Friday, November 2, 2007

The Medical Mafia

Something Sharyn wrote in a recent comment [I miss you too, sweetie; maybe we can come visit you in the sunny place you live . . . like, in March, when it's dreary here??? ] about hospitals and doctors got me thinking about what my mother used to call the Medical Mafia.

To me, doctors are body plumbers -- they know stuff about the workings of the body that I don't know. But they don't necessarily get it about people. And bodies aren't just bodies; whatever is the answer to the mind/body problem, it's got to be more than just the neurons in our brain. How we think about our body has to have some effect on how our body is doing. I had an ulcer once, confirmed with barium and treated for many years. Clearly a product of stress and mental issues. One day I decided I had to deal with mental problems in another way. Ulcer symptoms went away, and the next time I had a barium test, the doctor stated emphatically that there was NO evidence I'd ever had ulcer. And for that doctor, that was that. My body couldn't lie.

Oh can't it!? It lies all the time, and in really interesting ways. That's okay. I love it nevertheless. I just don't expect a doctor to have a clue. (I consider myself fortunate that my current physician -- I still go to the one in Philadelphia even though I live 160 miles away -- understands that some aspects of my life, like my obesity, are more complicated than he would like them to be. In exchange, I don't lie to him.)

But here's my big insight into doctors, and I actually think this can be useful in everyone's dealings with doctors. When I was starting up as an associate in my law firm life, my mother was in the hospital for what turned out to be the last time. On Thursday afternoon, I was in another office building getting Westlaw training, when my secretary patched a call through to me from my mother's doctors, both of whom were on the phone. They proceeded to explain her current condition to me, and then asked me (as her health care proxy) to authorize them not to take extraordinary measures to save her life. Well, that was easy (it was what she'd wanted), and I agreed. That all took about 20 minutes; not a quick conversation. At the end, I asked, "Can you give me six or eight hours' notice before she's likely to die so that I can get up there?" and there was a stunned silence on the phone. Finally one of the doctors said, "Oh. No. We think it will be in the next few hours."

That's when it hit me. Lawyers gather information with the certainty that at sometime, in some context, they will have to explain that information to someone. We're always fitting together facts and bits of law and case law to make the best argument, to explain to a client what is and isn't possible, to draft the most persuasive brief. Doctors, I realized, don't do that. They gather information with the certainty that they will have to act on it. All vital signs, symptoms, physical indicia are leading to a diagnosis (which isn't something you tell someone, but something that tells the doctor what to do) or to a treatment. This explains why they're so often bad at communication. The 20 minute call wasn't structured the way a lawyer would have; I'd have started with the news that the patient is dying and then asked for permission to take extraordinary measures. All the details would have come later, and possibly only if it was requested. The doctors were telling me all that stuff because it was, in effect, the course of treatment they'd already taken. It was the account of what they'd done, not how she was!

This story isn't as sad as you might think. My mother died on her own terms. In fact, the morning after the phone call, she woke up at the insanely early hour that grand rounds occurs, lifted her head up and looked straight at the doctors. The nurse told me later that the doctors were stunned -- she was not supposed to be that alert! But I knew her, and she wasn't going to die when they thought she should die. That weekend she was conscious but out of it. Her last words were to ask a nurse, "When does the party start?" On Monday evening, I got home in time for a telephone call from the first year resident left in charge (all the important doctors are there super early; by dinner time you're lucky the person left even has M.D. on the name tag). He explained that my mother wasn't responding, and then admitted, "We really don't know what's happening with her." She must have liked that modesty; she died 45 minutes later.

So, about doctors: The next time they're talking to you, understand they don't know how to talk. (I understand some medical schools are working on this problem; I'll believe that education is working when I hear it for myself!) Assume they haven't told you any of the stuff you consider important, so ask. Ask more than once. Understand, also, that when they look at you, they're more likely seeing you as a compilation of body parts and possible symptoms. If you have a doctor who doesn't make you feel that way, keep her or him. [Oh, it's not gender specific. I deliberately picked a female surgeon to remove a cyst from the back of my head, thinking she'd have a better "operating table manner." Hah! I was awake for the operation, and being a) interested and b) not squeamish, I asked at one point what she was doing. "Working," was the chilling response. I should have said, "Yes, but you're working on my body!" but I didn't think of it in time. That was okay, though -- the scrub nurse (a man!) answered my questions in a much nicer tone.]

And, about my mother: She was special. Coffee Jones and I were reminiscing about her the other day; she's missed, but she's remembered. I'll share some of my best stories about her as we go along.


  1. Having spent the last couple of years translating techie to legal and back again, I've come to the conclusion that really, very few people know how to communicate well.

    I think it's because many of us are taught how to receive, interpret and analyze information, but not how to disseminate it in a meaningful manner to others; particularly those that don't speak our particular brand of jargon.

    (BTW, I didn't drop off the face of the earth; I've simply been neglectful!)

  2. You and Starman have an open invitation to visit any time you want! We have plenty of room and March is a gorgeous time to visit. We'll be in Jamaica the first week in March (always celebrate Vince's birthday in Negril, and next one will be his *70th*), and Vikki/family will be coming soon after, but let's coordinate dates. We'd love to have you!

    BTW, I let my health insurance lapse as of 11/1. I figure (1) I can afford any care I really *need* and (2) if I don't have insurance they'll be much less likely to want to pull me into the system. I LIKE not being in the system.



  3. To Debbie -- Hey, there! How have you been? Let's "interface" sometime, hunh? I'll call you -- just e-mail me a time & date.

    To Sharyn -- We're so there, I promise! ((February might work; we'll see how things look after the holidays.) The house looks gorgeous, and it would be a nice road trip for the Starman, who's not seen that much of the U.S. Specific to the health care vs. insurance issue, have you checked out Health Savings Accounts. Basically, you're insured for catastrophic events, and you pay for everything else with pre-tax dollars that you save in your account on an as-you-go basis. It's how we're going to do it...

  4. Oh, good! I can't wait to see you again and to meet Starman! Although I will admit, having done that drive more often than I want to think about (15 hours door-to-door, dog in back seat -- oy!), it's grueling. Especially in the winter. But if you're up for doing the drive, our home is always open to you.

    I have not checked out HSAs. Was just planning to AmEx anything we need to pay for (however, it's been that two years since I've needed a doctor and many years before that trip to the ER), plus we have medical reimbursement from the company. But I'll look into them. Thanks!

  5. Right, but that's the beauty of the HSA system -- you're paying for your own treatment, but with pre-tax dollars, which you save up. If you don't spend them, they're still yours. And it's good to have the marginal insurance for medical expenses over $50K -- so when the dog in the back seat causes a car accident, you're covered!

  6. Not that your sweet dog would ever do that... :-)

  7. Will definitely look into HSAs.

    I don't think you've met this dog...there's nothing sweet about Miz Cedar! She's a dragon in a Golden's furry clothing...

    But I love her anyway.::grin::