Tuesday, December 27, 2005

Health Care: Making it Personal, Real, and Patient-Centered

Did you see the new longevity study? It says that people over 50 who play with dolls can live up to one-third longer than people over 50 who do not play with dolls. Since living longer is important to my wife Barbara and me, pictured below, we have been quick to take advantage of the new finding.

Skeptical? Good for you.

It took me a long time to realize that many of the health and longevity studies that regularly get on the TV news and in newspapers are as worthless as this fictional doll study. Scratch the typical study and you find skewed data and financial conflict of interest.

Pharmaceutical companies and medical device manufacturers fund many of the studies. Food companies pay for studies that magically find that their products have health benefits heretofore unknown. In one study, funded by Hershey, chocolate is transformed into a health food. In another, funded by the dairy industry, milk becomes helpful for weight loss.

Authors commonly have hidden ties to the companies who fund and benefit from the new “findings” and money – large amounts of money – changes hands. It's a sweet system for everybody, except for you and me. We get lied to. We get duped into taking pain-killers (Vioxx) and eating foods and using medical devices (faulty stents) that can harm us.

A peer-reviewed study published by the Public Library of Science, a rare source of independent health research, has documented it all. The study is scholarly and uses academic language but its overall conclusion is unflinchingly simple: most published health studies today are misleading and deceptive if not knowingly false. To read the PLOS study yourself, click on the PLOS link on this page.

In my own research of our health-care system, for the longest time I didn't believe what I was seeing seemingly everywhere. I didn't want to think that something as important as health information could fall victim to what can only be described as institutionalized fraud.

But now I see that this is exactly what it is. Now I know that we are all on our own when it comes making sure we have solid, untainted health information. And I feel humbled that I could have swallowed it for so long.

I have to confess another health-care-related humbling experience. For three years now, I have been writing something called Patient's Progress. I have envisioned it as a comprehensive, patient-centric study of health and the American health care system.

I have written enough for a book, maybe two books. Six long sections about the U.S. health care system as a whole, for example, are a book in themselves. These sections take a big-picture approach with lots of historical background and quotes from leading experts on every side of every issue.

Statements are backed up by authoritative research from such respected organizations as the Kaiser Family Foundation and the federal Centers for Disease Control, as well as professional journals like Health Care and the New England Journal of Medicine. Silly me, I believed what I found in these sources. Of these, only the Kaiser Family Foundation has remained truly independent.

In my mind, Patient's Progress was to have no agenda or point of view. With content theoretically free to go wherever it has to go, I imagined that everything would came out fair, balanced, information-packed, and worth reading.

“In my mind” is the key phrase here.

It is now clear that I have been kidding myself. Though I am not on anybody's payroll and serve no commercial interest, very little of what I have done could strictly be described as “objective.” Though drawn from many sources, it has been washed, wrung, and rinsed though my intellect, life experiences, and values.

Though I'm not taking money, I have personal biases and hidden agendas that color every word I have written. It was not an awful thing that I did. It was a human thing. It was human failure.

In addition to being naturally unobjective, I had also taken on too large a subject with too small a mind. Unfortunately, it took me three years to realize it. The more I researched, the more I learned, the more I wrote, the more I realized how big the subject was and how much more I needed to know to do it justice.

Instead of regrouping and rethinking, I just kept dipping my little bucket into an ocean of information about health care in America. Flawlessly playing the part of the naif, I went to work with my bucket farther and farther out to sea and deeper and deeper into murky, endless depths. I got into physiology, diseases, hospital infections, emergency care, everything about the heart, exercise, obesity, death and dying, Medicare and Medicaid.

You should see my files. Actually, let's go into them. In the A's, I have files on aging, alcoholism, AIDS, Alzheimers, alternative health care, aneurysms, anger, asthma, and autism. In the B's, I have files on back pain, blood, brain function, Big Pharma (with a sub folder on the Merk-Vioxx trials). I have a file on Jane Brody, the excellent health columnist for The New York Times. Over the past three years, I think I have read every single piece of hers and many of them are in this file.

As for the C files, I have material from which to write the last word about cosmetic surgery, Crohn's Disease, cholesterol, and the health implications of coffee. Under D is a massive file on death and dying with a sub-file on death by car (with which to write the definitive piece on the impact of the car culture on our health) and equally massive files on diet (for the last word on why diets don't work and never will work) and doctors (for writing authoritatively about why the medical profession is adrift, confused, and losing control of patient care).

Let's skip to the L's. There you find such files as lawsuits, longevity, and Lou Gehrig's Disease. Under the M's are files on mad cow disease, medicare, mental health, Multiple Sclerosis, and mind/body. Working our way down the alphabet, there are files on rare diseases, smoking, spare parts, sports injuries, stem cells, and supplements.

There are many more files, most bulging, that I am too embarrassed to mention. Okay, since I have gone this far, and to prove beyond doubt how far out of my depth I was, I'll just mention two of the most outlandish files. They are World Health and Women's Health. That's right, I have been planning to write authoritatively about health in the third world and, gulp, female health.

Oh, I forgot to mention all the research materials piled everywhere in my office that I have not had a chance to file. I have great stuff on Americans going to India for major surgeries, for example. I have the numbers (they are huge and growing), case studies, the quality of care (excellent, with patients receiving lavish attention compared to that normally received in the U.S.) surgical outcomes (again excellent, with the Indian surgeons being board-certified and mostly educated in the U.S.). And this is just one topic among many others for which I need to create even more files.

Yes, I was the flea climbing up the elephant's leg and thinking rape. I also have to accept something else that is much harder to swallow: most of what I have written is not only pretentious but unreal. Heavy concepts sit lifeless on page after page, all but shooing readers away. Yet health care is nothing if not real-world stuff packed with blood, guts, heartbreak, and life-or-death drama.

In my hands, however, it is detached (or, more accurately, faux objective), bloodless, dispassionate, ethereal. It comes, ex cathedra, from someplace on high. Dumping carloads of information on the reader, I said, in effect, “Well, I've done all this work so the least you can do is put some effort into reading it and filling up some of that empty space in your head. It won't be easy reading, or interesting for that matter but this is important information and, trust me, the effort will be worth it.”

Could it be this bad? One of the best things about writing without deadline and under one's own imperatives, is that one gets (sorry about all the ones; blame my old English teacher, Sister Francis Helen; once she instills the fear of writing the unlettered “you” intead of the literate “one,” one cowers for before her for life) a chance to put work to the sniff test. The good sister would have taken this last sentence and lashed my backside with it in front of the class. With each vicious stroke, she would have said, “Never divide a thought like that!”

As soon as I finish a piece, I am head-over-heels in love with it. Happens every time. I can't wait to send it out somewhere, anywhere. With a deadline, I would have to do just that. Without a deadline, I set aside each piece as it is finished and plow ahead.

But invariably, I get stuck or need a break or want to pat myself on the back. So I look back over what I have written. When I did this with Patient's Progress, it was like meeting an old girlfriend. What did I ever see in her?

Why did I not notice how stuck up she is? And, sniff, what's that? BO? Invariably, large globs of copy have gone bad and need to be thrown out. Other globs are spoiling fast. Love turns to something smelly in the garbage.

You know, I just love this last paragraph, don't you?

Let me give you an example of what I am talking about. (I know I'm not talking, Sister Francis, but I don't want to write “writing,” okay? Hey, after all these years, am I beginning to stand up to the fearsome nun?) Here is how the first section about the U.S. Health care system begins:

The American Way of Health, Part One

Patients, Providers, and Third Parties

There are three kinds of people in American health care-- patients, providers, and “third parties” who try to run the lives of the first two. The latter group is dominated by politicians, lawyers, government administrators, and executives of pharmaceutical and health insurance companies. All the players have competing agendas and work for their own interests while professing to serve patients above all else.

Based on how the system actually works today, the major players agree on four things: that those with the most money should get the best care; that companies in the health-care business should make tons of money; that everything should be based on who pays, how, and how much; and that health care should be as complicated and as rules-ridden as possible.

It's textbook schizophrenia. Hopelessly fragmented and structurally at war with itself, the health-care system endlessly chases after two powerful competing values: doing its best for every patient who comes for care (the moral thing) and unleashing the innovative energy and competition of the free enterprise system to provide better health care at market-driven, lower prices (the capitalistic thing).

These conflicting values are like two scorpions in a bottle. People espousing one or the other don't know what else to do except to try to destroy each other. Try as they might, however, the health care system's main ideological rivals can't kill each other off. So they do the next best thing: they trash each other's ideas and ensure that we have neither competition-based health care nor universal health care, but the worst of each.

There are pages and pages of this. But perhaps just a few passages like this would go a long way. (I say to myself gently; I do have feelings, you know.) The passage is way up there in outer space with not a human being within a couple of million light years. There is no patient with a health problem, no doctor trying to see a patient a minute, no nurse trying to juggle seven patients in acute care, no employer being buried by rising health insurance premiums, no middle-class family driven to bankruptcy by medical bills, no family that makes too much for Medicaid but too little to afford health insurance. There's not a warm person dealing with a real health-care problem.

And who is that narrator telling us how it is? God? Good question, if I do say so, and the operative word here is “telling.” God may be able to tell the whole story of health care in America in this way and have it be real, compelling, and complete, but I can't. It's also too much to ask a reader to slog through pages of concept-heavy passages like the one above.

And for what? For being fed somebody else's abstractions? For being hit on the head repeatedly with a pseudo-intellectual baseball bat? For, in the end, being left buried in information but feeling nothing and, worse, not growing in understanding?

What to do? Toss three years of work? I don't mind tossing out copy that is only wasting space on my hard drive, but I don't want to throw out the subject of health care. I can't think of any subject that is more important to more people.

Also, I want to learn more about it. The human body is without doubt the world's greatest feat of biochemical engineering. Tip of the hat to God or to Mother Nature or to the Intelligent Designer or to a little green alien from some far-off planet in a yet undiscovered far-off galaxy for an over-the-top achievement.

Can you imagine envisioning a human eye? A brain? A nervous system? A digestive system? Ears? A nose? An immune system? Arms and legs? And then figuring out a way to make it into a creature like you and me that walks, eats, thinks, talks, writes, loves, reproduces, and forms families, tribes, cities, and nations?

Our original designer had to be one smart cookie. What I don't understand is why we were also given the ability to lie, cheat, steal, rape, kill, and despoil the environment. How do these things help anybody? I'd really like to know.

In health care, these abilities only give us crooked health-care studies, greedy insurance companies, hospitals interested more in money than in patients, and people like you and me who have to fight to get the health care we need.

My interest in health care has also turned personal.

When I wrote that Zeus-like, omniscient passage quoted above, my above-it-all view came naturally. Except for creaky knees from ice-hockey wars and an episode of back pain some years before, I was in robust health, playing tennis three or four times a week and just sailing along quite nicely, thank you.

I had good health insurance and the ability to pay for it. Health care for me was an annual check-up that never turned up anything of note, except for borderline-high cholesterol that my doctor said could be safely “watched.”

Things changed.

My knees finally went. I had two total knee replacements, one after the other. My surgeon at Mass General in Boston, shown above with the x-ray of my new knees showing on the screen, would not do both knees at once because of the increased risks. Rehab after total knee replacement is long and tough. Going through the rehab twice was the longest, most sustained physical misery I had ever experienced.

It was a solid year before I even attempted to pick up a tennis racket. (Oh, you didn't know that I am a tennis player? Well now you do. And believe it or not, this will turn out to be a fact that will be significant should you read on. If you do, I promise to bring these parens under control.)

When I did get back on the tennis court, I was so weak I could barely get the ball over the net. Yet, after months of rehab, I managed to get back onto the court and into my normal active life.

Next, while visiting my daughter, Misha, in Seattle, I lost my balance while out walking and nearly passed out. I ended up in the emergency room, below, goofing around trying to cover up how scared I was. After receiving the usual blood tests, EKG, questions on medical history, and checking of reflexes, I was released. In the judgement of the emergency room doctor, there was little risk of a follow-up stroke or heart attack.
Shaken, and wondering if I had suffered a TIA (transient ischemic attack) which I knew is sometimes a precursor to a major stroke, I undertook a battery of tests – brain MRI, heart echocardiogram, carotid duplex scan, among other tests -- at Seattle's leading stroke center. All tests were negative.

Again, I managed to put the Seattle episode behind me and move on. I had one additional dizzy spell while walking out on the court to play tennis. It came and went within seconds. But I was in no mood to even acknowledge it, much less to rush off to the emergency room.

It was a beautiful summer day at the Worcester Tennis Club and I wanted to play tennis. I thought: To hell with it; if I'm going to die, I'd rather die on the tennis court. I played, losing to a good player in a tight match. You'll meet him later later. He is seventy and, like a ball machine, keeps the ball caming back at you until you miss.

The last time he went to a doctor for a checkup, the doctor all but threw him out of the office. The doctor said to him: “You got a pulse rate of 50. Get out of here. You're wasting my time.”

Next, on an August morning of that summer, hurrying out the door on my way to play tennis, I reached for my tennis bag – and felt like somebody had shoved a knife into my lower right back. I went and tried to play but had to quit.

In two days, I was reduced to screaming on all fours. I thought I was dying. There was another trip to the emergency room, followed by admission to Umass Memorial Hospital in Worcester, Mass.

I spent a week in the hospital, with more tests, and more doctors scratching their heads about what had put me in a wheelchair, unable to walk or even stand without pain. They were thinking things like tumor on the spine, but freely admitted they didn't have a clue.

Finally, after rafts of tests – all negative for anything organic – a physical therapist diagnosed the problem: a misaligned pelvis. A misaligned pelvis? What the hell was that? After three years of studying health care in America, I had never even heard of it. Sort of proves my point of how little I had learned, doesn't it?

I am shown above at UMass Memorial in Worcester (University Campus) with my great nurse who helped me get through a medicated MRI when it was torture to be flat on my back and still. The nurses called me their "walkie-talkie" because I cruised up and down the hallways in my wheelchair talking to everybody. I could afford to be sociable. Unlike a roommate about my age who had suffered a stroke and others on my floor, I was going home.

Next came weeks of physical therapy. Again, I go nuts overdoing the exercises and, according to a surprised physical therapist, make “remarkable progress.” I get dismissed weeks earlier than she expects.

On my last day, she confides to me that my case of misaligned pelvis was in the “top five worst” that she had ever seen. She said that when I came in all bent over and barely able to walk, she was not sure that she would be able to help me.

But, of course, I fight my way back to a viable life, including tennis. Defiantly or stupidly, I start playing singles. Normally I play only doubles. But given my penchant for self-delusion, I begin fancying myself as a singles player.

On a routine appointment with one of my two primary-care doctors – I'll explain later how I have two – I toss off the pelvis misalignment episode as “just another botched attempt on my life.”

But I wonder what will be next.

Have you noticed that things have turned personal? The all-knowing narrator has been cut down to mortal size, literally. He is now all too human. What made him nearly pass out in Seattle? Is he headed for a stroke? What is it with his body core that his pelvis caused so much havoc? Should anybody care?

And what's with this playing singles tennis on two titanium knees and, defying doctor's orders (and common sense, according to my wife, Barbara, who wants to strangle me) running flat out for every ball?

In the original draft of Patient's Progress, the writer – that would be me -- did not exist. In the name of objectivity and dispassionate analysis the “I” word appeared nowhere. It was all “according to researchers” or “studies show” or “doctors say” -- anything to avoid the dreaded first-person personal pronoun.

Writing the word “I” when the object is to be factual, informative, and faithful to the truth has always seemed to me to be not only an egoistic intrusion but a confession of failure. I have taken “I” to mean, by definition, opinion and lack of objectivity.

But my experience with Patient's Progress has caused me to question this. The passage quoted above purports to be objective, but is it? There is no “I” and the writer is nowhere to be seen. Yet the writer – me – is very much there. Every idea, every sentence, every word is me. Far from being nowhere in the passage, I am everywhere.

So if my best shot at objectivity doesn't hack it, why not go all the way? Why not use “I?” Why not go further and put my whole self into the mix? Isn't it more honest? Isn't it more realistic? And, the more I thought about it, aren't I really a legitimate part of the story of health care in America?

Don't I have a body? Don't I have a health to be responsible for? Don't I have to navigate our health-care system? Aren't I a patient? Don't I have a story that might be interesting and helpful to other patients?

For starters, I can tell you all about having both knees replaced, since I lived it intensively for a year and a half and am living it today – with an excellent outcome that many friends and fellow tennis players find hard to believe. I never knew it was possible to play hard, competitive tennis on artificial knees. But I am doing it.

I can tell you what it's like to be out walking on a bright fall day in Seattle and then suddenly feeling woozy and finding yourself lurching to the left and nearly falling. I can tell you what it's like to have your lights flicker and begin to go out; and then to have them go back on and be standing there, alone in an urban wild preserve, wondering what had happened and whether I was going to switch off again; and if I did go dark, having terrifying thoughts of lying there undiscovered while my life ebbs away.

I can tell you about back pain. Boy, can I tell you about back pain. The most recent episode, in which I spent a week in Mass General, was bad. But the one before that, some six years before, was probably worse. It began at my daughter Misha's wedding. Just as the outdoor ceremony was starting, she fainted and her husband-to-be, Ed, caught caught her before she hit the ground.

Instinctively, I rushed to the scene to help – and went ass-over-teakettle. Ed, cradling Misha in his arms, could not catch another toppling body and I landed on my back with a loud thud. I was helped up and I told everybody I was okay, but I wasn't.

Within days, I got an attack of lower back pain that put me out of commission for months. In the new Patient's Progress, I'll tell you what I learned about two serious, disabling episodes of back back pain and how I was able to overcome them both without surgery.

By the way, Misha quickly revived and the wedding went on.

With every health episode, I encounter our health-care system as a patient. That means that besides worrying about what is wrong with me, I have to make all kinds of decisions involving health-care providers, insurance, and medications. Getting sick in this country means getting in a little rowboat and navigating fast-moving rapids that sometimes try to take you everywhere but where you want to go.

The first thing you learn is that your health is not a priority. The system operates to serve itself and it cranks you into serving its best interests. If you manage to get good care, great. You are either very lucky, or very rich, or that rare bird able to figure out the system and literally force it cough up the care that you need. I believe that I am that rare bird, thanks in large part to having the world's best patient advocate, my wife, Barbara.

She understands health insurance. She's smart. She's organized. She fills out all the forms and files them for quick retrieval in case a piece of paper is needed to persuade an insurance company to do something for me instead of for itself.

When I am in patient mode, say in the hospital, she watches everything like a hawk. She knows exactly what medications I should take and when. When I am in pain and not functioning properly because of medications and anxiety, she steps in to make decisions.

She is my greatest asset.

Largely because of my wife, I have received superb treatment in every single encounter with our health-care system. In every case, the outcome has been all that anybody could hope for. Our health-care system is the world's best but only for patients with full access to it and the skills to navigate it. In the new, revamped Patient's Progress, I'll pass on what I learn about how to get the best possible care.

It will be from a perspective that is not heard from enough – that of the patient. We have fallen into the habit of believing that only doctors and medical researchers have anything important to say about the human body and health care.

But I am the world's leading expert on my body as you are on yours. Given that I live in it, I know when it is acting the way it should and when it is not. I know its history intimately and can reel it off to any doctor. So can you.

As patients, we have much to contribute to our own care. Some enlightened medical schools are now teaching medical students that patients tell a doctor 80% of what he or she needs to know to make a diagnosis. A new generation of doctors are being told that they must listen to patients and view each one as an essential primary source of information and a full partner in their care.

Until this new generation of doctors comes along, we will still have to contend with the traditional doctor who does all the talking. This doctor, relying mostly on lab tests, tells us what is wrong and what is going to be done and heads for the door.

If the patient tries to say something, he is quickly interrupted. By the time the patient gets a few words out, the doctor has his hand on the doorknob. It is a one-sided communication that I find unacceptable. When I go to the doctor, it is clear who is in charge. I am.

It is also clear that without the doctor working to do what is best for me, I am dead – maybe literally. So I think the smart patient doesn't come in giving orders and self-diagnosing based on printouts from the Internet. He comes in with an agenda for the appointment, questions thought out beforehand, respect, and a willingness to discuss all options the doctor may offer.

In a follow-up appointment with one of my doctors after my fainting episode in Seattle, I told him that the heart echocardiogram showed that I had mitral valve prolapsis. I asked him to explain it for me. He immediately launched into a beautiful and detailed explanation.

It is a malformed valve in which some blood seeps back into the atrium after each heartbeat. The condition is also called regurgitation. If a lot of blood seeps back, the ventricle has to work harder. Over many years, the extra exertion can lead to an enlarged heart. In extreme cases, the condition can lead to heart failure.

But after going over the test results from Seattle, he said that my case would require no treatment and would not affect function or life expectancy. I asked him to listen to my heart and tell me if he hears anything sounding like regurgitation.

He listened. “Nothing.”


“But you do have a little heart murmur,” he said.

“Heart murmur?”

“Yes, just a slight irregularity that I hear. But it's completely innocent.”

“You mean I can live with it?”

“Yes. Nothing to worry about at all.”

But I thought: Now I have to learn about heart murmurs.

The only reason I learned of the mitral valve prolapsis at all is because I pressed the Seattle doctor who read the echocardiogram to tell me if there was anything at all abnormal. He was looking for blockage only. I told him I wanted to know if there were anything else, however minor.

“You do have a small leakage in the mitral valve,” he said. “But it is very minor and nothing at all to worry about.”

“Nothing else.”

“No. Overall, the heart looks good.”

This was your common stand-up 30-second conversation. But it yielded new information to use in managing my health. And by the time I asked my doctor to listen for the telltale mitral valve murmur, I knew quite a bit about mitral valve prolapsis. Most people with the condition require no treatment and have normal overall heart function. This was the case with me.

There is, however, an increased risk of infection around the valve and my doctor explained that to me. As a precaution, he said that I should take antibiotics before dental work. I told him I was already doing so because of the knee replacements.

So in future posts you will be hearing more about mitral valve prolapsis if the condition gets worse. I am already looking ahead and asking myself whether I would want surgery to repair the valve or, if things turns really bad, a replacement valve. If the valve eventually needs to be replaced, would I want a metal one or plastic? Or perhaps I'll opt for a biological replacement: a pig valve.

As part of the effort to learn the cause of the Seattle fainting spell, my doctor ordered a stress test at UMass Memorial Hospital (Memorial Campus). With electrodes attached to my chest, I walked briskly on the treadmill for six minutes, after which the supervising doctor said, “Congratulations, you passed.”

I opened my mouth to ask a question, but he was already hurrying out the door. So while the technician was detaching me from the machine, I pumped her for information. “So I passed,” I said. “Did I just pass or did I do really good?”

“You did really good. You had no trouble elevating your heart rate.”

“Was there anything wrong, even something tiny?”

She hesitated. “Well, there was one thing,” she said. “You have an early heartbeat, but a lot of people have it and it's nothing to worry about.”

“Oh, really? How does that work? Can you show me on the graph paper?”

“Sure.” She pointed to a spike just before the heartbeat. “There. See, you just get a little ahead of yourself, that's all.”

That's how I learned that I have premature heartbeat. You will learn more about this conditon because I'll be living with it and passing on what I learn. It's amazing how hard a patient today has to to work to extract information from the health-care system about his own body.

The goal is always to get you in and get you out while giving you the minimum information. The last thing most doctors today want is to be drawn into a long, detailed discussion with a patient. Discussion raises questions and only leads to more discussion and more pesky questions.

It's not that doctors don't care about patients. They do. I know that mine do. In fact, I have had nothing but good experiences with doctors and also with nurses. The problem is that our health-care system puts doctors and nurses and other providers under such time and financial pressures that it forces compromised patient care.

I also learned completely by accident that I have spinal stenosis, a narrowing of the spinal canal. My doctor at the VA had left the Worcester clinic, leaving me without an assigned VA doctor. I had been seeing her for seven years. She used to call me at home to give me key test results and to discuss my care. I missed her terribly.

Months went by without my being assigned another VA doctor. It began to look like the VA was phasing me out. I was a veteran but had no service-connected condition. That put me in the lowest priority category. The VA no longer accepts unwounded veterans like me. I kept calling about it but got nowhere.

Finally, in one of those calls, I had a little lower back pain and asked if I could see a doctor. I wanted to let the VA know that I was still around and needed a primary-care doctor. The clerk making the appointment had my medical history on the screen as we talked about my pain and casually mentioned that I had spinal stenosis.

After going to the VA for many years, I thought that was a weird way to learn that I had spinal stenosis, which is a narrowing of the spinal canal. Oh well, we have to take the information any way we can get it.

As it turned out, I was assigned another primary care provider and a superb one. She wasn't a doctor but a nurse practitioner. At our first appointment, I called her “doctor” and she handed me her card. It announced that she was not an M.D. but an N.P. I don't care because she does everything for me that an MD could do and more.

She's a terrific “doctor” and I'm thinking about calling her that whether she likes it or not. When I told her about the near-fainting incident in Seattle, she had studied all the test results that I had dropped off for her. She immediately raised the possibility that the cause may have been an inner-ear problem and offered to arrange tests to find out.

Not one of the several Seattle doctors who saw me mentioned inner ear as a possible culprit.

After the appointment, she escorted me across the hall for a flu shot. The appointment had been patient-centered, patient-driven, with all questions answered and all care bases covered. All doctor visits should be this way and nobody does it better than the VA.

The VA will therefore be part of this story. It is where I go for superb preventive care. It is where I can get prescriptive drugs (should I ever need them) for a $7 copayment, no premium, and no gaps in coverage such as in the new Medicare Part D drug benefit. Under this new program, you pay a $250 deductible and then a 25% copay on the first $2,250, plus another $450 a year in premiums.

Then something bizarre happens. Coverage disappears for the next $2,850 in drug costs. The beneficiary is trapped in a “donut hole” in which he must pay $2,850 in drug costs before coverage resumes. Many people will not be able to pay these costs and will not be able to get needed drugs.

Needless to say, I won't be signing up for the new drug benefit, though the program does offer important benefits to those with low income and who take many prescription drugs. But compared to the prescription-drug benefits at the VA, the new Medicare Part D prescription drug benefit offers very little and does so at three and four times the cost to beneficiaries for the most common drugs used by seniors.

According to a study(a legitimate one) by Families USA, drug prices obtained by the VA are about 48% less on average than those expected to be charged people who sign up for the Medicare prescription drug program. But a year's supply of Zocor, the cholesterol-reducing drug, costs $251 to the VA but $1,323 to the Medicare drug plan. A year's supply of Protonix, used to treat ulcers, costs $253 to the VA and $1,080 to the Medicare drug plan.

Beneficiaries and taxpayers pay the difference.

Why? Two reasons. First, the 2003 law creating the Medicare drug benefit expressly prohibits Medicare from negotiating bulk discounts from the drug companies, as the VA does. Second, the Medicare Drug benefit does what it was designed to do: serve the pharmaceutical industry. Drug lobbyists all but wrote the bill. Big Pharma has succeeded Big Tobacco as the 800-pound lobbying gorilla in Congress.

Am I saying that the revamped Patient's Progress is about me and my personal health? Yes and no. Make that a barely audible yes and a screaming no. Yes, yours truly, George Pollock III, is indeed making personal appearances in Patient's Progress. But no, even though I will be a living and breathing character in Patient's Progress and I will be using the previously dreaded “I,” the story is about you and about us and what we can all do – or not do – to lead lead long, healthy lives.

It's about life, not death. It's about health, not disease. Many people wait until they are sick to begin managing their health. I think the time to start managing your health is when you are still healthy.

I said long life. I meant long, long, long life. I am thinking age 120.

I said healthy life. I meant robust life decades beyond age 65.

I said future. I meant living for today and for every day.

So what about today? Even though a couple of months ago I spent a week in the hospital with a misaligned pelvis, even though I have spinal stenosis, premature heartbeat, mitral valve prolapse, a heart murmur, two titanium knees and possibly an inner ear problem, it's all minor, wear-and-tear stuff. I think paying attention to these non-life-threatening things now helps prevent something bigger later.

My 1938 model biochemical machine doesn't run as smoothly as it used to and I never know when it will have to go into the garage for major repair, maybe a valve job. But I'm still on the road. How many 1938 cars are still on the road?

I also have to tell you how thrilled I am to discover that at an age when I am supposed to be an old man, I can physically do everything that I want to do. I can play a couple of hours of singles tennis and still have something left and not be wiped the next day.

My brain also still works which will doubtless be a surprise to my family and friends. The brain scan I had in Seattle showed no signs of Alzheimer's. I can write these words, such as they are. I plan to write many more words over the next half century or so.

Meanwhile, the most important thing is today. Today I am bursting with life and ideas for the next post. Today I feel great. Actually, I feel young. I feel like a competitive athlete.

Yesterday, I took a set, 6-2, from a fine tennis player ten years younger than I am. We will meet again on Monday, January 2 at 8 AM sharp. He will be gunning for me, I know that. A singles specialist and a student of the game, he rarely loses a set. Dropping a set to me does nothing for his rep. I am primarily a doubles player and have only recently begun playing singles.

We will concede nothing. We'll cover court, lunge for wide balls, chase down lobs, dive for drop-shots. We'll suck wind and sweat buckets and I'll be running flat out on my titanium knees. He'll try to wear me down with long rallies and drop-shot me to death. I'll try to force play and kill him with putaways at the net.

I'll be the clear underdog. On paper, I can't win. But we are not playing on paper; we are playing on clay. And I'm so happy to be out there that I'll be loose and swinging away – and anything could happen.

And so as I take the court at 8 AM on Monday, January 2, in the brand new year of 2006, how about giving me a little root? Just say “Titanium knees, don't fail the foolish boy now!”

Appreciate it.

If the knees hold up – and I think they will – it will be largely because of the superb work of my surgeon at Mass General, shown above with his happy patient. We'll leave him unnamed to respect his privacy and also because he is not looking for any more business. He already has too many people banging on his door.

So long and keep moving.


At December 05, 2008 3:16 PM, Anonymous Anonymous said...

My name is Michael Rodman and i would like to show you my personal experience with Protonix.

I am 39 years old. Have been on Protonix for 2 years now. Miracle drug I have suffered with gerd for a long time and tried many treatments, some because coverage wasnt allowed, so my dr had been given me samples. When I am on this meds I am painfree thank god. I feel normal. I have run out of supplies and I have been in such pain that I sleep sitting up. I go back today to get more samples, today thank god.

No side effects that i remember so they cant be that bad

I hope this information will be useful to others,
Michael Rodman


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