Sunday, July 15, 2012

Health Attention

CS Lewis was quite wise in pointing out that if you cannot say what you mean clearly in plain English, it means you have not clearly thought through what it is you mean. I have a post in which I maintain that one of the things we want is not just health insurance, or health care, but mere health attention, health comfort. (Yes, it is based on something from Bethany's hospital post.)

But it keeps getting garbled, and each definite statement immediately suggests so many exceptions and qualifications as to become rapidly useless.  It is about us as individuals, mainly, but it bears on the entire national debate as well.  We don't seem to actually want what we say we want.

I hope to wrap my mind around this and give you something to ponder.


james said...

And Eliot said that words slipped and cracked under the strain. Sometimes it takes a lot of preparatory material to be able to say something simply...

karrde said...

I think most people want magic.

Not just cheap-or-free healthcare.

They want a doctor to walk in, look at the file, use his stethoscope, prescribe a magic pill to make it all better, and walk out.

Texan99 said...

I want to be able to consult a professional who knows more about medicine than I do, to find out whether there's a way to address a health problem that takes into account not only the financial cost but the trade-off between intended effect and side-effects.

I'd like to be able to get reasonable information about the financial cost up front, and to be able to hedge against very large and unexpected costs by buying high-deductible insurance. I'd like the terms of the insurance to be fairly transparent, so that I can take the expected co-pays into account without having to guess too much about what the "invisible co-pay" will be; i.e., the unpredictable fraction of the actual bill that the insurance company will decide is excessive and therefore not covered.

Beyond that, it would be nice if the doctor and his staff treated me with courtesy and some kindness, without having to pretend to be miraculous healers or restorers of perfect lost youth and health.

In the meantime, I read up as much as I can so that I don't have to worm information out of impenetrable medical office bureaucracies and rushed doctors. I also frequent an urgent-care clinic for ordinary matters that need immediate attention in order to avoid needless complications, like incipient bacterial infections. And I have our names on a waiting list for a concierge practice, against the day when it will cease being merely difficult to get into an over-regulated doctor's office and become practically impossible.

Finally, I don't adopt every treatment or procedure a doctor recommends. I require some convincing, and I consult doctor friends about what they'd choose for themselves -- something they can tell me without the fear of lawsuits that my "real" doctor is forced to labor under.

Sam L. said...

Texan99 said' "Beyond that, it would be nice if the doctor and his staff treated me with courtesy and some kindness, without having to pretend to be miraculous healers or restorers of perfect lost youth and health."

I had a physics prof who told me once that if you act as if you know little or nothing, the doc will go into great detail using all the technical language he has; if you act intelligent, he does "the heart is like a pump" act.

Texan99 said...

I've had good luck signaling to doctors that I can be trusted to take in information and make decisions without freaking out. I require them to slow down and explain processes now and then if I'm unfamiliar with them, and I stop to write down some terms so I can do research later. But I spend a lot of time reassuring them in indirect ways that I will be responsible for my own decisions and will not second-guess them for imperfect outcomes when we play the odds. I hope that makes them more likely to share the real facts and odds with me.

I had a doctor get completely hung up a few years ago on whether to recommend a tetanus booster. He was uncomfortable admitting that the insurance company wouldn't pay for it, though he clearly didn't agree with their reasoning. I had to say, "Would you get the booster in my place if the insurance company didn't enter into it?' That finally freed him up to give me real advice. It's not as though it were particularly expensive, and with my high-deductible I expected to bear the whole cost myself in any case. There was a palpable relief in the room when he realized only the two of us were involved in the decision.

Donna B. said...

There's also a level below which lack of attention in general and to comfort more specifically are detrimental to health.

The first things I expect are competence and professionalism, which usually assure that enough attention and comfort are provided.

From experiences, both mine and several of my relatives in several hospitals and with several doctors in several states over the past several years:

1. I expect a doctor to know that antibiotics don't help with viral infections and should not be prescribed hoping for a placebo effect and that antibiotics can make fungal infections worse.

2. I expect a doctor to understand that an 85 year old, visibly arthritic, man who has been lying on an uncomfortable ER cot for six hours is probably not a drug-seeking junkie because he asks for something for pain.

3. I expect to not be essentially captive in a private room with no access to a way to call for help.

4. I expect a response somewhat more explanatory than being completely ignored (a silent stare, then walking away) or being told "I can't help you" or "that's not my job".

5. If whiteboards are used in a hospital room for exchange of information, I expect the information to be accurate and kept up-to-date.

6. I expect staff to either change gloves or wash their hands in my presence before touching me.

7. I expect doctors and nurses to refrain from telling care-taking relatives that the patient's cancer is the fault of the relative or that if the relative "would only love the patient more" they would get better.

8. I expect equipment to work or be replaced.

8a. Adding blankets as padding to an air mattress that won't inflate is acceptable for only an hour or two -- not the entire hospital stay (elderly patient, hip replacement).

8b. Unplugging a malfunctioning IV pump while commenting "Well, that's probably enough of that antibiotic anyway" is not acceptable for several reasons.

9. Barring unusual circumstances, I expect to be able to make an appointment with my doctor with only one or two phone calls. I'm not complaining of how far out that appointment might be, just the task of setting one up.

10. I expect surgical patients to be released with either medications or prescriptions for expected and easily treated side effects of a particular surgery. If that fails, I expect the surgeon's staff to promptly forward messages that a prescription is needed. I am not referring to pain medication.

11. I expect a doctor to at least consider that a symptom might be caused by something other than the already documented syndromes or diseases or the most common cause of that symptom or set of symptoms. Specifically, after two years 80% of the symptoms that had been attributed to age, alzheimer's, prostate and bladder cancer were eliminated by a shunt placed to treat normal pressure hydrocephalus.

12. A person presenting to an ER for a blood patch for a spinal headache at the request of her anesthesiologist should not be threatened with expulsion from that ER for lying down on the floor of the waiting room for part of the 5 hour wait or for ignoring the "no food or drinks" sign.

Are my expectations too high? If so, please explain to me why. I've already lowered them quite a bit as a result of these experiences, but they can be lowered further.

I understand the sentiment that we are spoiled and expect too much, but it's also rather smugly expressed sometimes. Drugs are not magic, the doctor is getting paid for his knowledge of use of the stethoscope and for his ability to understand the information in the file. Most of the time the doctor and the drugs and the procedures can and do make it better.

How much the doctor gets paid and by whom is a separate issue. Whether there is a basic human right to the expertise and product of another human is yet another separate issue.

karrde said...

Donna: the path from patient-presentation to final-payment may affect the things you complain about.

Of course, so does the way that hospital staff is managed.

And the number of regulations, and the paperwork involved because of those regulations.