Just Like Someone Without Mental Illness Only More So (2 page)

“You didn’t really think you could lose us, did you?”

PRACTICE, PRACTICE, PRACTICE

Most adults have forgotten what they had to do to survive childhood.

I’ve spent most of my professional life thinking about how to improve and safeguard the health of children, studying what others have figured out about their major and minor ailments and trying to cram this knowledge into the day-to-day work of a pediatric practice. It’s been a privilege to watch my patients and their parents closely to see what works and what doesn’t work.

If you had told me ten years ago that today my patients would routinely have to wait eight-plus hours in an emergency room to get not-very-good care, that every day my staff and I would spend hours arguing and doing paperwork to have my patients get basic medications, that there would be six-month waits to see specialists, again with the blizzard of paperwork, and that psychiatry would be essentially unavailable for children, especially ones with mental health problems, I would have asked what backward third-world country we were living in.

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 guidelines is that patients without asthma get crammed into asthma templates. Providers are rewarded financially and otherwise for small lies that make the templates and guidelines come out right.

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:

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)

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.