Friday, March 20, 2015

Three Meditations Upon Medical Stuff (20 March 2014)

Non-Incident at Podiatrist's Pay Desk

            Possibly in reaction to the latest fashion round of Day-Glo colors — yes, kids, those lime-green shoes you're wearing are indirectly from the 1950s — possibly for something totally inexplicable in teenage-guy culture, but when and where I grew up a guy would be kidded for failure to color-coordinate. There may have been a gay thing going on that we didn't recognize, but getting your clothing colors wrong was another opportunity for your friends to make you feel bad.
            Anyway, I may be in the supermarket in my worn-out sweats with a pair of shorts over the pants, but, goddamn, those sweats and shorts will coordinate!

            So, I was in the podiatrist's office, at the front desk, and handing in the photocopy I'd prepared of my insurance cards, wearing my Cornell cap: black with "Cornellian™ Red"® — they really do call it that — and close enough to matching my shirt and jeans. So I'm standing there, handing in my photocopy and giving only vague responses and pointing to the photocopy when asked which … entity, precisely, was my primary insurance and which my secondary and why I'd included photocopies of last year's and this year's Aetna cards.

            Now Ann Coulter is a Cornell product, reminding people that Cornell is as capable as any school in failing in basic education — e.g. manners — but there was a potential question of why a guy who just might have earned the cap, and a college degree, did know what the co-pay would be but was otherwise near-totally ignorant about his health insurance. "Uh, there was no problem last time, you say?" I said; "Then just submit it that way."

            And they will submit the insurance claim as they did the last time I was there (and equally ignorant), and they will get paid fairly quickly by the correct insurer or paid eventually by someone or other, or paid, anyway, before I'm in for the follow-up in three months. Beyond that, "Frankly, my dear(s), I don't give a damn": I paid my co-pay, and, in a new twist on the office rules, paid before I was allowed to see the doctor — and that was all I wanted to do to get to the actual treatment of a minor foot problem.

            I did not say the "Frankly, my dear" line nor say, "Hey, 'SEP,' ladies: Somebody Else's Problem — yours." What I was tempted to say was something one shouldn't say to the young woman at the doctor's reception desk who had nothing to do with setting up the system for paying for US medical treatment. What I wanted to say was that I do not understand my health insurance because I try to avoid as much as possible having my labor expropriated for unnecessary shit-work that produces nothing, e.g., reading up on insurance.

            For verily I say unto you, my fellow Americans, that we clearly need a national health service or some other kind of single-payer system, a system where citizens have one, single, unified, secure, computerized, backed-up, and simple account, where you go in for treatment, identify yourself, get the medical service you need, pay your fair share, and then get the hell out of there, perhaps to do something useful.

            Time spent on intricate methods of paying for medical treatment is, for one thing, time not getting that treatment and, equally important, time wasted and effort worst than wasted: unproductive labor pulling down any honest measure of economic value. When we calculate the cost of US health care, we should include citizen time at minimum-wage (minimally!) for our conscripted efforts.

            Until such time, to the degree that I can, I'm on strike: I photocopied the cards; I gave the medical clerks the photocopy; I paid my co-pay — the rest they (all the minor bureaucrats) can figure out without me.

"Notes" Not Offered on Table-Side Manner

            The title we decided on — my senior associate and I — for what I do, is "Film Script Analyst"; and when I do what I do in that capacity, I mostly do what are called "Notes." Notes are insightful and helpful suggestions I send on to my producer associate to select from and communicate to scriptwriters to help those writers improve their scripts. Such "Notes" correspond to the communications I used to receive from journal editors passing on comments by anonymous article referees on my writing, which the editors would suggest I could abide by or refuse as I saw fit, and they would publish or reject my revised essay as they saw fit — unless they were rejecting my article outright and only sending on the comments to make me feel bad. (See above on adolescent insult contests.)

            Notes are another one of those areas where it is far better to give than to receive, and, however much I occasionally wanted to throttle the wooden-headed semi-literates who occasionally commented negatively on my writing, I must admit that what we might call "Note-giving" (as opposed to Note-taking [although there may be a particularly kinky kind of masochist who enjoys reading referee/analyst comments]) — composing such "Notes" at least mentally can become something of a habit.

            And so I have occasionally found myself mentally critiquing a sermon or a political speech or, in the case here, the examination-table-side manner of my primary care physician.

            For most audiences, so to speak, my internist's manner would really suck. The guy is friendly and lively enough in conversation, but when he goes into doctor-mode, he's mechanical, impersonal, and, so far in my experience with him, bored. More specifically, he makes no effort to disguise his boredom with me as a patient, or, if he makes an effort, fails.

            I like that.

            Right after "Whoops!"or, "Mr. Erlich, I have some terrible news," about the last thing I want to hear from a physician is, "Gee, now that's interesting …."

            This last time the only scintilla of excitement I got from the internist was "Hmmm, oh — were you, uh, dry when you went in for the blood test?" And I said, "A little dehydrated? Sure — I went there fasted and straight from exercise." And he repeated "Oh," added, "Drink some water before you go to get blood drawn," and moved on.

            Bored again, obviously.

            Good. I fervently hope to keep him and the rest of the medical sect bored into a stupor with me until I hit 80. After that, the day they find me really interesting — the next day I want to be boringly dead.

Now Let Us Praise the Family Physician

            Whatever method the US of A finally settles down to for paying for medical services, one thing I'm sure of is that it should encourage people to have one (1) primary-care physician who knows families as groups and individuals as individuals: a physician or nurse-practitioner who knows them well enough to talk to them and get to know them still better — and has time allotted with each visit to actually talk.

            "A 'for instance' is no proof," but here's the experience that convinced me that whatever the breakthroughs in technology, whatever the economies of scale of large and bureaucratized medical practices, it is still a good idea if people get their medical diagnoses from practitioners who know them and know them well.

            Here's the story. I drove from Oxford, Ohio, up to the Chicago area to visit my family and found myself feeling a little woozy, slightly dizzy when I came to stops. This occasional light-headedness didn't go away, and I asked my-nephew-the-doctor if there was a way to get an appointment with an ear, nose, and throat person — or whatever the late-20th-c. equivalent of an ENT-guy was — to see if I had an ear infection or other such issue. My nephew got me a number to call for a medical doctor he found acceptable, and who handled walk-ins.

            I didn't have an ear infection, nor sinus infection, nor obvious balance problem nor anything else the Chicago-area physician could spot. He told me that I looked okay to drive but I should see a physician when I got home and talk seriously about getting an MRI.

            I already had an appointment with my physician, went to the appointment, and he, too, found nothing wrong.

            "About the MRI," he said — "How are you doing on Weight Watchers?"

            "Uh," I said (thinking, "Say what?!"); "I'm doing very well; I lost five pounds last week. I don't think I understood how much fat I was supposed to eat."

            "Yeah," he said; "Weight Watchers is really minimal in its fat allowance" (pause). "How's this …?" and he got out his prescription pad and asked, "Do you like your peanut butter smooth or crunchy?" I said, "Crunchy," and he said that was good, but it didn't matter much since Kroger's had pure ground-peanuts peanut butter on sale, and wrote down "Crunchy" and gave me the prescription.

            "We can talk about an MRI. First, though, try the peanut butter. People need fat in their diets even if most get too much. If you were low on fat on Weight Watchers, you were getting too little" — or maybe it was just too few calories — "and one possible effect is you feel woozy. So first try some peanut butter, or whatever; some decent fat."

            The peanut butter worked.

            I didn't have an MRI.

            That meant no wasted time and money on the MRI, no follow-up tests if the MRI was inconclusive, no unnecessary treatment, and no anxiety — on this issue — for a patient my physician knew to be not a hypochondriac but what he called "A worrier."
            Get the point?

            The doctor in Chicago probably had better credentials than my physician in Oxford, OH — my nephew was at the time and is now more so a hot-shot in the med-ed biz, with demanding standards — and I have no reason to question the Chicago physician's advice. But he didn't know to ask me a question about my diet whereas my long-established physician did know.

            Also, to end on a crass note but an important one — also my family physician knew me and knew that I knew him: and knew I wasn't going to sue him into bankruptcy if he failed to cover his ass and order an MRI on the off-chance that I might have a brain tumor or something else horrible.

            So two cheers for technology and bureaucratic rationality and quick-fix ways to save public money on medicine: There is still much to be said for, among other things, the efficiency of a long-term, professional but close, physician-patient relationship. 

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