Stopwatch Medicine

We all know the fable of the emperor whose raiment was only in his mind’s eye. I fear that medicine is in danger of a similar form of self delusion. For all the triumphs of science, for all the good intentions of planners and physicians, patient satisfaction with the medical establishment is crumbling. When millions of people face financial catastrophe if they become ill, and when those who must correct inequity wrap themselves in garments of denial instead of seriously attempting to fix the problem, I fear for the soul of my beloved craft. Assembly line health care is not the answer to the problem. Is the model of a country doctor, one who cares enough to listen and be available at a cost within reach, impossibly out of date? If I spoke with the thunder of Thor, I would demand better from all of us!

Medicine and “Business,” with a capital B, have always formed an uneasy alliance. Access to decent medical care is a right, not a privilege! The constant tug-of-war between assuring such for everyone needing it, and the grim realities of having to pay office staff, buy supplies and provide for my family, led me to consider an alternative to a traditional entrepreneurial practice. I had heard of Health Maintenance Organizations, or HMOs. My public grumbling about the rigors of practice reached the ear of Lance, a leader of such a group, whose headquarters were 200 miles away on Minnesota’s Mesabi Iron Range. Lance made an airplane trip to visit me in my office. We talked long. A pairing that seemed made in paradise emerged. I sold my equipment to the HMO and signed on as a salaried employee.

A year later, David and Bill, two freshly minted family physicians, joined me in what had been for decades a solo practice, based in our stunning North Shore village. We had a dream, affordable medical care without the constraints of that capital-B business.

Another year went by. Then...

Today was special. Mr. Barker, second in command with the HMO, was in our clinic for the day. Support time. Evaluation of process. “Let’s iron out any problems,” he said.

Martha V. was my first patient that morning. Her chart was thick, what we doctors call the Sears sign—notes and data from dozens of previous visits. I did not need to review it to predict that her symptoms would be vague, that physical findings would confirm mid-life average health, that trips to the hospital laboratory would be uninformative.

Time nipping at my heels with piranha teeth had been my excuse for previous failure to dig deeper into Martha’s living experiences. Time and its companion, a waiting room crammed with impatient patients.

But time was no longer an issue!

I leaned back in my chair, granting her permission to relax from an anxious perch on the edge of hers. I studied her with an eye untainted by a sense of haste. She was lean, with hands cracked by work and winter’s cold burns. Humor had left no tracks on her face.

“My stomach hurts,” Martha said in a soft drone.

“Can you explain?”

“It kind of knots up, and my bowels don’t work right.”

I nodded.

“I can’t sleep nights, then am so tired all day I can’t get my work done.”

I moved into new territory. “How are things at home?”

She started, and I was reminded of the response of a cat when it spies unexpected motion. “Home?”

I nodded again.

“There’s just Harold and me these days. Sarah’s married and... what has that to do with why I’m sick all the time?”

“Maybe nothing. Maybe a lot. How do you and Harold settle disagreements?”

“We never disagree.”

“Most married people have their little disputes,” I said. “How they are settled can have an effect on how a person feels.”

“Harold would never stand for any backtalk!”

Aha.

I said, “Pretend I’m invisible, an observer in your home. Let’s say you and Harold have had an argument—”

“Doc, I’d never dare!”

“How does not daring feel?”

“Well...”

Martha and I talked long past the end of her fifteen-minute appointment. I learned how Harold controlled those around him with alcoholic rages, why her bowel tied itself in knots, why I had never previously been of any help in finding relief for her symptoms. I arranged for a series of follow-up appointments. I could only hope she would muster the courage to keep them.

My schedule for the morning lay in tatters, but my feeling of worth as a physician, as a healer, had received a vitamin shot. I worked rapidly and by noon, I was only half an hour behind with appointments.

After a lunch crammed into fifteen minutes of coffee and part of a sandwich, I pranced into the afternoon lineup of patients. Click, click, responsible HMO doc on time. Then...

Honus G. was a businessman and president of the chamber of commerce. And president of the council of his church. And on the school board. His breezy style did not mesh neatly with my more laid-back approach to life. Our relationship consisted of chance meetings, where I traded comments with him on the weather, endured a joke dredged from his inexhaustible trove of sexual innuendoes, and “Have a nice day!” accounted for most of our exchanges.

Honus had come to the office for an insurance physical. Such ranked high on the list of appointments I would cheerfully have avoided. Aside from its assured lack of any interesting diagnostic challenge, such a consultation raises a conundrum. Who am I working for? I am sworn to meet my patient’s needs, yet now must swear with equal fervor to reveal to a faceless mega-corporation chapters from the life of a person I know.

Honus’ was one of those quickie insurance exams, vital signs, blood pressure, a listen with a stethoscope; good, a heart still ticking. We endured the experience, he and I. I signed the form that made him a candidate for another five thousand dollars of profit to his survivors and laid a hand on the doorknob of the exam room.

“Uh, Doc,” Honus said.

Oh, oh.

Important lessons maturity have taught me are that a patient is always apprehensive, and that the designated symptom justifying an office visit is sometimes only an excuse, a ticket of entry. A doctor’s hand on the doorknob and the patient’s coincident “Uh, Doc,” so often announce his or her real reason for calling.

I returned to my chair.

Honus flushed and he patted broad cheeks with a handkerchief. “There is one other thing. Look, does everything we talk about have to go on that chart of yours?”

“I use discretion,” I said.

“Meaning what?”

(Office helpers are local people. In a town as small as ours, that means Susan at the front desk is related to half the people from the west end of our county, while Joanna, in medical records, was born and raised here in town. Cheryl grew up on the nearby Chippewa Reservation. A slip of the tongue can be unintentional and virtually unrealized.)

I said, “Meaning that I record most of what happens here in the office, but some things remain in my head.”

“Doc, see, I’ve got sort of a problem. Not something a guy likes to discuss.” He buried his face in his hands.

I leaned forward, in silence.

“My wife is threatening to... to leave me, if I don’t... God, this is hard!”

“Try puking,” I said softly.

“What?”

“Every so often, a wonderful, wise old Chippewa man I knew years ago, set me straight about life and my approach to it. Told me things I needed to hear, forthrightly, without accusation. Puked words.”

Honus blinked at me, then nodded. “Okay. See, I can’t... perform anymore, and my wife says she won’t put up with that. I... don’t know what to do.”

“Tell me what happens,” I said. I leaned back to listen.

He talked for nearly an hour, and words that had been halting at first became fluent. I learned about his fears and yearnings, learned what personal affirmation he had come to place on the physical act of sex. What he told me was only the beginning of all that he needed to discover, but it was a start. He agreed to let me arrange sessions with counselors from the Human Development Center in Duluth. When he left the office, he turned back from the door.

“Thanks, Doc. I...”

Big as he was, his embrace threatened to crack a rib or two.

I grabbed a wad of Kleenex that was nearly as large as his.

By now my appointment schedule resembled the last car in a demolition derby. I slogged through the rest of my list of patients, endured their irritation over delays not explained.

I finished seeing patients a little after six o’clock. Mr. Barker waited in the back room that we three doctors used as our joint office. Dr. Bill sat at his desk; he stretched and yawned. Dr. David arrived ten minutes later.

I rubbed my face and worked tense shoulders. The wall clock showed six-thirty-one. I beamed. “We’ve finished early.”

Mr. Barker was not amused. He spread account sheets detailing our day’s efforts. David said, “Hope we didn’t cause you any headaches.”

Barker halted his brisk busying. “I don’t get headaches, I give them.”

Bill sat straight, David and I exchanged looks.

“You, Dr. MacDonald. You made a mockery of your schedule. This patient, Martha V. You spent four office-call units on her, threw the whole morning out of whack. You only charged one-and-a-half units, which means that you gave away two-and-one-half units. The same thing this afternoon.

“Now, you other two. Dr. Bill, this Mr. Benson. I heard him tell the receptionist that he wanted you to look at a mole. You spent twenty minutes. Can you explain?”

Bill’s eyes narrowed the way they did when he was chewing a zinger. “He was telling me about a good fishing hole out on Cascade Lake.”

“On our time? Doctors, we expect you to spend no more than five minutes on a five-minute problem. Productivity!”

Bill’s voice twanged. “Mr. Barker, patient-care medicine is very much an art. Five minutes spent talking about a shared passion, such as fishing, are five well-spent minutes.”

Mr. Barker wiggled his nose and swung around to face me again. “Doctor, this afternoon you used up three and three-quarter units of time on an insurance exam! That company will not reimburse us for such extravagance. Dr. David. Your first morning patient... ”

David, Bill and I glanced at each other, then hunkered down like schoolboys in the principal’s office.

We have a dream, Dr. David, Dr. Bill and I. Like army recruits still safely drilling on some parade ground, we march toward our bright future. Comprehensive care. Patient needs primary. Business no longer a barrier between physician and patient. Joy reigns in Mudville.