Wednesday, July 1, 2009

Pondering the Medical System

It might have been the wart. Or maybe it was the conversation with a friend reviewing this adventure and the current status of all my bits and pieces. Either way, it’s dawning on me just how much my expectations of physicians and the health care system have evolved in recent years. It feels like this realization might reflect bigger issues we must all grapple with as we move into the future.

Some months back, maybe three or four, something started growing on the side of one of my fingers, by the nail. In the scheme of things, pretty small potatoes, but still irritating. It was tough like cartilage, the same described consistency as the brain tumor. My first impulse was to cut it off with nail clippers, which I did regularly for quite some time; it always grew back. After a while, as it persisted and became more annoying, I started showing it to people. Michael diagnosed it as a wart.

Here’s a digression on warts. The only one I’ve ever had was on my elbow when I was in grade and high school. Eventually, in college, it went away. Michael, on the other hand, knows a lot about warts, as he says his (beautiful!) hands were covered with them while he was in high school. Given that both he and I had bad teeth and bad complexions in that stage of life, it provides important insight into his character that he was also coping with hands covered with warts. (Is having cosmetic flaws in adolescence a sorting factor for guy-geeks?) They also went away on their own, eventually, and he certainly hasn’t had any in the time I’ve known him, which is going on 35 years. In any event, he knows a thing or two about warts, so when he identified the thing as likely a wart, we acted on that hypothesis and started treating it. We bought and used an over-the-counter wart freezing remedy (his preferred method for removal). Yesterday, the last bit fell off, three weeks after the treatment. My finger looks relatively normal and in a few days, I doubt there will be any sign of its existence.

Why bring any of this up? It never once occurred to me to show this growth on my finger to any physician, or seek medical advice for it, though I’ve been seeing some pretty regularly through its existence. Maybe that’s not a big deal, as small as the thing was, with as few consequences for daily life.

Maybe it simply illustrates that we have a new metric for what’s a serious medical problem requiring medical advice/consultation. And maybe it also reveals something about the changes in the practice of medicine and is worth considering in that light, not for itself.

More backstory here: we have a family practitioner who has been our doctor for decades. He delivered Kearney (we think she was the last baby he delivered before his practice dropped obstetrical insurance for many of its family practitioners), and has seen all of us throughout. We feel personally connected to him and have watched his family grow up through pictures in his office and through knowing them in the community. He recognizes us out in public by face and name. He was the one who sent me for the MRI that revealed the tumor, the one who delivered the diagnosis, and the one who referred me to the neurosurgeon who did the surgery.

We never heard from him again. Not at any point during my hospitalization, not at any point in my recovery, not when I copied him on the letter we wrote the clinic and hospital leadership about our counting exercise with suggestions and observations about the experience. Not a call, not a card, not a word. Given how connected we have felt to him for a very long time, we were surprised. That might be the wrong word, actually, as we think about it: in recent years, office visits have gotten shorter and shorter and more rushed, as wait times for appointments has lengthened, both in making them and in being seen upon arrival. He no longer seems to function as a true primary care physician, and certainly hasn’t done anything to our coordinate overall care, at least not in any way that’s been visible to us. We’ve talked about this, and it’s likely he knows how my surgery has turned out, as he’s surely got access to all my records. But does he care, or have time to care, the way local practices are structured any more? He dropped hospital rounds when his office was moved to a satellite facility some miles away from the clinic connected to the hospital, coinciding with the advent of hospitalizes locally. Thus, while before that innovation he was around all three times I was in the hospital (miscarriage and babies arriving), and his office called and inquired after me after drive-through surgery (gall bladder removal), he was non-existent through the most serous medical problem anyone in our family has faced.

In consequence, we didn’t even think about consulting him before going to see the doctor recommended by my med school colleague. The new doctor is the one who spent time and thought to figure out the cortisol deficiency and a treatment plan. He’s the one who seemed to look at me as a complete person, not just a collection of parts various specialists seemed to see. It never even occurred to me that our long term friend and doctor would care, have time to think about it, or see it as his role.

That’s sad.

It’s sad for us, and likely sad for him as well. Our perception is that he took great satisfaction from the relationships he formed over the years, including with us, and that he’s become more and more stressed by the changes in his practice.

If this is a microcosm, as we suspect it is, for what’s going on across the country, it is of concern on many levels. It illuminates the move to concierge practices where people pay extra to get some actual personal attention. It sheds light on the loss of physicians due to lower job satisfaction and the concerning trend of medical students choosing specialities over primary care practices. The value of relationships in good outcomes is well documented in many fields: as with earlier musings about their value in airplane cockpits, the attenuation of personal connections and relationships in medicine seems like a backwards step. The coming crunch in health care--needed and important--surely will accelerate this trend, at least at first. Is there any design that would help? Does it even matter, in the big picture? I’d like to think so.

That’s a lot to write about a wart. It’s past time to get back to the day’s work. Michael is intent on replacing a window and I’m working on designing the new class and trying to structure my writing. It’s a gift to be able to work sitting on the terrace under the bougainvillea. May you find some beauty in your life today to lighten your load.

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