All the dirty secrets about American medicine you should know before you die - San Francisco Chronicle

John Hayward

Dec. 31, 2022

Physicians don’t beryllium to a concealed society, but they bash comprise a quirky sect whose past rituals deduce from the principles of Hippocrates. They look humiliation, injury, fatigue and the menace of contagious illness.

The members of a tight, well-lubricated aesculapian squad are a batch similar a submarine crew. Confined for agelong moving hours successful spotless, white, blindingly illuminated spaces ruled by despotic leaders, they are contemptuous of outsiders and loyal to nary but each other.

A bully woody has changed since my aesculapian grooming astatine USC successful the 1980s, doing 2 24-hour shifts a week followed by 2 12-hour days. I slept successful sweaty bunkbeds successful the attic of  the Los Angeles County General Hospital successful a stuffy eight-bed room, humming with fans and generators successful the dark.

I wanted it each backmost then: the emergencies, the gunshot wounds, the bosom attacks, the flesh-eating bacteria and the camaraderie that flourished wrong rigid bid and nerve-shattering chaos. I climbed the concatenation of bid from lowly aesculapian pupil to attending doc — doing immoderate it took until I ran my ain clinic, my ain signifier and had my ain unit of staff.

I’ve been a doc successful San Francisco for much than 20 years and, successful the decades earlier that, was a aesculapian student, an intern, a resident, a postdoctoral chap and a professor. I came into the concern erstwhile my professors inactive smoked connected the backmost patio of the infirmary and wore aftershave and abdominous ties.

Things are precise antithetic now, and not successful ways that are instantly obvious. 

Say it’s a quiescent Friday nighttime and you’ve conscionable checked into the caller urgent attraction installation that opened successful your vicinity oregon the caller exigency country astatine the infirmary that opened downtown, and you’re looking to get seen for fatigue oregon a acold oregon sinusitis. The installation is brand-new and sparkling and looks high-tech, you think. Why not spell for it?

If you similar a $20,000 bill, beryllium my guest.

Here’s however things usually enactment — the ER, urgent attraction and the session marque their wealth by squeezing your security beyond its maximum. Every Band-Aid and each stitch has a price. If you person a section anesthetic, the needle has a price, the syringe has a price, the liquid wrong has a terms and the idiosyncratic injecting it does, too. The doctors delegate you an ICD 10 code, which represents your diagnosis for billing purposes. For example, C50.411 is bosom cancer, and a CPT codification that determines the maximum reimbursement from your insurance. They mightiness spot you for six minutes and past they constitute a computer-generated enactment wherever they click a mates of boxes and complaint you for a broad sojourn — 1 that connected insubstantial is listed arsenic having been face-to-face with you for 25 minutes. They click a mates of much boxes and accidental that they talked to you astir your beforehand attraction planning, your surrogate decision-maker, your vaccinations and your allergies, your wellness maintenance, whether oregon not you’re being threatened oregon abused and that they gave you wellness tips similar eating much fiber, smoking cessation and harmless enactment practices.  

All you tin retrieve is the doc telling you his sanction and taking a speedy glimpse astatine the breached ankle oregon stuffed chemoreceptor oregon sore pharynx oregon chopped digit that brought you in. The billing and coding bureau compiles a measure and submits it to your security that includes tract fees, gathering fees, signifier fees, exigency fees and entree fees. You motion pages upon pages of forms, 1 of which has a condemnation saying that you hold to wage the full measure adjacent though you don’t cognize what it is yet. If you get admitted, the infirmary besides submits a measure for the room, the bed, the insubstantial cupful the Tylenol comes in, the gown you wear, the humor unit cuff connected your arm, the intravenous needle, the IV tube, the IV bag, the IV pole, the nursing care, the pharmacy attraction and for the nutrition — adjacent if it was conscionable a cupful of greenish Jell-O with immoderate past effect cocktail suspended successful it.

You presume your security is going to screen what your security is expected to cover. But it doesn’t.

The astute happening to bash to debar this script by going to your regular doctor’s bureau during the week. Weekends are the weapon and weapon club, the drunks, the overdoses, the pain-med seekers and the radical who similar to beryllium successful the hospital.

When I worked for the superior attraction supplier One Medical, we utilized to telephone a definite people of patients the “worried well” — radical who had nary existent aesculapian problems but wanted to get each fleeting ache and symptom evaluated. A doc would beryllium with them for 12½ minutes, motion knowingly and past compression their insurance, sending them to our herbalist and to our naturopath and having them travel up with the doc adjunct and get each their vaccinations up to date.

In different words, they paid for a hand-holding.

What these patients don’t deliberation astir is sharing an elevator, a waiting room, a clipboard and a pen with the past diligent who came in. Sure, they propulsion the insubstantial down connected the exam array for each patient, but what astir the exam array itself oregon your bare feet connected the tile floor? I’m definite immoderate janitor astatine nighttime runs a soiled mop implicit it, but that’s astir it. What astir the lingua depressors? They’ve been successful that jar for a year. Doctors who transportation their ain otoscope usage the aforesaid speculum connected each patient. And speaking of doctors’ offices, what astir those magazines successful the waiting room? Some of them are 20 years aged and person been flipped done by radical with syphilis and dengue fever. And the happening that ever surprises maine is that cipher thinks astir the information that astir gastroenterologists lone person 1 colonoscope and they usage it connected each patient.

So wherever bash doctors similar maine spell to entree aesculapian care?

Unfortunately, I person Kaiser Permanente and person had Kaiser for 10 years. I’ve ne'er had my ain doctor; I was assigned 1 doubly and they some quit. What you get successful that concern is an ever-changing excavation of doctors who are connected telephone responding to emails that were screened by bureau unit for the level of seriousness oregon urgency. Whenever you interaction Kaiser, play up the urgency, the acuteness, the request for response, the request for a diagnosis. Only that volition get you seen fast.

I emotion the strangeness of aesculapian life: the weirdos, the introverts, those with delusions of grandeur, the entrepreneurs, the schemers, the backmost stabbers with whom I proceed to work; the ever-present changing schedule, astonishment being connected call, the hard diligent near successful your waiting room, the play rounds astatine the hospital, the nights connected telephone for the aesculapian group. Admittedly, it’s a beingness that grinds you down. Most of america who unrecorded and run successful the aesculapian underworld are successful immoderate cardinal mode dysfunctional. We’ve each chosen to crook our backs connected the 9-to-5, connected ever taking much than a week off, connected ever having a mean narration oregon a mean marriage.

To beryllium a doc is to beryllium a ma and dad, drill sergeant, detective, psychiatrist and priest. Year aft year, physicians contend with administrative swaps, buyouts, mergers, resignations and Medicare regularisation changes, each portion navigating hopeless wellness attraction companies looking for the masterstroke that volition cure their hospital’s fiscal ills, similar having valet parking oregon a farmers’ marketplace oregon a h2o partition astatine St. Luke’s.

Since we enactment successful adjacent quarters with truthful galore crisp surgical instruments and poisonous chemotherapy astatine hand, you’d deliberation that doctors would termination 1 different with regularity. I person seen a bosom surgeon fume a cigar successful an oxygen structure with the foot-tall occurrence coming retired of the extremity of his stogie, but I’ve ne'er heard of a doc strangling a workfellow with IV tubing oregon inflating a humor unit cuff astir another’s neck. No, the unit is ever fiscal and covert.

We request courageous lawmakers to yet make a single-payer security strategy without succumbing to the whims of affluent security lobbyists.

That said, it’s not each doom and gloom.

My vocation has precocious taken a turn: These days I’m the aesculapian manager of the much-loved, old-school community-based hospice wherever patients and unit truly pass astir each portion of the patient’s attraction — the spiritual side, the intelligence side, the societal facet of their disease, the fiscal concerns. It’s each done done face-to-face visits, location calls, visiting nurses, multidisciplinary meetings, interdisciplinary teams and household meetings wherever everybody gets to talk and the existent goals of attraction are delineated.

It’s excessively atrocious that astir patients person to hold until they’re astatine the borderline of decease to get the attraction they deserve. Better precocious than never.

John Hayward is manager of palliative attraction for the San Francisco Department of Public Health and Hospice Medical Director.