OBAMACARE IN PERSPECTIVE

Before the mountains were brought forth or ever the Obamacare  launch was formed, there was another troublesome health care problem – finding an acceptable dermatologist in New   York City.  Over the past couple of decades, I’ve discharged ten for cause, and I’m still holding tryouts.

In 1988, Ann caught poison ivy while inside an airplane en route from Texas to New York to take the bar exam.  To us rubes, it seemed an unlikely place to catch poison ivy, but that was the expert judgment of the Brooklyn doctor (call him Dr. No.1) who treated her.  At that point, neither of us had yet learned to be skeptical of dermatologists, so we took him at his authoritative word.

Anyway, where she contracted it was not as important to us as was the $200 the guy charged for his house-brand ointment.  I can’t remember why we didn’t just go to a drug store and get some calamine lotion like we always did growing up in Texas.  I suppose it was because she’d been scratching right through the two-day bar exam and for a couple of days afterward and had created a condition that felt and looked like it was way beyond the reach of cheap medicine.

Slow to catch on, I saw No.1 later for a minor problem, and he sold me a different expensive ointment in a tube imprinted with his most excellent name.

Our primary-care doctor referred us to Dermatologist No.2.  His full-body examination (more on “full-body” below) was thorough, and he found a spot here and there, including a scaly spot that looked exactly like the basal cell growths I’d had in the past.  He scraped it off and sent it to a lab to be analyzed.  I didn’t think any more about it, until I got a postcard saying I needed to make an appointment to discuss the lab findings.  Uh oh.

I spent the next few days gagging while studying photos of disgusting looking things that grow on the human body.  I knew a lot about cancer by the time I took a seat in front of No.2’s expansive desk.  He shuffled some papers in a preambly sort of way, then announced that my condition was a basal cell growth, and I could pay on the way out.  I much preferred the way of my Texas dermatologist.  “I’m sure that’s a basal cell growth, but the law requires me to send it for analysis.  You won’t hear from me unless it’s something else.”

If No.2 needed money so badly he would require an office visit for me to learn that I had a basal cell growth ─  something that nine times out of ten a legally blind doctor would recognize without even squinting ─ he was not to be trusted.  He would probably find irregular growths that weren’t really all that irregular.  Feeling no urge to contribute to a comfortable early retirement for the money-grubbing quack, I moved on.

Dermatologist No.3 was an improvement.  Altogether acceptable, actually.  Thorough, fast, self-assured, and according to our primary-care doc, real smart.  But after I’d seen him a couple of times, he took a leave of absence from which he never returned.  No one would say why.  An unsubstantiated report was that he had back trouble.

Enter No.4.  I went to her for treatment of nickel-size spots on my thighs.  Easy diagnosis.  Eczema.  She prescribed an ointment.  It didn’t help.  She prescribed a stronger ointment and gave me to understand that if it didn’t work, I’d have to learn to live with eczema.  My condition didn’t improve, and I started learning to live with it.

Sometime later, I went to her for my annual full-body examination.  It got a little awkward.  She was skipping part of my full body, and I couldn’t think of an agreeable way to bring that to her attention.  “Don’t you want to see if there’s anything of interest under my shorts?” might be misconstrued.  She was a duly licensed physician with board certification in dermatology, and she held a teaching position at a prestigious medical school, but she was also blond and from my point of view young, and the lab coat suggested (mildly) a let’s-play-doctor fantasy.  I didn’t want to suggest that she take a close look “down there”, lest she think I meant something that in fact I sort of did.

Alternatively, “How is it possible to conduct a full-body dermatological examination without looking at the patient’s full body?” seemed a little challenging.  I wanted her to think me easy to get along with and a pleasure to be with.  Annoying your physician causes nothing but trouble.

I considered telling her about that time in Texas in 1974 when a GP checked out my nether parts for a hernia.  In the process, he spotted a suspicious growth.  He sent me to a guy who combined the practice of dermatology with misguided patriotism.

It was a memorable experience.  He took a look at my trouble spot and immediately said, “Don’t worry.  I cure cancer all the time.”  When the lab report came back, he said he hadn’t cut a big enough chunk out of my groin (it seemed pretty big to me) and he’d have to whittle off some more.  Seemed like sloppy work for a guy who cures cancer all the time and can spot it with the naked eye.  He didn’t get to cure my cancer, though.  I didn’t have any for him to cure.

I did, however, have a fair amount of annoyance about the two weeks of anxiety he’d inflicted on me.  Nor did I like hearing his John Birch Society political views while he was slicing away at that highly favored area of my body.  I was fearful of what he might do down there if I was unable to maintain silence and disagreed with him about the U.N. being an existential threat to American freedom.  (If he’s still alive now that there is a Muslim Kenyan socialist in the White House, he must be pretty upset.)

Back to No.4.  Ultimately, I never did ask this semi-dishy dermatologist (in the semi-fetching lab coat) if she’d like to see me naked.  I just lay on the table and let her do her half-ass job.  When she was all through and was writing up my bill, I asked her about a spot on my ear that was a little smaller than a match-head.  Oh.  Look at that.  She cut off a piece of me to send for analysis and wrote up a new bill.

I don’t expect dermatologists never to make mistakes.  (I’d rather they made them on someone other than me, but I can’t control the selection process.)  That spot on my ear was so small it might have been overlooked in even a careful exam.  But not looking at the substantial part of my body covered by socks and underwear seemed to fall seriously short of best-practice standards.  And it raised a variety of ancillary questions.  They were of little importance, but I was curious.  What, for example, was the reason she limited the exam in that way?  Did she treat every patient that way or was there something about me?  Was she afraid of what she’d find under my shorts?  And so on.

I expect her eighth grade Kuder Preference Test pointed straight at a career in accounting.  She probably had to become a doctor just to keep her daddy happy or something like that.  That’s OK; people do that sort of thing all the time.  But why didn’t she pick a speciality such as hand surgery or psychiatry?

The spot on my ear turned out to be a squamous cell growth.  Not a big deal unless left untreated.  The treatment in my case was Mohs surgery, a procedure in which very thin layers of tissue are removed and analyzed on the spot until all cancer cells have been excised.  The semi-dishy one who declined to look under my shorts was not trained to do that.

Enter dermatologist No.5.  (Actually he was No.8, but in the interest of good storytelling, I’ve omitted three from this recital.  They, too, were unsatisfactory, but not unsatisfactory in an interesting enough way to merit inclusion.)

No.5 was the senior member of a group of Mohs surgeons, and he was assisted by a Fellow from a nearby hospital.  After I was appropriately sanitized and set in position by handlers, No.5 sashayed into the room, took a quick look at my ear, exchanged a few words with the Fellow, and left.

For the next three hours the Fellow (No.5.5) performed the procedure.  OK by me.  He was young, affable, unpretentious, and, so far as I could tell, he had good hands.  As he shaved away layers of tissue, I asked him if was possible to perform a full-body dermatological examination without looking at a person’s full body.  (I knew the answer, of course, but I wanted to see if he did.)  He did.  Unfortunately, he was still in training and wasn’t yet seeing patients on his own.

I asked him if his mentor, No.5, was a shorts-on or a shorts-off kind of guy.  It didn’t matter.  No.5 didn’t do any kind of exam; he only did Mohs surgery.  If my experience as his patient was typical, he didn’t do much of that either.  His function seemed more like that of a restaurant hostess.  Junior (Dr. 5.5) did all the scraping and cutting and closing.  No.5 himself did come by after the eighteen surface sutures and uncounted subcutaneous ones were all tied up and I had my Dumbo bandage in place.  “Everything went well,” he assured me.  I suppose No.5.5 had told him; he sure hadn’t learned it by direct observation. “Stop at the desk on your way out and schedule an appointment for removing the stitches.”  Seemed like easy money to me.

Back on my feet, I asked 5.5 if he could recommend a dermatologist who did a proper full-body examination.  He gave me names of several in this group to which he was apprenticed.

In due time, I showed up in the office of No.6 ─ another youngish,trim, blond female.  This one looked all around under my shorts, and nothing bad happened to her.  She seemed  neither shocked nor inappropriately excited.  I thought about asking her to let No.4 know that she’d survived the experience.

After she’d hit a couple of spots with nitrogen and pronounced me otherwise blemish-free, I asked her if she had any ideas about how to fix the eczema that by then had advanced from a few spots on my thighs to ravaging my elbows.  And also, had anyone yet figured out how to get rid of toenail fungus?  Too bad for me, she didn’t treat either disease.  She wasn’t very clear about what she did treat, just that she was not a “general dermatologist.”  I inferred that she thought they were a lower order of being.  There was one two floors below (where else?).

Enter No.7.  Anything new in treatment of toenail fungus?  Sure.  First, though, he’d have to send a piece or two of my nails to a lab.  Maybe there was a best-practice rule that dictated such carefulness in diagnosing toenail fungus.  For all I knew there were many different kinds of toenail fungus and different treatments for each.  But I was suspicious.

We didn’t get around to talking about my eczema because he got sidetracked.  As he took an exhaustive medical history, he sort of teased out the message that his curative powers extended far beyond dermatology.  Taking meds for acid reflux?  There was a better way to treat it.  Back trouble?  Put away the pain pills.  He waited in what seemed to be a practiced way for me to exclaim eagerly, “Wow.  Tell me more.”  I didn’t take the bait.  I was there to get my toenails and elbows treated.  He generously gave me the secret to disease-free living anyway.

All I had to do was read any of Dr. John Sarno’s books and follow his instructions.  Gosh.  That seemed simple enough.  So I took a look at a couple while waiting for the lab analysis of my toenail clippings.  Sarno is a specialist in physical medicine on the NYUMedicalSchool faculty.  For decades he has preached (I choose the word deliberately) that all sorts of medical problems ─ chronic back, neck, and limb pain, gastrointestinal disorders, skin problems, and more ─ are caused by repressed rage.  Release the rage and robust good health follows.  For most people release can be obtained by attending one of his lectures and, if necessary, following up with another. Easy-peasy.

Mainstream medicine is skeptical of Sarno.  So am I.  No doubt, one’s emotional state has physical correlations.  For all I know, there are proven cause and effect connections.  I myself was in danger of developing hypertension because of growing rage about dermatological maltreatment.

When I went back to see No.7 to get the results of my lab work, he reported that I did indeed have toenail fungus.  He recommended a drug regimen that required repeat office visits and monitoring for side effects.  Years earlier I’d had experience with the Sporanox he recommended, and my liver didn’t like it.  I declined.

Anyway, something was off in that picture.  No.7 was born-again enthusiastic about the Sarno approach.  So why was he himself prescribing a drug?  I expect he thought Sarno was fine as an alternative to spinal surgery or Protonix or Flomax, but when it came to toenail fungus, the answer lay in traditional medicine.  So No.7 was not the dermatologist I was looking for either.

For a few months I continued treating my eczema with the ointments prescribed by No.4.  My condition worsened, though.  I began wearing long-sleeve shirts all the time.  On vacation in Texas, I wore a long-sleeve swim shirt, a so-called rash guard.  In my case it was more an embarrassment guard.  But I didn’t manage to hide my shame completely.  Friends, including a young doctor I had known since he was in utero, opined that my unsightly elbows looked bruised not diseased.  I held out against that view for a while.  No. 4 had been certain that it was eczema.

Still, no matter how disciplined I was in using the prescribed ointments, my condition didn’t improve.  It grew more unsightly, and the easy bleeding common in people my age became a serious nuisance.  I began carrying a cache of various-size Band-Aids.  Ann hardly had time to look for a job she was so busy washing bloody sheets and towels.  I removed the arms from my desk chair so that my elbows were in contact with nothing more abrasive than air.  I began wearing elbow pads.

Enough.  I turned to the website of the American Association of Dermatologists.  There I found No.8, a man who required an XXL-size merit badge sash.  He had immigrated from Asia at age 15, graduated summa cum laude from an ivy league college a few years later, received an M.D. degree from Harvard, then a Ph.D from another prestigious institution.  He’d written lots of journal articles.  That level of brain power and accomplishment held out promise.  He was probably a genius, and a genius was what I was looking for.

My revived hope knew no bounds.  It just could not happen  that this one too would disappoint me.  He didn’t, and he did.

I showed up at his office bearing a sheaf of lab reports, a list of the meds I was taking, my medical history, and a carefully worded written statement of the reason for my visit.  I used letterhead stationary that included impressively, “Ph.D., J.D.”  He set the folder aside without looking at it any more carefully than No.4 had looked under my shorts.

He preferred to grill me.  I’d expected to spend time on an examining table, but instead I found myself in a witness chair being worked over by a tough prosecutor.  After he got through bullying me with tough questions, he said (briefly casting his eyes toward the jury) “so we can conclude that you have a twenty- or thirty-year history of skin cancers, is that correct?”  I had expected him to be a genius, and here he was asking a question to which both of us already knew the answer.

He glanced at my elbows.  “You don’t have eczema.  That’s bruising.”  In an accusatorial tone he added, “Your problem is self-inflicted.”  I had just been lumped in the same category as heroin users and the clay eaters of Alabama.

Then he piled on, adding condescension and arrogance.  “This sort of thing happens when patients act without supervision.”  Without supervision?  I’d seen so many dermatologists over the past couple of decades, I couldn’t remember all their names.  Without supervision?

He explained.  The bruising and bleeding were caused partly by ibuprofen, of which I was taking a fair amount so that I could tolerate the aches and pains (which were self-inflicted) of strenuous gym workouts and skiing and generally not acting my age.  I’d known aspirin could cause easy bleeding and bruising, but I didn’t know ibuprofen would.

Besides that, the two ointments I’d been slathering on for the past year or so were also making the condition worse.  In this regard, I certainly had not been acting without medical supervision, just without competent medical supervision.

The solution was Ross-Perot simple.  Stop taking ibuprofen and stop using the ointment and in six weeks I would have normal elbows.  “Will this really work?”, I asked excitedly.  Apparently mistaking my excitement for skepticism, he got a little huffy.  “You can get a second opinion, if you don’t like mine.”  I wasn’t about to take that chance, not with my history.

The eczema that I didn’t have is gone now and my elbows don’t look any worse than other geezers’ elbows, and I’m grateful.  But No.8 was a jackass, so I’m still looking for someone who is competent and pleasant and not given to increasing his or her revenue stream by unnecessary appointments ─ all of the above.

I do, however, take satisfaction in having done my part to maintain the highest-in-the-world cost of American health care (WE’RE NUMBER ONE. YEA!) even as I demonstrated by personal example that we are dogged by inferior outcomes.

Signed copies of  A Franklin Manor Christmas are available from Historic Saranac Lake.  This two-hanky, deep-snow Christmas story of despair versus hope is good company on a winter evening and a gift your friends and family will treasure.

Click HERE to order the book and to read about Saranac Lake and cure cottages.

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