Just Like Someone Without Mental Illness Only More So_ A Memoir - Mark Vonnegut [2]
When I open the office on Sundays to see acutely sick kids, it takes my wife at least twice as long to check a patient in and verify insurance information as it takes me to diagnose and treat the problem. There’s an excellent chance even with all that checking that the insurer will find a way to not pay. Medical care has become a lot of crust and precious little pie.
PHYSICAL SIGNS
If I know their parents and siblings and cousins, I can look at someone with Down syndrome and see who he would have been if not for the split-second failure of chromosome 21 to separate from its copy. The disease is like a transparency. Separating out who and what a person is and what a disease is doing is much easier with acute illnesses and if you know the patient. In an otherwise well child, lobar pneumonia sticks out like a sore thumb. The longer a disease has to become part of a person, the harder it is to tease out. My job is to be an optimist and see people as potentially better than they are, and their problems as possibly removable overlays, as in “He’s a really great kid but he has a drug problem.” It’s also my job to tell the truth when there are things that aren’t going to get better.
I want my young hands back, the ones that don’t shake so much. The tremor that I’ve lived with my whole life is worse because I take lithium and drink coffee and am older. It’s my tremor more than being sixty-two or anything else that lets me know I won’t be able to do what I do now forever. It’s embarrassing to reach a stethoscope forward and have it shake against the patient and have to use two hands to steady the damn thing.
I’ve learned how to examine children without making them cry. I know how to quiet crying babies. I know that most blood tests, most referrals, and most medications are unnecessary. I don’t want my patients and parents taken advantage of. It is not a matter of great importance whether or not a given child has an ear infection. She will likely get better with or without help. But it is important that the person diagnosing the ear infection be doing so competently and honestly.
There’s an unfortunate hustle built into medical care, which favors doing things over not doing things. Most medical care is delivered by a provider who doesn’t know the patient and will never see him again. Doing things is more comfortable than not doing things. Doctors have much more at stake in their relationships with insurers and business managers than in their relationships with patients.
I worry more about patients now than I did when I was younger. Now a sick-looking child with a sky-high fever or a funky heart murmur I didn’t hear before doubles my pulse and makes me a little nauseous. I am confident that I can sink my teeth into any pediatric problem and hold on till the damn thing gives up, but that’s different from feeling like Clint Eastwood, the way I used to. Maybe I was unnaturally calm when I was younger and I’m paying for it now. A calmness debt.
It would help if I was a step back from the action, maybe in a tweed coat or corduroy jacket. At sixty-plus I didn’t expect to still be wrestling the terrified, swabbing the throats, being peed and thrown up on, and giving shots. I expected to have taken up a more gentlemanly position.
There are now a million templates and decision trees and practice guidelines, the underlying intent of which is to make medical care idiot-proof. Anyone with half a brain can check off boxes, and the pattern of the checked boxes tells you what the patient has and what to do about it. The problem with templates and clinical