“Optimism,” said Cacambo, “What is that?” “Alas!” replied Candide, “It is the obstinacy of maintaining that everything is best when it is worst.”
― Voltaire, Candide
Candide is a truly optimistic patient, as he is a truly optimistic electrician. Indeed, in all aspects of his life, regardless of whatever identity or role he may have, he is always, truly, unwaveringly, optimistic. Even when he suffers from an accident at work, he conveys only his characteristic optimism.
Like last week, while replacing light fixtures in the factory of the company he works for, he punctured his hand while holding a shattered bulb. The bulb pierced deeply into his hand, puncturing deeply, restricting his finger’s motion, and causing excruciating pain.
The calamity, while penetrating his hand, could not penetrate his optimism, and he told himself to remain calm and to go to the emergency room at the nearby hospital. A co-worker, impressed by Candide’s composure, offered to provide a ride so Candide would not have to attempt his hand at driving one-handedly.
But this co-worker, as noble as his intentions may be, drove a very ignominious vehicle, notorious for stalling at stoplights at the most inopportune time. And as one would predict, the vehicle stalled numerous times on the way to the hospital, taking an extra hour to a trip that otherwise would have taken only fifteen minutes. But throughout the stops, stalls, and restarts, Candide did not fret, and kept his hand wrapped tightly, as he waited patiently, stall-out after stall-out.
Once at the hospital, Candide thanked his co-worker and made his way to the main reception desk of the emergency room. He introduced himself to the receptionist and asked politely to be seen. She smiled, looked observantly at his hand, wrapped tightly but haphazardly, blood seeping through the wrap, and asked him to fill out some paperwork.
Candide asked how he could write when his writing hand is injured and essentially non-functional, to which the receptionist offered the option of using the hospital’s transcribing service, an offer he agreed to, prompting her to tell him to take a seat in the lobby and wait for the transcriber.
Candide smiled as he waited and felt thankful his injury was not worse. And he continued to wait, waiting for an hour went until the transcriber arrived. The receptionist handed the transcriber the documents to complete, and he made his way to Candide, his eyes fixed on Candide’s hand, as he sat in the empty chair next to Candide, and smiled warmly upon asking Candide if he was ready to begin completing the paperwork.
And together Candide and the transcriber completed all the requisite paperwork. They even found time to make some small talk and exchange some jokes. Over time, Candide nearly forgot why he was even at the hospital until the transcriber caught the time on his phone and left after making an excuse that he was late for another appointment. As the transcriber made his exit he returned Candide’s now completed paperwork to the front desk receptionist.
Candide, now alone, felt his hand turn cold. He wondered if that was a serious sign, but reasoned that the hospital would never allow him to just sit in a waiting room as his condition worsened. So he assured himself to remain patient. Normally he would pass time watching his favorite online video clips, mostly videos of cats and dogs doing much of nothing in particular. But, being down a hand, Candide had to make do with people watching in the real world instead. Which he did as another hour passed by, at which time a technician beckoned Candide from across the lobby, motioning Candide to follow him with the flick of his hand.
As Candide approached the technician, he smiled, greeted him, and nodded his head in an oblique motion while turning to walk ahead, intending for Candide to follow him in stride. Candide obliged instinctively, following him to a makeshift emergency room, demarcated by curtains instead of walls. After securing Candide onto the bed, the technician smiled and made his way out of the makeshift room.
No sooner did the technician leave did another man, a notably husky man with glasses, possessing a distinctly bad breath, walk into the makeshift room, introducing himself as the physician on duty and began examining Candide hands with his eyes. His eyes remained affixed onto Candide’s hands as he asked Candide what happened. Once Candide finished his story, the physician examined the hand up close, manipulating and contorting the hand in all sorts of positions, seemingly oblivious to the obvious pain Candide felt.
The physician noted a small piece of glass protruding from the hand and said he could remove it and sew up the hand letting it heal. The news delighted Candide who thought this whole ordeal was finally over. But unbeknownst to Candide, the physician required an x-ray imaging of the hand prior to removing the glass.
Something Candide only learned when he saw another man walk into his makeshift room instead of the husky, bad breath physician. This man, aloof and tense, asked Candide to verify which hand was damaged despite being able to see that only one of his two hands was bleeding. A man who then informed Candide that he would need imaging before the glass could be removed.
Candide took the extra step in stride as he rationalized to himself that it is better to be safe than sorry should any potential mistake happen. And the extra step would have been nothing more than a slight detour instead of an adventure in its own right had the physician documented which hand needed imaging. Apparently the handedness documented electronically is more credible than the actual site of a piece of glass piercing through the hand itself, and the conflict between what was written and what can be seen caused far more confusion that would be imagined.
But once reality matched what was documented electronically the technician took the imaging studies and Candide again found himself alone in his makeshift room. Alone with his thoughts and his hand, Candide began to look around the room. He saw a surgical tray adorned with a syringe, a scalpel, a curved needle with a nylon string, and a stacked layer of gauze, all perfectly arranged. He saw the perfect arrangement as a sign that his procedure would go similarly perfect and smiled at himself for remaining so optimistic.
His silent observations were interrupted by yet another technician entering the makeshift room. She began rearranging haphazardly the items on the tray and then manipulating Candide’s hand similarly haphazardly – first moving his hand, then his arm, and eventually his shoulder through layers of draping without making so much as a peep of small talk. The silence let Candide know that the glass would be removed imminently.
As the technician readied herself to leave, as almost an afterthought, she held up a piece of paper attached to a clipboard filled with words too small to read headlined by a blank line just under the word ‘consent’ which was written in a font size too large to ignore.
And the first words she uttered was a request for Candide to sign the document though her request was stated more as a statement than a question. When Candide began to squint his eyes to read, the technician mentioned with overt urgency that she needed to leave, indicating that Candide needed to sign the consent immediately.
Candide thought nothing of the gesture, smiled, and signed the document. The technician frowned in response, more out of curiosity than suspicion, not sure what to make of the smile, but not caring enough to interpret the smile. And like that, she was gone.
Candide, again left alone in the makeshift room with just his hand and his thoughts, smiled, enjoying the moment, a self-indulged respite, he thought to himself, despite all the missteps, setbacks, and side adventures, he never lost his characteristic, optimistic outlook. And now the moment had arrived, the moment the glass would be removed.
The physician walked in, gloves on, mask on, and eyes focused on the exposed hand protruding through the draped layering. He gave a terse, perfunctory greeting and began working on removing the piece of glass.
Candide sat in silence, keen not to move, his eyes fixed onto the ceiling, observing all the indentations and smudges that formed over time above him, not wanting to see what was going on in front of him. Candide then felt an intense stabbing sensation – a pain worse than the actual accident itself, prompting an instinctive recoil as Candide struggled to cope with the pain while remaining steady in place.
“Sorry to be so rough, it would not hurt so much had you arrived sooner”, the physician explained, in a tone somehow simultaneously calming yet demeaning.
Candide responded with an obligatory nod. He thought it best not to correct the physician about the sequence of events that transpired, choosing instead to focus on the fact that the piece of glass was finally being removed. And soon enough, it was out. And nearly as quickly as the piece of glass came out, the wound closed up, easy enough, and the blood stopped seeping. The physician excused himself and left, leaving Candide alone with his thoughts and his newly fixed hand.
Candide exhaled in a sigh of relief, finally seeing his hand without any tinge of blood, and indulged in another moment of welcomed silence.
A silence quickly interrupted, with a startling expediency that Candide did not expect, as he found himself ready for discharge. The rapid, nearly instantaneous sequence of events left Candide wondering where that expediency was when he had first arrived, but he told himself to be simply be thankful that his hand has healed.
And at last, yet another technician entered the room and gave him a copy of his medical records and discharge summary, and a list of physicians to see in two weeks. With a smile, and a visible sense of relief protruding through a toothy smile, Candide made his way to the lobby. He hailed a ride through an app on his phone and made his way home, just in time to enjoy his nightly beer on his well-worn couch.
At work the next day he impressed his co-workers with his resiliency and optimism. Something he made a point to display, for it is a source of pride for Candide as he considers these traits his strength, and fully took advantage of the opportunity to bask in the moment. While Candide’s hand did not bounce back as quickly as his optimism, within a few days Candide was fully functional.
And for Candide, this would be the end of the entire ordeal, only to be relived as a story over drinks among friends, if not for a letter in the mail he received from his healthcare insurance company, denying coverage for his procedure and requesting he pay the entire bill of $8,500 from his personal expense.
And this is where we find Candide, sitting on his well-worn couch, letter in hand, losing his characteristic optimism for the first time since he injured his hand.
Candide flew into a fit of rage, contorting and shaking while sitting on his well-worn couch as he stared at the lines in the letter until they all blended together into a blur. And Candide let his thoughts rage. What good was his optimism, his willingness to endure, if he is going to be taken advantage of? What good was his optimism, he persisting positivity, if he must bear the financial burden of an accident that happened at work?
While still enraged, he decides to act. He calls his health insurance company and asks to speak with a representative. After listening to a barrage of off-tone cover songs, one after another, he hears the voice of a representative who abruptly tells Candide there is nothing the representative can do to help.
But no sooner does Candide hang up, does he call again, his rage unsatiated. He believes if he can just speak with the right person, the right contact, he can explain his situation and ask his insurance to cover the medical expenses for a work accident. Candide, undeterred with the passion of rage, finds himself waiting again, and endures another barrage of off-tone cover songs, but eventually speaks with another representative who rudely tells Candide that he was already informed there is nothing they can do.
Fuming in frustration at the curt reception he received, Candide immediately ends the call, leaving himself alone with his thoughts. He recollects the sequence of events, from the stalled-out car rides to the seemingly incessant waiting. He remembers his characteristic, optimistic outlook, and how he remained so throughout the entire ordeal.
And through his memories, he finds a sense of calm in the presence. Candide, now devoid of his rage, fills his thoughts with his characteristic optimism and devises a way to speak with someone, anyone who can help him. In conjuring a plan, a strategy, he never loses faith, and resolutely believes that someone, anyone is ready and available if he plans his phone call just the right way.
He decides to call a third time, but this time, rather than beginning the phone call by disputing the bill, he begins by complimenting the service he received. That he is calling because he would like to extend a compliment to his care team based upon to the experience he received. He slugs through another slew off-tone cover songs, a series of awkward pauses from representatives, unsure how to respond, who in their confusion, direct the call to their immediate superiors. And after multiple bouts of alternating off-tone music and awkward pauses, he is greeted by a conspicuously confident voice.
Miraculously, he quickly finds himself on the phone with the regional medical director making small talk in between detailing the sequence of events from the initial injury to the final discharge. After a few minutes, Candide shifts from compliments to complaints as he laments the shock from the letter he received a week after his ordeal. The director, a physician by training but an administrator by occupation was impressed by the cordial exchange but perplexed that his hospital visit was not covered by his insurance. But over the course of the conversation the perplexity gave way to an uncanny honesty. The director lets the part of her that is impressed take over and answers with unusual candor:
“Sir, I understand your frustration, you had a work accident, while at work, and you have active healthcare insurance covered by your employer. It is obvious your recent care should be covered. You know that – the thing is, we know that too. But frustration is part of the process, and we price that emotion into our premiums. That unnecessary angst you felt, we account for that, that frustration you feel currently, we account for that too. And we bet that some patients will not follow up like you did – ensuring that we cover you as we are obligated to do – something we account for as well. The thing is, there is profit to be made through the frustration, and like it or not, we integrate that into our cost calculus. I say this not to prolong your frustration, but out of respect for your optimism, and persistence. Just mail your last paycheck stub proving your employment along with the healthcare bill and medical records, and I will personally ensure this matter is resolved.”
Candide delights with joy knowing his optimism and hope has paid off in the most literal sense. He thanks the director and ends call, siting in silence in his well-worn couch. When he began his series of phone calls, the afternoon was just settling into the evening, but now it was well into the night, and Candide, as per his routine, found his way to his nightly beer while sitting on his well-worn couch.
In between sips of beer he thought proudly to himself, now I have both optimism and understanding.
Opioid epidemic in one chart – correlation conflated with causation
There is no cause-and-effect relationship between prescribing and overdose mortality. But millions of patients are being denied safe and effective pain care.
Seniors over age 62 are prescribed opioids for pain three times more often than youth under age 19. But youth have overdose rates three times higher than seniors. No medical model can explain these demographics.
Source: Richard A Lawhern, PhD, Patient Advocate