Sex, Drugs, and Public Health

I.       The Auditorium

“Look to your left,” the little man said to us from behind the podium. Twin snakes wound their way up the front of the podium toward him.

“Look to your right,” he continued his command.

All 128 of us swiveled our heads obediently, even though we knew what his third line would be.  It was legendary and we’d all heard it many times.  He would say: “One of the three of you will not graduate and become a doctor.”

The real message, of course, which neither the Dean at the podium nor any of us in this Med School auditorium would say aloud was: work harder than you’ve ever worked before.  Sacrifice sleep for study. Sacrifice your social lives.  Sacrifice your marriages. Give your fellow students wrong answers.  Fear the professors and their grade giving.  Learn not just the human body, but the entire medical library.  And be able to regurgitate it in its entirety, on command.

But he was cute about it, this Dean.  After all, he had heard the famous saying, too.  He changed the third line:

“All three of you should graduate and become physicians…”

It should have been a relief, but he wasn’t finished.

“…as long as you work harder than you’ve ever worked before, and learn everything we have to teach you.”

He smiled beneath his bald little head, above the brass snakes entwining the brass staff of Caduceus on the podium, and awaited our applause.  He heard only silence.  Our hands were frozen in terror.  The underlying message, after all, had not changed.

We congregated outside the auditorium, as soon as we’d been released.

“Hi, I’m John.”

I responded to the stranger with my name. 

John added with a toothy smile, “believe me, I’m going to make it to graduation.”

I felt a powerful urge to be honest, but instead I just added, “Yep.  Me too. I’m gonna be an Internist. Like Kildare.”

We almost had a moment of optimism there, the two of us.  Then a tall guy with an intensity burning to the verge of homicidal maniac leaned into our conversation.

“You two don’t know what you’re talking about.”

“And you do?” chirped John.

“Yeah,” he pinned us to the wall with his eyes.  “I do.  I was here last year.  Right here.  First year student and – ”

“Well,” I interrupted him, “You’re here this year too, so you made it just fine.”

“Think so?” he hissed.  “I’m not a second year student.  I‘m a first year student.  Again.  Along with eight others.  They flunked us in Physiology Lab and we’re repeating.” He bore in deeper with his eyes.  “You only get one repeat.  The sword of Guillotine – Dr. Guillotine – is hanging over our necks.  Yours, too.”

“Damocles,” I corrected him because it made me feel better somehow.  “Sword of Damocles.”

“Well,” chirped John with a broad smile.  “Good luck this year.  We’ll see you in the study hall.”

The tall guy slunk away, into the milling group.

It was autumn in New York.  Beyond the dark paneled walls of the century-old Med School, trees were bursting into yellow and red and orange across the Avenue in Central Park.

“Come on,” John offered, “Let’s take a walk before classes start.  Exercise is good.”

“Thanks, but I have to do some business in the Dean’s office.  Catch you after lunch.”

When the Dean’s secretary said, “You may go in now,” I laid a letter on his desk for him, then sat in the chair, trembling as he read it.

“Hum-m,” he murmured as he read it.  “Looks like you’ve been drafted.  This is an order to report for Active Duty.”

“In ten days! They told me I’d be deferred,” I tried to say without wailing.  “Told me the physical this summer was ‘just a formality’.  Promised me they wouldn’t draft me.  They knew I was accepted into Med School.”

“Okay.  Okay.  Calm down.  I’ll write them a letter.”

 “I don’t mind going some day, but I’m worth more to them as a doctor.  If they pull me out now, I don’t know if I’ll ever get back to Med School.”

“I’ll take care of it,” he smiled beneath his little bald head. “You’ll get your deferment back.  I’ve got four other letters to write.”

”Four others?  Same issue?”

“Yep.”

“They tried to draft four other guys out of Med School?”

“Yep.”

“But if I’d gotten a ‘Report for Active Duty’ date just a week earlier, before school began, I’d have been gone.”

“Yep.”

“They lied to me!”

“Calm down.  They have quotas to fill. You’ve got other things to worry about now.  Study hard.”

So I left it to him. Not because I was overflowing with confidence in him, but because I knew I couldn’t do anything to change that letter which hung, Damocles-like, just inches above my entire future.

                                                                                              ( to be continued)

For some reason, the way the U.S. funds medical/health care is thru insurance policies. This is not the way it’s done in many other developed countries, and is inherently inefficient.

Inefficient because insurance companies operate for profit. All money deferred to profit and executive salaries is money not spent on health care.

And, as most physicians know, insurance companies put up lots of barriers to keep (or delay) patients from getting tests and treatment the doctor recommends. That is, obviously, good for their bottom line.

But what it means is that, rather than insurance companies providing health care to their insured – they frequently have powerful financial incentives to NOT provide expensive services.

However, politics in the U.S. is strongly biased against a major shift from
insurance to “Single Payer” (i.e. the government pays for everyone’s health care as it now does with Medi-Care).

Therefore, the Affordable Care Act is a complex law aimed at accomplishing the following:

A. Leave those who already have insurance alone

B. Help those who have no insurance or who are trying to buy
“individual” insurance (not group plan insurance)

Why did we need a law for this? Because obtaining individual policies is very difficult currently for many people due to insurance company activities like these:

- May deny a policy to someone with pre-existing
condition
(i.e. those who need it most)

- May yank coverage if someone’s health care is getting expensive

- May set premiums so high (especially on those with pre-existing
conditions or risk factors) that it’s practically not available

- May put annual dollar limits on benefits paid out of policy.

II. Timelines: There are a lot of them. We’ve passed several and more aspects of the law will be implemented from now thru 2018. Here are just some:

2013          Feds will pay for more Preventive services without insurance co-pay

2014         People will be able to buy insurance on Exchanges, instead of individual policies (where people have historically been
gouged).

Those who earn under 133% of poverty (around $23,000
for a four person household) will be eligible for Medi-Caide.

Insurance plans will no longer be able to refuse coverage for pre-existing conditions (i.e. deny insurance to those who need it most)

Insurance plans will no longer be able to put annual dollar limits on policies

People without insurance will be required to obtain it (this will drive down insurance costs since healthy people will be in the pool, and will take the burden of care off taxpayers who now end up paying many bills of this without insurance)

2015           Increase in federal funds into Children’s Health Insurance Program.

2018           Insurance companies that are still gouging people will have to pay higher               taxes

III. How has the Act already effected people?

A. Children under age 26 may now remain on parent’s insurance. 
This will help young adults, struggling to get started.

B. Seniors whose drug bills are high and who hit the “donut hole” will receive federal rebates and discounts to help.

C. People on Medi-Care (mostly seniors) are now able to get preventive services like mammograms and cancer screenings free.

D. Many more children are now covered thru Medi-Caide and CHIP.

E. When states have their “Exchanges” set up, people who currently can’t afford insurance will be able to do so.

IV. Conclusion:

Over the past ten years or so, fewer jobs have offered health insurance benefits, so there’s a trend that’s increasing the number of families without coverage.

The Act takes aim at Insurance Companies which have historically denied coverage to those who need it most, dropped coverage at will, balked at providing services ordered by physicians, and set premiums so high that it’s practically unobtainable for many.

We have a model of this Act – Massachusetts’ approach. So far, it seems to be working well and not breaking the bank

Speaking of funding, here’s how the Affordable Care Act gets funded:

A. Insurance companies must provide health coverage to everyone not otherwise covered.

B. Those without insurance must buy it (unless they’re financially unable). This drives the cost of insurance down by including the healthy

C. Low income families will be subsidized

D. New revenues on pharmaceutical companies, indoor tanning parlors, “Cadillac” insurance, and those on Medi-Care with incomes over $200,000 will help offset increased costs.

He came in for a physical, that’s all. Applying for a job. And it should have been simple: he was in his mid-twenties, trim, athletic. When he smiled, the muscles of his face revealed that the rest of his muscles would be well toned, too.

But even before he undressed, the jagged scar on his arm snagged my eyes. It gouged its way from his biceps down to near his wrist like the Colorado tears through the rocks of Arizona. Some places thin and presumably deep, other places thick, wide, a bundle of scar tissue knotting together the halves of his arm.

So, of course, I asked. I can get away with asking, what with the stethoscope dangling from my neck and all.

Me and three buddies, he began, we went up to Humboldt to surf. Great beach there with good waves. Not monsters, but challenging, you know?

It’s off the road quite a ways. Half an hour of slow driving over a cow pasture to the cliff where you can climb down.

Humboldt, you know, the water is cold and always stirred up. Kinda brown. Not much visibility. But the rollers were perfect that day. Fucking perfect.

I was into the water before my buddies had zipped their wetsuits. I wanted to catch the first big one.

He hit me while I was still paddling out, and pulled me down by my arm. I think he wanted to drown me first. My leg was dragging my board down behind me – I felt like I was being torn in half. I figured out right away what it was and knew I had, like, a 90% chance of being dead in a minute. And that pissed me off.

So, with my right hand, I felt around for his eye. Somewhere on that sandpaper head, I found it. And I started digging. Like my life, you know, depended on it.

Deep. I would have dug with my thumb to that bastard’s brain, if I could have. My thumb squeezed that gelatinous ball in its socket. I aimed my fingernail straight in, and pushed until I felt it explode, and my thumb fell deep into the puddle of goo oozing from his socket.

He spit me out.

The rest I don’t remember too good. Air. That felt good. A few heaving breaths of air. Then I yelled for my friends. They tell me I was thrashing in the “Red Sea.” Ha, ha. Very funny. Assholes.

They tell me they wondered if they were supposed to put a tourniquet on to stop the gush of blood. But they didn’t know what a tourniquet was, so they didn’t.

They tell me I was going unconscious as they dragged me up the cliff. They tell me they drove so fast over that pasture that the truck was airborne half the time. They tell me the doctor in the little one-horse hospital thought I was dead when they dragged me in, just dripping blood, no longer gushing it. No blood pressure to gush with, they said.

The doctor, they tell me, said the only reason I was still alive was ‘cause I was young. ‘Course, I know better. It’s because somewhere out there, some Son of a Bitch fish is trying to hunt seals with a patch over one eye.

Guest editorial by World – famous psychiatrist to physicians, Dr. Pannikatakus

I hear from physicians what, to no one else, they tell. Their secrets. Their fantasies. Their failures. Their sick little ideas.

 

 

Case # 69

“I was sent,” he snarls, this doctor. He is not a physician, I learn, but a surgeon. In this country, they license them the same. “Physician AND Surgeon” says the license. It’s confusing. But I digress.

“Ordered to come here,” he spews. “For the Public Health. Three sessions. So let’s get it over with, and you write to the Authorities that I came, and we’ll be done. Understand?”

“You are,” I say calmly toward his face, so flushed and hot I see steam rising from his sweat, “accustomed to giving orders, no?”

“Damn right. I’m a – ”

“Sit down, please,” I interrupt him. “On the couch. In this office, the orders I give.”

“It all started,” he begins, eventually, after a few more exchanges where, to him I make clear who is boss, “in the hospital. Late. Midnight, I think. I’d just finished an emergency torsion of the testicle, and was in the cafeteria, getting coffee from the machine. You know, for the drive home.

“The place was deserted. Except for this one guy. He was pushing an I.V. pole, his ass flapping in the breeze.”

“Asses can flap?” I blurt.

“The gown,” his eyes rise up and roll like exasperation. “The gown flaps. Don’t interrupt me. So, just as he’s passing me, he collapses. I look around for a doctor. An anesthesiologist. Even just an Intern. Hell, I’d have taken an E R nurse – if she was cute. But no one. The place was like a morgue with dispensing machines. This guy drools some saliva on the floor and his I.V. line pulls over the pole.

“Shit ! I think. Now I’ve gotta see if I remember any of that CPR crap. You know, this is not like on the table in the O.R.”

“No,” I say to fill the brief silence. “It is not like that. Continue.”

“So, he’s not breathing. No pulse. It’s – what do you guys call it? Cardiac arrest. So I can’t do CPR alone there until the 7 A.M. shift comes in, can I?”

“You said you don’t know CPR, did you not?”

“Well, there was that problem, too. So anyway. No way to call someone. Hours until someone might stumble by. So I get this brainstorm.”

Oh, oh, I think.

“Brilliant idea. Which makes sense ‘cause I’m a brilliant surgeon, you know.”

“Continue,” I say during the silence he creates, waiting, I assume, for applause.

“Anyway, I slice open his chest, reach in, massage his heart and, Boom! He wakes up!”

“Good,” I say. “You save his life.”

“Not yet. Every time I take my hand out, it stops again and his brain goes back to sleep. I need help, but there’s no one around. So, here’s the really brilliant part – - – .”

Another silence.

“Continue,” is all I say.

“And do you think he appreciates my brilliance? That I saved his life? No. After he recovers, he goes and gets a lawyer and sues me for mental torture or some such. Reports me to the licensing Board. So here I am.”

“Tell me,” I say, into the silence, “tell me your greater story of this brilliant idea.”

“I squeeze his heart until he wakes up again, then I take his right hand, put it down into his chest, around his heart, and I tell him to squeeze. Once a second. I tell him I’m going to get the E.R. doctor. And I warn him not to stop squeezing, or he’ll black out and die.”

“What did he say?” I ask.

“Say? He said what I told him to say. He said ‘thank you, Doctor’.”

With all the belligerence of teenage rebellion, I’d repeated incessantly that I was NOT going to become a doctor. The doddering old people in my hometown, their eyes all watery with memories of the grandfather I never knew, would say:

“You’re going to be a doctor, too. Just like the first Dr. Mosher and like your father.” A lot of times, they’d just hobble away after saying that, not even interested in hearing my rebuttal.

Problem was, I had to decide what I was going to “become,” since college was looming and they kind of required at least a vague idea.

“Dad,” I asked my father one night over a dinner grown cold waiting for him to return from delivering yet another inconveniently timed baby. “What does Uncle Jim do?”

“Jim? He’s an engineer.”

I was halfway into my first semester when it occurred to me that I should have asked a couple more questions. To at least, you know, get some idea what engineers do. Because that Calculus stuff was incomprehensible. At least it was when delivered in the thick German accent of our world-famous professor of whom the university was so proud.

World-famous for something, maybe. Not teaching, unfortunately.

At the end of that first year, I was an engineering student with “C” s in math and no summer job.

“I can get you in at the hospital,” my father offered. “They need an Orderly. To help the nurses.”

It was either that – which kind of seemed like a compromise of my anti – Doctor position – or back to stacking two-by-fours at the lumberyard. After a brief internal debate, I decided I’d learned all I’d ever need to know about two-by-fours the previous summer.

They gave me white pajamas to wear. I bought some white shoes. The nurses taught me how to fetch ice for the oxygen tents, how to tuck sheets under a mattress, how to catheterize men, and how to shave men’s pubic hair in preparation for tomorrow’s surgery without performing inadvertent surgery with the razor.

The other Orderlies taught me how to hide from the nurses.

“Shouldn’t we be doing something?” I asked the other Orderlies as we smoked around the Utility Room bathtub.

“Sh-h! The nurses will hear you and find us. This is just a summer job for you, but for us, it’s lifetime employment. Don’t ruin it for everyone by working hard.”

Nancy wore white, too, like the rest of us. After all, she was a nurse. But she sure didn’t wear her white like everyone else. Skin tight. I was mesmerized by her uniform when she walked. It allowed me to accurately visualize the human body’s individual muscle movements. Especially the gluteus muscle ( I’d learned that term from reading the patients’ charts. I was becoming more interested in this Medicine stuff than I wanted to be). The muscles of her legs I didn’t need much imagination for, since her uniform stopped about mid thigh, and when she sat –

“Chuck !” called the old crusty Boss Nurse. “Are you real busy right now?”

Gosh, I hope my staring wasn’t obvious.

“We need something from Central Supply.”

“Sure.” I was always happier to work than sit around the tub, whispering and smoking.

“Go on down and tell them we need a left handed Fallopian Tube.”

“Okay. What’s it for? Is it a catheter?”

“Sure,” she smirked. I think I saw the other nurses behind her turn their faces away. “A catheter. Hurry.”

So down into the bowels of the old brick hospital I went. I called from the door for the lady who ran Central Supply.

“Whatcha need?” she pushed from the corner of her tobacco-stained mouth. Her ash-colored face, devoid of any make-up, revealed decades of boredom and complete apathy for her job.

“Left handed Fallopian Tube,” I chirped. At seventeen, jaded older folks had no effect on my moods.

Her eyes rolled. Her head drooped. She exhaled chronic exasperation. “You go tell those sluts on Three West to stop wasting my time!” and she disappeared among the labyrinthine shelves of her personal cave.

Now my mood was effected. How could I go back up there empty handed? Having failed in my mission? I never wanted to do that. But no amount of calling, whistling, or yelling would bring back the Central Supply lady.

“There’s a problem,” I stammered in my best attempt to sound professional while awash in the shame of failure.

Boss Nurse fluttered her sparse, un – mascaraed lashes. “Oh?”

The other nurses all turned their faces away again. All except Nancy. She wore a sympathetic half smile like someone watching a puppy. That’s not all she wore – or almost wore – but I tried hard to concentrate on the job at hand.

“So what’s the problem?” Boss Nurse prodded. One of the nurses behind her snickered, and I got suspicious.

“They’re out,” I said. “On back order.”

And the floodgates burst. Everyone, even I, laughed one of those long spasms of laughing that leaves your rectus abdominis muscles sore.

I wasn’t about to ask them what a Fallopian Tube was – I’d consult my parents’ encyclopedia at home, later. But I was curious about one new medical term.

“By the way,” I broke thru the waning laughter, wiping my eyes. “What’s a slut?”