December 2013 - January 2014

The Medicine

Health care, American style

By Karen Hitchcock
Motivational slogans and pricey lungs in a US hospital

It’s months before the world will hold its collective breath because a handful of congressmen don’t want the United States to provide health insurance for the 47 million of its citizens who don’t have it. I’m in the Deep South, having a beer with a senator’s chief of staff, and he’s trying to explain to me why Obamacare is such a bad thing. It’s something to do with the deficit, with taxes and small business, and I’m not following, not even when he shows me a pretty pie chart on his laptop. I’m embarrassed at his effort and at my failure, and I keep wanting to say, “Stop, save your breath, you’re trying to convince a nobody.”

I spend my days downtown in a university hospital known for its innovations, for practising “accountable care”. Instead of doctors and nurses and patients, they have teams and “feedbacks” and outcomes. It’s the way of the future; they want to apply it back home, where we apparently have an unsustainable system. Enter the lobby and you could be in a five-star hotel: polished solid timber and deep leather armchairs, every surface designed to be easy on the eye.

The handover from the night staff to the day staff takes place in the tearoom on the medical ward. It looks the same as an Australian tearoom, except the mugs are all neatly stacked and there’s no threatening notice above the sink about how your mother doesn’t work here so you’d better wash your own mug. There are a lot of whiteboards for a tearoom, and they’re covered in flow charts and motivational affirmations, written by the clinicians who’ve all morphed into managers. There’s a cork noticeboard with a T-shirt pinned up at the armpits. It’s black with green text: Help Trent Get New Lungs. A flyer next to the T-shirt explains that Trent is 19, has cystic fibrosis and is trying to raise $50,000 to pay for his lung transplant. Buy a T-shirt for ten bucks! Help me in my quest!

The night was a tough one, but the staff aren’t allowed to use negative words, not even “busy”. Instead they smile like adverts and say the shift was “active” and “challenging”. Before the staff can get out of there, they have to formulate a team-building goal of the day for one of the whiteboards. They come up with Execute the day with joy and Work together, but settle on Spread the cheer.

We gather in the corridor ahead of the ward round. One of the doctors takes a call and announces, “She’s on her way.” Who, I ask? “The social worker. We can’t start without her.” Social workers in Australia never join our ward rounds. They have barely enough time as it is to organise all the respite and residential care, family meetings, emergency funding and home help.

The social worker arrives, and we crowd in the doorway of the first patient. He’s recovering from a bout of pneumonia, and the doctor thinks he needs a few weeks in rehabilitation to get him strong enough to return home. The social worker steps forward with her clipboard: “Unfortunately, Mr D’s insurance doesn’t cover rehab.” The doctor turns back to the patient: “Unfortunately, your insurance doesn’t cover rehab and so you’ll have to go home directly. Be careful, take it slowly, see your family doctor in a week.” Mr D nods. We move on.

The next patient is ready for discharge. The social worker asks the doctor to change drug X to drug Y as the insurance company won’t pay for drug X. The doctor changes X to Y. The next patient, a pensioner, is informed that he needs two more days of in-patient antibiotics for his infected prostate. He pleads to go home: “Doctor, please, it’s costing me $250 a day in co-payments. I can’t afford this.” The doctor says he’s sorry. The social worker says nothing.

After work, I drive around downtown. Dozens of young fit black men mill outside soup kitchens and in car parks, their portable bedding close by. I see a woman and baby wrapped in a quilt, lying under a scraggy tree beside a mess of men and clothes and boxes. I haven’t eaten all day and suddenly feel faint. I order a shake at a deserted diner. It is unimaginably delicious: chocolate ice cream made just soft enough to move through a fat straw.

I join the gridlock back to the suburbs; the streets grow quieter, greener, wider. I attend a party in a beautiful house. We are mostly doctors, drinking wine, eating steak. Our children roam the streets, clutching cups of homemade lemonade. I get to talking with one doc. To whom is he accountable, actually? How does he negotiate the health insurance minefield? What happens if the patient can’t pay? He looks over my shoulder. “Oh, we don’t get involved with that side of things … The hospital interviews them. They work something out.” Interviews them? About what? “You know, helps them calculate their assets …” I stare at him. He looks annoyed and says, “Do your patients have to wait 12 months for their hip replacements, like they do in the UK?” I raise my glass: “God save the Queen.” He smiles a winning smile. “Well, Americans sure wouldn’t put up with that!”

I couldn’t wait to get back to our overcrowded hospitals that stink of hot chips, where bad things are called bad names and you can swear freely in the tearooms. Where you’re a patient, not a customer, so the lack of a fatal car crash is the only thing standing between you and a new set of lungs. You may have to wait months in pain for your new hip and then share a room with three snorers, but you’ll get the drugs the government lets me prescribe you, and if you can’t walk post-op you’ll have physical therapy someplace ugly, and if despite all that you can no longer leave your house, the social worker will hook you up with Meals on Wheels. Spread the cheer.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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