Welcome to 'Out of Their Liberal Minds'

On July 26 I indulged a personal experience to highlight issues affecting the deplorable state of American health care:
"I missed my self-imposed bi-weekly deadline for commentaries because a health issue intervened. A bit of calf pain on the tennis court and a persistent good friend who pushed me to be examined to rule out a thrombosis risk led to a provisional diagnosis of popliteal cyst (a benign bulge behind the knee) which led to an attempt to drain it and an order for ultrasound for confirmation which was the first hiccup in the orderly process: it took over a week to get a simple ultrasound examination in Kailua Kona because there just aren’t enough techs to serve the island. Moving forward, I had not a cyst but a popliteal aneurysm (a bulge or ballooning) of artery, the major vessel behind the knee delivering blood to the lower leg and foot. There was blockage, and the ultrasound itself couldn’t determine if it was partial or complete. Since there seemed to be a well-trained vascular surgeon about 80 miles away we opted to seek local care. Fortunately the referral process went quickly, and Ruth and I headed off to Hilo to meet the new MD, and six days later space opened up at Hilo Benioff Hospital where I was invited to attend at 5:30am to get processed; anesthesia started around 7:30 then into surgery for angiogram to get an accurate picture of the blockage followed by surgery to bypass the blockage, and into recovery at about 3:00 pm. Two more days in the hospital. Now three weeks post-surgery things seem to be progressing at least as well as expected if not better.

The saga of confusion and concern that I experienced, I hope, will lead us to considering the broader progressive agenda I urge in these essays and consideration of what I perceive as major shortcomings in American health care which is now a national political crisis as well. I’ll also note that my concerns and observations were definitely influenced by my decades of experience as a medical malpractice trial attorney (something I don’t discuss with my health care providers for obvious reasons).

On admission I was asked if I had an advance care directive, a routine question before any major procedure or hospital admission. For anyone not familiar with this document, it is a simple statement of (a) who to speak for you if you are not able to make decisions about your medical care [for example, if you’re under anesthesia and complications require immediate decisions] or (b) what you want done in an extreme situation, and end-of-life decisions have to be made -- basically, do you want to have your life prolonged if you no longer have brain function. Each state suggests a form for these instructions. My personal view is that everyone should have such a directive as part of normal life planning, and Ruth and I indeed do have one -- in the stress of the moment I just didn’t think to print it out and bring it with me. But an aha moment: I had my laptop computer with me -- planning to be able to keep up with e-mails and do some writing while in the hospital -- and was able to e-mail the advance care directive to the admissions clerk which she acknowledged receiving and putting in my chart. In spite of this, throughout my three days in the hospital and contact with multiple professionals -- doctors, nurses, technicians, therapists -- all of them in their record entries referred to me as a “full code”, meaning no one was aware I had an advance care directive on file, meaning that contrary to my directive all extraordinary measures were to be taken to prolong my life even in the catastrophic case that I became brain dead and urgent decisions might be made by strangers without consulting Ruth as to what I might want! I’m sure you can understand my consternation when it was apparent that people weren’t reading the record or communicating amongst the staff.

I subsequently reviewed the surgeon’s operative report and learned that a physician assistant, not a surgeon, “scrubbed the entire case as first assistant as we had no available resident or co-surgeon” and performed important parts of the operation including surgically removing the saphenous vein used in the bypass and helping close things up when the grafting was completed -- tasks usually performed in medical centers by an MD surgical resident or an actual assistant surgeon. While nowadays it seems that the shortage of physicians means a lot of PAs are trained to act as surgical assistants and the the PA in my case seems to have done a good job as far as I can tell, this is another highlight of the general shortage of physicians, particularly in non-urban communities. (We’ll come back to that a little later.)

Continuing my story, after a short time in recovery, I was moved to a two-person hospital room to begin the recuperation process. I was visited by a variety of very nice people --nurses, physical therapy helpers, occupational therapists, orderlies, and the occasional doctor -- but it soon struck me that they didn’t seem to talk among themselves. Virtually every one asked if there were stairs in my home, who did the cooking, who lived with me; simple question and not bothersome by themselves, but increasingly annoying in that no one seemed to have looked in the chart which had all this information.

I never did actually meet my roommate because the curtains remained pulled, but I could hear his conversations with his visitors. The first evening a physician told him the results of his scan had shown considerable cardiac damage and he required prompt open-heart surgery. I could unavoidably overhear him telephoning people with his concern that he might not survive much longer and his conversation with his mother who had driven cross-island to visit the next morning. But then in came a nurse to tell him the good news: the doctor the night before thought my roommate was “John F” but he was actually “John M,” and wasn’t it funny that there were two patients named “John” on the floor at the same time. (I’ve changed the common first names, but you get the point.) Again, rushed and inattentive, the system breaks down.

My own experience was that no one could give me information about my condition, the expected length of stay in the hospital, the usual course of recovery or what to expect; everyone deferred to someone else. I could not escape the feeling I was encountering great disorganization, and subsequent events confirmed my concerns. It seemed that once admitted to the hospital, neither my vascular surgeon nor my primary care internist were my primary caregivers; I was under the control of hospitalists, physicians whom I never met and knew nothing of their qualifications but who were now in charge of my care, including my post-surgical care and deciding when I could be discharged. (There are notes by two hospitalists in my chart, both replete with multiple errors about me and my medical history, including a notation I was “full code by default”, but I digress.)
The next day I was moved. The hospital was over-populated (I later learned this hospital always operates over capacity, as does the other major Big Island hospital, something which could theoretically cause them to lose accreditation) and they needed my space for a patient who had to be hooked on to monitors, which I no longer evidently needed. I’m not sure who made that call since I was one-day post-major vascular surgery. I was moved to a 12-person “ward” which my doctor friends tell me they haven’t seen in decades. Here in what was called the Overflow Gym, and indeed may at one time have been a gymnasium -- perhaps for physicial therapy??? Here there were no electronic monitors, not even nurse call buttons (just a little chrome bell like you encountered when you checked into a motel in years gone by). Fortunately I was able to ambulate to the bathroom -- probably against medical advice given the roughly 18” of surgical incisions on my right leg -- and noted that the toilet seat remained stained and there was no evidence of regular sterilization of the bathroom servicing a dozen patients!

In general nursing and therapy staff was busy but comforting, seemed generally competent, but totally inadequate in numbers. Moreover a patient in the next curtained area had a persistent cough and one in an opposite curtained enclosure unexplained throwing up. Not reassuring to me with my post-surgical concerns about not getting an infection. So I was thrilled when the second hospitalist said I could leave on my third day. Now three weeks plus post-surgery, I believe I’m on the road to successful recovery.

As I’ve subsequently tried to examine this experience from a macro rather than micro view, it seems my experience was just a reflection of the greater disorder in American medical care and particularly relevant to the liberal mind. It is almost a certainty that all of us or someone very dear to us will have a similar experience: hospitalization, possibly on an urgent basis, surgery and recovery. They will encounter over-capacity hospitals, hospital facilities in need of renovation, inadequate supply of trained auxiliary staffing (nurses, therapists), medical caregivers without the time to read the chart or correct erroneous entries. Fortunately in my case the list of issues didn’t include incorrect medication, surgical complication, or other medical errors I observed in my legal practice.

The answers must emerge from the political and economic restructuring of the United States. The system needs a shake-up. Let’s begin with the use of hospitalists. Yes, statistically they do shorten in-patient time and reduce costs (for better or worse), supposedly without damaging quality of patient care. Some European countries have adopted a similar protocol, using internists to supervise the first couple of hospital days, but nowhere does it seem that you are entirely under the control of the hospitalist: turning you over to doctors you’ve never met, no continuity of care, post-surgical care under the supervision of doctors with no training in the area of your particular issue, all in the name of efficiency and reducing hospital cost. I for one like to know that my physicians are the product of good medical schools and well trained thereafter; I’m denied that information when assigned to a hospitalist on a non-emergency basis.

I’m still awaiting the first report of the cost of my surgery and hospitalization. Fortunately with Medicare it is likely my supplemental costs will be manageable. Imagine, though, if I had been a Medicaid patient in post-Big Beautful Bill Trump world with all of its Medicaid cuts. Without national health insurance many will not receive the care I got or will face bankrupty when the bills come in.

But the problem is far greater. We face a crisis shortage of doctors throughout the United States, particularly in the less urban areas. Projections suggest variously that we’ll be short anywhere from 86,000 to 124,000 physicians within ten years. Presently there are about a million doctors in the United States, about half in medical specialties; some twenty percent or physicians surveyed indicate they are likely to leave medical practice entirely within five years. Our doctor-to-population ratio is already significantly lower This starts from the fact that for generations the medical profession deliberately controlled the number of medical schools in the United States and made admission extremely difficult and selective. Add to this the fact it takes at least eight years (four undergraduate plus three in medical school and one year mandatory internship) to become an American doctor, add on years of medical residency specialty training, versus six years in European countries. Medical education is free in Germany and in France, Portugal, Spain or England costs about one-fifth the cost of U.S. medical education.

We need many more hospitals and beds to eliminate chronic over-capacity. We need many more nurses and other ancillary health care professionals. It should not take over a week to get a routine ultrasound examination and another week before a hospital bed becomes available for semi-emergency surgery. We urgently need many more publicly supported medical schools and government funding to reduce the high cost of medical education and speciality training. This will never happen in a Trump/MAGA universe. And post-Trump American health universe is going to be painful. An overhaul of the entire health care system requires a forward looking government and a progressive agenda. It should not be acceptable that the richest country in the world has increasingly third-world health care.

Once again I end with an urge to advocate. Organize, write, protest. Demand our legislators be people who will respond to these needs. It must start at the grass roots level.