A few weeks ago, Not So Confidential answered some of my questions about gun control. I enjoyed the format. I doubt that he changed the minds of most of my wimpy liberal Bush-hating readers, but it was cool to hear the other side of the story. And believe me, while I love Danny and his Huffington Post friends, I’d rather have NSC standing next to me during a bar room brawl.
Today, I’d like to turn to another subject in the news — medical care. This has been a big issue for several years, with very little being done. Things in the media will only get heated up more when Michael Moore’s next movie about America’s health crisis, Sicko, comes out in theaters.
Medical care has become a personal issue lately because of Sophia. Lately, I’ve been bitching about both doctors and hospitals, and how uncaring they can be. But what about the other side? Aren’t doctors just as miserable as their patients? Why don’t doctors and patients ever talk to each other?
Psychotoddler is a blogger, a musician, and a doctor. He was nice enough to take some time out from (playing golf) to answer a few questions. Feel free to grill him about any issue that is on your mind, and I’m sure he will answer you. Just be careful not to ask him for medical advice. He will charge you.
Neil: Sophia’s surgeon seemed to have been over-confident in thinking that he took out her DCIS, and never wrote down the orientation of the piece, which is now requiring Sophia to get more cut than necessary. All doctors obviously make mistakes. What should be our response to the error?
Psychotoddler: Sue! No, seriously, you have every right to discuss the issue with the surgeon and get an explanation of why the orientation was not marked. You are correct; doctors make mistakes. The issue is that doctors don’t like to admit mistakes because they fear litigation. The actual truth is that doctors who discuss mistakes with patients in an open and rational manner are less likely to be sued than those who try to avoid the discussion or cover it up. Never-the-less, there are lots of lawyers out there who would jump on an admission of error and so many physicians are uncomfortable discussing their mistakes.
On the other hand, not every bad outcome is a mistake. Sometimes it’s a judgment call that turned out badly.
The trick is to approach your doctor in a serious but non-litigious manner. Let him know that you appreciate the 99 things that he did right but want better understand why that one thing went wrong. Try to avoid being adversarial. A good doctor will respond in kind. You and the doc should be on the same team!
Neil: It seems that Sophia usually gets pretty good care because she is always calling and questioning her doctors (as well as shmoozing with them). Is this the only way?
Psychotoddler: I’d like to think that doctors provide good care to all their patients, but the truth is that we are pulled in multiple directions all day long and sometimes the simple truth is that the squeaky wheel gets the oil. On the other hand, squeaky wheels are annoying as hell and most people try to avoid them.
Again, I prefer the team approach. You need to let the doc know that you’re on top of things and paying attention, but also show some appreciation. Personally, although I try to be impartial about my patients, I probably do spend more time and effort on patients whose company I actually enjoy than on those that annoy me.
Neil: Any recommendations for making sure a person gets good care in a hospital?
Psychotoddler: This is tricky. I’ve seen this from both ends, as a doctor and as a family member (fortunately, not so much as a patient). You need to be an advocate for the patient, but not get in the way of patient care. I’ve seen families descend on hospitals, occupy rooms and hallways, question every staff member and every physician who comes in the room, all in an effort to make sure their loved one gets “good care.” Generally, this approach does NOT work. What happens is that the staff starts to avoid the patient’s room. If an aid or a nurse or even a doctor knows that they’re going to get a lot of hostility or endless questions, or just feel uncomfortable with all the people in the room, they will try to go in as little as possible. And in general, this ends up being bad for the patient.
The patient is in the hospital because they need the care that the staff provides, so every effort should be made to make the staff want to respond to calls and come into the room. Keep visitors to a minimum. Don’t yak on a cell phone (even if the hospital allows it—but especially if it doesn’t!), don’t feel the need to question every pill that gets dispensed. It’s enough to let the staff know that someone cares and is paying attention. Try to get the nurses on your side. An overbearing family can put a patient on the nurses’ sh*t list quickly. Be pleasant. Smile. Bring candy for the staff. Let them know you respect them, not that you don’t trust them or think they’re goofing off. In many ways, the care that the patient gets from the nurses is more important than that from the doctors.
That being said, some places are just BAD. My mom did all those things and my dad STILL got crappy care. Know when it’s time to bail out and transfer.
Neil: Are nurses undertrained?
Psychotoddler: I think nurses are better trained now than they’ve ever been. Many function on the level of a physician’s assistant or higher, especially on specialty wards like ICUs and Cardiology floors. The issue is that not everyone who looks like a nurse is an RN. Nurses are expensive and hard to come by, and many hospital floors have a handful of them and then a bunch of nurse extenders, like aids, certified nursing assistants, etc, who have minimal training. If you’re not sure about who’s giving care, don’t be afraid to ask.
Neil: Are hospitals understaffed?
Neil: If you had to go into a hospital, does saying that you are a doctor, give you special treatment?
Psychtoddler: I am loathe to mention that I’m a physician. I’m probably in the minority on this, though. I hate the idea of privilege, and have no problems with waiting in line. My mom, on the other hand, was sure to point out to everyone we encountered (the guard in the lobby, the elevator operator, the nurses and aids, the doctors and I think a few of the janitors) that I was a doctor. I suspect that on one level it does give me more access and makes the staff take me more seriously. On another level I think some providers are threatened by it and try to play their cards close to the vest.
Neil: Doctors used to be thought of on par with Gods. Now they are one notch above lawyers. What happened?
Psychotoddler: We let others take the reins of medicine from us. Bureaucrats, legislators, HMO administrators. We allowed them to take our profession and hack it up into little bits. As a result, we surrendered our authority. Most doctors used to be self-employed. Now many if not most are employed by large hospital corporations. We are like 1.5 or 2.0 FTEs, subject to the whims of middle-level administrators and can be fired at will.
I also think that the proliferation of readily available medical information, whether on the internet or through the mass media, has served to empower patients, and that power has been transferred from doctors.
Neil: Patients are always complaining about medical care nowadays. But I hear that being a doctor is just as bad today, especially compared to the way it was in the past? Why is that?
Psychotoddler: Medical care is actually much better now than it has ever been. People are living longer, healthier, medications are better, taken less often, with fewer side effects. We have procedures that can fix blockages in the heart and limbs, where in the past dangerous and painful surgery was the only option. We have better diagnostic tools than ever before, almost on par with Star Trek.
But it is also more expensive than ever before. Because it costs so much, it is much more regulated. People complain about medical care because they have to pay so much for it and yet it seems they have less access to it. There are many layers between the doctor and the patient, and just because something can be done doesn’t mean it will be done, if it needs to go through a maze of HMO prior authorizations.
People are also paying much more out of pocket, even as opposed to 5 years ago. And yet for this extra expenditure, many are seeing a paradoxical decrease in service.
From the doctors’ perspective, they are getting paid less and less and working more and more. There is more paper work than ever before. Since the new Medicare drug plan went live, my paperwork has tripled. Every month I have to submit new prior authorization forms for the same medications that patients have been stable on for years. I have staff members who now spend full time on the phone with insurance companies and pharmacies trying to get my patients their pills. All this costs money, and as a result more patients need to be seen and less time can be spent with each.
Documentation regulations are out of control as well. Doctors at this point don’t get paid to provide care. They get paid to produce documentation. There are now computer programs that can spit out an entire history and physical report even before a patient is seen. In the hands of less scrupulous providers this can lead to inaccuracy or even fraud.
Neil: Everyone thinks doctors are fabulously wealthy. How long does it usually take to pay off medical school expenses?
Psychotoddler: A typical doctor pays of thousands of dollars per month in medical school loans over a ten year period. If, like me, the doctor was not blessed with wealthy parents, he may be burdened with high-interest 30 year loans as well. I was fortunate enough to finish paying off my loans about a month before I started taking loans out for my daughter’s college tuition.
Doctors who do a lot of procedures, ie surgeons, cardiologists, gastroenterologists, make a good living. Those of us who rely on dispensing advice, like internists, pediatricians, family practitioners, make relatively little. I live paycheck to paycheck.
Neil: Why do doctors seem to care so little about their patients? Are they seeing too many patients?
Psychotoddler: Everybody is different. I don’t think my patients will tell you that I care little about them. Surgeons, by nature of their practice, are on a tight schedule and may not have a lot of time to chat, and may come off as aloof or uncaring. Primary care doctors may have a little more time with their patients. But not everyone is a people person. If you really don’t feel like your doctor is there to help you, maybe it’s time for a new one.
Too many patients? You know, you can’t have it both ways. Above I mentioned the pressures on physicians to see more patients (and by the way, employed physicians may have very strict requirements to see a certain number of patients per day). At the same time, patients want to see their doctors in a timely manner. A doctor could see fewer patients per day, thereby spending more time with each, but then many who want to be seen would be turned away. And the doctor would probably not be able to keep his doors open for long without either overcharging the ones that come in or finding some alternate means of income.
There are some physicians who charge a premium, say a few thousand dollars a year, and in return limit the number of patients in their practice, enabling them to see fewer patients for longer appointments and be available quickly for them. Obviously this would only work for a few providers out of many, as someone has to see all the other patients. What’s interesting is that people now have to pay a premium to have the kind of interaction with a doctor that was the norm 40 years ago.
Neil: Do you think there is too much specialization?
Psychotoddler: Yes. Not everyone needs to be a cardiologist.
Neil: Do you have any specific ideas on what you would do about health care or health insurance if you were President of the World?
Psychotoddler: Yes. I would ensure that everyone had affordable health care coverage, that no one had to pay excessively out of pocket, and that paperwork would disappear from the face of the earth. Also, I would make sure that we colonized the Moon by 2014 and that I could take a rocket ship ride around the rings of Saturn. I’ve always wanted to do that.
Neil: When I was a child, my family doctor would do all these tests, including holding my balls and making me cough. My family doctor in LA has never seen me naked — in ten years. Should I change doctors?
Psychotoddler: I don’t blame him. I don’t want to see you naked either. Seriously, there used to be something called the “annual physical”, the purpose of this was to get you naked so your doctor could look you over and screen you for things that you didn’t know you have, because they weren’t bothering you at the time. That’s called “preventative medicine.” But then Medicare and many other insurers decided not to pay for it. So it doesn’t get done. Many of us still do this. You may need to tell your doctor you want an annual physical, and be prepared to pay more out of pocket for what the insurance refuses to cover. Otherwise you may only be interacting with your doc for “problem visits”, and given the time constraints we mentioned, that doesn’t leave time for the other stuff.
Neil: A serious question — why are magazines so BAD in doctor’s waiting rooms? Why do I want to read his old Golf magazines? This shows the doctor as uncaring right from the start.
Psychotoddler: We take all the good ones home for ourselves.
Neil: Would you want your son or daughter to be a doctor?
Psychotoddler: From the perspective of working very hard, getting massively in debt, and then ending up in a profession that is a target of lawyers and legislators, working unbelievably long hours, for less and less prestige, the loss of privacy, constantly being a slave to the pager, etc, I’d say “no.”
From the perspective of this being a wonderful way to make a living helping people, I’d say, “yes.” I love my patients and I love what I do.
Neil: Are most of your friends other doctors?
Psychotoddler: I have no friends.
Neil: Do doctors treat patients differently according to their health plan?
Psychotoddler: Yes, primarily in the sense that different plans limit what you can prescribe or order. You have to factor that in when you make decisions. It’s nice to say that you go all out for everyone, but after a few come back and complain that insurance didn’t cover their MRI or whatever, you learn to take these things into account.
Neil: What’s the deal with all those sexy blond sales reps? Do you go out to lunch with them? Will they go out to lunch with me? Have you ever bought Prozac over Wellbutrin because the salesgirl bought you a nicer lunch or had a better ass?
Psychotoddler: I’d love to answer this, but there’s a hot drug rep waiting for me.
P.S. — Sophia has a question now that she dares Psychotoddler to answer honestly: “Isn’t it true that doctors make more money from HMOs if these patients DON’T come in for visits?”
A Year Ago on Citizen of the Month: Watch the Road