Wednesday, April 02, 2008

Healthcare proxy

By Carl

It seems to me that, when the American healthcare system works, there's not much room for improvement. It's when it doesn't work, or is non-existent, that things get cocked up.

I'll relate my story from yesterday as anecdotal evidence of how it can and should work:

As many of you know by now, I was diagnosed with a basal cell carcinoma on my nostril three months ago. Two months ago, I had it excised, and needed same-day plastic surgery to close the wound. During that procedure, another nest of suspicious cells was found, excised and biopsied.

Yesterday, I had the surgery to close everything up, since it was determined that I no longer had malignant cells in this region.

I arrived for surgery at 1PM at a New York City Catholic hospital, on an ambulatory basis. Surgery was scheduled for 2PM.

I filled out a couple of forms: a consent to allow the insurance company to pay the hospital, and a patient's bill of rights acknowledgement. I was then ushered to the pre-op area, where I might change into a gown and have my clothes secured. In that area, I was interviewed by two nurses, an anesthesiologist, and the surgeon. Two orderlies took my temperature. The area of concern was examined, and the surgeon initialed my nostril.

In the course of the interview with the first nurse, along with questions about what medications I might be on and what previous surgeries I had, the fact that I had eaten 7 hours ahead of surgery instead of eight was revealed (I misread the directions. My bad!)

So we waited an hour. No problem. At the appointed time, I got my IV unit inserted, and walked into surgery with the anesthesiologist. I laid down on the operating table, and was conscious for quite a while after that, which is a good thing, since the IV unit has jostled slightly out of position, wetting the linens I was on.

All three nurses walked in and interviewed me separately: what are you here for? Specifically where is the incision to be made? Who is your surgeon? Is this your name on the name tag?

The surgeon came in, and we spoke briefly, again, about my options for being out cold v. being groggy. The "late" meal was not a crisis, it turns out, but to be on the safe side, we agreed to put me out, but if I started to come to, it would be OK.

Precisely what happened.

I should explain. I'm not big into medication. I don't like to even take aspirin if I can avoid it. When I've had surgery in the past (not recently, admittedly), I've asked for local and pain meds.

This time, I wanted to be out given the proximity of a sharp object to my eye. I've always had problems with things flying at me. That's probably why I was such a good goaltender: I didn't want to get hurt!

By the time I woke up, however, the knifey part was done, and the doctor was into stitching. Needles and my eyes don't get along, but I was too groggy to really give a crap. But it was fun to listen to the surgical team talk about how I was awake and to even get off a one liner or two ("Hey, doc? Did I get Heath Ledger's nose like I asked?")

The other advantage to this strategy was I was practically able to get up and walk when we left the operatory. I was released on schedule, pretty much, despite being in surgery nearly ninety minutes later than planned.

So what went right here?

Well, for one thing, the rules were followed. There was great communication all around, no one fumbled for the next question. Information was passed on efficiently, and I was given as much choice as possible in my treatment options. The surgeon had already consulted with me about two possible options for closure, and I picked one, which we went over in the hospital. He said that one option would require less work to do, but might leave my nose
slightly misshapen (as in you couldn't tell unless you looked closely), and one would require a graft of both skin and cartilage, which is what we ultimately decided on. Good thing, too, because the wound turned out to be a bit more complex than we thought.

The staff worked quickly and as a team. No one was asking questions they didn't need to ask and everyone understood his or her role. I confess that, after the last encounter, I was very scared going in, but by the time I was in the operatory, I felt very at ease, despite my own error.

What went wrong here, however?

Ahhhh, and there's the rub: if you re-read all this carefully, so much of what transpired, while for my benefit, was not done out of concern for my well-being, necessarily. I'm not saying that this doctor, or these nurses and orderlies, or any doctor, nurse, or orderly, does not have the best interests of the patient first and foremost in his or her heart.

What I am saying is that a lot of this communication is generated for one reason and one reason only: to stem lawsuits.

By putting the onus on me for decisions, by making sure that I understand each and every choice and decision that has to be made, but more important, by confirming that I am fully aware and vested in each step of the operation, the hospital is mitigating their risk.

This was brought home to me today, when the hospital called for a follow-up: are you in pain? Are you satisfied with the results? Did you receive post-operative counseling?

As the healthcare system in America becomes more and more profit-driven, as hospitals and HMOs have to answer first and foremost to their stockholders as opposed to the public weal, we are all going to be forced to deal with the downsizing of authority to the patient, who in many cases may be the least informed party.

Think about it: I had a simple operation, and yet underwent grueling questioning of my understanding of what was to happen. I was fortunate in that my surgeon and his team were all communicative and helpful, and more important, understandable.

Imagine if I hadn't understood what was to take place. Imagine if my procedure was complex and risky. Imagine if I was of even average or below average intelligence.

Such enormous risk to place on the shoulders of a civilian, as opposed to leaving it to the expert. And if you've spent anytime in doctor's offices lately, this trend continues in there.

Exhibit A: The original lesion itself, which I've had for nearly thirty years now. In that time, literally hundreds of doctors have seen it, yet it took an urgent care doctor in a clinic to mention "You oughta have that looked at", nevermind how many doctors have stuck a probe up my nose or looked directly in my eye.

If you have a question about your health, even while you're standing there in your underwear, it's next to impossible to get taken seriously in an awful lot of doctor's offices, a circumstance I suffered two years ago when I had chest pains and trouble breathing, until I basically called a doctor and said "Look, if you can't help me with this stuff, I'm going into a hospital."

Which clearly triggered his self-preservation mechanism. He might have imagined that I was a bit upset over his inability to listen to my complaints.

I'm glad this ordeal is over because through it, I gained a new-found respect for the medical professions and confidence that not everytime I see a doctor, I get sicker.

But let me say this: It shouldn't have taken this long for just one doctor to prove me wrong

(crossposted to
Simply Left Behind)

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