Tuesday, March 15, 2011

An Appointment with Disappointment

Part Three of "Impatient"
    (april 14, 2013) How do people who are really sick -- who hurt, who are weak and dizzy, who are feverish and nauseated -- manage to survive the arduous process of getting help in today's vast, dread-inducing health-care monstrosity?
      It is a test of endurance that really ought to be reserved for those of us who are flushed with robust vitality. We need to march in there, and confront a doctor, and say: This system is terminally ill!
The doctor will see you, kind of, or will he?
    Seeing a doctor really is not designed for the sick among us.
    And once you actually jump through all the hoops and leap over all the hurdles, and reach that shimmering, distant goal of being in His presence, you are likely to have (cue ominous music:) AN APPOINTMENT WITH DISAPPOINTMENT.
    But we are getting way ahead of ourselves. 
    When you arrive for your appointment, allow plenty of time to find a parking place, particularly if you are visiting a clinic or hospital, and particularly if it has one of those dark, confusing multilevel parking "terraces," in which both the above-ground slots and even-darker below-ground slots seem to be all taken. You slowly prowl the spooky underworld, your heart pounding with anxiety, until finally you see someone getting ready to leave. There is a line of cars behind you. Which is worse, the stress of holding up the line while waiting, or the stress of moving on, risking being late for your appointment?
    If there's no parking terrace, perhaps there is a vast parking lot with a capacity of a thousand or so vehicles. How can it be so full? How far away do you have to park, and how far do you -- a person who is ill and/or elderly and weak -- have to walk to get in the front door? And then, how will you find your car later?

"Parking for subcompacts is still available on sublevel five, and on the eighth-story roof."

    If you're sick enough to see a doctor, it may be quite a daunting (if not tortured) trek to get where you need to be, even after you park and get yourself inside the building. It seems that medical facilities are getting HUGER by the minute. Their atriums create echoes that will intensify any vertigo you might have. People stride and bustle around you. There is the dinging of elevators and periodic intercom announcements: "Grand Rounds are commencing in the 12 North auditorium."
     It's a blur of sensory overload. The aroma of gourmet coffee and pastries makes one want to sit down and forget about the doctor.
   The lovely ladies at the reception desk (they're volunteers, to "save money") will send you somewhere to check in and fill out a bunch of forms before you are banished to a distant netherworld known as the "waiting room" (waiting for Godot, waiting for superman, waiting for a girl like you....whatever: It's waiting). The reception ladies' directions  are excellent but possibly quite complicated in a facility that has five wings and seven floors, each having hallways that head in so many directions it makes your head spin.
    ( I used to see a doctor at the University Medical Center, and I think I had to walk at least three-quarters of a mile to get from my parking space to his office. But I was half as old then as I am now, and I was very fit. Even so, it made me feel faint, plodding through all those fluorescent-lit hallways, dodging scrubs-wearing people carrying plastic trays of malodorous food -- like from 1950s elementary school cafeterias. Beefaroni!) 

Loads of room for lots of waiting.

    Regarding the forms you are now obliged to address: Why couldn't they have mailed them to you, so you could have filled them out in the comfort of your home, and you wouldn't have been required to show up 30-45 minutes early to complete them in this claustrophobic, overheated, sniffle-filled echo chamber? It is hard to sit there, bent over and squinting, to get through this paperwork. It hurts my back, shoulders, neck and eyes, and I'm not even terribly old yet.   

    My heart sinks when I see page after page of checklists and questions. 
    Many of these forms will ask questions that you have answered repeatedly at this clinic (date of birth, last menstrual period, extensive family history, medications, vaccinations, nutritional supplements) or inappropriate (marital status, Social Security number). You even have to provide your name, address, phone, contact person and insurance information, even though you've just reviewed all of that information with the intake person, and it's been in their system ever since they had a system.
     You will be asked to identify where you have pain on a picture of the human body. That makes sense. You will be asked to describe your pain, its onset and its likely cause. Perfectly reasonable requests.

Please describe your pain: dull, stabbing, blood-curdling?

    What turns it into an absurdist exercise, rather than a minor aggravation, is that I have never seen any evidence whatsoever that the material
you provide on all of these tiresome forms is used. My theory is that it is filed away in case a malpractice issue arises, so the doctor can "prove" that "due diligence" was taken to create a comprehensive medical profile of you and that a case for negligence can't be waged. The institution is  trying to give the impression that it runs a thorough, conscientious operation.
    It doesn't!
    When the doctor makes his appearance, he generally makes it evident that he doesn't know even the most basic information about my medications, chronic conditions or lifestyle, in spite of all that paperwork and my existing files, which are in his computer. More surprisingly, he doesn't care. It is rare for today's efficiency-oriented doctors to spend time on anything except for the specific issue that you are raising. Your health, your habits, your overall lifestyle, your mental health, your other, possibly related, problems are not addressed.
    And it has become unusual to the point of being startling for the doctor to express any interest in who you are and what you do. The billable timeclock is ticking, dude. Don't blow it by engaging in some human-to-human exchange!

    But we're getting ahead of ourselves. After you  finish filling out the questionnaires, you return to your seat to wait. In my experience, the average wait is 45 minutes. Finally, your name is called! But now it's time for another wait, as you are taken to an exam room by a medical assistant and left by yourself, usually with no magazines (although there are fascinating handouts from pharmaceutical companies, about their latest "breakthrough" drugs and devices). Before she leaves, the assistant sometimes asks me many of the same questions I've just answered on the forms    
    This exam-room wait usually lasts takes at least 15 minutes. I sometimes reach a point where I'm so hot and flushed that I seriously consider walking out. I did just that a few months ago, when I was told it would be at least another 15 minutes, for a total of 90 minutes, waiting to see the doctor.
Get comfortable -- it will be a while.
    I asked the staff why someone hadn't called me and given me the option of coming in later or rescheduling for another day. I have asked this question many times. All I've ever gotten is a shrug. The system operates at the doctor's convenience. If you're unwilling to devote half your day to see him for ten minutes, that's too bad.


    Each of us is supposed to be an indistinguishable part of a placid, plodding herd -- like supplicants who patiently wait for a brief audience with the baron who rules over the fiefdom. We wait quietly, uncomplainingly, because we have no choice: We need his help.
    Or do we?
The doctor-baron is in there somewhere, ye poor serfs. Just hold your horses!

     Doctors are behind, except when they're way behind. Finally, he rushes in. As is the fashion these days, he books two patients for each 15-minute time slot (some only allot 10 minutes).

    "There is no more wasteful entity in medicine than a rushed doctor." (http://www.nytimes.com/2014/07/21/opinion/busy-doctors-wasteful-spending.html?mabReward=RI%3A5&action=click&pgtype=Homepage&region=CColumn&module=Recommendation&src=rechp&WT.nav=RecEngine 
    I just learned about this double-booking device recently, and I think it's outrageously disrespectful to patients. A journal article I saw last year reported that both doctors and dentists can increase their income by more than 30 percent if they adopt this little juggling act.
    I mentioned this to an aggressive, hotshot young specialist I saw last year. "If you know how to use your support staff right, you can have three patients going at once," he said. Since I had waited an hour to see him, I didn't know whether I was part of the previous three or the current three. 

    This is one of many major factors that have buttressed my determination to stay away from doctors. It wastes way too much of my time. If they cared about their patients, they would arrange things much differently. They care about themselves. 

    The same doctor I just mentioned told me he wished he'd followed his first impulse and gone into investment banking. Being a doctor, he said, "is way more grunt work than I would ever have signed up for."
    It's not too late, my son. You look like someone who belongs on the stock exchange floor, sweating and screaming. 

    Go for it!
    But getting back to the doctor rushing into the examination room: In spite of the fact that you've explained to two people what you're there for, and filled out all those forms with the details, the doctor's first words are: "So what are we here for today?"
    He doesn't take a seat and lean back, as if he really wants to hear what you have to say about the onset and trajectory of your symptoms. He either stands there, as if he's mentally already running back out the door, or he sits across the room, "inputting" into a laptop whichever of your remarks seem pertinent.
    Today's doctors should have cheery cross-stitched signs on their examination-room walls that say, "Spare me the details!" 

   The paramount goal of this vast organism is to dispense with you -- to get you crossed off the list, out the door (you're hogging some valuable real estate, you know), and on your way to wherever, so that the next "customer" can be hauled in. Your bill is being processed as we speak. The doctor will hurriedly write you a prescription, send you to a lab, order a scan and refer you to a specialist, possibly without ever going through the excruciation of making eye contact with you. Each of these little tasks has a code attached to it for billing purposes. If he's one of the nicer guys, he'll cry "good luck!" as he scoots out the door.
    ("Even though physicians’ salaries account for a relatively small fraction of health care costs, physicians’ decisions may affect upward of 80 percent of total health spending. We order tests, prescribe drugs, hospitalize patients and — one of the costliest decisions a doctor can make today — call specialists for help.
    There are many downsides besides cost to having too many doctors on a case. Specialists’ recommendations are often contradictory. The kidney doctor advises careful hydration; the cardiologist advises discontinuing intravenous fluid. Because specialists aren’t paid to confer with each other or to coordinate care — although the Affordable Care Act is putting payment systems into place that will do just this — they often leave primary physicians without clear direction on what to do.
    More important, patients don’t always require specialists. Patients, especially older adults, often have disease syndromes that cannot be compartmentalized into individual problems and are probably best managed by a good general physician. When specialists are called in, each is apt to view a problem through the lens of his specific expertise. Patients generally end up worse off. I have seen it over and over." http://www.nytimes.com/2014/07/21/opinion)/busy-doctors-wasteful-spending.html

    More than one of my retired friends has told me that being a patient has become his full-time job (very little of that time, of course, is actually spent with a doctor). This works especially well if your wife has medical issues too, so between appointments you can run out to IHOP to enjoy its new all-you-can-eat "Pancake Revolution."
    Jumping on the medical-care carousel has evolved into a lifestyle for many older people. And grappling, as a couple, with the cold, confusing face of "Club Med" might improve your relationship, it seems to me. You're teammates, and the companionship may be worth more to you now than it ever has. Plus: Two heads really are better than one in trying to figure out what the hell is going on.
    Specialists refer these poor people to additional specialists, who refer them to physical and/or occupational therapy, or monthly "infusions," or regular lab work, followed by yet more "consultations." 

Turn every day of your golden years into a Club Medicine excursion.

    Despite all the "care" they're getting, they usually tell me they don't understand what's wrong with them or what the future holds. They laugh about all the pills they're taking. What are they for? 
    "Who can remember?" 
    Some of them are to counteract side effects that other pills are causing. Many of them would be entirely unnecessary if the "health" empire took the time to enlist patients in adopting and sustaining lifestyle and dietary changes. But that isn't BILLABLE.
    Patients who are not well-informed, and therefore feel helpless, must surely be doctors' favorites. They're deferential. They do what they're told. When the doctor says, "I want to see you again in four weeks," they never say, "What for?" I always say "What for?" Or sometimes I just think: "In your dreams."

     Are you old enough to remember when people went into medicine because they cared about their fellow man? They wanted humbly to comfort and to heal. They were beloved in the community, and they deserved it. If you called them in the middle of the night, they rushed right over. I assume they earned a decent income, but it seems to me that they were pretty much in the same "class" as the rest of us.
     Many of them delivered babies, and then delivered the babies of those babies and maybe even the babies of those babies. They took care of the whole family. A doctor in this era didn't sent you to an ENT specialist if you had sinus pain. If you got tendinitis, he didn't send you to a sports medicine guy. If you needed a Pap smear, he didn't refer you to an OB/GYN. I am almost always referred to a specialist these days, even for issues that primary care doctors used to handle all the time. 

"Oh my stars, Johnny -- that's quite a red throat you've got there!"
     Some call it progress. I call it racketeering.
     It wasn't so many years ago when your first stop was the doctor's actual office -- with his diplomas and family pictures -- rather than the examination room. Here, you had the opportunity to express yourself, with your clothes on, to a wise, easygoing,  kind-hearted gentleman. He would ask  questions about your overall well-being, your diet and activity level, your use of alcohol, tobacco and/or drugs, your mood, your job satisfaction and your relationships. He would be listening intently, not wishing you would shut up. He would ask insightful questions, express empathy and suggest a few theories about what could be causing your current problem.

    Then, if a physical exam was called for, he would send you to the examination room to put on a gown, and a few moments later, he would come in. As you continued to talk -- maybe about your health but just as likely about his kids or your garden --  he would be conducting a thorough physical exam. He would scrutinize your skin, hair and nails -- which can be great barometers of health -- prod your thyroid, assess your muscle strength, look in your eyes, nose, throat and ears, and check your reflexes and the level of sensation in your extremities. He would press your joints to check for pain or swelling. He would listen to your lungs and heart. He would have you lie down as you continued to converse, so he could prod your abdomen, palpate your liver and give you a breast exam. He would summon his nurse while he gave you a pelvic exam. He would have you stand up to check your balance, flexibility and coordination. He even smelled you, which was embarrassing, but had obvious diagnostic value. Sometimes, he'd  throw in an eye test.
    That's what I call a physical examination.

    The doctors of my youth didn't merely search for obvious signs of ill health. They used their intuition as well as their medical expertise to get a sense of their patients. They were "holistic" even before the term entered the popular lexicon.
     I guess I'm nostalgic for the times of Norman Rockwell, when we had the sense that our doctors cared. Silly us!

Give me an seasoned old man, not a CT scan.
   This is how it used to be, when seeing a doctor was so cheap, it wasn't a big deal not to have insurance. Now that it's almost unbelievably expensive, the system "can't afford" in-depth, personalized care. Treating you as a whole person rather than a list of symptoms "creates inefficiencies" that the balance-sheet boys won't tolerate. Talking is such a pointless pastime in our high-tech medical universe! And touching you all over? No, no, no: We don't do that anymore. It's not on the list of  "billable inputs."
   Over the years, I have known a number of people who dreamed of becoming doctors, and most of them did -- even if they had to go to a Caribbean medical school to get their training. For them, medicine was a noble calling -- something they'd aspired to since childhood. Medical training was a cruel, intense boot camp -- from which they would emerge strong, and flushed with pride -- prepared to go about the sober -- even sacred -- work of caring for people.
    How things have changed. Now that these Boomers are beginning to transition into retirement, it becomes more clear than ever that we have "generations" of doctors, who vary dramatically  in their motives and priorities.
    Most of today's younger doctors -- who are in their mid-30s to mid-40s -- have been ambitious, competitive and focused all their lives. Increasingly, they are from higher-income families, and there is little socioeconomic or racial diversity anymore. 

     Unlike my old friends, who went to medical school 40 years ago, the new kids listed "high income" as their top reason for choosing the profession, in surveys they took during the final months of medical school. They believed that having a medical degree would confer real power and prestige upon them. They also  expected to have independence and autonomy, ie, to be their own bosses. Many of them had been inspired by life experiences to choose the medical profession.  Most were highly motivated as "problem-solvers," and they looked forward to performing the magic of transforming sickness into wellness. They envisioned a large and grateful constituency of patients. They foresaw a gratifying practice and a life brimming with material pleasures.
     Now that they have finished with school, and with their modestly compensated residencies, they are ready to "go for the gold."


    If you find yourself the patient of one of these Masters of the Universe, you may notice an aura of barely contained ecstasy and triumph about them. They have made it. They are set. They are so self-satisfied, they can hardly stand it. They have already begun amassing one status symbol after another, even though they are still deeply in debt for their schooling. One young man, who bought a BMW and a luxury condo before he even completed his residency, said, "I'm not going to wait until I'm in my fifties to start 'living the life.'"
Because he deserves it.
    Today's young specialists seem to have gleamed and glided their ways into a more highly evolved plane -- almost another breed --  while the rest of us are in a genetically inferior past. They don't hide their arrogance very well. They are exalted creatures who make themselves completely inaccessible to "the little people," unless it is for a quick, $30-per-minute appointment. 
    These kids, who are 30 years younger than I, act as if they're superior to me. Let's compare resumes, why don't we, and see who deserves the deferential treatment. When I was your age, I'd had 10 years of national media exposure and three demanding jobs. So don't expect me to be an unquestioning supplicant and use an honorific term to address you, while you call me by my first name. Got it, Courtney?
    Their "medical assistants" protect them like guard dogs (it would be easier to get through to Lady Gaga), if you call with a question. And getting their email address? Forget about it! You've already paid two or three hundred dollars for a consultation and hundreds more for subsequent  procedures. All you want to know is what the procedures discovered. But they insist that you come in yet again -- another costly encounter -- to be informed of your results. I'm having none of that. I'm going to assume that the lump in my abdomen was just a wayward chunk of tofu. They keep doing scans and then cheerily proclaiming, "false alarm!"


    These ravishing Titans of Medicine can still hardly believe their good fortune, to have gotten in on this gig. The rewards blow their minds. This system is a money machine, if you know how to play it. You can almost see the calculators in their brains, racking up the charges. Most of them have adopted a ruthlessly entrepreneurial approach to their practices, to become even more efficient in this regard.
Hotshot docs, at your service. Whoops, our time is up.
    There is a new vanity in this generation of doctors. The men tend to be tanned and/or conspicuously muscled, with The Right Stuff posture. Pricey watches (Movado, Victorinox, etc.) seem to be a must-have. Earrings are prevalent.
    A specialist  I saw last spring was fairly typical. He had mousse in his hair and a photo-shopped picture of himself with Jennifer Aniston on his desk. His nails had clear polish on them. His Facebook page listed one interest: Women.
    He was headed for a four-day skiing weekend in Aspen.
    He wore cologne!

Can we dispense with the mousse, the earrings and the cologne?
    A physiatrist ($225) had referred me to him after I was unable to succeed in relieving the pain from two herniated discs and the resultant bilateral sciatica. I tried every physical therapy technique I could find, to no avail. He referred me to a pain doctor ($280) who gave me an epidural shot of cortisone (nearly $3,000 total), which was just as ineffective as my own efforts had been.
    When I told him I didn't want him to try again, because it cost too much, he said, "What do you care? You're not paying for it!"
    UPDATE New York Times July 3, 2014: "A widely used method of treating a common cause of back and leg pain — steroid injections for spinal stenosis — may provide little benefit for many patients, according to a new study that experts said should make doctors and patients think twice about the treatment.
Hundreds of thousands of injections are given for stenosis each year in the United States, experts say, costing hundreds of millions of dollars.
    "But the study, the largest randomized trial evaluating the treatment, found that patients receiving a standard stenosis injection — which combine a steroid and a local anesthetic — had no less pain and virtually no greater function after six weeks than patients injected with anesthetic alone. The research, involving 400 patients at 16 sites, was published Wednesday in The New England Journal of Medicine."

     This is a very common attitude, and is one of the zillions of reasons our health-care system is such a mess. He was right: I'm not paying for it.  Someone could write an entire book about this issue alone. We're all paying for all of us, one way or another. Who else is going to pay for it, whether you have private insurance or Medicare? Our co-pays are so small that it insulates us from the real cost of the medical services we receive. We will never get a grip on the cost of health care until this is addressed.
    When I rejected another epidural injection, the doctor wanted to enroll me in "ongoing" physical therapy. No thank you! 

    The young women specialists I've met seem too preoccupied with looking fabulous to be completely credible as caregivers. I got a colonoscopy from a stunning woman who wore patent-leather stilettos during the procedure (her assistant was wearing galoshes, and a yellow vinyl poncho with a face guard!). Her glossy lips had definitely gotten a bit of injected "plumping," and micro-dermabrasion had given her skin a pearly sheen.
    An OB/GYN wore a striking designer dress under her unbuttoned lab coat, and her hair was highlighted with several shades of blonde. Tiny sapphire earrings, perfectly matching her sapphire-tinted contact lenses, added a beautifully understated element of wealth and style.  

"I am one of the beautiful people," she said, without saying it.
    Her teeth were blindingly white, and her makeup looked as if she were ready for a high-fashion photo shoot. How incongruous that she was stuck here doing Pap smears.
    Sure enough, when the hospital advertised its "deeply caring, highly skilled medical staff," on television, there she was, with an alluring smile, and a Montblanc pen that seemed poised to write a delicious prescription. Everything about today's young specialists appears to have been enhanced in some way. They're not just doctors -- they're spokesmodels for the medical-industrial complex.
    They do seem to be better educated than their forbears, and they express greater respect for alternative medicine, which is nice.
    It's also obvious that medical schools finally realized that these aggressive high-achievers needed to be expressly conditioned to exhibit a set of behaviors that are quite unnatural to them: an empathetic "bedside manner." They have memorized a few caring stock phrases to placate patients and to make them feel "heard." I get a kick out of this script, and it is obviously a script, but I never forget that as a patient, I am merely the means to an end. They just finished with another "means," and once they get me out of there, there will be more "means" waiting.    

    Despite the prestige and pay of being a specialist, there is some irritable murmuring among the ranks.  
    You never dreamed you'd increasingly become a cog in a stupid machine, did you? You didn't realize that you'd be doing grunt work, paper work and lots of pathetic scurrying ("I'm late! I'm late! For a very important, um, appointment!"). You'd repressed the concept, hadn't you?, that patients would be flooding you with complaints. 
Why don't patients ever come in with a positive attitude? They're tiresome!
    They come to you because they have COMPLAINTS. And you get so tired of all that complaining! You learn to let it fly past your head.
    Doctors expected to be bosses, not serfs. They didn't expect to have every move dictated and scrutinized and possibly vetoed. They didn't expect to be subjected to quotas and revenue targets.
   Maybe that's why most doctors said in a survey this year that they wouldn't go into medicine if they had it to do all over again.

    (UPDATE: A September 2013 New York Times article reports that nearly half of doctors admit to feelings of emotional exhaustion, low sense of accomplishment and detachment. Nearly half of medical students become burned out during their training, which is "abusive and neglectful." Five out of six doctors say that medicine is in decline, and close to 60 percent would not recommend it as a career for their children. http://opinionator.blogs.nytimes.com/2013/09/18/medicines-search-for-meaning/?src=me&ref=general).
     Two young male specialists with whom I've spoken said they wish they had gone into derivatives or arbitrage. Another was "shutting down" his psychiatric practice and going to work for Big Pharma. Another decided to get an MBA, so he could get into the business of buying up, consolidating, restructuring and managing medical practices, reaping what he said would be a substantially larger income than he would earn practicing medicine. A pretty-boy internist moved to New York, hoping to break into network television as a reporter and commentator on health issues. 
Dr. Bob Arnot turned a medical degree into a lucrative job promoting energy drinks.
    His idol was former NBC chief medical correspondent Dr. Bob Arnot (who is now a pitchman for various products, and an author of "revolutionary" weight-loss books).
     A survey cited by Forbes magazine last year found that nearly 60 percent of doctors would discourage their children from going to medical school.
Despite the statistics, I believe that many of today's students still feel are they "called" into the healing arts by a spirit of compassion and a love for humanity, but it is obvious that medical schools -- in concert with our narcissistic, wealth-driven culture in general -- transform many of these young people into an aspiring Ultra Elite. 

    Greed is definitely contagious. The prospect of wealth is intoxicating.
    Meanwhile, the real workhorses of the system -- those who kept their commitment to become primary-care doctors -- are grossly underpaid and exhausted. The way the system is constructed, it is almost impossible for them to provide high-quality care, despite their best efforts.

(Being sick just makes you sicker if you have to cope with the exasperating and cold-blooded health-care system)

(Avoid the medical monolith, and take excellent care of yourself. It's thrilling!)
COMING NEXT: My Primary Concern