Monday, July 25, 2011

Physicians, Heal Thyselves!


Mother and Dad trusted an internist for all their needs until he developed a debilitating muscular disorder and had to retire at a young age. My parents were then at the mercy of a flawed health care system.

First, many physicians refuse to accept Medicare patients because they have come to believe that their educations entitle them to a very high status in our society, measured by the reward for the work they do. Consequently, our most vulnerable citizens, mandated to enroll in Medicare, have fewer options for primary care. In spite of supplemental insurers charged with narrowing the gap between what Medicare pays and Social Security’s limitations, prescription costs, and the high cost of medical care, seniors find themselves in the offices of the newest practitioners, the ones trying to build a clientele and score word-of-mouth referrals. These newbies accept Medicare, but their experience and training may be woefully deficient in the needs and problems that seniors face--and that brings me to my second point.

Physicians that Mother and Dad used in the last decade are indeed woefully deficient in one essential skill: communication. One man, an immigrant or first generation English user from a Latino home, had a strong accent and a cultural habit of speaking softly. Mother and Dad, their hearing dulled by age, struggled to understand and follow his instructions. A good nurse could have stepped into the breach and saved the day. Or detailed written instructions could have complemented the physician’s discourse. Or the doctor could have asked my parents to invite a relative to accompany them. None of those were available or suggested.

Another physician phenomenon is a pathetic attempt to compensate for age. I witnessed a white-haired cardiologist shout at my father seated in a chair not four feet from him. He was so loud that his sounds bounced off the sterile cement-block walls. He was so loud that patients up and down the hall must surely have heard his interview and assessment. He was so loud that my ears hurt after his first word, “Hello.” Dad tried to draw his ears down into his shirt collar like a turtle protecting itself from an enemy. Nurses, too, seem to have been schooled in volume--as if every person of advancing years is hard of hearing, a problem easily cured by screaming.

Has it never occurred to any of those health-care providers that rate must be monitored as closely as volume. One supposed expert in geriatric medicine spoke so rapidly that even she forgot what she had said. She repeated herself and offered the exact same advice on a subsequent visit, unaware that she had said anything of the sort previously. She grew petulant when reminded about what she had said we should expect and rushed to her computerized record, then complained about assistants with only a high school education who had conspired to lock her out of the records she required. Yes, the very same records she should have read before entering the exam room at all--bringing me to another complaint: computerized records.

Technology is grand. I have embraced it fully. I do not need anyone to persuade me that technology has made many things more accessible and efficient. I believe that health care records should be both easily accessed and efficiently processed, especially in light of the number of forms I fill out when visiting doctors I see regularly. I can’t understand why they don’t move to larger and larger office spaces biannually just to shelve all that paperwork.

But now that health care is trying to take advantage of technology, physicians use the few minutes scheduled to see and talk with a patient as time to review the patient’s history and record their diagnoses based upon observable symptoms. So instead of seeing and talking with a patient, physicians swoop in, sit on a little stool positioned in front of a computer screen, begin reading--but not the full patient history--and take notes while the patient talks--all without ever actually looking at the patient. One woman, that Mother learned to dislike very much, never even touched her patient. She just talked and talked, rapidly, unaware that Mother could not follow her.

The next doctor was so patient and attentive that we were briefly lulled into trusting her. On subsequent visits, she too became nothing more than a white-coated backside, seated at a computer screen. Even after a diagnosis of “dementia” became a fixture of Mom’s record, the doctor talked and talked, just as rapidly as the former one. Both were absolutely negligent in discharging their duties. They made no effort to communicate with their patient and seemed put off by Mother’s speech aphasia, suggesting that they could do little with a patient who cannot speak for herself.

That hospital and clinic bosses are aware of this tendency--this deficiency--in their staff is evinced by the question on a follow-up survey: To what degree did the physician look at the computer screen? Always, Almost Always, Some of the Time, Very Little, Not at All.

Still very little changes with physicians. They schedule the least amount of time with individual patients in order to maximize their time during a clinic day so that they can see many more patients, cover their overhead, and increase their bank balances. The real care is with, through, and from assistants and nurses. They complete the intake; they make the follow-up calls. They even screen the patients’ inquiries, providing an almost impenetrable wall between caregiver and client. So say everything to the intake nurse. Make sure he or she understands what your complaints are. Make sure he or she writes them down. This is what the physician will read--not the patient history--when she swoops in to sit at her computer. If the intake nurse doesn’t get it, you will not get it either.

Be very careful, however. Recently an intake nurse prioritized chronic, irritating cough above annual check-up. Thus, when the doctor had diagnosed the cough as no big deal (I’m not sure what the ICD-9 looks like for that diagnosis!), she started to leave the room. My sister and I cleared our throats and said that Mother had other concerns whereupon the mighty physician pulled herself up to her considerable height, especially in tasteful low-heeled sandals, and told us that she might have time after she had seen to her other patients but we would have to pay for a second visit or return at a different time.

After calming myself, I stepped out to speak with the discharge staff, asking how an appointment made for an annual check-up had become an appointment for a little cough. I assured the staff that, at no time, had I said anything but annual check-up until that very day in the exam room when I added, “Oh, and Mom has a little cough she’d like to ask about.” The doctor, having so thoroughly seen to the care of another patient in that short amount of time, stepped into the hall to overhear my conversation with the discharge staff. She then stormed off to ream the intake nurse, only to reappear and agree to see Mother a little bit more, all the while complaining about Medicare’s strict rules and fines leveled by the out-of-control Medicare oversight folks against the hospital with which she associates. She also lamented the high cost of child care--as if we cared about her economic woes--as if her child care had anything to do with Mother’s care.

This same medical group ordered stool cultures after a prolonged bout of gastro-intestinal woes. They actually expected a woman diagnosed with dementia to stop by and pick up lab orders, deliver those orders to the lab, pick up the kit prepared by the lab, comprehend the directions for completing the samples precisely and correctly, and return them within minutes of collection. Not once did anyone inquire who might help her. Not once did anyone suggest that there might be some other way to secure the information.

I drove 2 ½ hours to collect poop and had to repeat the sample collection because I was 1/8 inch below the magic red line which indicates the perfect balance between poop and preservative. Average adults--of which I am one--would have a tough time succeeding under the conditions set forth for this lab test; adults afflicted with dementia cannot possibly succeed. But the health care industry rolls on, secure in the knowledge that U. S. care is somewhere among the top 50 health care systems on the world.

Physicians, ya gotta long way to go--in my considerable experience and less than humble opinion. Get busy healing for all our sakes.