By SUSAN ADELMAN, MD
I just got off the phone after talking to a distant cousin and his wife, who recited a frustrating list of the medical and surgical problems that dominate their lives. They are my age, but neither can walk without a walker. My cousin is in a nursing home. I am active and traveling. Why? It is not clear. Some of their conditions obviously are not preventable. Some, I am not sure. Of limited means, they are trying not to spend more than their insurance will cover. In today’s environment, that may mean rushed 15-minute appointments, which make it hard for their doctors to deal in a calm, unhurried manner with complicated issues, prioritize them, and go over their treatments in detail.
They both have back problems. One of them received a series of steroid shots in the spine every three months until they no longer were effective. What about physical therapy? An effective course of therapy would have been good, but their benefits have run out. Do they go to the type of doctor we used to call general practitioners? I doubt it. If they really went to doctors with whom they could sit down and talk about their problems, they would not have had so many questions for me. Should they have back surgery now? Can one of them postpone it, or would that be too late for them to get back on their feet? Who needs the surgery more? Who should have it first? What type of doctor should they approach right now? Their neurosurgeon? Orthopedic surgeon? Neurologist? They did not mention a primary care physician.
It is as if they go to walk-in clinics instead of to real doctors with whom they have a long-standing relationship. But they say no; they have seen some of the same doctors for a long time. Yet, why did one of them have those steroid shots for months? Did any doctor ever sit them down, talk straight, and warn that steroids have side effects, or that they eventually stop working? Was it just quicker and more profitable to give them shots instead of insisting on adequate physical therapy? Who is guiltier of not insisting on the physical therapy, the doctor or the patient?
Physical therapy should be a matter of common sense. My mother knew that exercise is good, and most grandmothers give better basic medical advice than many doctors do. In Israel I caught COVID, a mild case. An Arab concierge said his grandmother used to insist he gargle with salt water instead of taking medicines, and he is sublimely healthy at 50. A Jewish concierge told me his grandmother taught him to gargle and it always works for him. Incidentally, once when I had a cold, a Chinese friend recommended her traditional Chinese cure—chicken soup!
Perhaps not surprisingly, an article in the June 9 Washington Post warned that, lacking faith in their doctors, members of the public are trying to take control of their own health, ordering DIY (do it yourself) tests by mail, and diagnosing their own ailments. The article cited some successes, but it explained that many of these tests have not been validated; they may be either ineffective or even dangerous.
In contrast, the Mayo Clinic and other institutions offer executive physicals for those who can afford them. Unconstrained by insurance company rules about what is compensated, the patient can have a comprehensive workup in a few days. What about those who cannot afford it? That is a problem. Yet, look at the cost tradeoff for the insurer. If my cousins are not well advised, what will their insurer have to pay for their surgery, follow-up in nursing homes, post-op therapies and other necessary care? In contrast, what would it cost for them to have an unrushed appointment with a qualified internist or GP, sit down, go through all their conditions, and evaluate their options? Part of this would be talk therapy, and that too might be something they need. But remember those limited physical therapy benefits. What if their clinic or insurer also offered physical therapy classes? These alone could lower their medical costs.
Would it not be worthwhile, at least for payers and maybe too for hospitals, to explore these alternate models? What if they set up programs like the executive physical or even an old-fashioned doctor visit, either with the patient’s own doctor or a specialist analogous to an inpatient hospitalist? Even if a clinic or insurer had to pay extra for it, I suspect that in difficult cases such a program would help the patient, and it would save everybody money in the long run.