Dirty secrets about American medicine you should know before you die

The doctors do not belong to a secret society, but they do form a peculiar sect whose ancient rituals are derived from the principles of Hippocrates. They face humiliation, injury, fatigue, and the threat of contagious disease.

The members of a tight and well-oiled medical team are a lot like the crew of a submarine. Confined for long working hours in immaculate, white, blindingly lit spaces ruled by despotic leaders, they despise outsiders and are loyal to none but one another.

A lot has changed since my medical training at USC in the 1980s, working two 24-hour shifts a week followed by two 12-hour days. I slept in sweaty bunk beds in the penthouse of Los Angeles County General Hospital in a sweltering eight-bed room, humming with fans and generators in the dark.

I wanted it all then: the emergencies, the gunshot wounds, the heart attacks, the flesh-eating bacteria, and the camaraderie that flourished within rigid order and nerve-wracking chaos. I worked my way up the chain of command from humble medical student to attending physician, doing whatever it took until I ran my own clinic, my own practice, and had my own team of staff.

I have been a physician in San Francisco for more than 20 years, and in the decades prior, I have been a medical student, intern, resident, postdoctoral fellow, and professor. I got into the business when my professors were still smoking in the hospital backyard and wearing aftershave and fat ties.

Things are very different now, and not in ways that are immediately obvious.

Let’s say it’s a quiet Friday night and you just checked in at the new urgent care center that opened in your neighborhood or the new hospital ER that opened downtown, and you want to be seen for fatigue, a cold, or sinusitis. . The facility is brand new and shiny and looks high tech you think. Why not try it?

If you like a $20,000 bill, be my guest.

Here’s how things usually work: ER, urgent care, and clinic make money by squeezing your insurance beyond your maximum. Every Band-Aid and every stitch has a price. If you get a local anesthetic, the needle has a price, the syringe has a price, the liquid inside has a price, and so does the person who injects it. Doctors assign you an ICD 10 code, which represents your diagnosis for billing purposes. For example, C50.411 is breast cancer, and a CPT code that determines your maximum insurance reimbursement. They might see you for six minutes and then write a computer generated note where they click a couple of boxes and charge you for a full visit, one that is listed on the paper as having been face to face with you for 25 minutes. . They click a couple more boxes and say they talked to you about your advance care planning, your surrogate decision maker, your shots and allergies, your health maintenance, whether or not you are being threatened or abused, and that they gave health advice such as eating more fiber, quitting smoking, and safer sexual practices.

All he can remember is the doctor telling him his name and taking a quick look at the broken ankle or stuffy nose or sore throat or severed finger that brought it on. The billing and coding office compiles an invoice and sends it to your insurance that includes site fees, construction fees, practice fees, emergency fees, and access fees. You sign pages and pages of forms, one of which has a sentence saying you agree to pay the full bill even though you don’t know how much it is yet. If you are admitted, the hospital also sends a bill for the room, the bed, the paper cup the Tylenol comes in, the gown you wear, the blood pressure cuff on your arm, the IV needle, the IV tube, the IV bag, the IV pole, the nursing care, the pharmacy care, and for nutrition, even if it was just a green jelly cup with some ancient fruit cocktail suspended in it.

You assume that your insurance will cover what your insurance is supposed to cover. But it’s not like that.

The smart thing to do to avoid this scenario is to visit your regular doctor’s office during the week. Weekends are the knife and gun club, drunks, overdoses, pain med seekers, and people who like to be in the hospital.

When I worked for primary care provider One Medical, we used to call a certain class of patients “well-worried”—people who had no real medical problems but wanted every fleeting ache and discomfort evaluated. A doctor would sit with them for 12 1/2 minutes, nod knowingly, and then squeeze their insurance, send them to our herbalist and naturopath and have them follow up with the physician assistant and get all their vaccinations up to date.

In other words, they paid to hold hands.

What these patients don’t think about is sharing an elevator, a waiting room, a clipboard, and a pen with the last patient to walk in. Sure, they throw the paper on the exam table for each patient, but what about the exam? The table itself or your bare feet on the tiled floor? I’m sure some janitor does a dirty mop at night, but that’s about it. What about the tongue depressors? They’ve been in that jar for a year. Doctors who carry their own otoscope use the same speculum on all patients. And speaking of doctor’s offices, how about those magazines in the waiting room? Some are 20 years old and have been browsed by people with syphilis and dengue. And what always amazes me is that nobody thinks about the fact that most gastroenterologists only have one colonoscope and they use it on every patient.

So where do doctors like me go to access healthcare?

Unfortunately, I have Kaiser Permanente and have had Kaiser for 10 years. I have never had my own doctor; I was assigned one twice and both quit. What you get in that situation is a constantly changing group of doctors who are on call responding to emails that have been assessed by office staff based on level of severity or urgency. Whenever you contact Kaiser, emphasize the urgency, the acuity, the need for a response, the need for a diagnosis. That alone will make them see you fast.

I love the strangeness of medical life: the weirdos, the introverts, the delusional ones, the go-getters, the schemers, the backstabbers I keep working with; the ever-present time change, the surprise of being on call, the difficult patient left in your waiting room, the weekend rounds at the hospital, the nights on call from the medical group. It is true that it is a life that crushes you. Most of us who live and operate in the medical underworld are dysfunctional in some fundamental way. We have all chosen to turn our backs on the 9 to 5 schedule, to take more than a week off, to have a normal relationship or a normal marriage.

Being a doctor is being a mom and dad, a drill sergeant, a detective, a psychiatrist and a priest. Year after year, doctors are faced with administrative changes, buyouts, mergers, resignations, and changes in Medicare regulations, all while desperately navigating health care companies in search of the coup that will cure their hospital’s financial ills, such as having valet parking or a farmer’s market or a water wall in St. Luke’s.

Since we work in confined spaces with so many sharp surgical instruments and poisonous chemotherapy on hand, you’d think doctors would kill each other on a regular basis. I’ve seen a heart surgeon smoke a cigar in an oxygen shop with a foot-tall flame coming out of the end of his cigar, but I’ve never heard of a doctor strangling a colleague with an IV or inflating an IV. blood pressure cuff around. the neck of another No, violence is always financial and covert.

We need courageous legislators to finally create a single-payer insurance system without succumbing to the whims of wealthy insurance lobbyists.

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

My career has taken a turn recently: These days I’m the medical director of the much-loved, old-school community hospice where patients and staff really communicate about every part of patient care: the spiritual side, the psychological side. , the social aspect of his illness, the financial worries. It’s all done through face-to-face visits, house calls, nurse visits, multidisciplinary meetings, interdisciplinary teams, and family meetings where everyone can talk and the real goals of care are outlined.

It is unfortunate that most patients have to wait until they are near death to receive the care they deserve. Better late than never.

John Hayward is director of hospice care for the San Francisco Department of Public Health and medical director of the hospice.