Monday, December 13, 2010

My Impersonal Physician (Reduction In Services)

You have arrived at your destination. 

     I first learned the phrase "Personal Physician" reading about President Kennedy's "Personal Physician",  Dr. Janet Travell, when I was quite young.  (It must have been in Life magazine or perhaps Look.)  Dr. Travell was the first female doctor ever to hold that post, and the Kennedy administration seemed so shiny, new and suitable for publicity that I remember so much about it perfectly (including, of course, its tragic aspects).

 Dr. Janet Travell, Personal Physician to President John F. Kennedy

     Hearing the phrase “Personal Physician” repeated over and over during the succeeding years on television and radio during presidential health emergencies, administration changes, in memoir publication reviews and  other celebrity contexts (Elvis and Jerry Lee’s Dr. Nick; the Beatles’ pseudonymous Dr. Robert, Michael Jackson’s legion of doctors who should all be in jail) ensured that it got stuck in my shallow unconscious.

Dr. Nick, legendary Personal Physician to Elvis Presley and Jerry Lee Lewis

I have two degrees of separation from former president Richard M. Nixon (see below) and Elvis Presley.

     I hadn't thought of it for quite a while, but two medical appointments last week brought it to the surface when I suddenly, jarringly realized that I had just visited my “Impersonal Physicians”. 

     These were both routine visits (one was for an annual physical, the other a semi-annual check-up with a specialist), but, contrary to the cliché “plus ca change, plus c'est la meme chose” (whose origin I examined in an earlier post), I was suddenly struck by the realization that some things do change, irremediably and for the worse.

     I have been a patient of both of these doctors for about four years, since we moved to Pennsylvania from New York.  Ostensibly, they are both superbly trained and they are affiliated with same distinguished university hospital, which maintains an extensive suburban facility near our house.  When we lived in New York, it was universally assumed that medical care of this caliber could only be obtained in Manhattan, and having access to this hospital is said to be one of the great benefits of living in our area.

He and I seem to be equally obscure to my Impersonal Physicians.

     However, both of these visits made it abundantly clear that neither of these two doctors knows me from Adam and that if I ran into either of them in public --  if I dropped down dead at their feet wearing an enormous name tag and a set of oversize Elton John-type lighted spectacles  spelling out my name and our doctor-patient tenure in 50-point type -- neither of them would have a clue or a care as to my identity, our relationship or my life or death (provided my account, including co-payment amounts, was in order).  This is disturbing.

Sir Elton John

     Impersonal Physician No. 1, my internist who administered the annual physical, has never once looked me directly in the eye.  Having been schooled from an early age, and then professionally as a lawyer, in the imperatives of eye contact, a firm handshake and not acting weird in professional situations, this is unusual and at this point upsetting.  Her responses to questions are cold, abstract and mostly irrelevant, indicating a lack of preparation for appointments, as well as the sort of passion and empathy we would like to expect from people engaged and paid to provide crucial health advice intended to bring positive results.  A polite inquiry of the "and how are you, Doctor?" variety causes a small electric shock effect to register across her face  (but no verbal response)  followed by a distinct frown.  I suppose that's at least something -- a runic sign of an irrelevant pulse.

William Fairland and Francis Sibson, Dream Anatomy, 1869

     Impersonal Physician No. 2, the specialist, is a much more responsive, live-wire individual, but appointments are all about him, not you.  A handsome guy, intelligent and self-possessed, he fancies himself a rock star among men and medical professionals, and there's a certain off-putting You're So Vain vibe in our conversations.  Having known and worked with some real rock stars over the years, this sort of thing can be charming and memorable in the appropriate context, which doesn’t include medical appointments where a little bit of self-effacement and quiet modesty would go a long way towards instilling a feeling of reassurance in always insecure, worried patients.

Noel Coward would have been a rock star, I think.

     Neither doctor exhibits in the slightest any degree of empathy, curiosity and engagement with you, their patient and client.  As legendary Cosmopolitan magazine editor Helen Gurley Brown would say when discussing the requirements for articles she wanted to publish, neither of them has any “me and you” about them; neither “sits down and visits”.

Helen Gurley Brown, 1964

     The reason for this Impersonal Physician situation, which represents a decisive change from past norms and practice, is, of course, the redefinition of  “customer”, among other changes in the medical "business model".  Formerly the customer was considered to be the patient being treated, i.e., the person who was  generally the direct payor for the services.  Now the customer is considered to be the insurance company, a non-flesh and blood entity who doesn't show up and isn't  kept waiting for appointments and isn’t being treated for anything except, possibly (but improbably) “insufficient P&L levels”.  The addition of this element  of abstraction and role misassignment is ruinous to proper and appropriate patient care.

Looking for a pulse, a glimmer of recognition

     It is interesting to compare this “new normal” health care paradigm (which everyone complains about, of course) to the way veterinary care of domestic animals is conducted and also to the way human beings were formerly treated by their doctors.  Caroline recently read an article in the UK press saying that while Brits tended to be very pleased and reassured by the way veterinary care is dispensed, in general the opposite was true in the case of their National Health Service.  The reason given for this was exactly the one expressed above, namely that vet care was a direct pay, cash on the barrelhead, situation involving normal business principles of courtesy and compassion intended to promote customer loyalty and retention, while NHS practice involves at its core government “self-insurance” pre-screening procedures conducted inefficiently, heartlessly and ruthlessly.   

Inefficiently, ruthlessly, heartlessly 

     A young lady from Cambridge, England stayed with us recently and she basically confirmed this (in a discussion involving orthondure), but with the benign indifference of the young and healthy.  She was aware of her parents’ concerns and the travails of other adults in these matters, but pre-worried youth really is grand.


     Obviously, in the United States things used to be different, especially for middle-class people who experienced to middle-class norms.  As a child, I had an old-school "Personal Physician" who made house calls when requiring a child to visit his office wasn’t advisable.  Caroline’s father was a surgeon practicing in the Philadelphia-Wilmington suburbs and was paid directly by his patients, both directly and sometimes “in kind”, rather than through insurance, and he both cared and cultivated his patient base based on a desire to retain business and obtain referrals, as well as out of natural caring, compassion and pride in his work.  

Portrait of Dr. Jules Bordet (Paul Delvaux, 1950)

     Before moving to Pennsylvania, my family maintained a similar relationship with one of the last doctors operating in this way in New York.  My doctor, a well-known and distinguished internist, and his daughter, who began practicing with him several years ago, did not accept any insurance.  Patients paid high fees directly and settled their insurance matters as best they could (which was not terribly satisfactory, as anyone who has ever elected to exercise “out of network coverage” options knows) on their own.  However, what this somewhat unaffordable arrangement purchased was expert, focused and individual care from a physician who knew you like a book and evinced the one-on-one compassionate focus that seemed exactly the correct approach to the work at hand.  My former doctor’s patients included former presidents and other prominent people who had figured out that, if you could afford to purchase care like this, it was worth the price for the palpable and real feelings of security that came with it.  You were not alone in your medical life. You had a  Personal Physician.  

     I would like to make it clear that this isn't a political essay written in direct relation to or as argument for or against the various competing health care provision and financing methodologies being constantly discussed today.  That is wholly another subject.  This is simply a complaint and a plea.  A few years ago, I heard the following given as a definition of morality: "Morality is treating people as ends in and of themselves, rather than as means to an end".  I agree with that I would be happier if all of us were treated like people, rather than ciphers or marks on a balance sheet, by our physicians.  It makes you seriously wonder why these people became doctors in the first place?   Fortunately, our family is all doing fine at the moment.  But I worry about the future and I worry about Jane's life.  Will she ever know what a Personal Physician is?

1984 (Donald Pleasence, Carol Wolveridge, Edmond O'Brien)

     End of rant.  I’m apparently fine, but based on certain predictable, non-brilliant advice I really should moderate calories (eating and drinking) for a while and, now that my back is healed, step up exercise for reasons of health and beauty, which I intend to put on display when we finally take our long overdue vacation.

     Therefore, I would like to share the following an excellent recipe, suitable for the aborning winter, which we discovered in the February, 2008 issue of Gourmet.  It is easy and enjoyable to prepare, beautiful on the plate, boldly but delicately flavored (I really love the tang of cider vinegar), low in calories and inexpensive.  It can be nicely paired with poultry, pork, meat and fish, and can even be reheated and eaten on toast for breakfast.  I never ever tire of it and could probably live on it for a long while. 

Carrots and Brussels Sprouts Gourmet | February 2008 (Ian Knauer Recipe)

Makes 6 servings 

2 tablespoons chopped shallot (from 1 medium)
3 tablespoons unsalted butter, divided
1 lb carrots, cut diagonally into 1/2-inch-thick pieces
1 lb Brussels sprouts, halved lengthwise
1/3 cup water
1 tablespoon cider vinegar

Cook shallot in 2 tablespoons butter in a 12-inch heavy skillet over medium-high heat, stirring occasionally, until softened, 1 to 2 minutes. Add carrots, Brussels sprouts, 3/4 teaspoon salt, and 1/2 teaspoon pepper and cook, stirring occasionally, until vegetables begin to brown, 3 to 4 minutes.

Add water and cover skillet, then cook over medium-high heat until vegetables are tender, 5 to 8 minutes. Stir in vinegar, remaining tablespoon butter, and salt and pepper to taste.

Cooks' note: Vegetables can be cut 1 hour ahead and kept at room temperature.

See Me, Feel Me, Touch Me, Heal Me:  Early 20th century doctor's office

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