In September we sold the monastery and immediately after closing, drove to New York City in quest of a new life and improved vision. We would buy an apartment, and I’d have my cataracts removed. I knew about New York real estate; it’s difficult to have your way with it. I was dismayed at how similar the medical experience was. It was redundant, non-standard, and corrupt. It made me feel foolish. (I was.)
I got my eyes fixed, and I’m grateful for that. But I could have had the same procedure with probably the same outcome (a doctor friend calls cataract surgery “routine maintenance”) for substantially less money – a cost borne by both me and the American taxpayer. The following is both a confession and an indictment.
The doctors involved blamed lawyers, of course. And they were right, sort of. But the medical industrial complex is complicit. I’m pretty sure that if malpractice and negligence suits were eliminated tomorrow, treatment prices and practices would change little. The malpractice insurance costs would be redirected to the doctor’s brokerage account; the unnecessary procedures would go on apace. To be fair, in my misadventure it was often difficult for the foot-soldiers in the fee-for-services army to act otherwise.
* * *
The story began in the office of Dr. Goodvision, a New York City ophthalmologist I’d been seeing for years. Last winter, he told me it was time to have my cataracts removed, but that he himself would not perform the surgery. “I wouldn’t let someone my age [early 70s] operate on my eyes.” He referred me to a Dr. Rich on Manhattan’s Upper East Side. I liked and trusted Dr. Goodvision, but he was remiss in not informing me that I had a choice in the type of procedure and its cost. (Indictment) And I didn’t ask questions or do any research. (Confession)
After putting it off for a long time, I phoned Dr. Rich for an appointment.
As usual, the call began with “What insurance do you have?” I don’t know why she bothered to ask. Like me, most cataract patients are on Medicare, and since the procedure would be laser-assisted, Medicare would cover only a small fraction of the fee. Likewise United Health Care medigap insurance. Because I hadn’t done my homework, I was not aware of that until several steps further into the process.
The voice on the phone scheduled two dates for me to come in.
The first was so Dr. Rich and his assistant, an optometrist, could examine my eyes and confirm that I did indeed have cataracts. Perhaps they also rendered deeply insightful judgments about the specific nature of my problem. I had no way of knowing; the optometrist’s role was purposely limited, and Dr. Rich hardly said anything. He fended off questions with “we’ll get to that later.” He was intense, though. When he focussed intensely on a computer screen or some piece of equipment, he stuck his tongue out like Michael Jordan taking a shot. (Short as the surgical procedure was, I expect his surgical mask had a wet spot by the time he finished.)
The second appointment was for measurement, a procedure that cost $375 per eye, payment in advance. The surgery itself would be $1800 per eye – $1200 to Dr. Rich, $600 to the hospital. I found those numbers a little rough, but I was still operating on the belief that Dr. Goodvision had superior judgment in the matter and that it was probably pretty much the standard charge for cataract removal. Reference to “the machine,” was sort of reassuring. too. It suggested that the charge was beyond the control of Dr. Rich or the hospital; it was in the natural order of things, like the sun rising in the morning. Thinking like that is one reason the cost of American medical care is the highest in the world.
After measurement, an office assistant explained how the next couple of weeks would play out – eye drops regimen, prescriptions, dates, and so on. Also, I would need to see my primary care doctor for a pre-op physical, and it would have to be completed within two weeks of the surgery. She made the appointment (which I thought a little presumptuous) and faxed a sheaf of questions and examination protocols to my good friend, Dr. Best, in Saranac Lake, where I’d remain resident until a couple of days before the surgery.
Dr. Best seemed perplexed by the surgeon’s requirement for a pre-op physical. After a close look at Dr. Rich’s long fax, he grew more so. He was to perform an EKG and a chest x-ray and an exhaustive general examination and fill out a history and order a complete blood count and a urinalysis. He was reluctant to do all that, but he didn’t say anything. What could he have said? “Your surgeon is a nitwit. You don’t need all those tests. Fire the guy.” That didn’t seem quite right. Also, he realized that to start the process over again would be a major inconvenience with no little expense for me since I was in the middle of a resettlement process that had as many pieces as a medium-size jigsaw puzzle. And I suppose he thought – mistakenly – that I had chosen Dr. Rich after careful consideration.
A few days later, we closed on the sale of the monastery, filled the Prius and a rooftop luggage carrier with all it would hold, and set off down the Northway. Along the way I received a call from the hospital asking numerous questions, the answers to which were in the records provided by Dr. Best. In an efficient health care system, the hospital would have found that sufficient. If I had asked why it was not, I’m sure they would have blamed it on lawyers. (I expect hospital administrators and other health care providers are not completely unhappy about the threat of law suits; it does, after all, provide an opportunity to generate fees.)
On Monday, I had the cataract removed from one eye. On Tuesday morning I showed up as directed at the surgeon’s office. The assisting optometrist examined me, pronounced me problem-free, and I went off to enjoy the day in Manhattan until the train to our lodgings on Long Island left at around five. Shortly after lunch, I listened to a voice mail from Dr. Rich’s office. I was to see my primary-care doctor for a second pre-op physical before the second cataract removal, which was to occur twenty-four days later. (Presumably, the results of the first examination were considered to be out of date.) She had already phoned Dr. Best in Saranac Lake – where I no longer lived – and made the appointment. I hurried back to Dr. Rich’s office.
“It was nice of you to make that appointment for me (though I resent the hell out of the way you are taking over my life), but I no longer live in Saranac Lake. It’s three hundred miles from here. And I don’t have a primary-care physician. We’ve got to work something out here.”
“Dr. Z will see you. He’s just a couple of blocks down that way.” She motioned in a southerly direction down Park Avenue.
She called Dr. Z and faxed my records to him.
It seemed a little odd to be able to get an appointment for a physical exam by a Park Avenue doctor on a moment’s notice. It got odder. Only one or two people were in the waiting room of this three-doctor, NYU-affiliated practice.
An unkempt man in a wrinkled white shirt that stretched tight over a big belly and with rolled up sleeves emerged from an examining room to greet me. I thought he was an office assistant or maybe part of a cleaning crew, but he was Dr. Z, cardiologist. He carried a stack of papers, which turned out to be my medical records, the ones Dr. Best in Saranac Lake had provided two weeks earlier.
Dr. Z led off the interview with a joke that I didn’t follow about lawyers on the Mayflower. Then he explained that this exam was necessary because of lawyers.
He asked me a few questions, such as what drugs I take. Like the hospital questioner, he had the answers in the papers he was holding. I guess he wanted to be really, really sure nothing had changed in the past few days.
The whole interview took about five minutes.
Then he said, “You seem healthy, Mr. Willcott, but I don’t know you. Now don’t be upset, but I have to run some tests – a urinalysis, EKG, and a sonogram of your heart, aorta, and carotid artery.” (On advice of counsel, no doubt.).
I spent the next half hour or so quietly enjoying the sonogram – it’s the next best thing to a massage – despite the realization that I had been transformed against my will from patient to profit-center and in the process was contributing to Medicare’s financial problems.
My primary-care doctor confirmed this view a few days later.
In an email, he apologized for “the American medical system. The current standard of care is to not require ANY medical evaluation prior to cataract extractions. [I] thought that your ophthalmologist was over the top to start with, but there is absolutely no indication for the sort of imaging that you are describing.”
Even after the surgery, the system continued its unnecessary manipulations. After each cataract removal, I was sent back to Dr. Goodvision for a brief post-op checkup. Dr. Rich could have performed it himself. I suppose his attorneys advised him to get disinterested verification of the unassailable quality of his work. I also suspect that Dr. Goodvision and Dr. Rich may have a mutually profitable arrangement that has little to do with medical care.
* * *
I can see a lot better now, and I’m grateful for that. But the procedure cost too much (actually more than I have indicated above), and it included a mountain of pretending that I was a patient though to a large extent I was a commodity.
I’m sending along this rumination to Medicare and various professional associations, but I don’t expect it to have much effect.
And I’m making notes toward a book on how to be a patient in America. Subjects include advice on how to get your doctor to listen to your narrative instead of checking boxes on his interview form, what’s wrong with the phrase “doctor’s orders,” and other ways to take control of your treatment.
Tentative titles include: How to Survive the Medical/Legal/Industrial Complex; Being an American Patient. It’s Enough to Make You Sick; A Field Guide to Being an American Patient.