Just Like Someone Without Mental Illness Only More So_ A Memoir - Mark Vonnegut [3]
Medicine can’t be made idiot-proof because idiots will always find a way to start or end up in the wrong place. The doctor gets credit for a 99214 ICD-9 493.10 and will be paid for such, with a bonus payment for asthma management under the quality-improvement asthma initiative. Unfortunately asthma might or might not have had much to do with what was bothering the patient. It’s amazing how well you can get paid for doing a crummy job.
There is something very pure—and easy to screw up—about trying to do the right thing without doing harm. Medical care has become a minefield of incentives that distort that purity. In some settings, revenues can be dramatically “enhanced” by ordering X-rays and tests or even doing unnecessary surgery. In other settings, providers can be penalized for ordering tests or making referrals. A doctor whose productivity incentives demand that he see four to six patients an hour delivers different care from one setting her own pace. A doctor under time pressure is more likely to come up with a quick diagnosis and treatment. Checklists and productivity goals become proxies for care. The proxies are what you get paid for, and the care goes to hell.
I want needlepoints on my wall that read:
The less you have wrong with you, the longer it will take me to find it
It’s faster and much more profitable to do a test than to explain why it’s not necessary
Beware of what you get paid for
If medical care makes people poor and dependent, it’s no different from cancer, whooping cough, or malaria.
Sometimes for me to get a stethoscope to the chest or push a tongue down or to move the earwax out of the way to see the eardrum is an epic struggle like the one described in Jack London’s story “To Build a Fire.” Sometimes I’m saving the world. Sometimes I’m just trying to see the damn eardrum. Sometimes by trying to see the damn eardrum I’m saving the world.
Of course I’m trying to save the world. What else would a bipolar manic-depressive hippie with a BA in religion practicing primary-care pediatrics be up to? If the saving-the-world stuff doesn’t work out, I have steady work and a decent income.
Young Jane and Kurt with me, circa 1948
(Vonnegut family photo)
chapter 1
A Brief Family History
It’s good to have a sixth gear, but watch out for the seventh one. If you think too well outside the box, you might find yourself in a little room without much in it.
The arts are not extracurricular.
One hundred thirty-nine years ago, my great-grandfather Bernard Vonnegut, fifteen years old, described as less physically robust than his two older brothers, probably asthmatic, started crying while doing inventory at the family hardware store. When his parents asked what was wrong, he said he didn’t know but he thought he wanted to be an artist.
“I don’t want to sell nails,” he sobbed.
Maybe his parents should have beaten him for being ungrateful, but they wanted their son to be happy and the business was successful enough that they could hire someone else to do inventory. He became an apprentice stonecutter and then went to Europe to study art and architecture. He designed many buildings in Indianapolis that still stand today. He drew beautifully, made sculptures and furniture. He was also happily married and had three children, one of whom was Kurt senior, my grandfather, who was known as “Doc” and who also became an architect. Doc could also draw and paint and make furniture. He made wonderful chessboards, one of which he gave to me when I was nine.
When he was sixty, Doc was pulled over for not stopping at a stop sign. The cop was astonished to notice that his driver’s license had expired twenty years earlier.
“So shoot me,” said Doc.
At the end of his life, which had included financial ruin in the Great Depression, his wife’s barbiturate addiction and death by overdose, and then