The Wake-up Calls
Section titled “The Wake-up Calls”It was 1973, a time before seatbelts were universal, and I was a newly-minted doctor. Working in the ER, I saw my share of faces that had been in an altercation with a windshield. Treating those patients, I had two wake-up calls.
One day, I was confronted with a patient whose bloody face was so lacerated I called the surgeon, expecting he'd do a better job than I could. For some reason he was angry about being pulled away from other matters and rushed through the job, tying knots so tight I feared the patient might develop stitch mark scars. The surgeon was old enough to be my father; fearful of intervening I watched and winced. Lesson learned: just because someone specializes in an area of medicine doesn't mean they're always going to do a better job than you will.
From then on I usually relied on my own obsessive self to do the job. Make sure the wounds are clean and free of debris, put in a deep layer of sutures to remove tension from the surface layer, and make sure you align the facial surface perfectly.
Later that year came my second wake-up call. For a good half hour, I had been bent over a bruised young man, needle and thread in my hand, patiently putting back together another windshield damaged face. Satisfied with my work, I sent my patient home with his instructions, washed my hands, and headed back to the nurses station. The clerk came up and asked me what amount the hospital should charge. Not having been asked before, I gave her a figure I thought commensurate with the time and effort involved, only to see her recoil in horror. "Oh, no, doctor, you can't charge that. The other doctors charge much more!" I asked what the others usually billed. Then I, in turn, recoiled in horror. But not wanting to rock my employer's boat, I split the difference. Note to self: money and medicine make complicated partners.
Indelicate Disconnection
Section titled “Indelicate Disconnection”In those days, insurance companies paid pretty much whatever the physician or hospital asked. Doctors weren't light on the billing pen. When patients asked about the price, the staff would react as if they had asked an indelicate question. "Don't worry," they would say. "The insurance company will pay."
The patient's disconnection from the real cost of service was one factor that has led to the soaring costs and inefficient medical system we have today. It led to insurance company regulations designed to combat excessive medical fees, unnecessary services, and fraud. It has led to a blurring of the relationship between doctors and their patients. Even worse, it has led to a loss of the idea that every single hospital and medical clinic has only one purpose and that is to provide service. You are, in fact, in many medical encounters, not just a patient, but a customer.
Patient or Customer?
Section titled “Patient or Customer?”When you go to the doctor, are you a patient or a customer?
In your parents' day, you were always a patient. You trusted the doctor. There was a parental aspect to the relationship. The doctor gave orders; you obeyed. Unpayable medical bills didn't go to collection. If the doctor's work wasn't perfect, if something went wrong, it was called a complication, not a lawsuit. If you even knew any lawyers.
Today the doctor is seen less as an authority than as someone with special skills who may or may not have the talents you need to get well. In many ways you're treated more like a customer than a patient. You get advertised to. Pharmaceuticals are aggressively marketed. More subtly, procedures such as colonoscopy and mammography have been marketed via the media. The doctor is assisted by technicians (some skilled, some not) more often than by trained nurses. Too often you find out the specialist you're paying has to send you to a different specialist.
In your mother's day, the doctor was more likely to feel a fiduciary responsibility toward you. He'd feel a moral obligation not to prescribe unnecessary procedures or services. Today, not so much. If you miss a payment, you may wind up in collection. Docs advertise their plastic surgery and special eye procedures, and I'd be surprised if one said "Gee, you really are better off without this." Often a doctor unnecessarily repeats lab tests and x-rays you've already paid for at your previous doctor's.
In today's medical system, you are both a customer and a patient. You have a dual role. Understanding this opens up both possibilities and responsibilities.
Customer's Rights
Section titled “Customer's Rights”As a customer, you have a right to shop around, to ask what things will cost and to find out whether there is some less expensive option. Remember, you are paying the doctor, and, in ultimate fact, you are the reason the doctor and his staff are there. You can express your opinion as to what options for treatment you'd like to prioritize. You can tell your doctor you want a second opinion. You have a right to respectful and competent service. If you need to see a specialist, you can ask questions and do research to make sure you get to the right one the first time.
Patient's Rights
Section titled “Patient's Rights”As a patient, you have a right to expect that your health care dollars are not wasted, that you are not asked to buy something you do not really need. You have a right to absolute privacy. You have a right to let your hair down and not to be taken advantage of because you are not at your strongest. You have a right to expect that your doctor will put aside his or her own interests during the time he or she is caring for you. You have a right to expect that, if necessary, your doctor will go the extra mile for you and not settle simply for the usual protocol.
We recognize these days that the doctor is not all-knowing. By the same token, the patient can no longer be passive. (If you are too sick to take charge, appoint a trusted friend or relative to be your advocate.) When both you and your doctor understand your dual role, you will be able to successfully navigate our imperfect medical system.
The Doctor Becomes a Patient
Section titled “The Doctor Becomes a Patient”On a personal note, an eye condition that runs in my mother's family will require me to undergo surgery later this month. From my perspective as a patient, it seems to me that doctors are learning to follow the spirit of service. For example, after I interviewed one surgeon as a candidate to do the procedure, I ended up telling him I'd rather go to a major center that specialized in this particular procedure instead of having it done in his general ophthalmologic surgical clinic. He readily gave me a few names and said he'd be happy to provide any necessary follow-up help, since these other clinics were far away. I felt well-treated, both as a patient and as a client.
No one wants to be a patient. When I am, I need to take the responsibility to be honest with my doctors about what I will and won't do. I need to pay them promptly. They didn't get where they are without a great deal of preparation. I need to give 100 percent from my side in following their advice, if that's what I've agreed to do. I must ask for what I need. The doctors can then tell me whether she can give me what I ask for, or whether she can not.
When everything is on the table, both doctor and patient benefit. Part of what we both need to put on the table is what medical care costs and who will pay. That part of the whole picture lets us rationally decide the best course of action.