Thursday, May 02, 2013

Notes on my middle-class health care

Today marks one week since my hip replacement surgery at Kaiser in Los Angeles, so I can’t say I’ve had the entire experience. Nevertheless I have some initial observations which I hope will interest both those who have been dependent on today’s medical practice and to those who have successfully avoided it thus far.

I aim to be balanced in my commentary. What I see is that on the spectrum of medical care in the world today, taking in all of humanity everywhere, I’m roughly in the middle as a member of the American middle-class, a designation I always like to surround with caveats because, with all its obvious advantages, the middle-class is tenuous in the extreme. One wrong move or series of setbacks and it comes down like a house of cards.

Nevertheless the middle-class is a relatively lucky place to be, obviously. As I look in one direction from my middle-class spot on the spectrum of health care, towards lower socio-economic levels in industrialized states, then on to regions experiencing famine and the disasters of failed states, medical care diminishes in quality and availability until it ceases to exist at all. I try to keep this in mind as I form my judgments on my own care.

I’m also keeping in mind what I see when I look in the other direction on the spectrum, towards higher income levels until we reach what we call the “super-rich,” or the 8%, or 3%, or 1%, or however you want to designate it, or groups like politicians who, though they may not personally be rich, benefit from a close association with the rich. What I see is that the quality of my medical care appears increasingly deficient, if not downright dangerous, compared to its more elevated forms.
Thus I hope to avoid a lack of gratitude for what I have, while pointing out its deficiencies.

At 67, two years past the big divide on all the forms-“65 and older”- I’m in as important a demographic as are teenagers, as far as marketing and sales. What Boomers lack in desire for the latest phones we make up for in elder care needs, a multi-billion dollar business and growing. The proof is in the commercials on the network evening news. Millions are spent every night to show us that our children and grandchildren will cluster about us in adoration if we take one or another kidney stressing, blood thinning nostrums, because then we won’t be pain-ridden, grumpy old things, but loving grams and gramps. Or how about those Cialis ads aimed at men? Am I the only guy who feels like blowing up his TV when subjected to those artful vignettes suggesting that the only way a woman will love us is if we maintain a chemically induced erection lasting no more than four hours? Note to pharmaceutical industry: Back off! There’s more to life than just your pills.

Anyway, to begin at the beginning, one morning about eight months ago I was enjoying a 7:00am breakfast at Wyler’s Deli in West Hills, Los Angeles with the Warner Center Kiwanis Club, a convivial group with a median age about five years beyond mine, when I experienced severe cramps in my right thigh, to the extent that driving home was treacherous. A friend gave me one of his Mobec (Meloxicam) tablets, and it wiped out the pain instantly. Mobec is a strong anit-inflammatory, but tolerance to it builds quickly, and when the cramps returned a few days later the Mobec did not work.

After this the progression became strange, in that the nature of the pain changed every time- though it always centered in the right thigh. The cramps disappeared and turned into an aching that seemed to travel around from the hip to the knee, almost as if whatever was wrong with the area was trying to figure out how to express itself. Eventually I went to my primary physician at Kaiser and began a process, starting with physical therapy that did not work, which resulted finally in a referral to an orthopedist. This is where the story becomes both revealing and mysterious. The orthopedist, whom I’ll call Dr. R, ordered an x-ray of my pelvis from a dorsal position. It showed significantly less cartilage in the right hip joint, which hurt, than in the left, which did not. Dr. R was not overly concerned. He said the cartilage loss was minor and that I was maybe five years from needing a hip replacement. He said I had the option of a cortisone shot to the hip. I got the shot and for about two months it provided significant relief. I was also issued a cane, which at that point I required to climb stairs.

Before coming to the “mysterious” part of the diagnostic process, I want to say a few words about the cane. I found that my debut in public using the cane was electrifying. People I had not seen in a while would rush up, concern bordering on grief welling up in their expression, and they would say things like, “Oh my God, I’m so sorry, what happened….?” Surely I can't be the only new cane-user who has been far from comforted by such displays. I know, as my wife reminded me, that this is how people show that they care, and maybe it’s unseemly of me to kvetch about it. But my point is that this is not how people should show that they care. What I heard, rather than, “I care,” was “I am devastated to see that from the vibrant and healthy young guy you once were, you’ve fallen into an abyss of increasing decrepitude from which you will find relief only in the grave!” Hey, that is not comforting! How then should people respond? Simple, just say, “How come you’re using a cane now?" As far as I’m concerned, that is caring.

The shot turned out to be only a temporary respite. In mid-winter, as unusually cold weather settled into Southern California, the cortisone wore off and the pain came back in much more severe form. I returned to Dr. R and requested another shot, but he declined, explaining that I needed hip replacement surgery, and that you cannot have a cortisone shot within six months of surgery because it inhibits the necessary inflammation. I was puzzled because this new diagnoses was based on the same x-ray which Dr. R had said gave no visible reason for pain, and that had indicated, as he said, that I was at least five years away from needing hip replacement. Dr. R ordered another x-ray, this one in standing position, and it showed a more severe bone-on-bone situation in the right socket than had the dorsal view. I was still puzzled, though, as to how two such radically different diagnoses could be derived from the same x-ray, so I requested a second opinion and was sent to Dr. R’s colleague, Dr. O. Dr. O told me that orthopedists do not go just by x-rays, which, he said, do not always tell definitive things about what’s going on in a joint. What they go by is pain. If a joint hurts as much as mine did, and other remedies like cortisone shots offered only two months relief (instead of the six months they can offer), then the joint needs to be replaced.

This conversation was a revelation to me, and I took it as yet another instance where, in our culture, we avoid saying, “I don’t know” (see previous essay, “Why I quit politics”). Dr. R and Dr. O had, in effect, told me that they didn’t really know what was going on in my hip, other than diminished cartilage. They just knew that it hurt, and that replacement surgery would likely make it stop hurting. Though I was satisfied that Dr. R and O were forthcoming and competent, I will critique American medicine for suggesting, or allowing people to think, that things are known when they are not.

I will also critique it for allowing people to lie. When my name was put on the three- month waiting list for hip replacement, it was apparently made available to a data base provided to private companies. I received an invitation to a post-hip replacement home recovery orientation at Northridge Hospital by a private home care company. I attended the free orientation and found it was an attempt to scare me out of my wits at the thought of staying in any hospital one hour more than necessary. It seems that infection is everywhere in hospitals, and if hip replacement patients stayed the three weeks that they did fifteen years ago, they would be dropping like flies. What a crock! People are rushed out of the hospital because it saves money, and here’s where we might make a comparison with the health care of the very rich. They are not rushed out of anywhere, and they face no risk of infection because wherever they are is scrupulously cleaned. I found Kaiser to be a very clean place and it has no record of troubling infections. But with a three-month backlog of hip replacements, they would have nowhere to put patients if the stays were longer, short of spending millions on new beds and staff. I’m not complaining about going home early- I was happy to go home- I’m just saying don’t lie.

The day of surgery finally arrived. I was quite scared because my previous two experiences with surgery, though minor, were fraught with problems of a decidedly middle-class variety. Fifteen years ago I had hernia surgery at a hospital in Burbank and was deathly ill from the general anesthesia. I actually remember waking up during surgery and vomiting into the oxygen mask, an obviously dangerous situation. If I hadn’t remembered it, though, no one would have told me. I woke up- in “recovery”- to five hours of intense nausea, in the presence of a nurse who gave me no medication. The doctor never came by or brought up the problem when I saw him three weeks later. This is middle-class health care- am I right? Any chance one of the senators from your state would be tossed in the oubliette like that?

Kaiser, you’re not off the hook: Seven years ago I had a bleeding polyp in my duodenum which was removed by endoscope, a wonderful device that has avoided much surgery. I recall that a salesman from the endoscope company was present to observe the procedure. Later the doctor told me that he had retrieved the polyp, biopsied it, and found it negative. Fast forward six years to my precautionary sigmoidoscopy. The doctor mentioned the polyp which he had read about in my file. I told him that it had been benign, but he said the file told that the doctor had been unable to capture it, that it was “flushed away” and there had been no biopsy. He was able to reassure me, however: “If there was something wrong you would have known by now.” Oiy gevalt! Come on Kaiser, you know I love you, but really!

My health care, though, in the big picture, has been excellent, including and especially at Kaiser. In return for 25 years of full time teaching, I get all these services for five bucks a pop, and I’ve come out more or less cured (of course I do have to read in the papers about the blood sucking teachers unions who have provided me with this selfish reward at the expense of my grandchildren's future well-being. Well excuuuse me!).

Returning to my hip surgery, the anesthesia was expertly done. I was fully briefed beforehand by the anesthesiologist, who explained I’d be given Propofol, the drug implicated in Michael Jackson's death. Propofol is a distinctive drug because it starts off with a very mellow twilight state- unlike the immediate unconsciousness induced by other methods- followed imperceptibly by something very like sleep. There was no nausea afterwards

The surgery itself went according to plan, and as a technical procedure deserves a grade of A+.

I did promise, though, to compare my own experience with that of the more privileged. For two days I stayed in a room in which I was separated by a plastic curtain from a man who vomited loudly and continually, when he was not shouting at his wife on the phone, “Get the fuck over here! I thought I told you to get your ass over here!,” then continued the abuse when she arrived. President Obama, you can’t hide from me! I know that if and when you are hospitalized there will be no such man four feet from your bed.

A note on my pain meds. After anesthesia wore off I was given hydrocodone- brand name Norco. It was great stuff for a couple of days, sending me off into blissful sleep in spite of my ranting roommate, but around the third day I discovered that Norco had been slowly turning me into some sort of alien insectoid creature, a really hideous sensation that’s hard to describe. Why anyone would abuse this drug is beyond me. At least alcohol and marijuana accentuate the pleasure centers and bring out a jolly version of oneself. This stuff is some advance attack from Orson Scott Card’s “Buggers,” the mantis-like creatures of "Ender's Game." Question for the DEA, ATF et al: Why are you so upset at party drugs when no one blinks that I’m given a 100 count bottle of these nasty pills and left to my own devices?

[Note, 11/13, six months after surgery: yesterday I discovered on Kaiser's excellent patient website that, at least four months after experiencing any appreciable pain from my surgery, there are refills available on my hydrocodone. Some elucidation comes from an article in this week's New Yorker online edition at http://www.newyorker.com/online/blogs/currency/2013/11/who-is-responsible-for-the-pain-pill-epidemic.html?utm_source=tny&utm_medium=email&utm_campaign=dailyemail&mbid=nl_Daily%20(59), which covers the pharmaceutical industry's role in over-medication, the patient's role, and recent moves by the FDA to redress the problem.]

All in all, though, I would like to give my middle-class health care an A+, but I do need to demur just a bit. I found that concerted efforts were made to divert my post-surgery attention away from my doctor and towards other professionals: physician assistants, pharmacist practitioners, physical therapists. A fifteen minute video I was shown on the blood thinner Coumadin repeatedly encouraged me to "ask your pharmacist," not once to "ask your doctor." My post-op discussion and bandage replacement was conducted, not by the surgeon, but by a PA who was not present at the surgery. When I go in next week for removal of the incision staples, I will see, not “my” doctor, but another PA (not the one I saw last week). As far as I can tell, other than one visit two months from now, I will never see “my” doctor again, or in fact anyone who was present at my surgery. This is no doubt some model of efficiency and money saving, but in my opinion it is a loss. Humans require continuity of other humans for bonding, repair and sustenance. I learned as a teacher that children need to see the same adults repeatedly- studies have shown that even the appearance of the same adult repeatedly is hugely beneficial, regardless of what educational contribution that adult makes. The new hospital model removes a consistent doctor from the patient, and that cannot be good. As I look across the spectrum from middle-class to health care of the wealthy, I would be surprised to see this removal of the doctor.

And yet, of course, in the other direction, towards the health care of the increasingly dispossessed and impoverished, we end up finally with no doctor at all. I’m grateful, then, for the health care I have and give it an A-.