The Importance of Earnest Service

My husband, Homer Byington, wrote this post a few hours after he returned from having his appendix removed.

As Jeanne well knows, and suffers through patiently– usually — I am one of the world’s most notorious pessimists,  a doubting Thomas, a Luddite, a true Cassandra and chronic complainer who is always telling anyone who cares to listen that life was better 50 years ago.

Like so many others, I have been knocking the way medicine functions in this country for years and even more so recently as a consequence of the inauspicious startup of Obama care. Yes, all sorts of things are wrong with the system, and much needs fixing. But people like me tend to forget how lucky we have been to have had the great doctors and nurses we’ve had and great treatment we’ve received at various hospitals both on an inpatient and an outpatient basis. Today was a good reminder.

This morning, just a few hours ago, I was in an operating room at Lenox Hill Hospital under the knife of a surgeon, Dr. Jeffrey Aronoff, [Photo at right] who was trying to resolve what he described as an “enigma.” I’ll skip writing about medical stuff because I’ll just get it wrong, and it is quite complicated, but both he and I fully expected my hospital stay to be considerably longer than just a few hours. Dr. Aronoff and my wife and I go back more than 20 years when, as low man on the totem pole of a team of five doctors doing colonoscopies, he first treated us. Then, when he went out on his own, we followed. Why?

A month or two ago, to resolve my problems, Dr. Aronoff suggested a routine preliminary colonoscopy. Then the question arose whether he, a busy surgeon working 12 plus hours a day, or another doctor should do the job. He told me bluntly, “I’m doing it. I’ve always done yours.” That is the nature of the man. In this cynical age, how could anyone resist such a doctor’s loyalty to his patients?

The O.R. on the 10th floor of Lenox Hill Hospital is a busy place at 6:00 a.m. Milling about are staff and patients of every shade of color, sex, age, accent and language, but it is an orderly and well-paced chaos managed by experienced professionals, a scene a little like what one might see in a well-danced modern ballet. It sure didn’t hurt that the two R.N.s who interviewed me first were old timers who fondly remembered our family doctor cardiologist Dr. Paul Bienstock. Each of them then spontaneously volunteered that I was lucky to have Dr. Aronoff as my surgeon and said that he was the best. (It did occur to me that they said that about their doctors to all the patients they interviewed, but in this case, I think they both meant it, and their positive words bucked up my already considerable confidence about what I was about to have happen to me.) Then the doctor stopped by. We chatted, and he listened and did not later forget something enigma-related that I had suggested to him.

A few minutes later I was on the operating table, and there he was again with a bunch of other people cheerfully doing various complicated looking things. The mood was calm and positive. An hour and half later when I came to there was Dr. Aronoff smiling. “You can go home. It turned out to be your appendix after all. It was pretty inflamed and I took it out. Everything else looked O.K.” We talked a minute and then he went off to the waiting room to update Jeanne.

The recovery room fascinated me, especially the interplay between all those different people with different problems and different duties. Like the prep area it was an ordered chaos, but all the professionals, busy as they were, took the time to be solicitous to their patients. There may have been the usual friction between staff members that occurs in hospitals and nursing homes, or, for that matter, at any large institution, but it certainly wasn’t evident here. Somebody brought me a cup of ice chips for my throat; somebody else, a cup of tea and a plate of crackers. Even one or two doctors I didn’t know who were coming to see other patients smiled or said, “Hi.” Or, “How are you doing?” Jeanne showed up an allotted five minutes to make sure I was alive, and then Dr. Aronoff visited yet again to check up on me.

Next I was moved to the main floor recovery room, Jeanne in tow, where one terrific nurse gave us common sense, understandable answers to all sorts of questions like when I could take a shower and what I should eat. We were not rushed but as soon as I felt ready, off we went home just before 2:00 p.m.

Looking back on the experience a few hours later, I thought to myself that this is how medical care should be delivered. Maybe I received special attention, but I don’t think so. Everyone else around me seemed to be being treated the way I was.

At least ten different professionals dealt with me and they all acted like they cared about what they were doing and about me. There is no way for me really to know whether Dr. Aronoff is the miracle worker I think he is, but his results do speak for themselves. Here I am at home, never in pain– and hardly at all during the day –and painkiller free, writing a blog post just after having had two procedures performed on me, my inflamed appendix removed, and I am damn near 80. Now that’s great medicine! Yes, we haven’t doped out all of the enigma that brought me to the O.R. in the first place, but we may have that answer also by the time pathology gets through with my appendix.

The question is if Lenox Hill and Dr. Aronoff were able to deliver like they did for me in the middle of a healthcare crisis, shouldn’t we trust them, and the many like them, to come up with a sensible, efficient way to keep us healthy instead of the Washington politicians who seem to be at the beck and call of Big Business, Big Insurance, Big Labor and their battalions of highly competent, self-serving lobbyists?

Friends and relatives post all matter of information on Facebook and Twitter thinking it will never adversely bounce back at them. I hope it never does.

Think of the contradictions. On the one hand we’re horrified that the government is spying on us—with good reason. Yet many hand scofflaws buckets of ammunition by  posting photos of family members [kidnapping?], sharing intimate information [will anyone be home when you’re at a funeral?] and political views [potentially losing clients or a job] without a thought of the future.

We purchase security systems and ask a neighbor to empty the mailbox so would-be robbers bypass the house as we simultaneously post photos of ourselves in front of the Eiffel Tower and the family waving from a gondola in Venice.

Art Caplan, PhD.

The head of the Division of Medical Ethics at NYU Langone Medical Center and contributor to NBC News, Art Caplan, Ph.D., told of a young man who was removed from a liver transplant list because he posted a transplant-damming photo of himself on Twitter. In “Is your doctor spying on your tweets? Social media raises medical privacy questions” he wrote: “There he was for all the world to see, surrounded by booze, hoisting a cold one in a picture he himself had posted,” wrote Caplan. The photo was seen by a person on the transplants team who sent it to a psychiatrist who was about to approve him for the list.

Caplan noted that no liver transplant team would accept a person who was drinking alcohol.  Result of this photo, according to Caplan, “in all likelihood a death sentence.”

With his ethics hat on Caplan asked: “Should this doctor or any health care professional have checked the transplant candidate out on social media?” He continued: “But even if ethical restrictions existed, it is probably fair to assume that a lot of doctors and those who work with them, many who grew up with Facebook and Twitter and the like, will be tempted to do so.

“Take for example, you say your back really hurts and you are disabled — let’s take a peek at your Facebook page to see if you manage to hit the tennis court, the jogging path or the golf links. Promise to be abstinent due to your venereal disease—what are you doing on dating sites on Craigslist? Swear to stay away from fatty foods and high calorie treats—why did your doctor just read a review by you of barbecue joints on Yelp or Zagat?”

He continued: “I think the transplant candidate had the right to know that he tweeted himself right out of a shot at a liver transplant. And you need to realize that information you put up on social media sites may wind up being used by your doctor, hospital, psychologist, school nurse or drug counselor.”

He concluded what we know—the Internet is the Wild West, without rules. “If they [doctor and patient] are going to continue to trust one another then we need to recalculate existing notions of medical privacy and confidentiality to fit an Internet world where there is not much of either.”

Do you think that it’s fair game for a doctor to research a patient’s social media sites to check up on them? Do you believe that there will ever be rules impacting social media? What’s the point of lying to your doctor anyway?

Photo: cdc.gov

As I awoke early on a recent Saturday I heard newsman Joe Bartlett on his WOR 710 radio program interview Dr. Blake Cady, professor emeritus of surgery at Harvard Medical School and Mass General. The doctor shared highlights of a study about mammograms and his findings about the age women should begin having them.

His conclusion—they should start at 40–represents a 10 year difference from what experts previously touted. While earlier screening doesn’t prevent cancer it has a dramatic impact on dying from it—far fewer women do.

I wasn’t near paper and pen to take notes while listening so I checked out some of the details of Dr. Cady’s conclusions on healthday.com. Reporter Kathleen Doheny wrote: “New breast cancer research reveals a significant death rate among women under 50 who forgo regular mammograms and casts doubt on recent screening guidelines from a U.S. panel of experts.”

Doheny reported that more than 70 percent of breast cancer deaths in the study of 600 women happened in mostly younger unscreened women—those who never had a mammogram or had one more than two years before diagnosis.

She wrote: “In 2009, the U.S. Preventive Services Task Force, a panel of experts that makes recommendations about health practices, said women aged 50 to 74 should get screening mammograms every two years.”

The task force describes itself as “…an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists).”

Doheny continued: “Women under 50, the panel said, should talk to their doctors and decide whether to be screened based on potential benefits, such as early detection, and harms, including over-treatment and anxiety caused by false-positive results.”

The specter of insurance wasn’t mentioned either during the radio interview or in the healthday.com article but I fear that five mammograms over 10 years multiplied by women in the 40 to 50 demographic– and who will pay for them–[once again] enters the picture at the cost of lives.

Aren’t patients better off being anxious about a false-positive than not having the test and having a cancer go undetected and untreated? The task force appears legitimate so I hesitate to sling arrows yet I wonder if insurance considerations are lurking in the background. Do you schedule regular health screenings according to your doctors’ or public health recommendations?

I first wrote a Full Measure post in 2010, a topic very much related to the Service of Inflation series launched the year before and I risk little in predicting there will be more to come. An eye doctor appointment, results of New York city and state student tests and a newspaper article inspired today’s post.

Insurance strikes another black eye hitting doctors and patients where it hurts

Before seeing my doctor and his staff for my annual eye exam the receptionist gave me an agreement–a first. I would check one box if I was willing to pay $75 to be tested for refraction; another if not.

In a nutshell the form explained that most insurance companies will no longer pay for a doctor to test for eyeglasses.

This was the wording: “Refraction is the testing done with lenses to determine and correct the errors in the eye causing problems with both distance and near vision. This information is required to prescribe glasses. Insurance carriers do not consider refraction a medical procedure. Medicare and most commercial carriers will pay for covered benefits only. When you receive a service that is not a covered benefit, patients are responsible to pay for it.”

But guess what? Staff told me that if you go to some optometrists–they mentioned a rip-off eyeglass store chain I’ve been warned by friends and colleagues to avoid–the insurance might pay for the test.

It’s easy to forget the precise differences between the training and expertise of an ophthalmologist and optometrist but it’s pertinent so I checked out webmd.com: “Ophthalmologists are physicians. They went to medical school. After school, they had a one-year internship and a residency of three or more years. Ophthalmologists offer …..Vision services, including eye exams; Medical eye care — for conditions such as glaucoma, iritis, and chemical burns; Surgical eye care — for trauma, crossed eyes, cataracts, glaucoma, and other problems; Diagnosis and treatment of eye conditions related to other diseases, such as diabetes or arthritis; Plastic surgery — for drooping eyelids and smoothing wrinkles.” [I didn't know about wrinkles....hmmmm].

Webmd.com continues: “Optometrists are medical professionals but not physicians. After college, they spent four years in a program and got a degree in optometry. Some optometrists undergo additional clinical training after optometry school. They focus on regular vision care and prescribe eyeglasses and contacts.”

This course doesn’t lead down a healthy road. It means that the physician who chooses to become an ophthalmologist will soon be left only with treating eye disease, severely cutting into his/her income and customer traffic. I also wager that the nations’ eyes will suffer. On the rush to the $500 eyeglass frame counter in the chain, diseases that should be diagnosed and treated/controlled early may be missed. How shortsighted.

Taxing information

New York City spent $25 billion on education, the state $74 billion according to research by WOR 710 NYC radio producer Michael Figliola for the John Gambling Show, yet the results are not equally stratospheric. The state spends more on education than anything else.

Lisa Fleisher wrote in The Wall Street Journal, “Less than 30% of the city’s third- through eighth-graders scored proficient in math and English Language Arts on the new exams, which are an attempt to measure whether students are on track to do higher-level work when they graduate and start their careers.”

Yoav Gonen of The New York Post reported: “The eye-opening passing rates for third- through eighth-graders of just 29.6 percent in math and 26.4 percent in reading reflected the first real measure of how many students are considered to be on the path to success after high school.”

Gonen continued: “Last year, before the exam standards were significantly boosted, 47 percent of city kids passed the reading exams and 60 percent passed math.” In a bulleted list he noted “New York City outperformed the state’s other ‘Big 4′ cities by leaps and bounds. Second-place Yonkers only had 16.4 percent of students pass in reading and 14.5 percent in math.”

What else is there to add?

Nothing to Sneeze At

Desheeting doesn’t relate to making beds, operating sailboats, rain [in sheets] or drinking too much [three sheets to the breeze]. It’s how the tissue and toilet paper industry describes fewer sheets of tissue in a box or roll.

Serena Ng reported in “Toilet-Tissue ‘Desheeting’ Shrinks Rolls, Plumps Margins” that Kimberly-Clark’s Kleenex packages contain 13 percent fewer sheets simultaneously claiming that each one is “bulkier” by 15 percent. Guess they know folks who want bulky tissue instead of lots of it when cold or allergies strike.

While on the subject, here’s some toilet paper trivia brought to us by Kimberly-Clark research via Ng: In five bathroom trips/day, Americans use some 46 sheets of toilet paper and according to Euromonitor International, companies sold $10.6 billion of tissue and toilet paper in the US in 2012.

Mayor Bloomberg, who watches NYC’s waistlines, would approve of some of the additional information in Ng’s article though as a consumer even he might expect the price to reflect less product which I’m certain it doesn’t. “Cereal boxes and bags of chips have in many cases become lighter over the years in what the food industry refers to as taking ‘weight out.’ A regular Snickers bar now weighs 1.86 ounces, down from 2.07 ounces in the past, which Mars says was done to cut calories to 250 per bar. Tropicana Pure Premium orange juice is now sold in 59 ounce bottles, versus 64 ounce cartons prior to 2010.”

I didn’t notice a decrease in my insurance premium to compensate for one less essential covered procedure. Does this new wrinkle smack of lobbyists at work along with insurance greed leaving men and women with limited incomes, their children and another specialty of doctor yet again in a reject pile? Have you examples of paying for and receiving full measure lately or the opposite–which seems to be increasingly in fashion?

Wait a Minute Doc!

A friend had a very bad reaction to an injection so she returned to the doctor’s office. Her arm hurt so badly she couldn’t lift it, she felt weak and dizzy and ended up missing two days of work.

She learned that she was to have this inoculation once every five years and she just had one last year.

There’s a hefty co-pay on her insurance plan so when a bill for $92 came for the second visit, she called the doctor’s office to say she didn’t plan to pay it. She explained that had it not been for the office’s mistake—nobody had checked her chart before calling her to come in for the shot and at the time she didn’t know that this was not a yearly precaution like a flu shot—she wouldn’t have had to come back to check out the side effects.

The takeaway: It’s up to you now. Before getting an innoculation, check online or with someone to confirm it’s an annual event.

Arf, Meow

Another friend took her pet to the vet and part of the checkup was extensive [expensive] blood work. She got the results and one was missing though she’d been charged and had paid for it. She had to go back with her pet and hoped that she wouldn’t get another bill for the doctor’s time. I can’t imagine she would. [Patients are never reimbursed for their time.]

The takeaway: Don’t just read the top line when reviewing blood test results. Make sure you see the results for each test you paid for.

Juicy Fruit

I stop by a street fruit and vegetable vendor on my way home from work at least three times a week. The quality is tops, the prices low to rock bottom and inevitably, when I buy a few things—four oranges, tiny sweet tomatoes in an attractive display, a couple of boxes of blueberries for example—he always knocks down the total by a few dollars. I ask for two potatoes and there are four, no extra charge. It’s quite fun to buy from him as I never know what the surprise will be.

The takeaway: If you are lucky, you find a vendor like this.

Do you have examples of when you’ve felt inappropriately charged or when a person has given you a welcome if undeserved price break?

With $67 billion of student loans in default it appears that some of the borrowers aren’t asking the right questions. Janet Lorin wrote: “Almost two-thirds of U.S. student-loan borrowers misunderstood or were surprised by aspects of their loans or the student-loan process, a study shows.”

She continued, in “Student Borrowers Lack Understanding of Loan Terms,” on Bloomberg.com: “About 20 percent of the respondents in an online survey said the amount of their monthly payments was unexpected, according to the study released today by Young Invicibles, a nonprofit group in Washington that represents the interests of 18-to-34 year-olds. The respondents had an average of $76,000 in student debt.”

In addition, borrowers probably didn’t calculate what their potential salary might be in their chosen field, what the job opportunities are and what the added value would be to attend a private school with its $60,000/year tuition, room and board–taking Georgetown as an example–vs. a state or community college where they can live with relatives. Undergraduate tuition at the City University of New York is $5,130.

How do you Feel?

Meanwhile, the Justices of the Supreme Court are looking at the legality of Obamacare. What they are considering is if there are limits to Congressional intervention in people’s lives. Talk show pundits refer to this question as “Can Congress make you eat your broccoli?” Wonder what the answer will be.

Hot Topic

I heard an articulate spokesperson make her case about tanning beds in a radio interview. She wanted the legislation in her state to follow California where it’s against the law for teens under 18 to use them. Emma Jones on Limelife.com reported on these findings by the Skin Cancer Foundation: “…indoor tanners are 74 percent more likely to develop melanoma than those who have never tanned indoors. What’s more, across the US each year, 2.3 million of tanning bed users are teens.”

Jones also reported:  “California had previously banned minors under the age of 14 from using tanning beds, but allowed those between 14 and 18 years of age to use tanning beds with parental consent. Texas has also banned the use of tanning beds for children under 16, but California’s new bill has made them the first state to set a higher age limit.”

When the MC asked this spokesperson: “How many tanning bed businesses are there in the US and how big a business is it?” she had no clue. Within a minute of hanging up, his producer had the answers. The takeaway: When you are a spokesperson, think of the obvious questions you’ll be asked about the topic you’re covering and keep the answers at hand. It’s so easy to do these days!

How Taxing

On his radio show about money, Ric Edelman was trying to make losers feel better about the outcome of the Mega Millions lottery. He told the audience about a winner of $10 million who divided her winnings: 49 percent for herself, 51 percent for her mother and siblings.

She lost a court case in which she fought the tax man, ending up paying 90 percent of her winnings to gift taxes.

Before picking up her winnings, she should have asked a whole bunch of questions. She’d have learned that the maximum amount of money she can gift someone without paying a gift tax is $13 thousand a year. She’d have been better off to have picked up the winnings with family members as a group. Ric was being funny when he said she should have hired an accountant and lawyer even before buying the winning ticket.

Have you landed in a spot because you didn’t ask the right question or weren’t prepared with the answers?

On the Gallop Healthways’ Well Being Index website Jeffrey M. Jones wrote “U.S. Financial Worries Rival Those of 1992,” on January 25. He noted that “Americans’ worries about maintaining their standard of living (51%), or being able to pay medical bills (43%) or losing their job (34%) in the next 12 months are among the highest Gallup has measured in the past 20 years, on par with the levels seen in 1991 and 1992.”

Worry about medical bills is 5 percent less today than it was 10 years ago, though many of the people I know [of all ages] were not polled. One friend’s co-pay for essential medicine just jumped 800 percent. Another who’d had heart bypass surgery called for a checkup and learned that his longtime doctor no longer takes his insurance, nor does one of mine. She requires cash or a check on the spot–no credit cards.

How many seniors opt out of taking their medicine when they reach the Medicare donut hole? Last year the insurance [they pay for] covered drugs-with a co-pay–up to $2840. Then, in the donut hole, the senior pays 100 percent of the cost up to $4,550, after which insurance kicks in for the full amount, minus 5 percent. And what if they can’t spare $4,550?

Robert Lowes wrote in “Medicare ‘Doughnut Hole’ Can Undermine Medication Adherence,” on MedScape Today News “between 11% and 14% of Part D beneficiaries reach the coverage gap each year and receive no subsidy, according to the authors of the study.” There are over 22 million people enrolled in that program.

It’s normal to feel anxious when unforeseen bills crop up for basic medical, shelter or educational reasons which happens increasingly in turbulent economic times. Your head feels above water when wham, a surprise wave looms.

Turning a stiff upper lip into a smile gets increasingly harder. I know admirable people who juggle and work things out regardless of financial haircuts and bad health news followed by exorbitantly expensive solutions. What tips can you share to deal or distract yourself so worries don’t further affect your wellbeing?

We attended a magnificent New Years Eve party with a wonderful group of people who gathered at the country home of friends handsomely dressed for the holidays both inside and out. Our hosts shared two stories that illustrate drastic differences between the care of animals and people.

I’ll start with John’s recent adventure to determine the cause for pain that has laid him low for weeks. During a recent visit to a specialist, the doctor noted that all tests came back negative and he told John to return in several months. Frustrated and wondering how he was supposed to work and live feeling as ill as he still did, [weeks of antibiotics hadn't done the trick], John asked, “Nothing showed on the sonogram either?”

The doctor said, “sonogram?” and scuttled out of the room returning with Xrays that clearly showed his kidneys and three large stones. The stones weren’t going anywhere, said the doctor, who planned surgery to remove them in the New Year. He sounded surprised when he learned from John’s primary doctor that one of the stones had decided to move out on Christmas Eve. [The pain involved in this exit is said to be equal to childbirth.]

Almost simultaneously, John and Bob found the perfect white kitten to join their family and to become their black cat’s sister. Before they could take her home from PETCO, that helps shelters find families for pets, they had to fill out a long form about themselves and agreed to be interviewed by the kitten’s human foster mother/rescuer. [By the way: January 15 and 16 is a National Pet Adoption weekend at some stores.]

Hoping to move the process along, John told the PETCO associate that they had a city and country home, both were employed, had shared their lives with Spooky [the cat] for umpteen years and so forth. The only information that drew any positive reaction was that they had paid thousands of dollars to save Spooky who, as a result of complicated surgery and intensive care, lived an additional eight healthy years. Nevertheless before they’d let John take home the diminutive furry friend, he and Bob would still have to be interviewed and approved by the kitten’s volunteer foster mother–no exceptions.

I’ve been a pet owner for years and I’m impressed that animals aren’t handed out to people helter skelter. But something’s wrong here. How do we beg for human care that’s at least as good as how we treat our pets?

Just how much empathy and compassion should a doctor feel and exhibit? I’m of two minds.

Dr. Sally Satel, who wrote “Physician, Humanize Thyself” in The Wall Street Journal, spoke of the White Coat Ceremony for medical students that she claimed Dr. Arnold P. Gold of the Columbia University College of Physicians and Surgeons popularized. The symbolism of the ceremony, according to the Columbia University chaplain, is for doctors to consider their coats “cloaks of compassion.” Medical schools all over the country now conduct these ceremonies.

And I’m all for it. Having witnessed a top-rated specialist [according to a yearly listing in New York Magazine] treat my husband, who was suffering and weak, with less compassion than a plumber would feel for a pipe, I question the man’s reason for becoming a doctor. We see misfits in all sorts of professions, which is no excuse, but this fellow was all sorts of things he didn’t have to be: Rude, offhanded and wrong to the extreme in his approach to a diagnosis. Turned out my husband did have something in this person’s specialty, generated by a nasty tick bite, causing two+ months high fever and eventually the inability to get out of bed. [Husband is fine now.] A person like this doctor wouldn’t understand the significance of this or any other kind of compassion-related ceremony.

On the other hand, when confronted with horrendous disfigurement and frailty or facing a tricky operation with scalpel in hand, a doctor whose empathy makes him fall apart isn’t of much help, either. Referring to “respectful attentiveness and a genuine commitment to a patient’s welfare” Dr. Satel wrote: “It happens not in the classroom, of course, but ideally on the wards and in clinics under the watchful mentorship of seasoned physicians.” Maybe the nasty doctor spent all his time in the classroom.

Dr. Satel points to government intrusion, at junctures in recent history, as the cause for lack of compassion. As doctors are increasingly robbed of options by insurance companies and/or time–because of paperwork required by government regulation in combination with the numbers of patients they must treat in order to meet budgets and satisfy what Medicare will pay for-they can’t squeeze in anything else, much less compassion. [Medicaid seems to have an unlimited bank account and my advice is if you get really sick, sell everything and go on Medicaid, but I digress].

Satel concludes: “Juggling the timeless injunction to all doctors-be a mensch-with concepts like ‘Medicare metrics’ and ‘standardization’ (the new watchwords in health reform) will make it even harder for the newly coated students to become the kind of doctors that they themselves would like to have. An induction ritual acknowledging as much wouldn’t hurt.”

Wouldn’t a compassionate person still be compassionate under any circumstances? Is it the patient’s fault that a doctor must see 30 patients in the time she/he used to see eight to 10 or that the doctor has a pound of paperwork to fill out after every visit?

What can the public do about changing this increasingly unreasonable turn of events?