Fractured Medicine: One Woman’s Struggle with Contemporary Healthcare
Writer’s Comment: The assignment was to write an essay in the style of Atul Gawande, whose collection of reflective narratives in Complications we had been reading throughout the quarter. Searching for a topic in healthcare, I needed look no further than my wife’s devastating injury and her four year struggle to regain not only her physical strength but her emotional strength as well. While it was not difficult to find a subject, it was rather difficult to take a personal experience and transform it into words. I think it was particularly difficult for her to read her own life on paper with all of the feelings associated with the injury and her prolonged recovery. Robin, thank you for letting me share your story. And thank you to my instructor, Janet Papale, for encouraging me to submit the essay. I would not have known of or considered the possibility otherwise.
Instructor’s Comment: From his first journals for 104F, Matt showed his interest in alternatives to traditional forms of medicine and his brilliant insight into medicine’s limitations and biases. From his first journals for this particular assignment, a case study, Matt seemed fascinated by how the personal story of his wife’s injury intersected with the politics of major healthcare reform. Inspired by the vivid anecdotal style of Gawande’s Complications and by the structure of Sacks’ “On the Level” (a narrative interrupted by technical interludes), he set out to tell this personal/political story. Though at one point frustrated that the two strands of his essay were too separate in style, he patiently reworked it until its parts felt balanced. I love this balance, and I love the boldness of his moral vision, his willingness to transform his sense of personal outrage into such an articulate political plea.
She went down hard and fast, without warning or sufficient time to react. Reaching out behind her in a feeble attempt to brace the fall, Robin could do little to protect herself from the impending injury. Palm side down and elbow hyper-extended, Robin planted her hand on the floor in a natural reaction to her feet slipping out from under her. She would have been better off just falling on her rear than landing full-force on her outstretched arm. Though only sustaining a few minor lacerations, the real injuries were deeper, immediately obvious by the increased swelling. In shock, however, Robin would not realize the magnitude of the injury for some time.
The ambulance arrived at the restaurant where Robin had been employed as a waitress for the previous seven years, a job she relied on to support her two young daughters. The paramedics tended to her injury while monitoring her vital signs. The nature of the injury apparent upon first sight, they loaded Robin on the gurney and transported her to the local emergency room where x-rays confirmed her worst fears; she had broken her arm. The attending, unable to fix the problem with a simple cast, referred Robin to the occupational health clinic. Since it was a Friday night, however, she would have to wait until Monday morning for an appointment. With a make-shift sling and a prescription for pain killers, the hospital released Robin late that night, never bothering to contact the on-call orthopedic surgeon for a consult.
In enormous physical and emotional pain, Robin had more questions than answers. Why did she have to wait to see someone and why occupational health? How was she going to pay for her care? How long would she miss work and what would she do for income? She worked part-time, without medical or dental benefits and relied on tips to make ends meet. How much help was Worker’s Compensation going to provide?
The answers would come in due time. Worker’s Compensation, a state-funded program, provides health insurance for work-related injuries. Marred by bureaucratic red tape, the program’s main objective, to settle claims with the smallest payout possible, comes at the expense of the care provided to the injured. Like any insurance coverage, the premiums are based on the number and severity of claims against that policy. This system automatically creates an antagonistic relationship between employers and employees. While the vast majority of claims for Worker’s Compensation are associated with repetitive movement disorders, such as carpal tunnel syndrome, occasionally acute traumas do occur that necessitate immediate care. Due to the overwhelming case load of these chronic issues, however, an acute injury may not receive the attention it requires.
Bogged down in proving if John Q’s lower back pain is really due to the job instead of his weekend ski trip, many Worker’s Compensation employees are reluctant to authorize necessary procedures. Even if the treatment is approved, there is still the question of fault for the incident. Employers do not want to be blamed for an accident because that would raise their insurance premiums, so oftentimes they will lay blame for the injury on the injured themselves. Therefore, not only do the employees suffer an injury, they have to deal with the threat of losing their job due to “their negligence,” as well. While it is technically illegal to terminate an employee because he or she filed a claim, it is also not uncommon for an employer to find another excuse why that individual is no longer needed at the company, particularly if that person only worked part-time. Consequently, this system, put in place partly to provide security to employees who do not have health benefits, compounds the lack of adequate healthcare with decreased job security, an added stress to an already traumatic situation, one that Robin could have done without.
The weekend passed, and Robin returned to the hospital, this time to the second floor to meet with a nurse in occupational health. In most cases, an injury such as Robin’s would have been referred to one of the orthopedic surgeons on staff at the hospital, but because this injury occurred at work, it automatically became a case for occupational health. The nurse unwrapped the sling, took one look at the arm, still swollen and bruised, and referred her to another hospital for another consultation. Without so much as re-wrapping her arm, the hospital sent Robin on her way. Frustrated and confused, Robin made her own appointment with a local orthopedic surgeon, hoping to get quicker results. While she managed to get an appointment, Robin became more discouraged when the doctor agreed to perform the surgery only after having one week to review the anatomy and procedures. Horrified by the prospect of a surgeon checking a “how to” manual before operating on her arm, Robin asked her case manager from Worker’s Compensation to make an appointment with another clinic, this time with a hand specialist in Sacramento. Another week passed before Dr. Clark, a junior resident in the clinic, examined Robin’s arm and, shocked by what he saw, insisted that she be scheduled immediately for an operation.
Like most hospitals in smaller communities, the facility where Robin was initially transported for treatment of her injury employed physicians with generalized backgrounds, such as family practitioners or internists. Even the emergency room physicians had more generalized training compared to their counterparts in larger cities because the majority of patients who walk into an ER in a small community are suffering from some form of non-localized discomfort, such as fevers or nausea, rather than acute trauma. Unfortunately, hospitals cannot afford to staff specialists because they do not get a high enough volume of cases to justify the cost. In most cases, when a serious injury does present itself, the attending physician does not have the requisite training to administer proper care. While some injuries, such as brain trauma, are automatically transported to larger hospitals, less obvious acute injuries still find their way into the local emergency rooms.
Understandably, not every emergency room can provide care for every patient. However, the network of healthcare professionals lacks the structure to efficiently handle the in-between cases such as Robin’s—not life threatening, yet still requiring immediate attention to avoid permanent damage. Upon assessing the injury, the ER doctor should have immediately transferred Robin to a centralized hospital with orthopedic staff who routinely treat all area orthopedic cases. A specialized staff with vast experience in the field can significantly reduce healthcare costs by limiting complications and the need for follow-up care, a situation that Robin clearly would have benefited from.
Instead, Robin waited two full weeks to receive the care that should have been administered the night the injury occurred. Finally having undergone surgery on her broken arm, Robin woke up, groggy and nauseated from the anesthesia, to find a large, metal brace attached to her limb. The “external-fixator,” which screwed into the bone (at the second metacarpal and radius) protruded from her skin in a grotesque attempt to keep the arm rigid and allow the bones to heal. The metal contraption required a great deal of maintenance in order to prevent infection in the open wounds. Robin suffered many long nights, waking periodically to take more pills or to clean the gaping holes in her skin. It was difficult enough to sleep or shower with the bulky apparatus on her arm, but since she had injured her dominant hand, even simple tasks like brushing her teeth or writing notes became excruciatingly painful and laborious.
Unable to work, Robin rarely left the house. She spent the majority of her day watching television in bed. On high doses of pain relievers and unable to exercise, Robin gained weight and suffered additional health issues. Her vision deteriorated, her menstrual cycle became erratic, and she struggled with depression. Compounding the social isolation was the stress of her now limited income. Worker’s Compensation only pays a percentage of an employee’s wages and, as a waitress, Robin barely earned minimum wage. Worse yet, Worker’s Compensation did not provide for the lost income from tips, the bulk of any server’s income. Without the financial and emotional support of her parents, it is hard to say what Robin’s fate would have been.
Robin ended up having three more surgeries to repair her damaged wrist. After removing the fixator, Dr. Clark attempted a bone graph, using a piece of her pelvis as a substitute for her shattered sphenoid bone. When that didn’t take, the surgeon tried using pins and a metal plate to brace the carpal bones in place. Again, the procedure failed to yield the desired results. Out of remedies, the next and last option would be to fuse the wrist bones to the ulna and radius, completely removing any flexibility and severely limiting the permanent use of her arm. Robin refused this option, instead choosing to live with the pain and the occasional popping of the radius as it slips out of place.
With months of physical therapy, Robin has regained only half of her flexibility and even less strength in what used to be her dominant arm. Relying heavily on her left hand for mundane tasks such as pouring milk, Robin has learned to cope with her injury. With no possibility of returning to her position as a waitress, Robin entered vocational rehabilitation, learning a variety of computer skills. However, unable to perform common duties associated with most clerical jobs, she found it nearly impossible to find alternative employment. Eventually deciding on Real Estate as one of the few possibilities for her combination of limited physical abilities and newly acquired skills, Robin found the confidence and self-appreciation she lacked throughout her recovery, but at an expense far greater than she bargained for.
Robin’s case highlights the glaring flaws in our current healthcare system, a system dominated by third party payers and inexperienced doctors. The inexplicably complicated authorization process, frustrating to both doctors and patients alike, severely limits a physician’s ability to provide the best care possible and, in many cases, a lack of available resources further restricts the delivery of even adequate healthcare. Limited medical school enrollment further exacerbates the problem of supply and demand for patient care, and with the high cost of medical training driving newly certified interns away from underserved communities into clinics that can quickly pay off their student loans, it is easy to understand the reasons behind one of the biggest problems with the current model: the discrepancy in the quality of care that exists between members of different socio-economic classes. The indigent are frequently forced to rely on free health clinics while corporate CEOs employ personal physicians, a rather ironic scenario given that higher wage earners tend to have better health and therefore less need for premium healthcare than those less fortunate.
Unfortunately, healthcare is a business and this tiered level of service is the result of simple economics. A capitalist economy such as ours rewards companies based on financial strength, and while an HMO’s mission statement may reflect a desire to provide care for the ill, the board of trustees, which issues quarterly statements to their stockholders, regards their organization’s success in terms of revenue targets and expense reports. It seems an inherent conflict that a company tasked with the responsibility of providing healthcare to the injured measures their prosperity in dollars and cents.
This contradiction, equally applicable to hospitals and insurance companies, could be eliminated by creating a system of socialized medicine. Instead of spending trillions of dollars fighting wars over oil rights, the government could utilize these funds to subsidize universal healthcare coverage that would alleviate the undue burden of high-cost, low-quality healthcare experienced by struggling families, single parents, and the elderly. The reduction in costs associated with third party payers could be in the billions of dollars. At the same time, this new system would establish universal standards for care, which would eliminate the disparity in quality of healthcare afforded to these divergent economic classes and thereby create a system where a waitress can receive the same care as the restaurant owner.