determined to get Mr. Silva out of bed.

Dr. Chu does her morning rounds and Mr. Nowak is her last patient. Mr. Nowak is in his seventies and has had a recent knee replacement. His personality is the opposite of Mr. Silva’s; he is talkative and likes to joke around. When she first met him a week ago, she asked him if he had done construction work since she suspected that his knee condition could be work-related. Only two days after the surgery, Mr. Nowak was in pain, but he appeared cheerful and replied, “You call it construction, but I call it demolition.” Remembering his humorous response, Dr. Chu smiles. Being a serious person ordinarily, she hopes Mr. Nowak can cheer her up before tackling the stubborn Mr. Silva.

Right before Dr. Chu enters Mr. Nowak’s room, she sees Michelle exit an adjacent room. She must have heard her steps again. Michelle points to Mr. Nowak’s room with her chin and gives the doctor a mysterious warning wink.

Since she is in a hurry, Dr. Chu doesn’t stop. She nods at Michelle, then enters Mr. Nowak’s room. It is a double room, so she pulls the curtain between the patient and his roommate and greets him warmly as usual, “How are you, Mr. Nowak?”.

Mr. Nowak is sitting upright in a chair, watching TV. When he sees the doctor, he extends his arm to mute the audio, then turns to face her.

To her surprise, Mr. Nowak doesn’t greet her back with his typical merriment, and instead, he says, “Doctor, to tell you the truth, I’m not happy today.”

What a day, as if one grouchy patient isn’t enough. How come even the nicest patient is cranky today? The doctor suspects that either nurses have done something that the patient didn’t like or his roommate bothered him last night, so she asks attentively, “Not happy? Why?”

“My daughter is getting married.”

“Getting married? Isn’t that good news?” The doctor raises her eyebrows, thinking, is he kidding, or he doesn’t like the groom?

Mr. Nowak shakes his head. “She’s forty-five and this is her fourth marriage!” He holds up four fingers disapprovingly.

“Oh...” That does sound a bit too much. Hiding her feelings, she comforts him. “But still, she’s your daughter. It’s her choice. You don’t want her to be unhappy...” She stops. It’s not her style to preach to a patient about moral lessons. Who is she? Life is too complicated to be judged.

Nonetheless, as if her words have touched him, or perhaps he’s been waiting for affirmation, Mr. Nowak nods and says in a conceding tone, “Yeah, I’ll pay for it. But I’ll tell her, this is the last time!” Dr. Chu smiles, noticing a perceivable hesitation in the words “last time,” too tender to be carved in stone.

Ah, a typical Dad! So many of them have soft spots for their daughters. Dr. Chu remembers the novel Father Goriot by Balzac, where the Father’s love for his two extravagant daughters led to ruining his own retired life. And even so, Father Goriot had no regrets. How could he? Many fathers are willing to be their daughters’ insurance at all cost. Who can blame them? On the other hand, not every daughter can pay back. One has to be lucky for that, like in the case of Mr. Silva and Jessica.

*

It turns out that Mr. Nowak’s “unhappy” claim is a false alarm. Now, Dr. Chu sets to visit Mr. Silva to deal with the hardball. She hasn’t given up on him and thinks if he sits up today this will be “progress.” Maybe he will turn around and still have a chance to go home. She looks at the wall clock and figures that he has received his pain medication already, so he should be ready to get out of bed now.

Mr. Silva’s room is in the corner, so when Dr. Chu walks toward his room, from the far end of the hallway, she can see Jessica sit at the same spot by the bedside. She remembers Mr. Silva told her that Jessica wanted to talk to her. She wonders if Jessica wants to make sure that her dad is up for lunch too. If that’s the case, the two of them may have a better chance to get him out of bed today.

Encouraged by her thought, Dr. Chu hastens her steps, straightens her white coat, and brushes her short hair behind her ears. As she gets closer to the room, she sees Mr. Silva lying in the bed as still as a log. She glances at Jessica, whose gaze meet hers. In the distance, she senses a shade of anxiety in her eyes. It’s hard to tell if Jessica is sad, disappointed, or angry at her dad.

Dr. Chu doesn’t have time to think further since she has walked inside the room.

Even before she can open her mouth to greet them, Jessica jumps up as if there were an electric trigger. Pointing her index finger at Dr. Chu, she shrieks, “Why did you cut down his pain medication? Don’t you know he’s in pain?” Her face turns crimson.

“I know. That’s why I want to talk to you, Jessica. I want to try to wean him off the narcotics. It’s not...” Dr. Chu gestures to Jessica to calm down with her hand.

“Wean him off? Just because you can’t see his pain? How can you measure pain on a scale?” Jessica interrupts Dr. Chu. Her body trembles. Her pearl necklace wavers.

Dr. Chu is stunned. She hasn’t expected such a strong reaction from Jessica. Looking at the fragile and cachectic man, she suddenly realizes that once upon a time this very same man was a strong, handsome, and loving dad to Jessica, perhaps his only child. The shining necklace reminds her of Jessica’s words, “Years of saving to buy me this necklace.” Now his strength has faded, his hair has grayed, and his eyes are tinged with melancholy. Isn’t it the daughter’s turn to protect him and pay him back? She is his only sanctuary, his insurance. Am I being cruel to him? Perhaps she’s right. How can one measure pain on a scale? After all, who can define what is pain?

Attempting to convey her good intention, she speaks again apologetically, “I’m sorry, Jessica. I did order as needed pain medications and he only has to ask.”

“Only has to ask?” Jessica’s lips quiver and her cheek muscles tighten. Placing her right hand on her necklace, as if to protect it from someone, she continues, “You don’t know him. He doesn’t ask. He’s unable to ask. He never did!” Angry words pound at Dr. Chu.

“I see. In that case, if he truly needs it, I can and will put him back on his original dose.”

Hearing that, Jessica’s body relaxes, and she drops down into the armchair.

At this point, Dr. Chu knows that Jessica is not in the mood to help her get her dad out of bed. And Mr. Silva, with his eyes closed, shows no intention to move whatsoever.

Defeated, she tells Jessica that since her dad hasn’t participated in therapy for three days, he has to be discharged either to home or to a nursing home the next day. “The case manager will come to discuss the plan with you this afternoon,” Dr. Chu adds, then she leaves.

 Back in her office, Dr. Chu calls Michelle. “Do you have time to come to my office now? We need to talk about Mr. Silva’s discharge plan.”

“I’ll be right there. I want to tell you something, too,” Michelle says hurriedly. She looks at the wall clock which shows one o’clock. She has to pick up the kids at three. She has only an hour and a half left.

While waiting, the scene of her last hour encounter with Jessica comes back to Dr. Chu. She thinks about her own parents who lived thousand miles away, and she used to visit them once per year. Yet, it’s only when both of them passed away that she realized while they were living, no matter how far away they were, she felt a security as if she were sheltered. Now, that security, or one can call it a sense of virtual insurance, is gone. What’s left is a strange feeling of emptiness.

Still thinking about her sense of security when her parents were alive, Michelle walks into Dr. Chu’s office. Slouching down into the armchair like a pricked balloon, she starts to vent. “You won’t believe who just called me.”

“Who?” Dr. Chu asks, sensing it is more bad news.

“Jessica’s brother.” Michelle gives her a have you guessed it look.

“She has a brother?” Surprised at first, she then becomes less anxious. “That’s good news. How come they have never mentioned him before?”

“Yeah, I wonder the same. But, you never know what’s going on in a family.” Michelle shakes her head, then rolls her eyes.

“It’s typical that sons aren’t as close to their fathers as daughters are. But still, there is a possibility that he and Jessica can take turns to help their dad.”

“Maybe.”

“Well, I know that you have to leave soon. So, let me get to the point. The reason I want to talk to you about Mr. Silva is that up until now he hasn’t been out of bed. You know that already. I thought he was tired the first couple of days, but today he said he is in pain. I re-examined him from head to toe, but I didn’t see any usual painful signs or behavior. I can’t say that he doesn’t have pain, but I can’t figure him out either.”

“No headaches or chest pain?”

“No. I asked him where the pain was, and he said everywhere. I even considered fibromyalgia or some sort of rheumatism. But his blood tests and physical exams are not consistent with these diagnoses either.”

Michelle knows that Dr. Chu is very thorough, and she has no doubt about her clinical judgement. Yet, she feels confused. “But why did his primary physician put him on oxycodone several months ago if there is no obvious source of pain?”

“Pain is the most intriguing condition because it’s invisible. And different people have different pain thresholds. A doctor can exhaust routine tests to investigate the possible cause of pain; yet, he or she may not get an answer. Nonetheless, the doctor has to prescribe something. Patients demand a solution, even if the source of pain is elusive. When doctors are cornered with limited patient visiting time, such as thirty minutes and the need for lengthy ‘objective justification’ of more tests, narcotics become a handy choice, an efficient alternative.”

“But oftentimes, that’s not a solution, but a delusion.”

“You’re right, Michelle. But failure to find a cause of pain is a double-edged sword. It implies the doctor’s incompetency on one hand and evokes the suspicion of something mentally wrong with the patients on the other. These patients are sometimes considered by doctors and others as hypochondriacs, which may have social and workplace repercussions.”

“On the business side, insurances require doctors to be objective and specific in their diagnostic codes, or else, our services won’t get reimbursed.”

“Michelle, no wonder you’re are a case manager and you’re always on the money. Unfortunately, pain is not always identifiable and measureable. I wish it were.”

“I agree with you. But in Mr. Silva’s case, I think I have a clue,” Michelle says pensively.

“Oh? Can you explain?”

“Yes, this is why I want to talk to you. The brother told me that Jessica is the one who took oxycodone, not the dad.”

“Really? Why and how? This can’t be true.” The doctor’s eyes widen.

Michelle shakes her head and says, “Apparently, Jessica has been separated from her husband because he cheated on her. They have no children. She didn’t tell her dad about their split, but naturally she’s been depressed. According to the brother, she has been taking a few oxycodone pills a day so that she can continue working and functioning. It sounds like they don’t have much choice.”

Dr. Chu listens and reflects, indeed, what are his choices? To watch Jessica suffer and lose her job or to help her out and hope her problems magically go away with time? A dad always has hope for his daughter, doesn’t he? Father Goriot hoped his daughters were going to be out of debts; Mr. Nowak hopes his daughter finds a good man; and Mr. Silva too. Is that wrong?

Seeing the doctor drift into deep thought, Michelle adds, “He’s really between a rock and a hard place.”

“I see why Mr. Silva insists on a large dose, so once he goes home, he can share with Jessica. If this is the case, we are back to square one, and it would be better that Mr. Silva doesn’t go home. But we have to persuade him to go to a nursing home. I think this is the best choice for both of them,” Dr. Chu proposes. She knows that she has to make a tough but right decision.

“I suspect that he won’t agree. She’s his only daughter, and he doesn’t have the heart to hurt her. I’m also concerned about our performance measures. If someone like him, who has family support—a daughter and a son—goes to a nursing home, what about others who don’t have any support? If more patients go to nursing homes after their rehab here, our discharge to community rate will be lower and will be deemed less effective.” Michelle points out the consequence of the bigger picture.

“But, if he goes home, you know who will use his medications,” Dr. Chu argues.

Michelle shrugs, “If you force him to go to a nursing home, I bet he’s capable of making a big fuss and writing a negative comment in the patient satisfaction survey when he leaves. That will damage our facility image.” Michelle looks at the wall clock again.

“I can’t care too much about surveys or performance measures. I’m going to talk to Mr. Silva later today. We’ll discharge him tomorrow, one way or the other. You have to go to pick your kids up. Don’t be late. Otherwise, they’ll wonder where Mom is.”

Unable to see the bigger picture is one of Dr. Chu’s shortcomings. If hospital beds are not filled, or patients are not satisfied, who can claim this is a good rehab place? In today’s world, one can’t afford to ignore the rating or ranking. For businesses, people say the customer is God; and for hospitals, patients are first and their opinions count. It’s as simple as that.

“Okay. Anyway, it’s your decision. I’ve said what I have to say. And good luck with him,” Michelle says. It’s useless to fight, since the doctor is stuck in her own rabbit hole again. She stands up, waves goodbye, and hurries away. She’s well aware that this is a tough case, but it’s moments like this that make Michelle appreciate her own job more. Leave the hard ones to the doctors. After all, they are paid to do this, aren’t they?

In the late afternoon, Dr. Chu returns to Mr. Silva’s room. She walks slower. Remembering his and Jessica’s angry outbursts in the morning, she is not confident that she can convince him to go to a nursing home, which means asking him, in a sense, to abandon Jessica.

After a few minutes, Dr. Chu arrives at his room. Surprisingly, she finds Mr. Silva appearing calm. His eyes are wide open, as if he expects her visit. Dr. Chu greets him and sits down beside his bed. Not wanting to pour more salt onto his already wounded feelings, she tries to find a proper word to begin.

Mr. Silva waits, then lets out a sigh. Dr. Chu senses an air of helplessness. She says calmly, “Mr. Silva, I heard that you also have a son. How come you haven’t mentioned him? Does he visit you often?”

“Sometimes, he comes. He has his own family with three kids. That’s a handful. I can’t bother him too much. He’s the bread-earner and is busy enough. So, it’s always been Jessica taking care of me. We’re very close. But she’s paid a price for it..., for me.”

What a dad. He confesses a feeling of being a burden to his children. Dr. Chu blinks to fight back her tears. She takes a deep breath and says, “I understand. Daughters are close to their parents, especially their dads. My dad used to be close to me too. Mr. Silva, you have a good daughter. She loves you. Many daughters, including myself, can’t do what she has done to our own parents.” The doctor pauses and watches the patient’s face.

Mr. Silva nods and presses his lips down.

“But, as parents, we have to make decisions and sometimes they can be tough.” She pauses to let her words sink in.

Mr. Silva raises his eyelids and looks straight at her. Unexpectedly, he speaks slowly and clearly, “Doctor, you’re right. It’s better for me to go to The Manor’s.”

The Manor’s? Dr. Chu can hear a touch of helplessness in his tone. She is shocked to arrive at this conclusion this easily. And what’s more, he even knows where he’d like to go. Has he thought about this already? Or, maybe his son talked to him, too? No wonder he’s tired. He must have had quite a few sleepless nights.

Although feeling slightly relieved, the doctor is struck by his somber look. She doesn’t want to press further, so she says, “Okay. If you agree, I’ll ask Michelle, the case manager, to  talk to you in the morning. If The Manor’s is your choice and has a bed available, then you may go there tomorrow. Michelle will let Jessica know about the plan and arrange transportation for you.”

Mr. Silva nods and lowers his eyelids again. With a heavy heart, Dr. Chu leaves him and sends a message to Michelle with the latest information.

The next morning, when Dr. Chu arrives at the hospital, she sees a message from Michelle. “All set. Mr. Silva will be transferred to The Manor’s at ten a.m.”

“Thank you,” the doctor replies. She puts in a transfer order for Mr. Silva along with the same quantity of pain medications.

At ten o’clock, Dr. Chu goes to the unit to see him off and finds Jessica by his side. She says to her, “I’m sorry that your dad has to go to The Manor’s, but I believe this is the best choice for him.”

“I hope so. Dad knows that place. He’s been there before,” Jessica says without looking at Dr. Chu.

The doctor turns to the patient. “Mr. Silva, I’s glad that you know the place. I hope you’ll like it. When you get better, your doctor can taper down your pain pills again. And I know that place has a long-term care unit in case you’d like to consider it.”

Jessica interrupts. “Dad and I will talk about that later.”

“Of course,” Dr. Chu says.

The ambulance arrives and two paramedics put Mr. Silva on the stretcher. A unit nurse pats on him on his shoulder and says, “Work hard, Mr. Silva, so that you’ll get better soon.”

His lips twitch and his head shakes slightly.

Up until now, Dr. Chu believes that this is the right decision. Somehow, seeing his sad face, she feels torn and confused, no longer sure if this tough decision is the right one. She watches the stretcher move farther away in the hallway, out of her sight.

 Michelle stands by Dr. Chu. She says, “I feel sad for them.”

“Yes,” she says. “But what else can we do?”

*

A few months later, Dr. Chu walks into the adjacent main hospital to attend a mandatory training on coding. She feels fortunate that the hospital doesn’t require the doctors to know all about insurances. Maybe the hospital knows it would be futile? At least for now, knowing how to code is all that’s needed.

*

As Dr. Chu enters the building from one end of the hospital, she sees a thin silhouette from the other end moving toward her. It’s a woman pushing a wheelchair with a skinny man sitting in it. They look familiar. As they get closer, she recognizes them: the woman is Jessica, and the man is Mr. Silva. So, he’s gone home?

At that moment, Jessica seems to recognize Dr. Chu as well. She turns her face to the side, pushes the wheelchair into an adjacent passage, and together, they disappear into the hospital maze.