Four weeks after his suicidal crisis, Thomas is in a better mood. He no longer thinks about killing himself.
August in Madison is hot and unusually dry. The landlord still can’t repair the air conditioning in his apartment, so Thomas spends as much time as he can at his office in Oz.
Dr. Carlene Oakley, Paul Hulseberg’s supervisor, returns to her Wisconsin goat farm from vacation in Colorado. She has not reviewed Thomas’s medical record or discussed the case with Hulseberg.
Under Wisconsin law, Physician Assistants like Hulseberg are supposed to work under the supervision of a medical doctor. Group Health Cooperative has a unique understanding of “supervision,” where the physician does not examine the patient, review the medical record, or discuss the case with the Physician Assistant.
Healthcare providers like Group Health Cooperative want you to believe that Physician Assistants are just as good as real doctors. That’s bullshit. Their real motivation is economics: they pay PAs about a third of what they pay doctors, but charge your insurance plan the same amount.
On August 28, Thomas meets with Hulseberg in a Telehealth session. He’s taking the Wellbutrin as prescribed and reports no adverse effects.
Thomas says that his focus and endurance for work have improved. His sleep is still “horrible,” but he feels less fatigued during the day. Wellbutrin is a stimulant; it works like a “pep pill” during the day, but makes it harder for some patients to sleep.
Have you tried Meetup? Hulseberg asks. Nope, says Thomas, and no plans.
Current stressors? Nothing new.
How is your diet? Thomas says it’s “fine,” but it’s not. He eats two meals daily and “stress eats” at other times. Due to that recent weight gain, he’s still clinically obese.
Exercise? Nope. Thomas is “thinking about it.”
Do you feel depressed? “Not really very much this week.”
The call is over in twelve minutes. Thomas doesn’t trust Hulseberg, and he has no desire to chat.
Hulseberg records some notes:
Normal motor activity
Good eye contact
Well-groomed, appropriately dressed
Clear and coherent speech, with normal rate, rhythm, and volume, sounded much more positive.
Good mood
Appropriate affect and congruent with mood, great big smile at the beginning of the interview, much less depressed/flat appearing
Logical and goal-directed thought, without auditory/visual hallucinations, no delusions or obsessions noted
Alert and oriented to the situation
Appropriate attention and concentration
Memory appears intact
Good judgment, medication adherent, continues with therapy
Good insight, able to discuss symptoms and identify the benefit or lack thereof from medications.
His risk assessment: No suicidal or homicidal ideation or tendencies noted. The current clinical impression for the risk of suicide attempt is low to none.
Hulseberg declares victory: The current plan has been very effective, with an excellent response.
Thomas visits the Group Health Collective pharmacy four days later to pick up his first Wellbutrin refill. He has one refill remaining before Hulseberg must refresh the prescription.
Thomas has nowhere to go and little to do for Labor Day weekend. He plays World of Warcraft and orders a GMAT prep kit from Amazon. He hasn’t decided whether to apply for an MBA, but preparing might be a good idea.
Group Health Collective admonishes members to wear masks everywhere “when you are around people outside of your household.” On social media, the HMO tags its messages with #MaskUpMadison. Wisconsin Governor Evers found a loophole in state law allowing him to issue a statewide mask mandate.
Masks protect you from bacteria, but they do not protect you from the COVID-19 virus. All the smart people want you to mask up anyway, in some sort of performative voodoo ritual.
A colleague posts pictures of a Labor Day parade in his Wisconsin hometown. The parade celebrates the local Trout Festival; it features farm equipment, fire engines, antique cars, the local rod and gun club, a phalanx from the American Legion, and dense crowds of happy people.
No masks. Not one.
Some people in Wisconsin have good sense.
Negative feedback about Thomas’s “abrasiveness” comes from the RJW/Barnabas team. He spends more time now with his other clients at Baptist and Mohawk. He also presents his work on Downtime Prevention to Epic colleagues, to good reviews.
Meanwhile, he teaches himself how to use Microsoft Project to develop project management skills. The work makes him feel like he’s progressing towards one of his “Escape from Madison” goals.
The weather in Madison is cloudy and cool on Friday, September 11.
Thomas visits the Hy-Vee on South Whitney to pick up some food for appetizers; he’s attending a birthday party tomorrow for Priya, one of his colleagues. He hasn’t been to the supermarket since before the COVID lockdowns.
After selecting some food for antipasto, he chooses a line at the register and waits for his turn. The double-masked person just ahead of him turns, points at his feet, and snaps, “Six feet!” One of his shoes is outside the circle on the floor. He corrects this egregious error.
The birthday party is fun. It’s Thomas’s first social event in six months. Several other colleagues show up, enough for an extended game of Settlers of Catan.
Priya calls him on Monday. She got a COVID-19 test yesterday, and it came back positive. He emails his primary care provider at Group Health and asks what he should do. A nurse tells him to self-quarantine for three days and monitor for symptoms.
Thomas self-quarantines for three days. He has no symptoms.
The following week, Thomas meets with Michael Hussey, the social worker, in a TeleHealth session.
Thomas rates his mood as 7-8 out of 10. He says he is busy at work, doing some interesting projects. He’s eating better, but still not exercising. He misses his family in Massachusetts, and the COVID travel quarantines limit his ability to visit them.
Hussey does not ask him about his sleeping problem.
The 50-minute hour is over in 30 minutes. Thomas says he has nothing he wants to discuss.
Hussey records notes from the call:
Well-groomed
Normal concentration
Superior intelligence
Normal speech rate and tone
Good eye contact
Affect correlated to mood
Full orientation
He changes the diagnosis from Major Depressive Disorder to Adjustment Disorder and updates the treatment plan accordingly. He plans one more session with Thomas in six weeks.
His risk assessment: Patient denies homicidal or suicidal ideation and impulses.
At this point, Thomas has seen Hussey three times for “psychotherapy” and Hulseberg twice for meds, all by phone call or TeleHealth session. His physical symptoms, including sleeplessness and sudden weight gain, remain untreated. Group Health Cooperative has not performed a physical exam or ordered blood tests to rule out a physical ailment. There is no evidence in the medical record that either Hussey or Hulseberg consulted or notified Thomas’s primary care provider.
The week following his last session with Hussey, Thomas decides to stop taking the Wellbutrin. All those cautions that Hulseberg so diligently recorded in the medical record had no impact.
Thomas does not discuss his decision with anyone.
He has one pill left. He doesn’t take it, and he doesn’t pick up the second refill.
A week later, Hulseberg sends Thomas a note asking him to complete a depression questionnaire before their TeleHealth session. Thomas does not respond.
On October 7, Hulseberg calls Thomas to see if he plans to log in to a scheduled TeleHealth session. Thomas says the session is not on his calendar because Group Health Collective never notified him. He promises to call back to reschedule.
Thomas does not call to reschedule.
Group Health Cooperative knows from its pharmacy records that Thomas has not picked up his second refill of Wellbutrin. That’s a strong signal that he stopped taking the medication. Medication compliance is a critical issue in healthcare; an HMO that cares about patients would contact Thomas, verify that he stopped taking the medication, and encourage him to resume.
Group Health Cooperative does not contact Thomas.