Our Hypocritical Oaths:
When people complain about healthcare problems they tend to zero in on an isolated part of the system, like insurance. When they try to solve healthcare problems then focus on another part, like technology. They dredge up scapegoats to blame by accusing the poor or immigrants of driving up costs by depending on emergency rooms as primary care. The truth is, we all play a role in the gargantuan capitalist collective that is healthcare, and no matter how hard we try to be diligent consumers or responsible patients, we each enable a very unhealthy healthcare system.
On some level you may understand this. As you dangle your legs from the examining table clutching the corners of that little paper towel, you may recognize that you're sitting in a "care" facility that spends millions marketing to you about meeting your medical needs while unfailingly accommodating the needs of many other players -- the insurance company's stockholders, the investors in the shiny new medical complex, the medical fellow's future success, the administrators of various insurances, and the doctor's kids' educations.
Regardless of how smart and realistic and educated you may be, you aren't clever enough to avoid unnecessarily driving up health care costs, a fact you may well choose to ignore. Usually you can rationalize that the problems are not your fault. And since we all agree that it's not our fault, the dysfunctional system thrives and perpetuates itself.
But once and a while, a twinge of regret or guilt may creep over you. Perhaps it will happen after you wait five months to visit a certain specialist that everyone said is the best, only to realize that the ten words he deemed worthwhile his time to impart were less informative than what you read on -- except uttered by him they cost the insurance company and you $400 -- with the insurance discount. Maybe you should have known better.
Or perhaps someday you will look at what "you pay" on the bill compared to the five thousand dollars that insurance payed and momentarily feel as though you've scored a bargain at Ross Dress For Less -- even if you recognize that the insurance companies extraordinary profits came directly out of your pocket. Someday you'll be too busy to insist that the insurance company honor the preventative procedure contract; someday you'll acquiesce to doing some unnecessary high-cost procedure; someday you'll agree to do five more blood tests because you don't feel like getting your old records.
What the Teabaggers Deny
There's the everyday differences of opinion about how to diagnose and treat certain diseases and other issues, these drive up healthcare costs. Then there are the recognizable and seemingly avoidable mistakes that you participate in and recognize. Regardless of, or because of your expertise in economics or medicine or finance or business, someday you'll be slapped by undeniable buyers' remorse or the chagrin of being duped or overtreated. Someday you'll sit down on the examining table fully aware of the trade-offs and controversies of health economics, of third-party payers, of diagnostic options, and treatment controversies, only to recognize sometime after your "care", in an exasperating burst of awareness, that your time or money (if not your health) got wasted.
Before then, you may choose to be too overwhelmed with life's business to consider your participation in the sorry healthcare system. Or you may hear other people talk about some useless procedures they endured and think 'poor sap - wouldn't be me'. Such was the case with Dr. Jack Coulehan, who relayed in last month's "Health Affairs, that he "lost the smugness and condescension I often felt when listening to others' stories about being trapped by the system and manipulated into excessively complex and specialized medical situations", and ended up as "a poster boy for excessive medicine."
Coulehan, a primary care doctor, professor emeritus and public health fellow at NYU, described his exasperating experience in the emergency room one Easter Sunday. The doctor knew he had shingles, having diagnosed at least one hundred patients with the disease:
"but I decided to visit our hospital emergency room to confirm the diagnosis and get my prescriptions. My wife drove. I sat in the car with my eyes closed, wondering how it was possible for me to have turned into one of those elderly people who suffer from shingles."
The attending physician confirmed his self-diagnosis, but Coulehan relented to see two more specialists. He relays his confused thinking during an exchange with the attending physician:
Attending: "Maybe we should have an ophthalmologist and a neurologist take a look at you. What about it, just in case?"
Coulehan: "I don't know...I don't think so...well, OK...maybe it's a good idea." A tiny doubt crept into my mind. Could we be missing something? Might it be a tumor behind my eye? Or a weird form of glaucoma? I wondered whether she was being extra careful because I was a fellow physician. But, if so, why?
After one MRI, Coulehan observes:
"When the attending neurologist returned from his lunch he seemed absolutely delighted that I might have a blood clot in the sinus -- a finding, he said, consistent with the redness around my eye. "Did you have any recent dental work?" he asked, searching for an infection as a possible cause of venous blockage. (I hadn't.) I was gripped by molasses-like passivity. The reasonable part of my mind cried, "This is crazy! Get me out of here!" But a twiggy little nugget deep in my brain asked, "What if there is something serious wrong?"
Coulehan went through hours and hours of waiting and testing, testing and waiting, into the evening, noting that "Easter Sunday appeared to be a dead day in the ER, except for me and my shingles". By the end of the day, Coulehan finally got the medical prescriptions he had decided he needed at six in the morning while sitting on the beach with his wife. After two MRIs, a CT scan, and a $9000 bill, the doctor concluded: "I understand now how all those people could have been so gullible, so easily manipulated by the system. Now that I'm one of them, that is."
If you've already been chagrined after relenting to some test or procedure that's totally useless if not harmful, Coulehan's article will assure you that you're in good company. Which of course is comforting but also ironic. Since we're all making the same choices, more than a few of which are undeniably bad or unnecessary, many people feel no particular personal responsibility. In fact some people, like the teabaggers lining up in Washington DC like it's 3AM the day after Thanksgiving at Best Buy, fear that any change in the system will deny them their rights to those bargains advertised on their insurance receipts.
Coulehan's whole article is available at Health Affairs September/October 2009; 28(5): 1509-1514 (subscription).
