Debra E. Blaine's Blog

Healthcare has become the buzzword for what used to be the field of medicine. While medicine implies the healing of dis-ease, healthcare, in its raw meaning, sounds like it is about taking care of our bodies so we will not need to resort to medicine. And yet, it has become exactly the opposite.

Healthcare has become an institution based—not on promoting healthy humans—but almost solely on profit. It has become an oxymoron. Healthcare in the United States is now Big Business, shrouded in media marketing and frequent corporate mergers.
Last week, I heard a radio commercial from a large healthcare system say to its audience: “We haven’t seen you a while. Don’t forget, our urgent care offices are open seven days a week and we can help when you or your family get sick from…” fill in the blank. It went on to list multiple common problems, some of which, like a cold, have no clear treatment options, while promising the convenience of being in and out in less than an hour. I happen to know that company’s offices are understaffed and overcrowded.
The source of this commercial is the establishment that manages your neighborhood healthcare clinic, 160 sites large and growing, which purports to be there for you and your health. The purpose of this commercial is to make you, the patient—the consumer of healthcare—consider that perhaps you aren’t feeling as well as you thought you were, that perhaps you are in fact ill, and maybe you should sit in a waiting room with standing-room-only people coughing and sneezing and wearing their masks under their noses—if at all. 
Please make the distinction: this was not a well-intended notice that you should consider getting your colonoscopy or mammogram or other standard preventive medical procedures. This was not for primary care. It was not a cardiologist suggesting you get a stress test if you are over the age of sixty.
This was for an urgent care office, a place that takes care of urgent medical problems, and it was prompting you to evaluate yourself for an urgent medical need. As if you needed to be told when you are ill. It was suggesting to the general population that they are sick and need medical attention. Why? Because healthy people do not to go to an urgent care facility, and therefore, they do not contribute to the profitability of that arm of the organization.
This was solely for the purpose of generating revenue. It was not in the interest of your health. Furthermore, it encourages unrealistic expectations on the part of the population, which has been promised the eradication of any discomfort in the utmost convenience.
Consider another commercial. You may have heard it. A woman is relaying a heartfelt story about having been so ashamed to be seen in public that she felt compelled to wear sunglasses even in the dark, because her “thyroid eye disease” (exophthalmos) was so disfiguring. Of course, this is an advertisement for a drug, and after she takes the drug, we see her happy as a lark, socializing at the pool or with her friends.
Now, please understand that some of these patients do have serious symptoms associated with hyperthyroidism, and of course, should be treated. (The sunglasses could be for photophobia). But the “hook” in the advertisement is to tap into their basic insecurities and make them self-conscious about their appearance, and that seems rather cruel. How many people with Grave’s Disease were not focused on how they appear to others but who, after viewing the commercial, now lack confidence to go to a gathering? How is this contributing to the welfare of this population?
Have you ever found yourself wondering, after watching one of the myriad of commercials for antidepressant medications, whether you yourself might, in fact, be depressed and need to be medicated? Wouldn’t you love to take a drug that would transport you to those beautiful fields or beaches and run with your dog at the edge of the sunny surf and feel wonderful? And the music is so calming and delightful. Can taking a medication make you feel that good? Because that is exactly the subliminal message you are receiving.
In short, we have become a culture of sickness. Disease has become an expectation, fostered and cultivated by Big Pharma, Big Healthcare, and Big Business. It is an industry that goes far beyond traditional medicine or ethical values. 
In 2005, Ray Moynihan and Alan Cassels wrote the book Selling Sickness. It called out specific pharmaceutical companies whose outright stated goal was to turn the entire population into patients. To make buying medicine as commonplace as buying chewing gum, and to therefore, make them rich. They have indeed succeeded.
Since 1997, television in the United States has aired commercials convincing people that they were depressed, tired, unfocused, too focused, that they have headaches, allergies, are too fat, too skinny, and on and on, and—most importantly—that they cannot cope with life without pharmaceutical intervention. 
And the American population has consumed this information and made it part of their personal reality.
We have fought back, to be sure. How many businesses have cropped up encouraging healthy eating, yoga practice, meditation? We have naturopaths and reiki healers. But underneath it, the carpet upon which our society has been laid, is the pharmacy and the doctor’s office. The places where sickness is not treated, but sold.
This is the logical outcome of peddling health and human life the way we would sell Apple TVs. The business model has no place in the practice of medicine. Except, of course, for profiteering. 

What are the “undue influences” in our lives? What determines our behavior? In our day-to-day existence, are we exercising our free will?

We often go through life on autopilot. Can you blame us? We’re overtired, overworked, and hyper-stressed much of the time. Our families want our attention and our jobs want us to see more customers, sell more products, and get higher “customer satisfaction ratings”—no matter what. Time has become a commodity.

It can be overwhelming, but we slog through. Often we see only half of what’s in front of us, focused on that distant moment when we’ll have free time to do what we really want to do with our family and friends, and just maybe, we’ll find a sacred few seconds to give to ourselves. We rely on our tried and true habits which have gotten us this far, and we don’t register much unless it is severely out of the ordinary. Unless the “red alert” goes off. Like, if the driver next to us strays into our lane, or if we get an exorbitant bill for something we didn't order. Most of the time, we do our best to sail on through, as the days and the weeks and the months of our passage tick by. 

Most of the time, we tiptoe through our lives, hoping to make it safely to death.  

Why do we exist this way? Is this really the legacy we want to leave?

It does satisfy a lot of parameters. It’s secure, relatively risk-free, and with a little luck and a good head for saving, we can pay the mortgage and send our kids to good colleges. Maybe take a few trips along the way, and when inclined, party down and show off designer clothes and fashions. That way, we will fit in with the “in crowd.” That way, we will belong.

Besides, it’s all in keeping with what we’re told we ought to want, who we ought to be, what we ought to strive for, and where we ought to end up. And, of course, there is the other side: what we’ve been told we cannot have, what we should not want, and where we must not go. It’s all part of “survival mode.” We rarely think about the sources of our thoughts or our dreams, or whether they are even our own. We absolutely do not evaluate if they are serving us.

But so much of our beliefs have been hijacked. First, by our families who raised us, who inadvertently (or intentionally) instilled in us the blueprint for what was, in their opinion, a “worthy” life. They meant well.

Our minds have also been hijacked by the press and social media, for less noble reasons. They capitalize on our need to agree with the factions they tempt us with, hoping we will spend our money on their website. And the powers in government are also manipulating us for their own political agenda, and we barely notice any of it. 

The amount of information pouring onto the internet is so overwhelming, we just don’t have time to sort through it all—if we even acknowledge it. We often adopt our friends’ opinions, or our family’s, or our organizations’ because it’s just too cumbersome to evaluate each headline, each advertisement, every accepted “norm” about what a successful life looks like. We live in a world that provokes a severe attention deficit disorder. A world of unremitting distractions and information overload.

Add to that the lies that are reported as truth. Few people remember the Fairness Doctrine anymore. It was introduced in 1949 by the United States Federal Communications Commission, and required that in order for a journalist to hold a broadcast license, they were obligated to present “controversial issues of public importance in a manner that fairly reflected the differing viewpoints.” (Say, what?) When I was a kid, newspapers and television stations always presented both sides of a story, lending the news a sort of “Just the facts ma’am” character—for those of you who remember Dragnet. 

In 1985, it was decided that this doctrine had a “chilling effect” on freedom of speech, and by 1987, it had been repealed completely. We are living with the results. Depending on which station you listen to or what rag you read, you will get news that presents a story in line with that organization’s opinion. It is no longer news. Half of the articles are written in the first person, and do not even try to disguise their prejudicial nature. 

Even your Twitter or Facebook accounts will selectively serve up to you info bites that it has determined you will be most receptive to. And let’s not even talk about Google. Almost all our information is given to us according to an algorithm based on personal data that has been gathered about each one of us when we weren’t looking.

No, I’m not advocating we cower under fear of conspiracy theories. I am proposing that we take back our intellectual power and systematically unpack the material we are fed so we can decide for ourselves what resonates with us versus what is merely being accepted by habit or social standards. And I am suggesting we do this with the plans we make, the products we buy, and the platforms we support. Do we have the time or energy to do that while juggling everything else in our crazy, busy lives? Probably not. But for the things we have not fully evaluated, we can reserve judgment. 

Why is this important? Getting us in the habit of questioning where our values are coming from and in what direction we are headed, invites us to search within to see if we really agree with these principles, and then we can ponder why we are on the path we are on. Only then can we make conscious changes where appropriate. 

What a project. Who has time? Does it matter that much?

Yes, it matters. Our life is like a movie. The movie of us. We each get one movie; no more, no less. We should each be the star of our own movie. Yet, too often, we end up playing a supporting role.

That is not to say we should be conceited, arrogant, or obnoxious about our stardom. But we should each be playing the main character in our own flick. Otherwise we risk looking back with regrets. Time cannot be replaced. 

I suggest you spend just a few moments every day to stop and breathe the air. If you get to the shore, stand quietly on the sand and appreciate the roar of the ocean, the vastness of the sea. In your own neighborhood, gaze at a flower newly bloomed. A chipmunk running in the garden. Genuinely connect with your dog when you’re out walking, and ignore your cell phone for a few minutes. This is where to find the answers to the important questions.

These important questions are not which high-priced wedding venue to choose or which top-ranked college is the best choice for our kids. The important questions are: what legacy are we leaving and what will our eulogy will reflect. That should be a conscious decision.

So, what do we think about as we journey through our lives? Or… do we think at all? Are we stuck on an autopilot that has been programmed by some impersonal process that does not care at all about us as individuals? 

In Stranger in a Strange Land, Robert Heinlein said “In the absence of clearly defined goals we become strangely loyal to performing daily trivia, until we ultimately become enslaved by it.” Have we examined and defined our goals? Or are we slaves to the habits our society has implanted in us to feed the financial needs of faceless entities?

What do you want from your life?

--Debra Blaine, MD, author of Undue Influences: a frighteningly plausible political thriller.

No, it’s not COVID. It’s not even opiate abuse. Or depression. It is not something we even consider to be a disease per se. But it is pervasive and destructive, and it leaves even the most successful people ultimately empty.

It is the addiction to more. More power, more wealth, more things… just for the sake of having more. You know this monster. It is commonly called “greed”. 

Greed has evolved from something we think of as an individual’s flaw to encompass all of global commerce. It is insidiously destroying humanity.

There are precious few solo doctor practices, they are now almost all corporate entities. And each one strives to become larger and larger, swallowing up multispecialty groups and laboratories and radiology services. They are driven to cover larger regions, cross state lines, and prove themselves the biggest. Presumably, so they can negotiate higher compensations, but what is the ceiling on reimbursement? As they expand, they say it is to “serve the needs of more patients”. This advertisement is designed to suck people in, by pretending to old-style values like compassion and excellence and promising convenience and customer satisfaction. But the marketing is strictly calculated to increase revenue, even if it means demanding unnecessary testing, seeing unprecedented volume, and squeezing the life force out of the healthcare staff by demanding they please the consumers, once known as patients. 

This is not unique to medicine, by any means, but is especially distasteful when dealing in the currency of human life. We see this in book retailers, as Amazon, Barnes & Noble, and other huge distributors crowd out local bookstores. We see it in privately-owned pharmacies who are drowning in the shadows of CVS and Walgreen’s. Bodegas disappear in the wake of huge and growing supermarkets. The pandemic has only accentuated and accelerated a process that was set in motion years before. 

Have you ever noticed how many advertisements have nothing to do with the product they are selling? They entice you in with sweet, little animals and babies and family scenes while they create an auditory association with whatever they are marketing. Love, compassion, integrity have all become vehicles by which corporate moguls get the average person to buy something. Anything. Our values are being tainted, transmuted, defiled.

The question I’d like to ask the CEOs, the really important question, that needs a really honest answer is: How much is enough? 

How much do you really have to earn in a year for you to feel like your life is a success? That your existence is justified? After you’ve paid for the finest schools for your kids, have several houses on a couple of different continents (or islands), have your own private jet, swimming pools galore… How much more do you need? A trip into space? Do you not realize that your employees will work harder for you and be more productive if you treat them well? Give them a bonus? A gold watch? (Remember those days?) I may sound like a lone wolf howling in the wilderness, but the wilderness is vast and there a number of wolves baying with the same voice. You just can’t hear us. You are not really in this world anymore. You are not part of the collective consciousness. 

How often do our patients “yes” us to death and then ignore our advice? They seem to understand us in the office, they may even be able to repeat back to us every word we’ve said, if asked, so what happens when they go home? Why would a diabetic eat cake every night and a cardiac patient continue to smoke? They don’t appear to have a death wish, so what is happening?
One day in the 1950’s, when my Baba was forty-eight years old, her doctor told her she must quit smoking immediately, or she would lose her legs. She had been smoking since she was sixteen, but she left his office that day and never smoked another cigarette again. Just like that. She carried that noxious, half-empty pack of Salem cigarettes in her purse for nearly twenty years—just in case. But she never touched them. And her legs served her well until her death in 1996, at the age of 87.
Why doesn’t that happen anymore? I can’t count how many patients I’ve told not to smoke while on birth control pills. I tell them if they can’t stop smoking, then stop taking the hormones. I have even given them real life examples: the twenty-eight year old with a clot in her leg, and the thirty-three year old with bilateral pulmonary emboli—that she waited two weeks for hospital admission because she wasn’t insured yet, and nearly died. Or the twenty-two year old with a cerebral embolus who will never walk again. I’ve even invited young women to spend five minutes in our wheelchair and imagine they will never get out of it.
I tell them, and they say “I know.”
But they don’t know.
They have processed the intellectual information in their brains, but they have not let it in. It does not touch them where their souls live. They have not allowed it to be a tangible truth. It is simply more data amid an overabundance of other data, and it does not penetrate their hearts. Unless they have lived through real adversity, bad outcomes are not real. And sometimes, not even then.
We exist on such a superficial plane in most of our experience. Barraged by a quanta of instantaneous bits of information: masses of text messages, news clips, emails, and thirty-second encounters with family, coworkers, and friends. It is next to impossible to have an authentic encounter. By and large, we relate to each other as objects, not as individuals.
And then there is the underlying assumption that medicine can fix anything. Humans can fix anything, and life will always go on. Nothing serious will ever really happen to “me”. Even today, with all the calls to action, petitions to sign, marches to support, climate issues to protest, even with all our “heart-felt” sympathy and intellectual understanding of events, it’s so hard to believe, deep inside, that anything irreparable will ever happen.
Maybe that’s where my Baba had it different. She lived through not one, but two World Wars. She watched her family and her people exterminated. And she came to this country with nothing at all.
So, when her doctor told her something bad was going to happen to her, she believed him. Because she knew, in her heart, that bad things do happen. That people die. That life breaks down, if you’re not careful—and sometimes, even if you are. She considered herself very fortunate to have gotten the warning in time to save her legs. Even though she carried those smelly old cigarettes with her for decades—just in case.
Our challenge as physicians to reach our patients only worsens every year. With EMRs, “productivity” requirements, and as we are forced to treat our patients like consumers instead of patients—instead of humans. Borrowing from the philosopher Martin Buber, especially in medicine, this “I-It” relationship is demoralizing for both sides. We can’t touch our patients anymore; we can’t make them hear us. How can they, when we only have eight minutes with them, and we spend most of that time staring at a tablet? Even with a scribe, our attention is divided and we cannot be fully present to the human in our office. It’s no wonder they are not fully present to us.
The problem did not start with EMRs and productivity measures. Our entire society, in its unflinching progression toward appearance over substance, quantity over quality, and its relentless march toward inauthenticity, finds it perfectly acceptable to relate only to the surface of each other. So it is no surprise that it inspires the same in medicine, and ultimately in our treatment of and by our patients.
In a culture which proceeds at breakneck speed, faster than the heart can process, a whole dimension of reality ceases to register in our beings. Most of life becomes relegated to our thoughts, and to our current intellectual construct, until humans come to live almost entirely in our minds. We have effectively distracted ourselves from the “larger, intangible reality”. It leaves in its wake a hole, crying out to be filled. A perfect breeding ground for depression, frustration, dissatisfaction, and emptiness.
And indeed, we have more patients on psych meds and more physicians depressed and burned out. As the sense of meaningfulness in our lives decreases, the hunger to fill ourselves with excesses, like nicotine, alcohol, and drugs increases, and we are not open to hearing they are bad for our health. Patients are not listening to their doctors. We, as a society, are not listening to each other. We are not even listening to ourselves.
There is an old proverb about a Western traveler on safari in Africa. He pushed his guides to move more quickly to their destination, but after a few days, suddenly, the Africans sat down and would go no further. The impatient Westerner asked “why have we stopped?”
“We have been traveling a very long way,” the guides replied. “We must wait for our souls to catch up.”

Back in the day, being a doctor included being a coach. Getting to know our patients, discussing their desires, their strengths and weakness, and how best to approach keeping them healthy within their unique life circumstances. Back in the day, we docs could spend an extra ten minutes schmoozing and doctors came to understand their patients needs and special circumstances.

In this age of commercialized medicine, there is no time to actually get to know our patients-- who have now become our "customers"-- and it is rare that in the 15 minutes or less allotted to the doctor/patient encounter, that there is time for more than a cursory history and physical regarding one focused problem, making a diagnosis (assuming it is an easily diagnosable problem), prescribing medication or other instructions, and charting it all in the electronic medical record, or EMR. Half of that 15 minutes may be spent in the EMR.

After 30 years, I had to give it up. Life is too short to be unhappy so much of the time. To dread getting up in the morning to go to work, to spend my days being stressed, exhausted, and feeling like a hamster on a wheel. It didn't matter that I was earning more money than I ever thought I would, or that I have a wealth of experience that a few of my colleagues would occasionally ask me to share, or that rarely, I could feel like I made a difference for someone in need. There seems little time or place for that in the "real"world of medicine now.

After I wrote my book, CODE BLUE: The Other End of the Stethoscope, I could not pretend I didn't know how miserable I was. Being true to myself has always been a priority, and to continue to live a life of such darkness was inauthentic for me. And, I refuse to wake up in ten or twenty years and say: why didn't I do something different? 

So now I am a coach. A coach does NOT diagnose, treat, refer, or make medical recommendations. I leave my medicine hat off and instead, I get to spend time talking to clients, getting to know them, and helping them discover their inner strengths. I can help them devise their own strategies, cheer them on, and together we can celebrate their victories, big and small. I can do those human things I used to really enjoy about being a doctor. And, no more prescriptions (which may or may not be covered), no more insurance authorizations (which may or may not be forthcoming), and no more hoping I haven't missed something in a diagnosis because maybe I didn't get to hear the whole story in the three minute history of a patient's illness. Now it's just the human side.

Because often, we know the answers to the important questions in our lives, but we shy away from facing the questions themselves. Because change is scary. But as the plaque on my kitchen wall says:

Life is change
Growth is optional
Choose wisely

Medicine should be an essential human service in a country as wealthy as the United States of America. Instead, it has become a profit-driven industry, its status just another vehicle for entrepreneurs to scale to Fortune 500 ranks. As if saving lives was on par with marketing a new microchip or a “must-have” fashion wardrobe. There are some functions of society that should not be treated with the standard business model. Medicine should be the sentinel that guards the sanctity of human life, not the revenue-generating commodity it has become.
Last year, a 64 year old patient came to my urgent care office for removal of stitches in her chin. She had been knocked over by a bicycle on her vacation in Paris the week before. She told me she was taken to a Parisian hospital and had x-rays of her neck and shoulder, a CT scan of her head, and sutures placed in her chin. I asked her if her health insurance had covered her overseas and she said the Parisians had treated her for free. It cost her more out-of-pocket to be seen in our urgent care center, in her native country, just for suture removal, than it did as a stranger in France to have a full evaluation of her head, neck, and shoulder, and repair of a facial laceration.
As more and more American medical practices are consumed by corporate amalgamates, and multibillion-dollar insurance companies determine what procedures are permitted, our humanity is being pushed ever further to the sidelines. If a French woman had the same bicycle mishap on Broadway in New York City, she would be lucky if her bill was less than $5000, as would our own uninsured citizens. Half the commercials on our airways are about how wonderful and caring various healthcare systems are, and the ever-present pharmaceutical ads portent sympathy to various diseases, but it all comes priced for profit.
What looks like concern and is passing for compassion is not that at all. When patients receive a customer satisfaction survey after their visit to their gastroenterologist, it appears to be kindhearted. But the survey’s purpose is not to determine if patients were treated with a high level of medical acumen, or if the front staff was friendly and courteous, and it is not focusing on the outcome of their medical problem. These things matter only as a measure of one thing: how likely is it that these patients will patronize that particular office and corporate system in the future.
Meanwhile, we doctors are being evaluated on our “productivity”, meaning how many patients we can see in an hour, or a day, and how much revenue we can bring in for the corporate owner of the practice. We are also evaluated on the scores from those customer satisfaction surveys. Sometimes this includes a patient’s displeasure at the coffee creamer selection in the waiting room. What we are not evaluated on is how many lives we save or how well we are adhering to evidence-based medicine. Or how much we care about our patients.
Because the surveys are so important now to physician salaries, bonuses, and promotions, we docs really feel the pressure when our patients desperately want an inappropriate antibiotic for a simple cold, or insist they want to try a new medication or procedure they heard about on television, even if, in their case, it could cause more harm than good. Often when we choose to practice good medicine, recalling our oath to “above all, do no harm”, we then wait for the proverbial hammer to fall, as we are called to task for not keeping someone “happy”. And it has become even more challenging to find the time to explain our reasoning to our patients because that extra time compromises our productivity.
When patients become customers, or consumers of healthcare, the priority of service changes from healing them to pleasing them. Physicians try hard to hold fast, but the financiers that own us are literally writing the script. One hopes, of course, that there will be a high degree of overlap between happiness and health, but in the short-term, the time when the patient is filling out their questionnaire, it is not always evident yet.
In the past, I was required to take risk management courses to minimize human error; now I am required to take compliance seminars, to maximize billing. Much of the extra time we are obligated to spend on the EMR, or electronic medical record, is simply to justify the highest possible charges or to satisfy insurance companies.
As a physician, I hope that my patients can see that the apparent benevolence this new industry shows them is only the same consideration any company shows to its potential consumers. Nothing more, and nothing less. As consumers, my patients can expect to be preyed upon by the media which is trying to entice them—the customers—to choose that which will fill the pockets of the corporate giants more quickly: the insurance companies, Big Pharma, and the multitude of new impersonal commercialized healthcare systems. Advertising is not at all necessarily related to what is best for the health and well-being of patients.
I am old enough to remember when doctors routinely treated a percentage of patients as charity. Now, I cannot give a nebulizer to a disabled, wheezing, mother of three who cannot afford it without clearing it first with the board of directors of some multibillion-dollar corporation; a monumental task. Greed is consuming every corner of our existence in Western culture, but some aspects should stay sacrosanct.
What would it look like to have a society whose highest value was not the accumulation of wealth, but the practice of kindness?

"Doctors are the worst patients," my surgeon said to me in our pre-op discussion.

"I know," I answered.

"No, you really are. You're going to have to follow directions. I want you to get on the carousel and take the ride. The problem with people like you is you try to do too much too fast. Listen to instructions, and follow the rules."

I recently had the experience of becoming a surgical patient. After years of hip pain from arthritis, and encouragement that turned into annoying nudging from family and friends, I had the total hip replacement. I knew I wouldn't handle this well. I don't do "disabled" well, and I absolutely don't do "patient" well.

I spoke with my insurance carrier prior to the surgery to make sure there would be no surprises. I was told that if I did it at an outpatient surgery center, there would be no out-of-pocket expenses and no deductibles. 

"What about physical therapy? The anesthesiologist? Nurse home visits?"

The well-mannered gentleman on the other end of the line put me on hold for each question and researched it. It took over an hour. "You have a very good insurance plan. There are no out-of-pocket expenses and no deductibles, as long as you do it in the out-patient center. All services rendered in your house are fully covered. There is no co-pay for physical therapy up to forty visits for the calendar year."

That sounded pretty good, so I scheduled it at the surgicenter. I went in at 6:30 am and was home by 4:00 pm. I even walked up the stairs to my bedroom that night, aided by the handrails, and had a walker at the foot of the stairs and another at the top of the landing. I felt like I was ninety years old.

By the next morning, all the anesthesia and local pain medicine had worn off, and I had the most excruciating pain I have ever experienced. I was forced to take the narcotics. The instructions said one to two tablets every four hours, so, of course, I started with a half tablet. Not riding the carousel. 

I had a hematoma on my butt that felt like I was sitting on a two inch metal pipe, which took two weeks to resolve. I had to force myself to eat food in the morning so I could take the aspirin intended to prevent a blood clot. The meds made me sick to my stomach. The pain made me sick to my stomach. I had to get up and walk the living room with the walker every hour, which made me sick to my stomach. I soon found I could eat mini cream cheese and cinnamon muffins for breakfast (and snacks) and I continued to lose weight. Well, I could see the weight loss, but the scale, if I could have stood on it, was sure to have said something different. The titanium and cobalt/nickel weighs a pound and a half more than my bone did (so said my surgeon) and the swelling from the procedure and the aspirin-induced bruising had to have added another pound or two at least.

I was cleared to drive at two weeks and two days, but I probably wasn't supposed to be vacuuming the house. And I could drive to the supermarket, but why did they have to put the bread all the way at the other end of the store? And who needs such HUGE stores, anyway? Only in America... But there I was, not riding the carousel.

The hospital system sent me updates on bills. The physical therapy and nurse visits had been entered as "hospice", which had not been approved, so it showed that I owed $2,700. There was a charge for lab work the day of the procedure, of which I have no recollection, for which it said I owed $342. The surgery center was charging me $300. The anesthesiologist's bill was still being processed, and was for the exact same amount as the surgeon's, another error. At least the surgeon's bill, while only a fraction of it was covered, showed that I owed nothing.

Three phone calls to the insurance company to rectify; another two hours. No, I am not a hospice patient (thank God!) I am a post-operative patient who fully expects to get well and walk again. And run. And play tennis. And... climb trees. Well, maybe not, I haven't done that since I was a kid, but my surgeon did say I would ultimately be able to rappel and rock climb again, although he thought I was nuts to have ever engaged in such activity.

After forever on the phone, everything was settled except the surgicenter's fee. I explained that I made my decision to come home after eight hours based on the conversation with the lovely gentleman. They said they would look into it.

Two hours before Kol Nidre service, the beginning of Yom Kippur, I received a call from the insurance company. They had pulled up the recording of the conversation and reviewed it. Yes, indeed, I had been told I would have no out-of-pocket expenses, and, lo and behold! They were going to honor that. The insurance company was going to pay the surgicenter. I owed nothing. I hope the poor guy didn't lose his job over that.

There are so many things I used to take for granted. Walking, for starts, standing, reaching into the dishwasher, being able to cross my legs, put on socks and shoes-- not to mention jeans. It was a month before I could wear anything other than sweats. My cat loved the little gadgets I had to use to put my pants on every morning, and she took it on as her job to assist me in my daily dressing. That is, after she rested assured she would continue to get fed and have her human around to care for her. She refused food for the first two days. If you've met my cat... you know how extreme that is.

Both in-home and out-patient PT, or physical therapy, is provided by trained individuals who surely take a course in torture tactics toward the end of their curriculum. They save it for last, in case the student chooses not to complete the program. Once they graduate, they are sworn to secrecy regarding this part of their training. It's actually part of the graduation ceremony. Really.

It's been six and a half weeks. I am having a hard time breaking the habit of eating mini cream cheese muffins, and it's finally it's starting to show. I still resemble Frankenstein when I walk, and while I no longer need the cane in the house, I do take it if I'm to walk more than a few feet outside. I actually clipped my toenails six days ago, which was a major cause for celebration, but there are so many things I still cannot do. I can squat down in the kitchen, but when I tried to reach to the back of the cabinet, my hip screamed at me, and it took several minutes to get back up. I can take a shower AND put on make-up AND blow-dry my hair without having to sit and rest for ten minutes between each activity. I can bend over and change my cat's water bowl all by myself.

But I am not nearly back to normal. I can't run, can't drive more than twenty minutes without pain, I can only walk a half mile before my groin is on fire. But I am so much better than I was. And I "know", even if I am so impatient with the process, that by all rights, I can expect to return to better than before activity. It's just taking it's sweet time.

I am tasting what it's like to be disabled. To see my loving cat in front of me and not be able to pick her up. To have an itch on my foot and not be able to scratch it. To need someone to take out the trash for me. To be unable to carry a plate of food it to the table. 

There is so much I take for granted every day. That I can breathe without wheezing, walk without getting short of breath, get up the stairs without a chair lift. I can drive my car-- that I have a car. That I am generally in excellent health, arthritis not withstanding. And that I have health insurance. 

Yes, it took me many hours on the phone, both before and after the surgery to get it all sorted out, but with the exception of the "hip chair" that my surgeon wanted me to get, everything was covered 100%. Of course, I pay a hefty price for that insurance. This year for the first time, they lost money on me instead of the other way around.

I did not ride the carousel, not entirely. That was the doctor part of me. My surgeon said no vitamin supplements, but I took milk thistle (since I live on Tylenol), and glucosamine; I knew there was no interference. He insisted I use the mupirocin ointment, not the cream, in my nose for five days before the surgery, but I knew it was to prevent MRSA and I knew the original studies were done with the cream, which I had in the house. I used the cream anyway. I had no choice but to be on my feet much more than I was supposed to. It's really hard to get a physician to follow all the rules.

I have a new empathy for patients with disabilities. I was always sympathetic, but it was a theoretical sympathy. Now I have lived the frustration and the pain, and I imagine how much worse it would be if it were not temporary. There is something to be said about "walking a mile in someone else's shoes". Especially if they cannot walk.

Unfortunately, I already knew, from working on the other end of the stethoscope, how ornery and difficult insurance companies are, but I found the frustration is magnified by pain and fatigue on the patient's side. 

I hope I never lose my gratitude for all the things I can do, all the things I do know, and all that I have, like caring people in my life, health insurance, and money in the bank. Of all these, my greatest gratitude is to my friends and family. Special thanks to all who helped me through these past weeks.

Medical school did not prepare me for 2019; it sure isn't what I expected it to be when I matriculated at Baylor College of Medicine some 36 years ago. I chose to go into medicine because I thought I could do some good, and I thought it would be rewarding to help sick and injured people get better, because, let’s face it, everyone wants to be a little bit of a hero, right? It all sounded very exciting, meaningful, and medicine was well respected. As a doctor I thought my life would mean something.

Well, that was in the old days, in 1983, and it was true for a while. I loved connecting with people and being able to make a difference in their lives. Their smiles and their confidence made me feel incredible and grateful, and I didn't mind the long, crazy hours without food or sleep. It was enough that I could help someone in need. 

But that was in the before-time. Before entrepreneurs decided that health care was a great way to make their next fortune. Before insurance companies dictated what procedures we could order and what medications we could prescribe. And definitely before medical practices and hospitals were gobbled up by corporate tycoons whose primary interest was profit, not people. We physicians signed on with these insurance companies and merged our practices to corporations because our operating costs were higher than our reimbursements if we did not. The independent medical practice is now a rare phenomenon, since it gets compensated only a fraction of the amount for the same service as the practice that belongs to a large collective. And these collective groups are rarely operated by physicians.

Today the relationship between physicians and patients is different. People don’t really respect doctors anymore. Doctors get blamed for everything. We are supposed to be able to make you better no matter what your problem is, and—no matter whether or not you take our advice on treatment. And we're supposed to be able to do it right now. There’s been this unspoken “truth” floating around out there, that no one should ever suffer and everyone should be curable. If not, someone must be to blame. It’s usually the doctor.

I don’t know where this came from, but it’s just not true. Some things we can only make less miserable. And some things, maybe, we shouldn’t fix. That’s the subject for another blog.

Doctors are reprimanded by their patients for not spending enough time with each one, but we are also taken to task for not documenting a hundred thousand bits of information in each patient’s chart. Only about a quarter of that information is necessary to understand the treatment of the patient: what we found, what we think, what we recommend. So we or the next physician can look at the chart and know how to proceed. The rest of it is strictly for billing purposes for your insurance company. I’ve heard numbers as high as 75% of a hospital intern’s time is spent on their tablet "documenting." That’s where the patient-contact time is going, and that is what we hate. Or should I say, the “customer”-contact time?

Yes, my friends. You are no longer "patients." You are "customers;" consumers of health care.

We are also required to make our “customers” happy, above all else; make sure our patients customers are pleased with our care, so they will give us good Press Ganey scores on customer satisfaction surveys. If we don’t get the good scores, we are obviously “bad doctors”. Poor scores could accumulate because we didn’t recommend a medicine advertised on TV that interferes with other conditions you may have, yet even after we have revealed this information, you still wanted to give it a try—because, well, the commercial looked so enticing. Or perhaps we explained that the potential risks of a procedure you read about actually outweigh the benefits to you in your given situation. But the scores could also mean you didn’t like the coffee creamer selection in the waiting room. If we get poor scores, we lose our standing, our bonuses, and your hospital may not get the appropriate Medicare compensation. Gotta keep everyone happy.

I didn’t go into medicine to make a lot of money. I figured I’d be comfortable, able to put my kid through school, live in a decent house in a nice neighborhood, and have a nice car. “Nice” for me is my 2010 Subaru Outback. I like it just fine. It has over 90,000 miles on it, and I’ve been happy with it for every single one of those miles. 

So, this customer thing. I always thought that patients were sick, suffering, vulnerable humans, maybe even a little bit scared. They’d cut themselves, maybe broken a bone, had a fever they could not explain, or just felt lousy. Maybe their appendix ruptured or they were having a heart attack. They needed help. That’s where we physicians would come in, to fix them up, give them medicines if indicated, and reassure them. And their families. I never dreamed that they would show up in my office angry, demanding inappropriate treatment because the media told them it would cure them instantly, and then become incensed that I had taken care of someone sicker than they were first. 

Someone walked into my office one day wanting to be screened for strep throat because they were with a friend who had it. If they weren’t even sick yet, why were they so angry that I took care of the patient who was having an anaphylactic reaction to the nuts in her banana muffin? Or the person with a new onset cardiac dysrhythmia, who was terrified, having trouble breathing, and had a fever of 102? How could the not-yet strep-infected patient say to me that the cardiac patient should have gone to the hospital instead of wasting her time because I didn't pause for a few minutes to order a rapid strep test while I attended the cardiac patient? Medical school did not prepare me for this.

When we treat patients like customers, is it any surprise that they behave like convenience is a cardinal index of quality?

This customer thing. A patient came in with classic influenza, in the height of flu season. His flu test was positive for Influenza A. He insisted he knew his body better than anyone, and that the flu test was wrong. He has never had the flu and he will never get the flu, he said. He demanded high dose clindamycin, which is a powerful antibiotic, and prednisone, which is an immune suppressant. I explained to him that antibiotics do not work against the flu, since it is a virus and not a bacteria, and that the steroid in this case could make him worse. He said to me “I realize that is your opinion, but I did not come here for your opinion, I came for my medicine. Send it my pharmacy now.” (Or I will give you a zero Press Ganey score). 

Yeah, this customer thing. If we do the right thing, we get slammed. If we do the wrong thing (not that we would), we get sued. Our malpractice carriers used to teach us to empathize and document everything. Our corporate bosses tell us to cut the time we spend on each patient so we can see more patients per hour. We no longer get risk management courses to help us minimize human error; we get compliance seminars, so we can bill for maximum revenue. 

This customer thing is about money, just as the word suggests. It is not about your health. When your doctor’s office sends you a survey to fill out, it is not about how well your malady was treated. And don’t be fooled, it is not even about how friendly the front desk staff was to you. It is about whether you can be counted on to patronize their institution again. Yes, patronize. Dear patients, you are no longer sick, suffering, vulnerable, possibly scared human beings. You have become consumers of health care. 

The media preys on consumers, you know; entices them to buy this drug or go to that corporate hospital system. You’ll be in and out in a half hour, they say about their urgent care clinics. Our hospital is the most up-to-date—except they may be referring to the interior décor. Take this pill and you’ll be well (if you don’t suffer any serious side effects from the enormous list, one of which is nearly always death). No, the surveys come from the same place the Apple TV surveys come from, or Verizon Wireless surveys, or your Subaru dealer.
This is the Voice of Greed, the voice which has crept into every venue of our lives from the water we drink to the “must-have” clothes we buy, to the food we eat. Of course, it is in health care now, too. No aspect of life is exempt.

This is to let you know that your doctors are as outraged as you are, and we miss our time with you.

Please note: Blog is never medical advice.