An Anguished Doctor Explains the High Price : Medical Miracles Cost More Than Money

It was lunchtime and I was alone, away from home at a medical conference. A group of physicians at the next table spoke of serious matters. I realized that I had heard the same conversation a week before, 1,000 miles away. Only the faces had changed.

They spoke quietly, always in control. But three of them had seen enough. They no longer wanted to stay in practice. They would quit any time, if only they could “stow away enough to retire on.” They looked to be in their early 50s.

One had a son who would be applying to medical school. He had tried to discourage him. He said he hoped that the boy wouldn’t be accepted.

Bureaucratic Hassles

They talked of bureaucratic hassles, senseless regulations, endless raises in insurance premiums. Their work was scanned by computers and picked apart by clerks. Their fees were frozen, their expenses ran wild. Now they faced an onslaught of payment schemes.

Four of them recently had been sued; two had been devastated by the experience.

The eldest listened in silence. Then he asked the question that haunts America’s doctors:

“When did the joy leave the practice of medicine?”

Doctors are an unhappy lot. They have been taught to be self-contained, “professionally detached.” Keep your troubles to yourself. Who can you tell, and who cares?

In the name of professional detachment, have we become too insulated to communicate?

One of our hospital administrators asked me to give a talk during Health Week. He wanted me to defend doctor bills. I told him I couldn’t; they’re too damn high. “Oh,” he said, taken aback. “If you can’t defend them, could you explain them?”

I primed myself with a dozen clippings. They seemed to be the same article written 12 times. The same figures made the same points. There was no mention of people, only numbers. Statistics, no surnames; diagnoses, not faces; conclusions, but no heart. Medical care had become an abstraction.

Medicine is under attack. Doctors are driven to frustration and their patients to anger.

I am a rural family doctor, an R.F.D. I have only one area of expertise. I know what it feels like to be a family doctor in Blackfoot, Ida. I’ve known that for a long, long while.

There has been a Dr. Miller in Blackfoot for the last 54 years. My father came here in 1933, at the height of the Great Depression. I was born in November of that year.

The Eccles Hotel, at three stories, was the tallest building in town. It still is. We lived in the corner apartment on the third floor.

My dad’s office was directly across the street, on the second floor, over Hegstead’s Drug Store and Snowball’s Sport Shop, which was a pool hall. When dad was out of the office, he’d be downstairs playing snooker. The phone number at Snowball’s was 320.

The office was a wondrous place. It smelled the way a doctor’s office is supposed to smell--like antiseptic. The cabinets had narrow drawers, filled with trays of instruments. I knew them by heart.

In one cupboard there were large jars of salves and poultices. Most were brown and greasy, and some would bring tears to your eyes when you unscrewed the lids. They were used for infection.

There were two main types of infection. Some localized and formed pus, while others raced through the tissues like wildfire. The pus-formers were best. If the pus drained, patients got well. The spreading infections could kill people. The salves were used to “draw out” the infection.

Mumps Were Expected

We were all expected to come down with the mumps and the chicken pox and the German measles, and the hard measles. One kid down the street got the measles and went stone deaf.

Dad kept quarantine signs in the back of his ’38 Plymouth coupe. That was about the only thing to do for scarlet fever. Whooping cough could be fatal. We found out all about polio and the iron lung. And, of course, there was rheumatic fever, which killed several of my friends.

I have not seen rheumatic fever for 15 years.

In the 1930s some kids got upper respiratory infections that didn’t clear up. Ears that ran with pus were an everyday sight. There were mastoid infections and brain abscesses and infected lymph glands.

Penicillin had not yet been invented.

Sometimes tonsillitis came and stayed; and most everybody had their tonsils out. We had no hospital in town, so Dad did hundreds of tonsillectomies in the back room of the office. On “Tonsil Day” the place would reek of ether. One morning he did seven kids in one family. Three for free.

My father faced an army of demons, armed with a cupboard full of salves that didn’t work. We now use antibiotics of the third and fourth generations. Some cost $300 and $400 a day. I can’t remember when I last saw a young person die from an infection.

Take Miracles for Granted

We take our miracles for granted. Seven million children died preventable deaths last year. But they were in “the Third World”; we could no longer see for ourselves.

One day my dad came home in the middle of the afternoon. He went into the bedroom, closed the door, and it was the only time in my life that I heard him cry. A kid with a badly broken arm had been brought in from a farm accident. Dad had set the fracture in the office. As the boy awoke, he vomited from the ether anesthetic, aspirated, and died before they could get an airway into him. That was not a rare event in the 1930s.

As I said, we had no hospital. In the early years, all babies were delivered at home. If several came due at once, we might not see Dad for two or three days. A postpartum hemorrhage could mean a 25-mile dash to the nearest hospital for a transfusion.

Dad drove all around the county. He often took me along. I generally waited in the car, but sometimes he would take me into the houses.

I remember some of the faces: A gray-haired lady who lay motionless in bed. She cried out with pain whenever her family tried to move her. My father said she would probably die soon. I didn’t know why, or what it meant to have a broken hip.

In the 1940s we learned to pin hips. The same woman could have lived and moved without pain. Even if she didn’t walk she could have been up in a wheelchair.

Several old men limped around town, or rode wheelchairs. I now realize that they had arthritic hips.

I sometimes wonder what my dad would think to see the entire hip carved away and replaced with a plastic joint. What would he say when he saw these people walking without crutches, a few weeks after surgery?

On one of “our” house calls I was frightened by an old lady with strange white eyes. She had cataracts. They came naturally to old people. She was totally blind.

Years later I watched a master eye surgeon remove a cataract. The operation lasted all morning. For two weeks after surgery, the patient stayed flat in bed, his head braced with sandbags. He was eventually fitted with thick glasses that looked like the bottoms of Coke bottles. He didn’t see well, but he could see.

The current procedure takes 45 minutes. The clouded lens is removed and a plastic lens is implanted in its place. The patient goes home on the same day, and often needs no glasses.

Dad occasionally called on some special cronies who had angina pectoris. Whenever they exerted themselves they had chest pain. They followed advice, stopped exerting, and became invalids. They lived in their bathrobes. When they had angina they took nitroglycerin pills and at bedtime they had a shot of brandy. Always they waited to die from a heart attack.

My father learned to read cardiograms from a book, but he never saw much sense to them. What would he say about the treadmill and monitor in our basement, or angiograms, or coronary bypass?

Look again at “skyrocketing” medical costs:

Not Available in ‘30s

The bills for the lady with the white eyes were around $10, enough for the doctor’s visit and a white cane. The cataract surgery will probably cost around $5,000. It could not have been bought for any price in the 1930s.

The bottle of nitroglycerin cost less than $1. Coronary artery bypass costs around $20,000.

The hip replacement costs around $20,000. The “cost-effective alternative” is a $350 wheelchair.

I have read a newspaper article that said: “In the past 25 years, the price of a postage stamp has risen from 3 cents to 22 cents. Only the medical Establishment could keep pace with the runaway prices of the post office.”

Such a comparison bothers me. In the 1930s, a letter mailed to my grandmother in Portland would be in her letter box in three or four days. Today a letter mailed to Portland probably will arrive three or four days later than that.

In 1963, I came home from my medical training and a hitch in the Air Force. In one patient we discovered a brain tumor. We hustled him off to the medical school for every test they could dream up. It was on old story. They sent him home to die. By the time his tumor could be diagnosed, it was no longer operable.

The CAT scanner costs half a million bucks. A CAT scan is safe, painless and rapid. It reveals more in 20 minutes than we found in two weeks of painful, expensive, dangerous testing.

Mobile X-Ray Machine

Dad had an X-ray machine. It was small, built into its own wooden box, and it could be carted around in the trunk of the Plymouth.

It had a fluoroscope, like the screens that showed your foot bones at the Buster Brown Shoe Store. Dad used it to set fractures and remove foreign bodies. As dad got older, the skin of his hands broke down into raw sores from the overdose of X-ray.

Cancer of the lower bowel was very bad news. At one time it could be diagnosed one finger-length away. We bought a proctoscope for $75, and we could look nine or 10 inches up into the bowel. Our new fiber-optic scope bends around corners and will generally reach a full 20 inches. I wouldn’t dare show Dad the $3,000 price tag.

Charlie was one of Dad’s fishing buddies. His cancer was the first we found with the new scope. It was 14 inches away. Our $3,000 scope bought him several good years.

My father died in 1969. A week never goes by that someone doesn’t mention something he said or did. Our office bears no resemblance to the rooms on the second floor over the pool hall.

Florence Jex was his office nurse for 23 years. She has been replaced by a physician assistant, two nurses, a receptionist, a bookkeeper, a cleaning lady and occasional visits from a medical manager.

There were no charts. What Dad might forget, Florence would recall. Our active office records now fill 75 feet of shelf space.

No Appointments

There were no appointments. Dad’s patients sat and waited until their turns came.

We now have a modern, up-to-date schedule. You make an appointment, and then you still sit and wait until your turn comes.

Florence would hate the telephone today. She would not believe 60 to 70 calls a day. She would throw up her hands at the endless insurance forms. She would be swamped by the daily stack of mail. We once measured our mail for a month. It makes a pile 4 1/2 feet tall.

Bills were posted once or twice a year--usually after the crops were in.

Dad had strong feelings about overcharging. He once told a young surgeon: “You’re going to make a lot of money. Stop trying to make it all at once.”

If he were to see our charges, he would take me to the woodshed for a stern lecture. If I told him that today our expenses now exceed a dollar a minute, he’d be speechless. Seventy or eighty dollars slipping out of your pocket every hour!

I know what would bother him most. How do you sit with people for a few minutes of talk about the crops, or the brown trout, or their kid on the football team?

The blind shall see, and the lame shall walk. Cataracts and hips are no longer miracles. They are everyday events, even in small towns like ours.

How can it be that this same medical technology has created a hell on Earth?

The Andersons know all about it. Grandma Anderson was always old, at least as long as I knew her, but she was special. She kept all her marbles, well up into her 80s. She sparkled. She liked to tell you a joke with a straight face, then wink if you got it.

A series of small strokes left her bedridden, diapered and crying out with the noises of an animal in a trap.

Her daughters gave her loving care, beyond what was considered reasonable.

When she was taken to the hospital it was with a sense of relief. She was ready for her reward, and so was her family, except for the prodigal son who moved to Los Angeles 25 years ago. Motivated by a sense of overdue guilt, he streaked to her rescue in a jet plane. “Do everything possible, doc. That’s my mom and she deserves the very best.”

‘Do Not Resuscitate’

That night, three years ago, God called Grandma Anderson with a gentle cardiac arrest. Her “Do Not Resuscitate” order was unsigned. Her earthly shell survives, and still sits, tied into a wheelchair in the nursing home. She has lasted long enough to use up every last dollar of her family’s nest egg.

Then there was Emma, overweight and hypertensive. She called one day to complain of chest pain. I ordered her to the hospital.

That was my mistake. While signing into the emergency room, she dropped over in ventricular fibrillation. Help was close at hand. Six times her heart stopped, and six times it was shocked back into sinus rhythm.

But from the time of her first fall in the emergency room, she never showed the slightest hint of brain activity. She lived just down the hall from Grandma Anderson. She was kept alive by a feeding tube into her stomach. If the tube had not been inserted in the first place, she could easily have been allowed to die. Removing the tube once it was inserted was another matter.

To my father, premature death was the constant enemy. Fifty years later I have been too successful at stalling death. I have prolonged the act of dying for poor souls whose times, by rights, had come. With the excuse of “saving lives,” and with a little technology, I have justified tortures worthy of the Inquisition.

Their cases were not reported in the journals, because they were neither rare nor unusual. Protracted dying is an American epidemic. The total bill is inconceivable. For Emma and Grandma Anderson, it approached $200,000.

Their relatives were twisted to the breaking point by the wonders of modern medicine. The Almighty Dollar never made their decisions, but they were stunned by the expenses that followed.

Wallow in Numbers

No one has yet documented the total costs for extending the death process. We wallow in numbers too large to be understood.

We are told, for example, that the country spends $3.5 billion each year on artificial kidneys; or that expenses for surviving 2-pound premature babies run around $125,000 apiece, or that babies born to teen-agers cost the nation $16.6 billion in 1985.

Any list must include the ultimate statistic: Medical care in America currently consumes 10% of our gross national product.

Which, in turn, is taken to mean: “We can no longer afford to do everything that modern medicine is capable of doing.”

For health planners, this is the battle cry. They have conscripted an army of clerks and a paper war has been declared. The indiscriminate rationing of health care has become national policy.

One last story now, about my friend Christina, who was cut of Irish cloth, about 80 years ago. Her doctor visits are social occasions for both of us and her infirmities are tended promptly, saving a wee minute for talk. No matter the topic, she is the weaver of words into joyful commentary in her rich Irish brogue.

Over the years she has told me not to be keeping her beyond her time. She would “niver be a boarden to the family,” but a burden she has become.

‘Please, Can’t I Die?’

A case of shingles, no more, left a perpetual pain in her right arm. Nothing there to be seen, but her life is now dominated by the hurting. Medicines are useless. She remains alert and intelligent, but says: “Please, can’t I die and be over it?” Her family hears: “Do no more for me.”

Then a fall, a fractured pelvis, and more to come.

The years, the blood pressure, and a bit of the diabetes have narrowed the arteries to her legs. She cried last night, as usual, but she awakened this morning with a cold, black great toe. Her left femoral artery is closing up shop.

“Do nothing” and watch the march of gangrene up her leg, a series of amputations, and a new source of pain for her final days.

Then again, to “do something” means an operation which might well be futile. Damage control only.

As I write this, Christina waits in a medical purgatory. She has a unique series of choices, all bad.

Her decisions, right or wrong, had best be made at her bedside. This is the way most medicine really happens.

Not any more. What’s right for Christina is now listed in a book, to be dispensed on demand by an admissions nurse. Merely speak aloud her diagnosis and a computer immediately cranks out the number of the dollars which may properly be spent upon her care.

Do the pieces begin to settle into place?

Medical care, at its best, produces miracles at a bargain price. If all the money we spend made the blind people see, there would be nothing to quibble over.

At its worst, modern medicine is wasteful and inhumane. We have not yet reckoned with the technology of dying; neither the inhumanity nor the cost.

Medical care is overpriced, and medical people are under attack. Our solution has been to limit the delivery of care. However, we are rationing the miracles right along with the waste and inhumanity.

We are slowly losing the right to make our own medical decisions.

These things didn’t happen by chance. Always unspoken in the background is the belief that all doctors are rich. The small-town doctor’s brat never heard it any other way, from other kids, from saleswomen, from teachers.

The Needling Barber

I heard it regularly from fat barber Clark. When he cut my hair he’d whisper in my ear: “Your daddy’s a rich doctor. How does it feel to have all that money?” He was chummy, acting as though he were telling me a big secret, and I hated his guts.

Ron came to town fresh from residency training, worn at the collar and hungry to pay off his debts. He was a tireless worker and a first-class orthopedic surgeon. Now we could provide good orthopedic care without sending people away.

He’d been here a year and a half when I was given the bad news with my morning coffee. “I suppose you heard about your friend, Ron? Bought the farm last night.”

I live in vernacular country, so I figured he’d died in a car crash or something. “Oh, my God!”

“No, no, the farm. He bought it.” Ron had outbid the local land barons for a large parcel of farmland. A bid of $420,000.

Ron had done nothing wrong. He hadn’t cheated people. He had only charged the going rate in a system that overpays surgeons for procedures.

Certainly an orthopedic surgeon is worth more than a family doctor. But how much? Ron could easily put more on the books by Monday noon than I made in the week.

Surgical fees reaffirm the belief that doctors are overpaid. That belief has brought the system crashing down upon us. And more.

Could the perceived wealth of physicians have anything to do with the crisis in malpractice suits?

It certainly could.

Dad had a weakness for hunting dogs. Once, driving through the countryside, he noticed a young brown short-hair that caught his fancy. He turned in at the next farmhouse and asked if they owned the dog. “Yup.” Dad asked what the dog was worth. “Depends.” On what? “Well, it depends on who just ran over him.”

No essay on medical costs can avoid the liability crisis, the No. 1 squanderer of medical dollars.

My father practiced medicine for 30 years without malpractice insurance. When I returned from the service, I persuaded him that it was necessary. He didn’t like the price. A policy for the two of us cost more than $100 in 1963. A hundred dollars of malpractice insurance now won’t cover me for five full days.

Patients End Up Paying

This year my premium exceeded $100 a week. That’s low. As an R.F.D., I’m considered a low risk. Local obstetricians are asked to pay $45,000 a year. They won’t pay it; their patients will, adding another $200 to the cost of each delivery.

The malpractice threat permeates everything I do. Many of its costs have gone unnoticed.

Our last vial of D.P.T. vaccine, the routine baby shot, cost $179.50. Not long ago it was $5. Liability suits against the manufacturer have made the difference.

We were told: “Keep good records to defend yourself in a lawsuit.” The medical record is no longer there for patient care; it is a legal document. In our hospital a page a day per patient in 1950 has grown to 10 pages of chart work in 1987.

When my kid twists his ankle, I’ll use judgment. I’ll probably watch him for a day or two. If it’s your kid, I’ll take an X-ray. My judgment might be wrong. I won’t sue me, but you just might.

The physician has been blamed for outrageous medical expenses that are beyond his control. On the other hand, people are paying an outrageous price for their medical care.

It’s time folks got together.