magbo system

Good medicine is all about blood flow and organ failure, mutation and degeneration. Good medical care is all about trust, contact, communication, listening, figuring out your goals and being heard. For doctors, it’s also about danger — risking the dark microbial forces of COVID, staph, monkeypox, MRSA, C. diff and hardening of the arteries. Your first 207 antibiotics may transport you to a state of health. Your 208th may send you into anaphylactic shock.

Medical training is the science of pain.

Physicians don’t belong to a secret society, but they do comprise a quirky sect whose ancient rituals derive from the principles of Hippocrates. They face humiliation, injury, fatigue and the threat of contagious illness.

The members of a tight, well-lubricated medical team are a lot like a submarine crew. Confined for long working hours in spotless, white, blindingly illuminated spaces ruled by despotic leaders, they are contemptuous of outsiders and loyal to none but each other.

A good deal has changed since my medical training at USC in the 1980s, doing two 24-hour shifts a week followed by two 12-hour days. I slept in sweaty bunkbeds in the attic of  the Los Angeles County General Hospital in a stuffy eight-bed room, humming with fans and generators in the dark.

I wanted it all back then: the emergencies, the gunshot wounds, the heart attacks, the flesh-eating bacteria and the camaraderie that flourished within rigid order and nerve-shattering chaos. I climbed the chain of command from lowly medical student to attending physician — doing whatever it took until I ran my own clinic, my own practice and had my own crew of staff.

I’ve been a doctor in San Francisco for more than 20 years and, in the decades before that, was a medical student, an intern, a resident, a postdoctoral fellow and a professor. I came into the business when my professors still smoked on the back patio of the hospital and wore aftershave and fat ties.

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

Say it’s a quiet Friday night and you’ve just checked into the new urgent care facility that opened in your neighborhood or the new emergency room at the hospital that opened downtown, and you’re looking to get seen for fatigue or a cold or sinusitis. The facility is brand-new and sparkling and looks high-tech, you think. Why not go for it?

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

Here’s how things usually work — the ER, urgent care and the clinic make their money by squeezing your insurance beyond its maximum. Every Band-Aid and every stitch has a price. If you receive a local anesthetic, the needle has a price, the syringe has a price, the liquid inside has a price and the person injecting it does, too. The 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 the maximum reimbursement from your insurance. They might see you for six minutes and then they write a computer-generated note where they click a couple of boxes and charge you for a comprehensive visit — one that on paper is listed as having been face-to-face with you for 25 minutes. They click a couple of more boxes and say that they talked to you about your advance care planning, your surrogate decision-maker, your vaccinations and your allergies, your health maintenance, whether or not you’re being threatened or abused and that they gave you health tips like eating more fiber, smoking cessation and safe sex practices.  

All you can remember is the doctor telling you his name and taking a quick glance at the broken ankle or stuffed nose or sore throat or cut finger that brought you in. The billing and coding office compiles a bill and submits it to your insurance that includes site fees, building fees, practice fees, emergency fees and access fees. You sign pages upon pages of forms, one of which has a sentence saying that you agree to pay the entire bill even though you don’t know what it is yet. If you get admitted, the hospital also submits 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 intravenous needle, the IV tube, the IV bag, the IV pole, the nursing care, the pharmacy care and for the nutrition — even if it was just a cup of green Jell-O with some ancient fruit cocktail suspended in it.

You assume your insurance is going to cover what your insurance is supposed to cover. But it doesn’t.

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

When I worked for the primary care provider One Medical, we used to call a certain class of patients the “worried well” — people who had no real medical problems but wanted to get every fleeting ache and pain evaluated. A doctor would sit with them for 12½ minutes, nod knowingly and then squeeze their insurance, sending them to our herbalist and to our naturopath and having them follow up with the physician assistant and get all their vaccinations up to date.

In other words, they paid for a hand-holding.

What these patients don’t think about is sharing an elevator, a waiting room, a clipboard and a pen with the last patient who came in. Sure, they pull the paper down on the exam table for every patient, but what about the exam table itself or your bare feet on the tile floor? I’m sure some janitor at night runs a dirty mop over it, 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 every patient. And speaking of doctors’ offices, what about those magazines in the waiting room? Some of them are 20 years old and have been flipped through by people with syphilis and dengue fever. And the thing that always surprises 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 medical care?

Unfortunately, I have Kaiser Permanente and have had Kaiser for 10 years. I’ve never had my own doctor; I was assigned one twice and they both quit. What you get in that situation is an ever-changing pool of doctors who are on call responding to emails that were screened by office staff for the level of seriousness or urgency. Whenever you contact Kaiser, play up the urgency, the acuteness, the need for response, the need for a diagnosis. Only that will get you seen fast.

I love the strangeness of medical life: the weirdos, the introverts, those with delusions of grandeur, the entrepreneurs, the schemers, the back stabbers with whom I continue to work; the ever-present changing schedule, surprise being on call, the difficult patient left in your waiting room, the weekend rounds at the hospital, the nights on call for the medical group. Admittedly, it’s a life that grinds you down. Most of us who live and operate in the medical underworld are in some fundamental way dysfunctional. We’ve all chosen to turn our backs on the 9-to-5, on ever taking more than a week off, on ever having a normal relationship or a normal marriage.

To be a physician is to be a mom and dad, drill sergeant, detective, psychiatrist and priest. Year after year, physicians contend with administrative swaps, buyouts, mergers, resignations and Medicare regulation changes, all while navigating desperate health care companies looking for the masterstroke that will cure their hospital’s financial ills, like having valet parking or a farmers’ market or a water wall at St. Luke’s.

Since we work in close quarters with so many sharp surgical instruments and poisonous chemotherapy at hand, you’d think that doctors would kill one another with regularity. I have seen a heart surgeon smoke a cigar in an oxygen tent with the foot-tall flame coming out of the end of his stogie, but I’ve never heard of a physician strangling a colleague with IV tubing or inflating a blood pressure cuff around another’s neck. No, the violence is always financial and covert.

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

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

My career has recently taken a turn: These days I’m the medical director of the much-loved, old-school community-based hospice where patients and staff really communicate about every part of the patient’s care — the spiritual side, the psychological side, the social aspect of their disease, the financial concerns. It’s all done through face-to-face visits, house calls, visiting nurses, multidisciplinary meetings, interdisciplinary teams and family meetings where everybody gets to speak and the real goals of care are delineated.

It’s too bad that most patients have to wait until they’re at the edge of death to get the care they deserve. Better late than never.

John Hayward is director of palliative care for the San Francisco Department of Public Health and Hospice Medical Director.

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