Grouse if I Want To

So, I've been sick again; same old stuff: acute and overwhelming abdominal pain with no apparent cause. This latest bout struck about 24 hours after completing a harrowing 1-2 punch of endoscopy and colonoscopy thought prudent after the last bout. (n.b.: if anyone ever offers you a colonoscopy, run. I have no idea if the test is bad because I was unconscious but the "prep" is miserable).

So yeah, about 24 hours later, finally feeling better from the insults of the two previous days, I had this horrible onset of pain in the center of my upper abdomen---go figure. Right to the ER, we went because I could NOT deal. Of course everyone always wants to think horses not zebras so after they'd ruled out the possibility that something had gone terribly awry with my diagnostics the previous day, everyone was at a loss. Hospital admission.

I wasn't going to say anything about this episode or the current debate about healthcare reform in our nation. But the whole thing was too much demonstration of exactly what the problem is with the system and how badly we need a solution, any solution so long as its pointed in the right direction. We can all believe we'll have the opportunity to revisit the issue in Administrations to come ad nauseum.

First and foremost, if you are among those who don't believe change is needed; if you believe that the current way of practicing medicine and providing for the wellness of our citizens benefits any entity more than it does insurance companies or pharmaceutical companies, you are obviously high, insane or otherwise beyond cogent discussion. Just stop reading now. Absolutely no one makes money in medicine or health unless they are aligned with those two enterprises.

For now I'll focus on my most recent experience and how it plays out regarding physicicans and their patients in the current "system". For over 20 years now, physician payments for patient care in participating insurance plans have been capitated---that is, the doctor receives a flat fee for an office visit of a certain class: an initial complaint, a follow up, a physical...but just a handful of very broad categories of visits, regardless of what actually happens in the encounter. This is what keeps your physician moving at the speed of light and also what drives some recent Harvard findings that the average amount of time a physician allows a patient to describe their reason for presentation is 20 about seconds, sometimes as little as 3 seconds. Three seconds!

Capitation not only plays out in office settings; it also acts in institutions. In fact, physicians are paid such low rates for hospital visits that most will not see their patients in hospital unless the case is surgical and the doctor is a surgeon. This has given rise the new "specialty" of hospitalist: a physician who does nothing other than assume responsibility for patients upon admission, order their tests and drugs, directs consults. These hospitalists, no surprise, are more frequently likely to have successful careers when their clinical judgement and actions just happen to closely match the objectives and standards of the hospital they serve.

Imagine! Hard to believe, I know. Still--true. So Monday I had a look-see from mouth to the outside and there were a few minor findings, a few snips taken here and there for biopsies but the enterologist, the guy I had run to after my LAST 5-day hospitalization for abdominal pain says, "good news! Looks like there's no problem!". Huh. That wasn't how I was feeling, really. I was really feeling more like "WTF did you just say?" because you know, I've been sick like hell for almost a year now; I had surgery on Christmas and its quite likely my gallbladder was yanked out needlessly because no one is slowing down long enough to take a long, good look at a situation. (just as a side note: when the hospitalist called the enterologist who did my endo/colonoscopy he declined to come to the hospital or even speak directly to me. I'm supposed to follow up as scheduled. Nice.)

I was also feeling lost---what now? Sure, I'll have the follow up and maybe if I'm lucky, the lab studies will reveal something microscopic to account for all this: cancer, micro-ulcerative colitis; something---well, then I'd kinda' be the lucky girl wouldn't I? Because then the enterologist would know what to do. For now, assuming the follow up is also negative I don't have a single idea of what to do besides to wait for the next episode of my stomach turning to molten lead and hope the hospitalist I draw has some imagination and is a little bit of a cowboy.

For this round, the hospitalist didn't find anything remarkable when he repeated all of the same tests that my insurance company has paid for on six occasions this year so as soon as he felt my pain was under control and I was stable and I'd stayed the maximum number of days the hospital can bill for that particular diagnostic code---its out on the streets, baby. See ya next time?

Have any of you noticed that I haven't mentioned my own internist? Nope. That guy who has been my general physician for five years---hasn't once even poked his head in a room to give me a big thumbs up or mention it in a subsequent office visit. He's not going to manage this for me...its the hospital's problem---that's where I presented, they're the ones getting the bigger dollars---he'd only get follow up money. Its not worth it for him.

So all you guys sitting around mouthing off about how lucky we are to have such great healthcare in this country---why not try getting sick with something just a bit vague or mysterious. Let me know how that goes for you. Because you won't have a skilled, trained physician to lead you through the maze of specialists and their tests with "great" results. You'll be left to piece it together yourself. And our collective costs for care will continue to escalate because of misdirected efforts, redundant data collection...

But I'm home now. My abdomen only hurts a little and I've only been nauseous three or four times today. Haven't thrown up at all.

More later. But as a little teaser on my next commentary: please don't steal those pens from your doctors' offices with drug names on them. It only makes the drug companies hand out more and I'll bet you can guess how those costs are covered.... I try my best to avoid even using them in the doctors' offices. They love me!