And What Will They Say?

One gorgeous late summer afternoon last year my dog's delight at the dog beach prompted me to seek a similar treat myself. So I hopped on my bike and headed for my favorite local sandy shore. Settling on a spot, I pulled out the old sheet that serves as a beach blanket, and bent to spread it out as I had a million times before . . . and saw stars. Sudden, sharp, jolt-out-of-nowhere, take-my-breath- away-and-don't-give-it-back pain in my lower back. I hadn't twisted or turned, hadn't picked up anything, hadn't bent or moved strangely, but in a flash I could barely move at all. No positioning, no deep breathing, nothing seemed to help, so I gingerly reclaimed my bike and laboriously trudged slowly home, pushing the bike and trying not to breathe too much, because it hurt too badly.

When my first-ever deliberate mixing of drugs and alcohol (a cold beer to wash down an over-the-counter pain reliever) and hours of rest interspersed with various efforts to find a comfortable position failed to bring relief, my neighbors put my shoes on my feet and gingerly carted me off to the Emergency Room. There I was asked repeatedly to sit down, despite having explained that if I did so getting up again would be excruciatingly painful, and perhaps impossible; examined by a most deliberate medical student; and graced with the presence of the attending physician for approximately 90 seconds, after which came the pronouncement that my problem was muscle spasms, which would go away if I took a narcotic pain reliever and a sedative, and then got a good night's sleep, thereby relaxing the muscles involved. I then was to find and see an internist, and have a MRI somewhere along the way. An injection of a narcotic was administered to jump start the process.

So, after the obligatory pass through the drive-up pharmacy window, my neighbors carefully deposited me back home, where I downed the prescribed pills, and went to bed . . . only to wake up unable to move because every part of me seemed directly connected to my back, and anything more than twitching a finger sent that sharp, stabbing pain shooting through me once again. In desperation I figured a way to turn over while keeping my back straight, then push myself up with my arms, and finally shift my weight forward until I was standing on my feet. I then could shuffle to the bathroom, and swallow more pills. I felt groggy and mentally cloudy, but the physical pain remained as strong. The earliest available MRI appointment was a week away. The internist was out of the question.

A physician friend who had been monitoring my (lack of) progress via text message finally declared that if those drugs weren't helping me it was clear that I had slipped or torn a disc and would need surgery; he had a wonderful surgeon standing by, and was coming to get me. Back surgery? Me? Oh, no! I insisted on one more day.

The next day dawned with equal misery: Drugged stupor, and excruciating pain. There were two more doctors I wanted to see, who practiced together in what we loosely termed an "Arthritis Clinic" that we took on the road to various senior communities. More friends to the rescue, and my stuporous self was deposited among the oldsters in my very own clinic. "I won't even touch her until she has that MRI," shouted the MD. But the Doctor of Chiropractic sitting next to him, who also happens to hold the MD degree but chooses to practice chiropractic medicine, grinned slightly, watched me move, listened to my tale, and repeated, "I know what this is." He got me on the exam table (somehow!), did some kind of manipulation for just a moment, and asked how I felt. The answer was, "Fine" [shocked!]. He showed me three simple exercises and told me to do them twice a day, recommended that a Physical Therapist friend stop by and give me a few ultrasound treatments, and promised that I'd be good as new in a week.

He was right.

The Emergency Room and doctor there cost thousands of dollars and yielded an incorrect diagnosis and ineffective treatment. Had I agreed to see the surgeon and undergo surgery the cost would have been much greater, and the surgery would have proven unnecessary. Of course I would have lost time at work and created additional expense for my company, not to mention the unpleasantness of the post-operative recovery period I could have anticipated. The MRI would not have been cheap, and would not have yielded useful information, and of course my insurance company and I paid for the drugs that didn't work. I can only speculate about what the internist might have done, and that speculation includes additional costly tests and referrals to more (expensive) specialists. My problem was capsular entrapment; the chiropractic manipulation released it, and the drugs didn't touch it because the capsule doesn't have a blood supply. The MRI would not have visualized it, and blood tests and scans would have yielded normal results.

I have written previously about my concern about the availability of health care providers to meet the needs of those who need services. The "cousin" of that concern is the larger issue of how we are to evaluate and treat health needs, who best can serve patients with different problems, and how these providers shall be paid. My hunch is that if the full spectrum of reputable health care providers were covered by insurance and were not subjected to MD "gatekeepers," treatment would be more holistic and effective, and less costly.

Modern medicine is wonderful, and its doctors (MDs) knowledgeable, skilled, and concerned. But it is but one perspective, and one set of tools for maintaining and repairing the incredibly complex human organism. It is about the diagnosis and treatment of pathology, according to one model, and one set of standards. There are others.

One fifteen minute session with a perceptive and skilled chiropractor did what hours in the Emergency Room, drugs, expensive tests, and surgery could not. The doctors were not wrong; rather they were practicing without the tools they needed to do the job that I needed done. They did the best they could with the knowledge and tools they had. The chiropractor brought another set of knowledge and skills; this one happened to be the one needed. Some years before an accupuncturist brought me relief for a chronic tendonitis that medicine and therapy had not touched. As a nurse, trained in the science of people's experience of and reactions to changes in their health states, and in teaching and collaborating to move people towards their health goals, I have knowledge and skills that MDs do not. Certainly they have knowledge and skills that I lack. Are patients not best served when we work together?

As a patient, I want my providers to have a full "toolbox" from which to select the treatments that are best for me. Sometimes those will be prescribed and overseen by MDs, but other times a psychologist, chiropractor, accupuncturist, nurse, therapist, or other professional will better serve my needs. A prominent physician at a major medical center once remarked in a presentation at a scientific meeting that one of the things he had learned from his "colleagues in reflexology" was the value of the light touch in a physical exam. Reflexology? Snake oil for sure, I would have thought. But this highly credentialed, accomplished, and respected physician and professor had troubled to learn what "colleagues" in that field had to offer, and had come away with something of value. My guess is that more of us could benefit from such open-mindedness.

There is the legitimate argument that many "alternative" or "complementary" methods and treatments remain untested by rigorous scientific research; this is important. However, it also is true that this research often is blocked or given very low priority in the competition for funds and support, thanks to the overarching influence of western medicine and associated lobbies and interest groups. So support for research continues to go primarily to the sorts of problems and methods that have received priority for years, with fine results . . . but also at the cost of equally valuable findings in other fields of health care practice.

The House and Senate now have passed "health care reform" legislation, and are beginning the arduous process of hammering out their differences to reach a compromise package that can be passed by both chambers and signed by the President. I still get a headache thinking about this. But whatever the final bill that emerges, I wonder not only who will answer the phone call for an appointment, and the call light at the hospitalized patient's bedside, and the other pleas for health care help. But also I wonder when those responding providers meet the patients who summoned them,

What will they say?

Will they have only the perspective, tools, and training of western medicine, or will they be able to offer a full complement of health science and skilled, reputable practitioners to evaluate and meet those patients' needs in the most comprehensive, creative, and cost-effective ways possible? What tools do you want your providers to have in their toolboxes? Perhaps it's time to let your legislators know.

Who Will Answer?

Today's morning paper is full of updates in the ongoing debate about health care reform, a misnomer, in my view, in that the bills on the table by and large are about access to and payment for services, rather than about the care that patients receive once they have that access and a means of payment (or not). Be that as it may, as another long week draws to a close I wonder about the question no one seems to be asking: When millions of uninsured and underinsured people suddenly have health care coverage, who is going to take care of them?

There is little doubt, and there are many data demonstrating, that people without adequate means to pay for their health care often defer needed services. Regardless of the specifics of whatever eventual "health care reform" package emerges, clearly a great many new patients suddenly will have viable options for securing health services that previously were beyond their reach. This is a good thing. We don't find it acceptable that our neighbors, family members, or we ourselves may have to live with relentless pain, growing tumors, untreated and uncontrolled chronic illnesses, acute diseases and injuries, poor vision, bad teeth, a wobbly gait, and more. Yet even now those who have insurance often are told that their doctors have no appointments available for weeks or months. Tests and consultations require still more waiting. Phone calls are not returned for hours, and some messages become lost entirely.

Providers are busy. A physician colleague remarked today that the primary care providers in his practice routinely work six long days every week, and have phone calls and paperwork to manage on the seventh. Another physician friend shared over dinner this week that while on call the night before she was awakened every two hours to deal with a problem, had to work the next day, and was on call again the day after that. My company often turns away referrals because there are no nurses or therapists available to see new patients. I know well the exhaustion of having too many patients crammed into a work day, with the attendant temptation to hurry, to cut corners, and to discourage questions and discussion; and I know the oversights and errors that can result. As a more senior clinician in a leadership position I sometimes make those difficult-to-staff or unscheduled emergency home visits myself, and more often than I like to think find evidence of shortcuts taken, skilled services withheld, and significant clinical data overlooked, no doubt because the nurse who preceded me was busy and tired.

The doctors and nurses with whom I speak are not happy in their work these days, and many are leaving their professions. Last year a doctor described seeing a new patient in his clinic, doing a complete evaluation, and then providing a treatment. After all the associated paperwork had been completed and submitted the patient's insurance company paid the doctor $12.00. Twelve dollars. This doctor is no longer practicing medicine, except for occasional appointments after his new, non-medical job is over for the day. I know of many other physicians who have closed their practices and left medicine in recent years. Two weeks ago I sat in a conference of medical superspecialists and listened to concerns about the paucity of "new blood" entering the field, as young doctors choose specialties with easier hours and fewer demands. Primary care doctors are closing their practices; new doctors are not choosing primary care or many specialties, opting instead for careers in fields with steady incomes, regular hours, and no "on call." So as scientific knowledge burgeons, the number of those who would put it to use in patient care dwindles.

The "nursing shortage" has been in the news for years. Actually there are plenty of nurses out there; they just no longer practice nursing. After a few years of long hours, physically and mentally taxing work, toxic organizational cultures, rigid rules, and lackluster compensation and benefits, many nurses move on to other lines of work. No longer confined to traditional roles, many women do not choose nursing, and those who do are aware that there are many other options available to them. The knowledge, skills, discipline, and insight that make people good nurses also make them good business people, lawyers, administrators, politicians, clergy, and more.

With the national economy in the sewer and thousands of jobs lost, there has been an influx of students into nursing and allied health programs, particularly at community colleges. While it is good to see people from a wide range of backgrounds coming into and enriching the health care professions, one must wonder if he or she truly wants to be in the care of a nurse, therapist, or other provider who went into that line of work only because his or her real estate, dot com, banking, or manufacturing business failed, and entered the profession with the minimum credential for licensure. The shortage of qualified faculty to teach these students is real as well.

The posturing and politicking going on in Washington as "health care reform" is discussed give me a headache. But what gives me a heartache is that few seem to be remembering that when we say someone has a right to receive something, such as health care, we implicitly say as well that someone else has a duty to supply it. Clearly it is not acceptable for injured workers to go untreated, for isolated elders to need to choose between food and medicine, for children to be denied preventive care, and more. But when "health care reform" passes, in whatever form it may take, and millions of the previously uninsured and underinsured persons join the rest of us in the quest for health care services, when we call for doctor appointments, ring for the nurse, or otherwise ask for help,

Who Will Answer?

This question needs to be on the table alongside those of access and payment, for without a coherent plan for all three, all will fail.