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Health care system discussions

The Prostate Saga, Part 1

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I have something in common with Ian McKellan, Robert DeNiro, Colin Powell, Mandy Patinkin, Warren Buffett, and the Grateful Dead’s Phil Lesh. We’ve all had prostate cancer.

You might ask, “What is the prostate and what does it do?” Well, since you didn’t ask, I’m going to tell you anyway.

The prostate is both a blessing and a curse. Located just below the bladder, the prostate is a collection of muscular glands surrounding part of the urethra, that tube running from the bladder and through the penis to the outside. It has been compared in size to a small apricot. It secretes fluid containing zinc, citric acid and some enzymes which act as a sort of Miracle-Gro® for sperm, aiding in the quest to be the one lucky bastard that fertilizes the egg to create a pregnancy.

The prostate also provides an endless source for amusement for urologists hell-bent on pimping medical students. It works like this. The urologist asks the student to perform a rectal exam on a male patient and describe the impression, then sneer and say, “He’s had a prostatectomy. So, what were you feeling, “doctor?”

However, in our later years, the prostate often enlarges and squeezes the urethra, a condition known as Benign Prostatic Hypertrophy, or BPH. It turns a urine stream rivaling that of a firehose into an annoying dribble that usually ends in our underwear.  

Back in the Dark Ages (more than 30 years ago), we treated BPH with a ghastly procedure known as Transurethral Resection of the Prostate or “TURP.”  A surgeon would put a resectoscope, a lighted tube with a wire-loop cautery at the end, through the penis and drag the prostate out in pieces. I remember seeing men in the recovery room hooked up to 3-liter bags of irrigating fluid to flush out blood and chunks of well-done prostate.

Now we have a group of drugs called alpha-blockers (tamsulosin and others) which make urinating a lot easier. They still don’t make up for the overly large prostate compressing the bladder, which makes us pee a lot during the day and get up two or more times during the night.

The prostate also produces Prostate Specific Antigen (PSA), an enzyme that changes semen’s consistency from Elmer’s glue to runny-nose mucus. Measuring PSA in a blood sample is a screening test for prostate cancer; a “normal” value is ­< 4.0 ng/ml. A value above 10 ng/ml means a 50% chance of prostate cancer. A PSA value of 4.0-10 ng/ml is concerning and often means monitoring more often than yearly.

PSA testing has some of the same limitations as other screening tests. Remember when Gene Wilder promoted CA-125 screening after Gilda Radner died from ovarian cancer? CA-125 only picks up half of Stage I ovarian cancers, and CA-125 can be high with endometriosis, early pregnancy, ovarian cysts and pelvic infection. I had a patient who died of metastatic ovarian cancer with normal CA-125 levels.

A normal PSA doesn’t mean you don’t have cancer, while a high PSA doesn’t mean you do, since levels can increase with BPH, infections and ejaculation within 48 hours of testing. A man I know has been living with elevated PSAs for years despite negative MRIs and biopsies.

I’ve been getting annual PSA checks since 2007, which had been 1.0 ng/ml or less through 2017. It was 1.5 ng/ml in early 2018, but my prostate was larger and neither my urologist, Dr. Li K?, nor I were worried.

However, my level in March 2019 was 2.7 ng/ml. Even though this result was technically “within the normal range,” I couldn’t rationalize an increase this high. Dr. K? agreed and recommended a repeat test in six months (September).

Knowing the health care system often moves slowly, and mindful of the fact that the end of the year (and our deductible limit) was approaching, I got another sample in August, opting for both total (circulating PSA bound to proteins in the blood) and free (PSA wandering merrily by itself like an unaccompanied child) levels. The percentage of free PSA can predict which men with levels between 4 and 10 will likely need biopsies to detect cancer. The higher the percentage, the lower the risk.

May I have the envelope, please? (Drum roll)

PSA, total 4.4 ng/ml
PSA, free 0.4 ng/ml
% total/free 9
Probability of cancer 56%

Well, shit. I sent the results to Dr. K?.

“I want you to get an MRI at our facility. I know our radiologists and trust them.”

I texted my kids with the news, shamelessly figuring it might get their attention as they rarely contact me about anything. It did. No one actually called, but they did text me replies, the communication choice of Millennials everywhere.

“Is there anything you need?”
“How bad is it?”
“Am I in your will?”

No one texted that last one but I’m willing to bet it was in the back of someone’s mind.

The MRI
An MRI is something everyone should experience once, like visiting Graceland, then check it off the bucket list. Have another go at it? No, thanks, I’m good.

I had my MRI the day before my 65th birthday. Imagine stuffing a bratwurst inside a cannoli tube and then loudly banging on a variety of metal objects, at varying tempos, for an hour while telling the bratwurst to lay still. Oh, and we’re going to roast you low and slow.

The earplugs they provided did little to block the noise. A sleep mask would have been more helpful as the top of the machine was about 2 inches from my eyeballs, a bit unsettling even though I’m not normally claustrophobic. I started getting really warm about thirty minutes into the procedure. I complained to the tech who said, “We’re almost done. Just a few more minutes.”

Yeah, right.

Finally, it was over. The tech helped me off the table and said I should get results in 1-2 business days. That was on Tuesday, but I hadn’t heard anything by Friday.

Peg asked, “So, are you going to call them? This is ridiculous. It’s been three days.”
I said nothing.
“So, you think no news is good news?”
“Pretty much.”

On Saturday I got a text message, “You have new test results!” from MyChart, an electronic health record application and one of the few things Epic has done right. My MRI result was posted, and I figured it must be good news since no one had called me. Wrong.

“IMPRESSION: Overall PI-RADS 4: Clinically significant prostate cancer likely within the left posteriolateral peripheral zone.
FINDINGS:
PROSTATE:
Size: 33cc, 4.4 x 3.9 x 3.8cm in the greatest transverse, AP and craniocaudal dimensions. Central zone/transitional zone: There are multiple nodules of varying signal intensity on T2 weighted imaging within the central-transitional zone in an appearance consistent with benign prostatic hypertrophy.
(No shit, Sherlock.)

Peripheral zone: Oblong ill-defined 1.2 x 0.8 cm lesion within the left posteriolateral peripheral zone at the base and mid gland demonstrating markedly hypointense signal…Mild capsular abutment without extraprostatic extension.”
(Translation: You have a tumor about the size of a small blueberry in your apricot and that’s not good.)

Most physicians have had to give patients bad news during their careers, but it’s a bit different when you’re on the receiving end. I wasn’t surprised given the relative rapid rise in my PSA and the probability given on my last test. Still, I stared at the screen for several minutes before printing the report and giving it to Peg.

She was livid.

“No one should get a cancer diagnosis without a phone call from a physician! What if you were someone with no medical background?”

Well, I can’t argue with that.

Sometimes I’ve merely confirmed what patients had already been suspecting. One was a woman I met during one of my locum tenens jobs. I curetted her uterus for heavy bleeding and knew she had cancer just by the tissue’s appearance. A few days later I asked her to come to the office to talk about the results. She had an aggressive endometrial stroma sarcoma that would end her life in less than a year. The irony of working in hospice with terminally ill patients was not lost on her. She was calmer than I would have expected, but I didn’t know what she might have felt in the following weeks.

Peg found my lack of response unsettling.
“Are you not saying anything because you’re worried?”
“Not really. I’m processing. Would you like me to be hysterical?”
“No, I just want you to react! At least say something.”

I didn’t say much to Peg about the probability of having cancer. Maybe it was the physician in me that was used to dealing objectively with bad news. And it was somewhat perplexing as I figured my crappy lungs would eventually do me in.

I texted my kids again with the MRI results and that I’d need biopsies. Number two son said, “Well, if you have to have cancer, it’s good to have the boring kind.”

My eldest texted back, asking if the cancer had spread. Using talk-to-text, I said, “Nodes and pelvis are clear,” which it changed to “Nodes and Elvis is queer.” Gotta love technology.

I was looking for a client’s house somewhere in the northwestern part of Chicago when the office called to set up prostate biopsies. I’d already made an appointment for the following Wednesday to discuss the MRI results, so the scheduler changed the appointment to the procedure. She also said I had to take Thursday and Friday off.

I sent an email to my handler. “I need to take off next Thursday and Friday. I’m having a procedure done and I need to lay low for a couple of days.”

He replied: “How long have you known about this procedure? I need a lot more notice to move things around. I can’t just move things around so easily.”

Ok, wiseass, I was trying to be discrete. Now I’ll be blunt.

“I just found out about it yesterday while driving around Chicago.  I had an MRI last week that indicates probable prostate cancer. They called to set up an appointment for biopsies.”

Silence for several hours. Then: “understood.”

Prostate biopsies are usually done transrectally (through the rectum). The urologist inserts an ultrasound transducer into the rectum, then passes a spring-loaded biopsy needle through a guide and takes several samples, using the ultrasound image for guidance.

The only thing that produces pain in the large intestine is distension (you can clamp, cut, or stitch it with impunity), so, poking a needle through the rectal wall isn’t terribly uncomfortable. Injecting local anesthetic into the prostate produces a familiar pinching sensation, but it doesn’t burn as it does when injected into skin. And it’s much less painful than the old transperineal route, which required an incision between the scrotum and anus, known colloquially as “the taint,” and often done under general anesthesia.

Peg and I arrived early for my 5 p.m. appointment but then sat for 45 minutes in a nearly empty waiting room. The reason for that will become apparent in Part 2.

When we were finally granted access to the inner sanctum, Dr. K?’s nurse led me to the procedure room. The first thing I noticed was an instrument stand covered with a sterile drape on which sat several small containers filled with Formalin, a long needle attached to a syringe, and something that looked like a light sabre handle with a needle sticking out of the business end. She told me to take my pants off and put on the exam gown which barely covered my ass.

After Dr. K? engaged in the usual pre-procedure pleasantries, I lay on my left side on a very uncomfortable examination table, then she inserted the ultrasound transducer through my anal sphincter and halfway to my tonsils. It’s like using a butt-plug with fangs, with none of the erotic sensation.

“First I’m going to inject local into the right side of your prostate.” About thirty seconds later, she said, “Now the left side.”  She waited a few minutes for the lidocaine to do its thing before she started sampling.

The biopsy instrument is a very fine, spring-loaded needle that snaps when one pulls the trigger, capturing a piece of prostate tissue. It’s less noticeable than the anesthetic injection, but still made me wince slightly every time I felt that snap. I lay still and listened as she called out the locations to her assistant, who put the pieces into the small containers.

“Left apex.” *snap* (wince)
“Left mid.” *snap* (wince)
“Left base.” *snap* (wince)
“Right apex.” *snap* (wince)
“Right mid.” *snap* (wince)
“Right base.” *snap* (wince)

She told me to expect blood in my urine and stool for a couple of days and to call if I started passing clots. Clots???

“I’m going to call you with the results before I release them to MyChart.” (You’d better or Peg will have your neck. )

I made a follow up appointment for two weeks later.

My urine was slightly pink that night, but yellow the next morning, like a fine chardonnay. The only rectal bleeding was from an irksome hemorrhoid. Yeah, getting old sucks. I think I could have easily gone back to work, but I welcomed the break.

Dr. K? called me a few days later to tell me she’d received the pathology report; it was what we’d both expected.

Biopsy pathology report
Prostate needle core biopsy, right base:
-Atypical Small Acinar Proliferative (ASAP), in one of two cores
Prostate needle core biopsy, left mid:
-Adenocarcinoma of prostate, Gleason 4 + 3 = 7 (Grade Group 3)
–Tumor in 1 of 2 cores, tumor length 1mm, discontinuously involving 5% of submitted tissue.

Pathologists grade tumor cells based on how abnormal they appear under a microscope. Prostate cancer cell grades number 1 through 5 with five being the worst. The Gleason Score takes first and second most predominant grades and adds them together. The least malignant score is 2 (1+1) while the most malignant is 10 (5+5).  A Gleason score of 4+3 is worse than a score of 3+4, even though the sum of both is 7.

I’d considered radiation treatment as the lesser of the evils but the small amount of tumor in the biopsy relative to the size of the lesion, along with the “atypical” cells on the right side convinced me surgery was the better approach. I like having tumors in a jar; surgical specimen pathology is often more severe than the biopsies.

We saw Dr. K? the following week to discuss options, but I’d already settled on surgery. The problem with doing radiation first is that if the cancer recurs, surgery is nearly impossible because radiation has turned the prostate into mush, and you’re screwed. If you have surgery first, radiation is available if the cancer comes back.

There are considerable risks to radiation: difficult or painful urination; diarrhea, bowel cramping, fatigue, “sunburn” on abdominal skin, and the possibility of developing cancer in bladder or bowel. A Facebook buddy undergoing radiation for colon cancer told me “may I suggest rather than using the very pleasant descriptor, “you may experience occasional diarrhea” with “by week three you will have come to believe you’ve eaten and (sic) entire jar of jalapeños and are pissing pure lemon juice.”

Dr. K?, being a general urologist gave us the names of two colleagues, Dr. Fine. and Dr. Howard, both of whom specialize in robotic radical prostatectomy. Peg caught her off guard asking, “Who would you personally go to and who has the better bedside manner?”  She replied without hesitation. “Dr. Fine.”

I made an appointment with Dr. Fine for the following week.

Next month: To Surgery, and Beyond!

Apricot: © Can Stock Photo / Tigatelu
Prostate © Can Stock Photo / rob3000

Field Report

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I’ve been on the new job for more than three months now and it’s been a delight. I don’t regret walking away from the chaos into which my profession has descended. I don’t have to deal with ill-tempered administrators expecting the impossible. My visits aren’t rushed and there are no productivity targets.

And I have a lot of stories to tell.

Dead Men Walking
I’m astounded by how willing men are to put their lives and balls in jeopardy by lying like a cheap rug in front of their wives. I’ll ask the husband a question about health status he’ll say, “Of course, I’m fine!” She will roll her eyes, snort or say, “You didn’t tell him about this!”

I’ll ask men, “Are you under any stress right now?” They will shoot furtive glances at their spouses, sitting a mere few feet away, and snicker. I’ll shake my head and mutter, “Don’t poke the bear,” while thinking you’re living on the edge, fool.

Another question on the list is: “Are you short of breath at night when you’re in bed?” An eighty-one year old guy chuckled and said, “It depends on what I’m doing.” His wife narrowed her eyes and said, “Don’t go there.” You want to sleep on the couch?

There’s a memory test near the end of the evaluation.  I give members three words to remember before asking them to draw a clock face and hands to indicate a random time. I then ask if they can recall any of the words.

One woman got two out of three. Her husband, two rooms over, and in a wheelchair, blurted out all three words.

She yelled, “You shut the f*ck up!”

I thought, she’s going to beat his ass as soon as I leave. It’s best if I’m not around when the cops find the body.

And That’s When the Fight Started
I evaluated an octogenarian Hispanic couple with the aid of a translating service I call on my cell phone. It’s not as efficient as an in-person interpreter; often one side doesn’t hear the questions or answers. I make sure I look at the person directly rather than telling the translator, “Would you ask him/her…?” It’s far more polite and lets them know I recognize them as individuals rather than anonymous subjects.

Her answers were short with few explanations. Her husband, however, responded to every question with a dissertation before getting to “yes” or “no.” It went well until the end when I foolishly asked, “¿Tiene preguntas?” – “Do you have any questions?”

She began a tirade in Spanish to which her husband responded just as vociferously. The interpreter waited a few minutes before translating the argument.

“She says her husband is always tired because he watches the television too much and then can’t sleep, and isn’t that bad for him? He wants to know what is wrong with watching TV because he enjoys it.’”

Their son, who’d been sitting at the table during the entire interview, just snickered.

I said, “I’m not getting involved in this; thanks for your help” and hung up. The couple and their son paused to bid me adieu before resuming their, uh, discussion.

No Good Deed Goes Unpunished
I saw a woman in her mid-70s one afternoon. I had time to see her two hours earlier, but she didn’t want me to because “I have to finish doing my nails.”  When I arrived at the appointed time, her husband greeted me when I arrived and graciously offered me a seat at their dining room table. A red-headed ball of fire who reminded me of Gladys Kravitz joined us a few minutes later, snapping at her husband, who appeared to be the perfect Abner. “Where’s my insurance card? It was here on the table! Go find it!”

She had a badly infected toe, purple and swollen. She’d also had both hips and knees replaced, running the risk of infecting the bone around the replacements. When I pointed it out, she said, “I don’t want to go on antibiotics because they give me diarrhea. And I don’t want to go to the hospital to get IV antibiotics. Can’t they do it here at home?”

“Well, it looks pretty bad to me. If you don’t get it treated, you’re likely need it amputated.”

She scowled at me.

Being a conscientious sort, I called her primary care physician and relayed my concerns. She said she would call Gladys and prescribe antibiotics for the infection.

The woman called me the next morning on my way to another evaluation. “This is Gladys Kravitz. Are you the doctor that snitched to my primary care doctor?”

“Yes, I did. Yer gonna lose that toe if you don’t listen to your doctor.”

“I told you I don’t want to take any antibiotics.”

Well, one can only go so far…

Curiosities
Halfway between Harlem Road and Ridgeland Avenue, on US 30, the Google Map lady says, “Welcome to Indiana.” A hundred yards or so farther down, she says, “Welcome to Illinois.”  Indiana is a good fifteen miles to the east as the crow flies. A wormhole, maybe?

A hypertensive, obese Pakistani man spent much of the evaluation extolling the virtues of natural medicine, telling me how things like turmeric and lime would cure my own hypertension and obesity.

Only the Good Die Young
She was an adorable 88-year-old with a charming smile and a voice like Georgia Engel. She was legally blind and used a walker. And, like the Little Old Lady From Pasadena, she could be a terror.

I met her with her daughter and one of two caregivers who always stayed with her. I introduced myself and the first thing out of her mouth was, “Are you going to give me my driver’s license back?”

Her daughter said, “We had to take it away because she’s now legally blind and it’s not safe for her to drive.”

“Well, no, I can’t give you your license back.”

“Then what good are you?”

I continued with the usual questions.

“Have you had a heart attack?”

“Not yet.”

“Have you had a stroke?”

“Not yet.”

“Have you had any kind of cancer?”

“Not yet.”

“You sound like you’re looking forward to it.”

Before I left, I said, “Well, you are doing pretty well for 88.”

Her caregiver replied, “She can still give you the finger,” which prompted her to flip us off with both hands.

Tea and Sympathy

It’s not all fun and games. Sometimes I act as bartender or father confessor, listening to sorrows, regrets and frustrations.

A man from Pakistan brought his extended family to the U.S., along with their bitter familial feud. When I asked if he had any regrets during the depression evaluation, he said sadly, “I’ve begged my family to forgive me for bringing them here, but they refuse. Some of them won’t talk to me.”

A woman’s worsening arthritis left her unable to walk more than a few feet without agonizing pain. When her adorable, diminutive Shih-Tzu wanted a potty break, I let her out (and had to coax her back in because she wanted to play). We continued the evaluation, but she started to cry.

“Look at me! I can barely move. I used to go out all the time and now I can’t. I’m in so much pain all the time and there isn’t much they can do.”

A man only a few years older than me had lost his wife one month earlier after a short but horrible illness. He sat next to me on the couch, his late wife’s two Shih-Tzu puppies by his side, wagging their tails as they looked me over. He looked like a biker, big and burly, but he was completely lost without her.

“I have to get the house ready to sell, but I don’t have the energy.” His voice trailed off and he looked as if he could cry.

Early in my career I learned I couldn’t fix all the ills of my patients. Often, just listening without judgement or reproach is sufficient therapy.

Changes

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When I was in medical school an instructor admitted, “Half of what we teach you is wrong. The problem is, we don’t know which half.”  I could say the same about residency. Some of what I learned as an intern fell out of favor by the time I was a chief resident, such as x-ray pelvimetry to determine a woman’s likelihood of delivering vaginally, or the internist’s casual approach to glucose control in diabetic pregnant women.

The pendulum continued to swing over the next thirty some years of my career. We went from “Once a (Cesarean) section, always a section,” to “Every woman should be offered the chance to deliver vaginally after a Cesarean,” to “Let’s put a little thought into who should be doing this!”

I did a rotating internship after medical school because I had no idea which direction I should take. Obstetrics was the last thing on my mind because the physician with whom I had the most contact could be sarcastic and demeaning. That changed during two months of obstetrics in a completely different environment. I ended up taking the second-year position vacated by one of the first-year obstetrical residents who left to fulfill his three-year obligation to the U.S. Air Force. (I heard he went into radiology when he got back.)

Fast forward three decades. I was working as a locum tenens physician for the medical school I’d once attended. My old obstetrical tormentor had retired from practice but continued to be heavily involved in student and resident teaching. The years had mellowed him, or maybe it was because he didn’t have the stress and burden of a private practice.

One afternoon he asked to join me while I was doing an abdominal hysterectomy. I doubt that he remembered me from so long ago, but I was honored that he’d ask and was truly interested in what I was doing. The circle was completing; the student was now the master and the master was now “master emeritus.” Side note: I’ve never been cocky enough to consider myself a “master.”

A few months ago, I met a delightful young medical student doing her obstetrical rotation. She is intelligent, capable, ambitious and learns quickly. She began her first year as an ob/gyn resident in July, which has prompted me to reflect on what has changed since I was the youngster under the gaze of my mentors, some of whom were approaching retirement.

Ultrasound:  Ultrasound has been around since the early 1960s, but the first images looked more like abstract paintings than recognizable body parts. The ultrasound tech would swipe the transducer – a thing about the size of a restaurant salt shaker – that sent and received sound waves – back and forth across a woman’s abdomen. The results looked like this:

I couldn’t tell you what this was, and we suspected neither could most radiologists. More than once we would explore a woman’s abdomen because a radiologist swore “there is definitely an ectopic pregnancy present,” and find nothing.

Ultrasound has evolved. Machines can produce three dimensional images in real time, check on blood flow into and out of organs and measure minute structures in developing fetuses. Emergency departments now have FAST ultrasounds (Focused Assessment with Sonography in Trauma) which can rapidly detect internal bleeding or a pneumothorax (collapsed lung) at the bedside, obviating the need for a CT scan. It’s much better than the old way of diagnosing a ruptured tubal pregnancy, which was sticking an 18-gauge needle through the posterior vagina into the pelvic cavity looking for non-clotting blood.

Gonorrhea testing: Neisseria gonorrhoeae, the bacterium causing gonococcal infections, grows best within an oxygen-poor environment. We used to take a sample from a woman’s cervix, smear it across a culture plate, then stick it in a one-gallon pickle jar with a lit candle and close the lid, burning off the oxygen. By the end of the day we’d have 20 or so culture plates in the jar and the room would smell like burnt wax. Now we look for gonorrhea (and chlamydia) DNA on a cervical swab or in a urine sample.

Fetal monitors and intrauterine pressure catheters: Fetal monitors, which track a baby’s heart rate and a mother’s contractions, were introduced in the late 1960s and early 1970s.  Both were accomplished with devices placed on the mother’s abdomen, but the results often were inaccurate. The scalp electrode, created in 1972 by the venerable Dr. Ed Hon, allows us to monitor the baby’s heart directly.

The modern intrauterine pressure catheter (IUPC) measures contractions through a solid, transducer-tipped catheter threaded into the uterine cavity. The early catheters were fluid-filled tubes connected to a small strain gauge transducer which required a dome of water placed directly on the pickup before the cover was screwed on. The transducer then had to be taped to the bed rail at approximately the same height as the uterus.  Sometimes we’d use a tongue depressor and thick adhesive tape to keep it in place. Then we’d open a stopcock to “zero out” the system, close the stopcock and hoped it all worked.

Determining ruptured membranes: Back in the old days we determined if a woman had “broken her water” by inspecting the vagina with a speculum for amniotic fluid, testing any visible fluid with nitrazine paper, and then slapping some fluid on a slide, letting it dry and look through the microscope for “ferning.” If there was any question, we’d have the woman wear a pad and check for fluid an hour or so later, or, in rare cases, inject indigo carmine dye into the uterine cavity and look for blue fluid in the vagina.  When ultrasound came into widespread use, we looked at fluid levels around the baby.

Then a company created an expensive test to check for an amniotic fluid protein to determine whether membranes had ruptured. Their ad campaign preyed on all our fears by asking, “Are you really, really, absolutely, positively sure?” Hospital administrators took away our nitrazine paper and microscopes because now they had a test for which they could bill. Doctors liked it because it meant they didn’t have to stagger out of bed in the middle of the night to do an exam, or so they thought.

Then in August 2018 the FDA issued an alert reminding physicians “that the labeling for these tests specifies that they should not be used on their own to independently diagnose…ROM (rupture of membranes) in pregnant women.”

A Korean study found a positive test in a third of women in labor with intact membranes. A review of ROM testing published in The Journal of Obstetrics and Gynaecology of Canada was cautiously optimistic about protein assays although they cautioned “Further studies are needed to assess the reliability of the test according to the time from membrane rupture.” So what would make the critics happy?

We do our best, but nothing is perfect.

Hysterectomy: Vaginal hysterectomy has been compared to rebuilding an engine through the tailpipe. The Grand Old Man of vaginal hysterectomies attached to my residency program retired during my second year, so I learned to take out uteri through an abdominal incision. Not that I couldn’t do a vaginal hysterectomy, but I liked being able to see what I was doing. Few things are worse than fishing for a bleeding artery through a vagina.

Laparoscopic-assisted vaginal hysterectomy (LAVH) started to become popular in the 1990s, but the learning curve was steep. I knew physicians who spent seven hours on their first few LAVHs after going to a weekend course, which is no substitution for extensive residency training.

The alleged advantage of LAVH was being able to detach the tubes and ovaries under direct visualization, but one still had to finish the procedure vaginally. Most of the required equipment was disposable and expensive, making it 40% more expensive than a traditional vaginal hysterectomy. Some of us thought LAVH made up for a lack of skill.

Robotic surgery started becoming popular in the early 2000s, but robots were used more for marketing than for patient benefit, and they weren’t cheap. A robot cost $1-$2.5 million up front and came with a $100,000 to $170,000 annual service contract , enough to give any hospital bean counter palpitations.

But, after years of experience and refinement, doing a hysterectomy exclusively with laparoscopic equipment made total laparoscopic hysterectomy (TLH) a truly “minimally invasive surgery.” One surgical assistant told me taking the detached uterus out at the end was like uncorking a bottle. More than one study found there was no advantage to using robotics over TLH. I suspect many of those machines will be gathering dust in closets, sitting next to $100,000 carbon dioxide lasers used to treat precancerous cervical lesions before LEEP (wire-loop cautery used to whack out a chunk of cervix) became popular.

Employment: Physicians were masters of their domains for most of the twentieth century. In the early days, you graduated from medical school, did a year internship to get a license and hung out a shingle as a general practitioner.  Specialties (and specialty boards) started appearing during the 1950s, along with residency programs lasting three to seven years, and the old GP would become extinct. Physician practices were still largely independent even into the 1990s. Being employed by a hospital or, worse yet, a “goddam HMO” made you a substandard physician who couldn’t get a job anywhere else in the eyes of the Great White Fathers who still ran things.

But, as I’ve previously discussed, things have changed. By 2017 less than half of American physicians owned their own practices, especially in metropolitan areas. I live in the Chicago suburbs where a large majority of private practices have been absorbed by large medical groups and/or hospitals. New physicians expect to be employed rather than deal with the headaches inherent in independent practices: personnel, equipment, rent, taxes and liability insurance, which can run $150,000 a year for an ob/gyn. We gave up autonomy for financial security and lost both in the process.

Patient care and ownership: The generation of physicians before me cringed when administrators used terms like “customer service,” but in their hearts they knew what it meant. They took good care of their patients because those patients were their livelihood. In a group practice the patients were all OUR patients, rather than MY patients and YOUR patients.

Primary care developed “concierge care” as a backlash to corporate medicine. Concierge care promises same day or next day appointments, access to one’s physician 24/7, unhurried visits and “personalized care,” or what I used to know as “doing my damn job!”  I’ve called patients with test results, talked to them at all hours of the night and I made at least one house call to check on a patient’s Cesarean section incision that had opened up.

This “white-glove customer service” comes with annual fees ranging from $1000  to a whopping $25,000! And that is just for the privilege. Actual care still costs money. You can’t use Flexible Savings Account (FSA) or Health Savings Account (HSA) money for the fee, so this isn’t an option practical for the masses.

I’d like to think there’s a new generation of physicians willing to fix what’s broken for everyone, but I’m not holding my breath.

An Epidemic of Stupidity

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I’ve declared the third week of July as National Health Care Stupidity Week, for I’ve never encountered such high levels before.

I saw an ophthalmologist for a problem with my left upper eyelid at the beginning of July and scheduled surgery for three weeks later. We asked the scheduler how much the procedure would cost but she said, “It depends.” That’s not much of an answer to a physician who understands the vagaries of CPT coding and insurance reimbursement. You give the insurance company the codes and your charges. The insurance company laughs their asses off and then tell you “No fucking way. THIS is what we’ll reimburse you.”

The scheduler said, “I’ll ask the doctor what he plans on doing and I’ll call you in two days with the charges.”

I can understand if the physician wasn’t quite sure what he was going to be doing right after seeing me, so we let it go.

The week’s aggravation started at Drugs ‘R’ Us, a national chain, which the threat of litigation prevents me from identifying. I’ve used a maintenance inhaler for life-long asthma, for which there is NO generic. The price has climbed from a $150 insurance copay for a three-month supply from a parasitic mail-order pharmacy benefit manager to $400 for one and NO insurance coverage until (my very high) deductible is met. I brought this up to my pulmonologist last month and asked for a little-known generic equivalent (different medications but should have the same therapeutic benefit).

He said, “Well, Thieving Bastards Pharmaceuticals have this discount card that will give it to you for free if you have insurance. It’s good until December 2018.”

I learned a long time ago there ain’t no free lunch, but if they are willing to part with it for free, I’m in. I took it to Drugs ‘R’ Us and, after 20 minutes or so of fighting with the computer, I got my inhaler. ONE inhaler. I have to go back every month for this charade.

The pharmacy’s robot phone said I could pick up this month’s inhaler. However, the pharmacy tech brought me a bag with three inhalers and a bill for $935 “because you haven’t met your deductible.” No shit, Sherlock. I have insurance with a high deductible and a health savings account (HSA) which is great at a certain income level but completely useless if you’re making minimum wage (in which case you probably don’t have any insurance and you’re a drain on society, at least according to the bastards who’ve been trying to undo the ACA for the past 8 years).

“Last time I got one and it was free! Here’s the card and I’m NOT going to pay almost a thousand bucks for this. I’d rather die a quick and painless death.” (I’m using that phrase more often these days.)

“Well, let me change it but I have to run it through the system again. It’s going to take some time.”

Fine. I sat in one of the uncomfortable chairs in the pharmacy waiting area and perused the local paper, which didn’t help my mood any.

Then my phone rang.

“Hi, this is Brunhilda from the Pretentious Suburban Surgery Center. Your insurance is going to pay 80% of the procedure after you’ve met your deductible, but you haven’t met your deductible, so we want your left testicle ($1305) as a down payment.”

“First of all, why? Second, what is this going to cost me in total?”

“Well, we ask everyone for a down payment.”

No, you said it was because I hadn’t met my deductible but, please, proceed.

“Why? This isn’t a cosmetic procedure and I’ve already signed the boilerplate insurance assignment form that says I’m responsible for the remainder.  So, again, what is this going to cost me?”

“We can’t tell you what we charge, and the insurance company won’t let us tell you what they will pay us.”

“Why not?”

“It’s in our contract.”

“You’d tell me if I was paying for all of this out of pocket, wouldn’t you?”

Silence

“Well, my financial adviser has told me that’s not a great idea. I’ve got an HSA funded with pretax dollars and if I overpay you and you then reimburse me directly, I might run afoul of the IRS, which is not known for being gracious.  Would you be willing to talk with her as I have to leave town in a few minutes?” (Translation: “If I acquiesce to this extortion, Peg is going to ream me a new one. We’re going to play good cop/bad cop and I’ll let her ream you a new one. You really don’t want to poke this bear, but you’re gonna have to learn the hard way.”)

She says, “I’d be happy to!” and I hung up, snickering.

An older woman came to the pharmacy while I was waiting. She was bent over a wheeled walker, wheezing audibly as she shuffled up to the counter. I suspect she had long-standing COPD and it made my lungs hurt just to hear her breathe.

“They called me and told me my prescriptions were ready.”

“What’s the name?”

She wheezed her name.

“Your prescriptions have expired, and we put a call into your doctor’s office to get authorization for refills.”

“But someone called me and asked if I wanted all my prescriptions refilled. She even listed all of them and I said ‘yes!’ Then I got a phone call from you!”

“That is an automated system and we don’t have any control over it.”

This went on for several minutes with the poor woman protesting that she’d done everything she’d been told but slowly realized this trip had been for naught.

Finally, she sighed, said, “Well, what are you gonna do,” turned around and shuffled out. She was far more resigned than I ever would have been. ( is one of my all-time favorite revenge movies. Just sayin’.)

The pharmacist came out, handed my drug card back to me and said, “We put in a phone call to the company and we’re waiting to hear back. It shouldn’t be too long.”

Twenty minutes later I was still waiting. Finally, I got up and said, “I have to leave town. Can my wife pick this up?”

“That’s no problem. We’ll let her know when it’s ready.”

Then I asked her. “Is there a generic for this because the card expires in December and I can’t afford $400 a month for this.” I gave her the generic medication names.

“It looks like the only one is ‘Yerstillscrewed’ but insurance doesn’t cover it.”

“I KNOW that, but I can get a three-month supply using GoodRx for less than half of what one of the brand-name inhalers costs.”

It’s turns out that Thieving Bastards Pharmaceuticals changed the program so that it only covers that drug up to $200/month. You know, the drug for which they set the price at $400.

I left and started my drive to Springfield. I was just about at Joliet when the phone rang.

“This is Vinnie, the enforcer, uh, business manager from the doctor’s office. I wanted to let you know that your insurance is going to pay 80% of the procedure after your deductible is met, but you haven’t met your deductible, so we want your right testicle as a down payment.” (It’s been two weeks since the initial visit and less than a week before surgery.)

“Why?”

“It’s our policy.”

“I’ve had other procedures and visits, and no one has EVER asked for money up front. You just told me what my deductible is, and you know how much I’ve met, which means you also know I’ve been paying towards it. The surgeon’s fee and the surgery center charges are likely to eat up the rest of my deductible. Again, how much is this going to cost?”

“It depends.”

“What do you mean, ’it depends?’ That’s bullshit. There’s a CPT code for the procedure, and you have a charge for it. I know that because I’m a physician and I’ve had my own charge list. You’re going to give the insurance company a bill with a CPT code. They are going to send me an EOB (Explanation of Benefits) which will tell me what YOU charged, what they allow, what they’ve paid and what my obligation is. So, to pretend this is a deep, dark secret is disingenuous. The only thing that “depends” is how much the insurance company is going to pay you and your contract with them defines their reimbursement. So, to ask me for money up front is insulting. You’re making me sound like a deadbeat.”

“No, no, we do this with everyone.” (Where have I heard that before?)

“Yeah, well no one else has ever asked me for a deposit! No one asked for a deposit before my colonoscopy, or when I went to the ER for a doppler scan for lower leg pain. Look, at this point I’m ready to cancel the whole goddam surgery and find someone else!”

“No, no, no! I’ll talk to the doctor and let him know how you feel and you can discuss it with him.”

I called Peg, who spent the next three days dealing with the office, getting nowhere. Finally, she got a call from the new office manager, a far more reasonable person. They talked for a couple of hours about what appears to the patient to be a hostile approach to payment. It was both illuminating and infuriating.

High deductible health plans are sometimes several hundred dollars a month less expensive than plans with lower deductibles. Some high-deductible plans come with Health Savings Accounts (HSAs), a Republican wet dream Paul Ryan drags out as an alternative to the ACA. HSAs are funded with pre-tax dollars – a maximum of $3450 a year for singles and $6900 for families in 2018 – which can only be used for health care expenses, at least until the account holder reaches 65. Old goats like me (over 55) get to put away an extra $1000 per year in our HSAs. The plans still come with  out-of-pocket maximums of $7,350 for singles and $14,400 for families.

This is a great idea if your income level allows you to part with a few hundred bucks a paycheck and you’ve got a tidy sum in your bank account. It sucks if you don’t have the income, the savings, or if you anticipate ongoing medical expenses.

Here’s the problem. Lower income people get high-deductible plans because the premiums are affordable, but they are at greater financial risk because they don’t have the savings to cover the deductible. They may avoid preventive care if they are unaware that most high-deductible plans cover it with no out-of-pocket costs, opting to take a chance they won’t develop a more serious (and costly) illness later. Because they often can’t afford the deductible, they are more likely to default on outstanding medical bills. Hospitals and physicians have caught on and now demand money up front.

Asking for a down payment would be far more palatable if it applied to everyone. It’s no different than a contractor asking for money up front for a pricey remodeling job. Pay some now, pay the rest when the job’s done. But framing it as something required only of people who haven’t met their deductible implies they are deadbeats and is insulting. Further, waiting until a few days before surgery to extort money is infuriating. It should all be explained up front when scheduling the surgery.

The logical solution is universal coverage, but Congress lacks the political will and there are too many people making waaaaay too much money off the current system.

Hang on, because it’s only going to get worse.

 

Commencement

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June is the month for graduations and commencement speeches. I accomplished the former in 1979 and it’s unlikely I’ll ever be asked to do the latter. I wrote this in 1998 in response to a long-forgotten question my sister-in-law asked and revised it for this blog post.

To all graduates, family members and faculty, welcome. It’s my honor to be here today. I might not be if it was not for persistence, determination, and the fear of being stuck with loans I couldn’t repay if I was unemployed.

First, to the esteemed faculty:

When I applied to medical school, admissions committees wanted applicants who looked good on paper: science degrees, high test scores, ambitious undergraduate years, and largely male. They frequently weeded out those with the characteristics patients wanted in their own doctors, replacing them with what they were most familiar – future Great White Fathers.  If those anomalies survived medical school and residency, they were often ostracized and driven out once in practice because they refused to follow the herd and questioned what we did. The heretics among you kept you honest; you needed them to grow. And you have made progress.

Medical school classes have become more diverse. Women made up slightly more than half of applicants and new students in 2017. The FlexMed program at Mt. Sinai’s Icahn School of Medicine in New York has admitted nontraditional students for thirty years. There are fewer white and more Asian-American students admitted, but the percentage of African-American and Hispanic students remains low.  A lot of work remains.

There are many different ways to teach and to learn.  The creation of medical schools was done, in part, to standardize what was taught and to ensure some semblance of consistency in medical training.  But much has been lost confining students to classrooms and expecting them to read volumes of medical literature taken out of context.  The old guys used to say, “Look at the patient, not just at the lab tests!”  Teaching at the bedside still has a place and cannot be replaced by expensive computer-controlled models or simulations.  It can be done with integrity and respect for the patient — and for the student.

Be careful what you say, for the damage might be permanent.

I did a month rotation with a faculty urologist during my junior year of medical school. At the end he wrote “He does not have what it takes to be a physician,” on my evaluation. I should not have been surprised; his over-achieving son, a year ahead of me, had highlighted the entirety of Harrison’s Principles of Internal Medicine – a 1200-page tome – in four colors, and he had purchased his own indirect ophthalmoscope. I was stunned, humiliated, and spent the next six months wondering if he was right, if I should drop out and career for which I was better suited.

Remember the golden rule.  Do not “teach” medical students with sarcasm, derision or humiliation. Bitter, cynical students and residents become bitter and cynical physicians. We all suffer for it – patient and physician.  If you can’t say something nice, don’t say anything.  But it is not that hard to find something good in someone.

Always teach the art along with the science.  Teach students and residents to laugh and cry with their patients, to rejoice in the little accomplishments and grieve for the losses.

Above all, teach them the grave responsibility that comes with the profession. This is not shift work; a job to endure until retirement. It should still be viewed as a calling.

To the new graduates:

Even though William Hurt’s movie The Doctor is dated, all beginning medical students should be required to watch.  Your patients will be people with weaknesses and vulnerabilities hidden behind their strengths. You share those same weaknesses and vulnerabilities although you are loath to admit that to yourselves, your colleagues and your families.  Walk many miles in your patients’ shoes; you will be a better physician for it.  Accept that you are not perfect and never will be; your patients already have.

Long gone are the days when a physician hung out a shingle and practiced the way he wanted in an office he owned, before he retired after forty years. I say “he” because back then women physicians were few (and resented). Many, if not all, of you will be employed by a corporation.  Be careful and realistic.  The perceived security of a steady salary, liberal vacation and “avoiding the business hassles” comes with a hefty price tag.  When we trade autonomy for financial security, we end up with neither.  Some of my colleagues regretted selling their souls.  You will be judged on how much you cost the company, not on how compassionately you treat patients, which may adversely affect the care you provide your patients.  You will also be judged on your loyalty to those who sign your paycheck. They expect you to be a “team player,” even when the team bus is headed for a cliff. Or, as one of my former partners asked me, “Why can’t you just take the money and shut up?” Don’t leave your conscience at home.

Managed care is not intrinsically evil, but its implementation has been fouled by greed, callousness and stupidity.  It is an imperfect response to the rising cost of health care, an event which has largely been ignored by the medical profession.  My predecessors robbed the candy store and left all of us with the aftermath.

People do not trust the health care system; you can help restore that trust.  But don’t make promises you can’t keep.  Properly managed, there will be care for all.  But health care dollars are not infinite. You must choose between want and need; what is desirable and what is necessary.  As the Rolling Stones sang, “You can’t always get what you want, but if you try sometime, you just might find, you get what you need.”

Beware of the Golden Handcuffs. Avoid conspicuous consumption and remember money cannot buy happiness.  You can’t spend it if you are 6 by 6 in the dirt, and you can’t take it with you.  He who dies with the most toys still dies.  Keep in mind you will still be making more than 99% of the population.  Also remember you told the admissions committee some ridiculous story about going into medicine to help people, not to make a lot of money.  If you tell a lie long enough, it becomes the truth, so make it true.

Be kind to nurses, because they can make your life easy or a living hell. They also have your back and may one day prevent you from doing something completely stupid.  You owe them far more than those in the administrative suite who often have no idea what you really do.

Be grateful and acknowledge the other people that help you do your job: unit secretaries, housekeeping, maintenance, phlebotomists, transporters, techs. It won’t kill you to smile and say hi. Trust me, they will notice.

Find other things to do with your life.  Medicine cannot be your entire universe; you need to strike a balance in your personal life.  If not, your spouse may leave you, your kids may hate you or, worse yet, not know you.  You will be tempted to ease the pain with drugs and alcohol.  Some of you may be driven to suicide–a waste of a good doctor and the taxpayers’ money.  You won’t be much good to your patients–and yourself.

Don’t be afraid to pick up a colleague who has fallen.  Someday, the favor may be returned.  Don’t compete, keep score, or ostracize each other.  There isn’t any point.

If you find yourself wondering why you go to work in the morning, it is time to pick another profession.  If you never question why you go to work, you made the right choice.  This has been an honorable profession.  Let’s keep it that way.

Thank you and good luck.