Nine Problems in Health Care that Neither Republicans Nor Democrats ever Address
Nine Problems in Health Care that Neither Republicans Nor Democrats ever Address
By
David Gottfried
When Democrats and Republicans, or liberals and conservatives, talk about health care, we hear only the same two ideas again and again and again: The Democrats: We need to do more to help the beleaguered, the poor, the sick, and the government must spend more cash. The tired and anti-diluvian republicans: Government involvement breeds bureaucracy, inefficiency and waste and we ought to kneel down before the altar of the marketplace. That’s all they ever say, except for a few derivations from these themes. However, there are a million other problems, and I propose to deal with some of them:
A) DOCTORS GET PAID IF THE FORMS LOOK OKAY. YOUR HEALTH IS IRRELEVANT.
A doctor’s compensation is contingent, for the most part, on just one variable: The quality of forms submitted to Blue Cross, Blue Shield, Medicare and other third-party payors. If the form looks good, the doctor gets paid. Whether you get better, don’t get better or drop dead five minutes after you exit the doctor’s haughty, affluent office is quite immaterial.
Of course, many people get teary eyed for docs and will bemoan increasingly restrictive reimbursement schedules. But that’s easy for a creative doctor, with a scheming bent, to elude. All he has to do is put down the sort of services which command reimbursement. I had an enterprising Gonif (That’s Yiddish for thief) of a relative who used to bill insurance companies for nonexistent x rays for non existent pneumonia when his patients got colds. (Years ago, there were fewer regulatory burdens on getting x ray machines and most doctors had them in the office.)
B) THE CONCEPT OF FIDUCIARY DUTY IS DEAD.
When one is selling a service, and one is a fiduciary, one cannot simply try to recommend the service which yields the greatest dollars. Let me explain by comparing a fiduciary to an ordinary businessman.
Suppose one sells sofas. Whether one should get a red sofa or a black sofa does not matter that much and one doesn’t have to spend four years in sofa school to learn when black sofas are better than red sofas. The seller of sofas is therefore free to convince the buyer to purchase the sofa which gives the seller the biggest profit.
However, suppose one goes to a doctor. One did not go to medical school. One might feel sick and might not be able to wade through and analyze the complex issues involved. Since one does not know what one needs, one cannot bargain with the doctor. Because the patient cannot bargain with the doctor, the Law holds that the doctor is a fiduciary, meaning that he must recommend that which is best for the patient’s health, not that which yields the most bucks to the doctor.
However, doctors often transgress this rule. More specifically they will recommend inferior treatments because those inferior treatments are more lucrative.
Example: The New York Times of July 14, 2007 reported something downright scandalous. At that time, it was almost universally agreed that Zevalin and Bexxar were the most effective agents for the treatment of non hodgkins lymphoma. However, these agents were almost never given, and the greed of physicians was the reason. Very simply, oncologists are paid when they give their patients chemo in their offices. However, The Times explained, most doctors can't give patients the relative life-savers, Zevalin and Bexxar, because these agents are radioactive, can only be given in the hospital because they are radioactive, and most oncologists' offices are not situated in hospitals. Accordingly, doctors prescribed less effective drugs that they could administer and reap what were sizable profits for simply sticking an IV in an arm.
Example : Doctors at times will enlist patients in clinical trials. Often, the doctor will give patients the impression that he, the doctor, is going to great lengths to enroll the patient, is doing the patient a great favor and that the patient should be extremely grateful. However, the New York Times reported that doctors are paid thousands of dollars, per patient, for corralling patients into clinical trials and the doctors generally don’t tell the patient that the doctor has gotten paid for rounding-up the patient. Indeed, the New York Times reported that drug companies often enter into contracts, with doctors, which prohibit the doctors from disclosing, to the patient, their receipt of round up fees for patients.
One of my doctors once wanted to enroll me in a clinical trial, but that doctor was messing with the wrong dude. I knew the medicine and I knew the law and I am still alive. Most of my confederates are six feet under. I am glad I am alive. I am forever angry at that lying, thieving, duplicitous overpaid fucking killer of a doctor.
C) NOT EVERYTHING IS AS EASY TO DIAGNOSE AS A STREP THROAT AND MOST DIFFICULT PROBLEMS ARE NOT DIAGOSED UNTIL MANY YEARS ELAPSE OR THE PATIENT IS NEAR DEATH
If you have a sore throat, cervical lymphadenopathy (swollen glands), a fever, a high sed rate (This value goes up in infection, inflammation and malignancy, and you can easily diagnose strep without this test), white spots on the throat and a positive result to a strep test, the answer is simple: You have a strep throat and it’s usually pretty simple to determine the appropriate antibiotic regimen.
But most of the time the answer is not so simple. Am when the problems are not simple, the patient often deteriorates.
Very often, illnesses have manifestations in different organ systems. For example, a complex ailment may manifest itself in the neuro muscular system, the gastro intestinal tract and the male reproductive organs. The unhappy patient may have had a neurologist, a gastroenterologist and a urologist who saw signs of a specific and complex ailment. (Let us call it syndrome X) However, the patient’s specialists did not act on any of these diagnostic clues because one symptom or aberrant finding does not constitute a disease.
Of course, if a clinician knew that our sorry patient had manifestations associated with this disease in three different organ systems, he might take notice and diagnose syndrome X.
However, very often NOT ONE OF THE PATIENT’S DOCTORS WILL KNOW that aberrations associated with Syndrome X appeared in three different organ systems. Of course, neither the gastroenterologist, nor the urologist nor the neurologist will know this because he is happily and merrily oblivious to everything outside of his area of expertise.
(Once I had a sore throat. I had an appt. with an ear, nose and throat specialist. I asked him to listen to my chest because after I had made the appt the malady went south into the bronchi. He refused to listen to my chest, smugly telling me that he was not a pulmonologist or an internist but that he would be happy to give me the number of a doctor who could listen to the chest. He seemed to forget that before he did his residency in ENT, he was an MD and that as an MD he was completely qualified to put a stethoscope to my chest)
Of course, the patient’s internist may have gotten reports from the gastroenterologist, urologist and neurologist which indicate that the patient had symptoms or findings consistent with syndrome X. However, in my experience, internists never have sufficient time to review the reports of other doctors. They are too busy writing letters to exempt a patient from jury duty, too busy filling out absurd forms and time is money and they have to move onto the next patient.
I have an illness that was not diagnosed for more than ten years. It has neurological manifestations but it also had manifestations in other organ systems. I wanted to tell the neurologist about symptoms and findings in other organ systems, but he happily cut me off, advising me that he only wanted to discuss neurological problems.
D) ARE AMERICAN DOCTORS TOO JADED
I wonder if American morality is so “bent out of shape by society’s plyers” (“Bob Dylan, “It’s all Right Ma, I’m only bleeding”) that American people cannot help but do the wrong thing. Perhaps, the harshness of capitalism makes it impossible for doctors, lawyers, teachers and clergymen to do the right thing. And of course, young doctors are put through an arduous, hellish course known as internship whose stated goal is the nullification of emotion and human kindness. After the discombobulation of being an internist, of working endless hours and taking shit from stupid people all around you, a young doctor may have but one thing on his mind: Grab the greenbacks and to hell with the hordes of motha-fuckers.
Consider the case of JFK and his Addison’s disease. Kennedy was sick throughout his life. In his youth, he saw American doctors exclusively and his care was, arguably, exclusively mediocre.
(Actually, the Kennedy’s exemplify the futility of money when the richest doctors are shit heads. The eldest of JFK’s siblings is reputed to have become retarded because of intentional mischief on the part of the midwife and doctor: Rose Kennedy gave birth to her eldest child at home. It was customary for the doctor to receive a lesser check if the baby was born before the doctor’s arrival. Therefore, the doctor’s subordinate midwife delayed Rosemary’s birth. Because she was still inside her Mother’s body when it was time for her to breathe, she suffered hypoxia and the consequent crippling of intellectual function. Of course, after a bully beats you up for the first time, he generally beats you up again and Rosemary was utterly destroyed by a crippling lobotomy which made her lose all speech and kept her institutionalized for the balance of her life)
JFK’s savagely wealthy father got the richest doctors, but they never found out what was wrong with him. Of course, they were able to diagnose the immediate problems, from the scarlet fever that he got when he was two to the dozens of illnesses he suffered throughout his emaciated youth, but they never figured out why he was getting the illnesses. Perhaps, they never asked.
For example, I have known many people who will have, for example, dozens of ailments and aberrations. Of course, the probability that a young or middle-aged person will have a great number of ailments is limited. For example, if the chance of getting illness A is one tenth of one percent, and the chance of getting illness B is one tenth of one percent, and the chance of getting illness C is one tenth of one percent, then the chance of getting all three ailments is one tenth cubed, or one in a thousand. In such situations, the doctor should investigate: Is there a deviation or genetic quirk or infection causing so many disparate illnesses.
Doctors, when presented with patients with a multiplicity of different ailments, usually don’t look for a unifying cause. As I said in a preceding section, medical practice is far too fragmented: the neurologist saw one ailment, the cardiologist saw another ailment and the neurologist saw something else and never in a million years will these docs confer and dare to try to analyze the underlying illness lurking in the shadows.
In the case of JFK, the clouds miraculously lifted. He left the U.S and spent time in England. His English doctors diagnosed his Addison’s diseases right off the bat. Maybe, just maybe, they weren’t the sort of scoundrels who often practice on this side of the pound.
E) HOSPITALS DISPENSE SERVICES LIKE POTLUCK DINNERS.
It is so easy for a case to fall through the cracks
There is an incessant hustle and bustle of doctors and nurses – and people who dress in white but are a far cry from doctors and nurses – buzzing around, making noises, creating a hubbub, but there is no one watching over you to organize your treatment. No one in the hospital is devoted to your case and the resolution of your malady. There may be a brilliant surgeon, but he is gone and lost and far away when complications from the surgery arise. Your nurse may draw your blood expeditiously and painlessly, but the minute after she has drawn your blood it is out of her hands, and forgotten, and if the laboratory forgets about it, or loses it, or doesn’t process it properly because the tech was smoking a joint (The NY Times once reported that the NYC Dept of Health lost 50,000 pap smears) that really is just your tough luck. And so you will see a great succession of people, and they will start procedures that they do not finish, and they will make incisions that they do not close, and they will open avenues of diagnostic inquiry that will soon be forgotten, and you will languish. And when you make a protest, and you try to articulate, as reasonably as possible, your concerns, you will inevitably be shouted down by an inevitably fat “nurse” who will tell you, “Mr. Gottfried, you be complaining too much. Why don’t you just calm down and watch a soap opera.”
F) IT’S NOT MY RESPONSIBILITY
Every person in a hospital, it appears, has one job to do and only one job to do. They happily put blinders on to ignore problems that might give them extra work. I once knew a guy who was in the hospital for a brain tumor and cryptosporidiosis secondary to AIDS. The guy kept coughing. And coughing.
I suggested to medical staff that they examine his chest. They told me, in a predictably stern and condescending manner, that he was admitted for the crypto infection and the brain tumor. Those were his illnesses and they were the only items on the agenda. Of course, since he had AIDs, his immune system was extremely weak and he could get many additional infections. The hospital staff seemed not to care. Perhaps this is one of the reasons why 100,000 Americans die every year from infections contracted after they entered the hospital.
In any event, when it was too late, they recognized that the guy had pneumonia. He died. Moral of the story: Trust your gut. When you think the doctor is talking bullshit, he probably is.
G) SCAN, SCAN AND BY ALL MEANS LOSE THE SCANS
Hospitals possess many great and powerful technologies which can illuminate pathology. Among other things CT scans are remarkable tools for visualizing anatomy. At times, they are absolutely indispensable. When a patient is seriously ill, and simpler means are unavailing in the quest for a diagnosis, a CT scan may do the trick.
However, one should not use CT scans lightly. They emit 400 to 500 times as much radiation as an x ray. Indeed, a doctor from the prestigious Mayo Clinic was quoted in the NY Times, about 10 years ago, as saying that CT scans will give us, or are giving us, 25,000 extra cancer deaths per year.
Nevertheless, doctors often will recommend a scan before more basic and often very fruitful means of inquiry are exhausted. For example, if one has abdominal pain, a good physician will palpate, or feel, one’s abdomen. Also, before subjecting the patient to a ton of radiation, there are so many lab tests which can yield useful information. However, some doctors are lazy, and some doctors may have special deals with special enterprises that perform scans (Oh, I can tell you stories !!), and some stupid patients are very impressed with any and all technologies and pills and treatments and will take to doctors who prescribe lots and lots of excessive tests and treatments.
Once I told a doctor about abdominal pain and his very first suggestion was a CT scan. His suggestion was wholly out of line.
In addition to performing lots of tests, doctors are so damn disorganized, or so damn cavalier in the practice of medicine because they know their pay is based on forms submitted and not on patient outcomes, that they very often forget to look at test results when they arrive. I used to litigate medical malpractice cases. (I am sorry to say that I started off doing defense work, at a medium size firm in lower Manhattan.) In one amazing miscarriage of medicine, an eleven-year-old boy had a sore throat and a fever of 99. Then it was 103. Then they did a chest x ray. They entirely forgot about the chest x ray especially as the child seemed to improve as someone saw him eat a piece of proof. Then his temp soared to 106,4. Then someone’s IQ managed stay above room temperature long enough to take a look at the chest x ray: It showed severe pneumonitis of both lungs. The boy suffered brain damage.
H) LET’S BE PRISSY ABOUT THINGS, LET’S NOT DISROBE AND NOT NOTICE IF A PATIENT’S FEET ARE SWOLLEN
In my youth, when a guy went to the doctor he was told to strip to his shorts. This is how it should be. To evaluate the body, we need to look at the body.
However, something has come over our society. While we are more mesmerized with physical beauty than a twelve-year-old boy looking at porn, most Americans are timid, insecure fuck ups who are terrified of showing any skin. So nowadays men don gowns even when they are being examined by other men. Sometimes, patients don’t take their shoes off.
Very often, severe illness will be reflected in swelling of the feet and the legs. If the patient is fully or semi clothed, the doctor won’t be aware of this. And please don’t tell me that it’s up to the patient to report all his ills. Very often, the patient is too distraught to remember all his ills. Also, medicine and psychiatry have long known of the phenomenon known as “La Belle indifferent” (This was first found in women with conversion hysteria.) Very simply, there are some patients who are practically indifferent to their most glaring problems, perhaps because if they were aware of the problem it would be too upsetting.
I) NURSES AIDS JUST WANNA HAVE FUN
I think Medical work is much more important than the work of my profession, law. However, I find that subordinates in law offices always work much, much harder than subordinates in doctors’ offices and hospitals.
There are so many bratty, bitchy women who seem to be on an interminable vacation. They are incompetent and they seem to be pleased about their incompetence. Just a few examples: A) I have been in hospitals waiting for over an hour for a fat nurse to give me a urinal that only arrived when the beleaguered doctor gave me a urinal. B) When I told a nurse at NYU that my vitals should be gauged, she cattily twirped, “We only do patients’ vitals because the law requires it.” C) I have called secretaries to make appointments with doctors, but now secretaries, filled to the brim with an inflated sense of their self worth, think they are professionals, and one will get the secretary’s answering machine throughout the day. D) I had a friend who had a complex regimen of different AIDS drugs, that could not be taken together, but the nurse who was taking care of the patient couldn’t be bothered with the details. E) I remember an AIDS patient who vomited when the nurse spilled rubbing alcohol in his mouth, and the nurse screamed at him, “Faggot.”
Not too long ago, New York’s governor, for a brief spot of time, was Elliot Spitzer. He was a brilliant man who had gotten perfect scores of 800 on both the math and verbal sections of his SATs. The powers that be got rid of him, alleging that he was a bad boy because he screwed some prostitutes. I think they got rid of him for another reason: He was one of the few politicians that wouldn’t kiss the butt of the union of health care workers in New York City. This is a union that has decreed that people shall be paid for not doing a damn bit of good. For example, if one enters any one of the buildings which house any part of Columbia Presbyterian Medical Center, one will have to take a map of Columbia’s buildings, written on very heavy paper, before one enters the building. Over the years, I have gotten well over one hundred maps from Columbia. I never asked for or needed any of them. But the union’s prowess enabled it to force Columbia to hire people to perform a task that does not do a damn bit of good for anyone.