Surviving American Medicine

By Daniel L. Blumen

This is a story about 21^st century American medicine. It’s a personal story that touches great themes and issues in American society. And because it is a personal story and not a scholarly work, your author has taken liberties for catharsis and entertainment.

The working title that came to mind was “The Gas Man Cometh” from a song of the same name with lyrics by Michael Flanders. It is the song of a homeowner whose gas tap wouldn’t turn and the cycle of tradesmen brought in to remedy the problem. The gas man needed to rip out some boards to find the gas main requiring a carpenter to put them back, an electrician to correct an error by the carpenter followed by a glazier to replace some glass broken by the electrician and then a painter to restore the room to its original condition – while accidentally painting the gas tap shut - again. The refrain after each stanza is “It all makes work for the working man to do” and this seemed particularly appropriate to my experience. But Flanders and Swann are British and this is an American story, hence the title “Surviving American Medicine”.

Into the Web

We begin in late summer 2007, near Chicago. It was a hot summer; sticky and pollen laden. Strenuous exercise was a bit less pleasant than usual and even the White Sox were looking forward to a seasonal change and the end of their misery. In our story there was no seasonal relief and so an appointment was made with a physician’s assistant supporting an overburdened and long- serving general practitioner.

I love my GP but hate the office which is anchored by an instrument of modern medical torture. A television broadcasting health care information from companies with a passionate concern for our personal well being. To ensure that the messages are fully absorbed, the device does not have an “off” switch or a volume control.

Now it’s churlish to complain about an industry that addresses society’s critical problems be they restless legs, non existent erections, or eroding esophagi in need of a purple pill. Stifling my ingratitude I rubbed elbows with a representative of the pharmaceutical industry seeking an audience for her medical expertise, some pens and, perhaps a free lunch for anyone in the office with the power to prescribe. I introduced myself to the receptionist and established that I was, indeed, Daniel L. Blumen.

Accustomed to working with suburbia’s baser elements the receptionist established my ability to pay and surprisingly, requested a medical history. As a long term customer of the practice this concerned me. Had my behavior caused me to become personna non grata to a database administrator? Fortunately the diagnosis was benign, a new computer system was being introduced and there was the need to populate the system with data. Given the cost of moving the existing data to the new system it was cheaper to have customers complete another history.

A short wait and I was called to the presence of the PA, or physician’s assistant. Symptons were described, orifices inspected and vital metrics were noted. The PA was stumped but had already used almost six minutes of my allotted ten. More data was needed from elaborate and expensive tests some of which might be recognized by my insurance provider and therefore reimbursed.

Testing

Steered to a local hospital sharing branding with the PA’s practice, it seemed like a good idea to discover if other local facilities might be in a position to perform the same tests at a better price. We are, theoretically, in the era of consumer driven medicine. We were recently in an era where hedge funds had mastered risk management. In sum, a virtuous exercise for those with patience, a good sense of humor and a telephone plan with unlimited prime-time minutes. Many facilities were able to quote a price for the requested services. None had any interest in quoting the net cost to the customer after the discount offered to the insurer’s network; a discount offered to induce the use of their facilities.

The cobranded facility did mention that discounts were generally 25-50% of the list price. For this bit of candor I decided to compromise. The cobranded facility didn’t have to disclose the discount but I would receive a 20% fee reduction in return for prompt payment of their invoice. Pause and reflect on how our world would be changed if the cost of all health-care procedures were immediately reduced by 20%. Would it be enough to provide care for an additional million families? Or would it savage Lexus dealerships throughout the land as needy providers were reduced to the use of Chevrolets or public transit?

But this is a story, not an economic analysis and the next part of the story involves a nuclear imaging stress test. On the day of the test I presented myself to the facility, established my ability to pay, promise to pay, willingness to pay whatever fee was ultimately assessed and consent to a number of other indignities spelled out on a form that clearly stated “No changes to this form will be accepted”. I made some changes just the same.

While waiting I had the chance to inspect a display of cardiac instruments provided by a leading medical device manufacturer. The manufacturer was recently in the news because 250,000 of their customers had been implanted with faulty defibrillator leads. Perhaps a bit less time spent on advertising and a bit more time spent on quality could have turned the tide. Defibrillatorless and feeling blessed I was soon led through a carpeted and wood-paneled maze to a room with a treadmill and some chairs. After a bit of poking, the insertion of an IV and the attachment of electrodes I was instructed to get on the treadmill and get moving.

As the exercise technician, lab technician and I waited for my heart rate to reach the correct level we chatted about the procedure and placed bets on how long it would take. Having been tossed off the treadmill in a previous stress test when the technician got bored after eighteen minutes I surmised the same. But this was Friday afternoon, the technician was young and so, having failed to achieve the target heart rate and in the absence of any other anomaly I was terminated in just under fifteen minutes. A brief wait and I was whisked off to the camera for some very expensive 8 by 10s. I’d aced the exam! Arriving home, it was time for a drink and, if I could persuade my wife, an exception to general dietary habits in the form of a steak, creamed spinach and cheescake for our evening meal.

Disappointed

A cholestorol drenched evening was not in the cards. Shortly after arriving home the PA called and asked me to return for an additional test on Monday. I was told not to exercise over the weekend as there was the possibility that I had some form of hypokinesia, a Latin term meaning “we don’t know, but it’s going to cost you”. I returned to the facility on Monday, again established my ability to pay, promise to pay, willingness to pay whatever fee was ultimately assessed and consent to a number of other indignities spelled out on a form that clearly stated “No changes to this form will be accepted”. I made some more changes.

The second test completed, it was back to work and off to Cleveland for an exciting day of meetings in windowless conference rooms. Returning home that evening, a colleague and I listened as the pilot of our flight advised the use of ground-based facilities because the expected turbulence enroute to Chicago would not permit the removal of seat belts during flight. This cheerful news was topped by a call from my wife telling me that there were several phone messages from the PA.

A quick call to the office and the PA – through her nurse - explained that there appeared to be a real problem and my physician had pulled some strings to get me an appointment with a cardiologist in just three days. I was to keep this appointment and by no means fly to Dallas for a final presentation to a prospective client on Friday. No advice was offered on my immediate predicament: stay in Cleveland or board the flight and possibly spoil the evening of my fellow passengers. Cleveland had some appeal because my father’s bypass surgery had been performed at the Cleveland Clinic but I passed on this chance to be a legacy and boarded the flight.

Procedure the First

Before meeting with the cardiologist it was necessary to complete another medical history. Same basic questions as the earlier history but in a different order and typeface. My wife and I watched as the cardiologist’s assistant dutifully transcribed the information I had faxed in advance of the appointment to a computer. Technology is wonderful. Modern medicine should make use of it. Prepped and ready we met the cardiologist who explained what I already knew – my problems came from my parents. It wasn’t Latin or insightful but by nodding vigorously he was persuaded to talk about the options. Most interesting was the fact that every number quoted for options and the associated probability was divisible by five. An improbable natural situation but easy to grasp and consistent with the financial discounts mentioned earlier, which were also all divisible by five. We selected the Angiogram and made an appointment for the following Tuesday.

My mate and I arrived promptly on the day of the procedure and announced ourselves to the receptionist. Told to “proceed to cubicle C” I waited for a representative who established my ability to pay, promise to pay, willingness to pay whatever fee was ultimately assessed and consent to a number of other indignities spelled out on a form that clearly stated “No changes to this form will be accepted”. I made even more changes.

While waiting, my mind drifted to recent experience at the veterinarian’s. Unlike this facility with its pompous receptionist and pretentious wood paneling, the vet’s office was brightly lit and cheerful. Patients at the vet’s office can be anxious and noisy and might bite but there was always a genuine warmth about the place that the “people oriented” facility could try and copy. And to be honest, the scrubbed veterinary facility felt a bit cleaner too.

The wait was not long and we were taken to a holding pen next to the catherization lab. Stripped, I lay in bed wondering if it really was genetics and not a surfeit of pizza in graduate school that put me in this mess. An attending nurse had me complete yet another medical history which was exactly the same as that provided to the GP and the cardiologist. Too tired to protest or ponder which of the three histories would ultimately govern treatment it was a relief to be wheeled into the operating room and get the whole thing over with. The relief was short lived as the rulers of the operating room liked loud music by their favorite performers and had piped this in for their comfort. Before succumbing to some marvelous medications I looked around the facility and found that it resembled a cleaner version of my local Jiffy Lube. Only the Jiffy Lube was better lit and much quieter because no loud music was permitted.

Awake but groggy the cardiologist informed me – or more precisely my wife – that there were some blockages, expressed in percentage terms divisible by five, that would best be repaired using a drug eluting stent. Not an unexpected diagnosis but the prospect of another round in the operating room wasn’t thrilling.

Information is an antidote to anxiety and Google is always at hand to provide information. In the case of stents there was general information on their use and benefits from sources such as the American Heart Association and Wikipedia. There was also an ad on the main search page that read: “Stents - Injured By A Drug Coated Stent? - Large Firm - We Can Help!” Clearly this was raising, not lowering, the anxiety level and I needed to stay off the internet.

Procedure the Second

Scheduled for a Friday, the angioplasty was to be performed by another specialist with particular skills in this area. Appointments were cancelled, coverage was arranged for client matters and mental preparation was begun. Until a phone call on Thursday afternoon cancelled the procedure because the specialist was unavailable. It was not clear if this availability was driven by a medical emergency or the availability of a desirable tee time and the specialist’s representative was not about to tell me. So we rescheduled meetings and coverage. Time appeared to have value to only one participant in this transaction.

Monday morning came soon enough and we presented ourselves once again to a representative who established my ability to pay… You get the basic idea and, yes, more changes were made to the unchangeable form. Now for this procedure an overnight stay was required to be sure of the patient’s status before a brief home convalescence. And overnight stays require precertification with the insurance company. This certification was quickly granted as the insurer explained that the overnight stay was not a hospital admission but a hold for observation. Who makes this up? Frustrated English majors with a taste for Kafka? This would be consistent with the natural order in medical care in which those who like organic chemistry become physicians. English majors must work for insurance companies and cheerleaders become pharmaceutical representatives.

More medication, loud music and wheeled journeys through the facility until we arrive at the room where I will spend the night, wired but unadmitted. The time passed with routine inspections of the incisions to each of my femoral arteries. A cheerful nurse would look at the area, press gently and exclaim in a satisfied tone “nice and soft”. Sleep was not in the cards because patient’s cardiac functions were under constant monitoring with alarms for out of range results. In my case, a pulse below 50 would set off an alarm. Unfortunately, 50 is close to my regular resting pulse of 56 and so, with the aid of exhaustion and medication I breached the 50 beat threshold on multiple occasions. A good thing I was healthy and didn’t need the sleep.

Home at Last

Dawn broke and the wait for release began. Nurses came to check my medications. Technicians came to take my blood. A patient advocate arrived to assess my satisfaction with the facility. And a salesperson arrived to tout the benefits of cardiac rehabilitation. Mercifully the cardiologist appeared to pronounce the procedure a success and released me to my family. But not before giving me a prescription for a new medication, available in generic form.

Which leads to the last anecdote before the sweeping generalizations that will conclude this paper. My wife filled the prescription at our favorite pharmacy paying a mere $9.87 for a 90 day supply of the drug. That was probably half the cost of my morning breakfast while an unadmitted guest of the hospital. Inside the bag, nestled snuggly with the traditional patient insert, was a two page “Information for Patients” notice – with my name on it. The notice advised that there was another medication that might be even more effective than the one my cardiologist had prescribed. The notice did not mention that the recommended drug would be considerably more costly because it was a proprietary formulation. The notice also failed to mention that data from a major study on the drug’s efficacy was not being made available to the medical community despite protests from the same community.

A good marketing idea; if you can’t convince the experts, panic the consumer. Was the company also monitoring obituaries, prepared to advise my spouse of medications to ease any anxiety she might suffer upon my demise?

Sweeping Generalizations

I have certainly enjoyed forming these anecdotes into an amusing story and must now redeem the exercise by finding a message in this experience with American medicine. Could it be the statistical improbability that all numbers in medicine are divisible by five? Was it the ethically unbound cupidity exhibited by some participants in the system?

My conclusion is more basic. American medicine has distilled the wisdom of Eli Whitney, Henry Ford and other industrial pioneers creating the perfect assembly line where each contributes according to his ability, takes according to position in the medical hierarchy and passes the consumer on to the next provider. I am relieved and grateful to have survived.