Drive Away Doctoring: American Medical Apartheid

 While most Americans are currently outraged about drive-by-doctoring, I am personally experiencing the effects of a different kind of medicine I would call drive-away doctoring. Drive away doctoring is the exact opposite of drive-by doctoring. As witty commentator Max Keiser pointed out, drive by doctoring is a phenomenon that will affect the wealthy with some assets to extort. While these well-heeled potential patrons of the medical arts will receive lots of specialist care and intervention, many others more like myself will receive the opposite. The extent to which those of us without assets have experienced the exact opposite of drive by doctoring in the USA, Obamacare or not, has been under-reported.
 My own personal experiences in the US medical system have shown me that there are systemic problems. The experiences I had were not just as a doctor, but as a patient eventually diagnosed with an endocrine problem. I returned to the USA after leaving my civil partner abroad, and thus losing visa status. I had failed to produce any babies in spite of trying and I did not ask for or get any alimony. (Well, technically, my partner's mother had given me a shirt, a tin of cookies and an offer to help me when I last saw her, perhaps a bit embarrassed by how her son had run off after another woman at the most inopportune moment for me. ) I had too much pride to take even a shred of help such as even help reading all the legal documents in Hebrew I was stuck with in the aftermath so I returned to the US worse than penniless. I came back with new debt to a lawyer who had helped me try to sort my paperwork, and an only unpaid externship in a hospital which might eventually lead to an offer for work. Again, my pride kept me from taking any hand-outs. I refused welfare and ate from the trash at times. But having landed post-Obamacare requirements, I did acquired the supposed handout of state health due to fear of a penalty I would be unable to pay if I did not. Sunk under med school debt without a high paying job I was shuttled to Medicaid. I suddenly found myself with a borderline incompetent primary care physician. I dove deeper into debt to see a private doctor. After paying a total of about $1000 dollars for a single visit I discovered that doctor could not be bothered to even renew my prescriptions unless I redid my testing at his recommended laboratory and came back to see him. My anger welled. I was essentially being extorted for money I didn't even have. He just presumed that as a doctor I would find a few thousand lying around my couch cushions for such procedures and tests. I didn't. I ended up in an ER at one point tachycardic and hypertensive. I was discharged with a diagnosis of anxiety in spite of telling the resident I was more than likely having problems with my thyroid. I explained through use of Bayesian logic why he should test my thyroid. He explained that I didn't look like I was going to die from thyroid storm that particular day. I emphasized that I had no children in spite of trying, and I was afraid my thyroid was malfunctioning. The young doctor seemed more convinced that I was looking for drugs, or on even drugs than someone who had once also prescribed drugs- just like him.
Let me back up and mention that I have some training in Emergency medicine. The focus of emergency medicine is very dependent upon which doctor you ask. Some doctors treat nearly anything in an understanding that they are really the only point of care for some of their patients. Other doctors treat a more limited scope of illness as they understand their own limitations, and want their patients to receive the best care possible; which may involve specialists. Both approaches are entirely legitimate, but at a minimum it is incumbent on an emergency physician to treat threats to life, limb, vision and fertility. ED docs who do otherwise are not true emergency physicians, rather emergency hangers of saline bags who wait for the real doctors to show up. We have a profession for that: nurse's aides.
When tests of my thyroid done over the next months by both a PCP and an endocrinologist revealed I suffered from thyroid disease I was not shocked by my diagnosis. I was only saddened that I had spent unnecessary time suffering from thyroid disease, and the subsequent further loss of fertility in that time period it implied. In my mind, by leaving me untested the doctor I saw in the emergency room had done something only marginally different than seeing a man in testicular torsion, and telling him to follow up because he didn't want to bother with the ultrasound machine. I asked around about why anyone would do something so stupid. All doctors I spoke to mentioned reimbursement in one way or another.
One doctor I respect took a logical stance for a highly market oriented of system healthcare. "If you don't like one doctor, see another." It sounded logical, until I saw three more doctors in a row. After those three visits, I had to take a break. I had become so horrified by the treatment I was getting by every doctor I visited that I contemplated suing all of them on principle. At one point I saw a gynecologist specialized in ovarian problems. I told her of all my symptoms and problems. I asked for nothing more than recommended by the American College of Gynecology for a woman with my diagnoses: a couple genetic tests. She responded by stating that she would consider testing me in 6 months. Even my 13 year old god-daughter can tell you that barring gene therapy, the genetic make-up does not change in the same person over 6 months, or 6 years for that matter. I was suffering symptoms of my diseases then, not six months in the future. In the final blow to my confidence in American doctors the Gynecologist proved she was also selectively deaf. Not 20 minutes, after my explaining my inability to conceive, my miserable problems with childlessness, and breaking down in tears over the fact that the adoption system was nearly insurmountable for me, she recommended that whatever I did I stay on a steady birth control regimen for the rest of the year. When I began explaining to her why this did not make sense for me, she told me I could also do nothing and not receive treatment implying that I was free to ignore her "expert" advice.
I was flustered. I left the office without bothering to tell her I would not be back. I had reached a breaking point because the endocrinologist I had seen a few days before had treated me equally poorly. Although she wasn't selectively deaf she was a racist, borderline mentally retarded or so hopped up on hormones from her own bulging pregnancy she could no longer think. Outside this woman's office there happened to be a lot of literature about how poor people could be "helped" by introducing more contraceptives to them.  The picture on one handout showed a smiling black couple. I did not smile. The literature made me angry due to the inaccurate generalizations about my population. Nowhere in this literature so clearly targeted at my population, did it mention that black women have more problems with fertility than white women, yet receive far less treatment. When I walked into the office I was greeted by a smiling doctor with a huge pregnancy bulging out from under her opened white coat. Her smile went away as she refused to give me a drug to try to induce ovulation. "When you get a partner, then I can give you this drug." I looked at her shocked. She treated minority patients all the time from the looks of the waiting room. The entire waiting room was filled with low income minority residents of the Bronx. I asked her if she would tell me the probability that a woman like myself demographically would find a partner before my fertility profile became even more dire: a sarcastic "trick" question given that any woman my age has a fertile profile that plunges every month. She got an embarrassed look on her face, then repeated herself that it was "policy" not to give "partnerless" women help with fertility. I wondered who cooked up such an asinine policy unsuited for today's realities. 74% of black women give birth when unmarried. Marriage in our population happens after fertility wanes. Like it or hate it as I do; the social trend means most black women who want children will often have to go it alone. What stake did this woman have in pretending it would be easy for me to get a partner or that I didn't deserve healthcare until I did? She wasn't going to pay after all, neither personally or as a taxpayer, I was. I was going to have to pay the whole 20$ that the prescription cost, and potentially save myself from the state paying to supplement my hormones for the next 15 years- a cost quite a bit higher than 20$. I mentioned that I was a doctor and could look up the cost of drugs on software I owned. I mentioned the cost of trying to return me to a normal ovulatory state was far less than the cost of treating me with continued anovulation due to the sequela. She didn't seemed moved. And then I threatened to sue her is she didn't write me the prescription I was asking for. No sooner had I implied a lawsuit than she reached for her pen and told me she would make an "exception" in my case. Then she did something that floored me. She asked when I would follow up with her. "Never." I said flatly.
Years of condescension by doctors have shaped my personality, beliefs and actions. I'll never forget the first time I mentioned to my primary care physicians that I was considering medicine as a career choice. He leaned in, his light eyes looking at me coldly, analyzing me, and perhaps making some calculations about me based on my address in Brooklyn, skin color and no frills health insurance. "Well, I highly doubt someone like you will end up going to Harvard Medical School" he said with an air of condescension. Over a decade later, I have realized as an American born primary care doctor in a bad Brooklyn neighborhood, poor young black women were probably just about the only people he could have the joy of condescending. Back then I had the strength to swallow such incidents and let them motivate me. I woke up every morning at 4 AM before work, to study for my MCAT. My score was so high it earned my quite a few interview invitations; even at places like Yale where the interviewer congratulated me on my score. But ultimately, the doctor was right, I did not graduate from Harvard specifically. I recently tracked down this doctor via the internet for the sake of writing this piece. Shockingly, it turns out, as to graduating from Harvard, neither did he. In fact his medical alma matter was someplace I had never heard of...and that fact gets to the heart of the problem.
Most of us are not being serviced by expensive drive-by specialists graduated from Ivy-league residencies. We are getting medical care from average doctors with average thought patterns sufficient to handle average patients. When I visited the slew of doctors I tried in the pseudo-public system that dots the Bronx I had to repeat myself several times about the fact that I had no children in spite of wanting them. I suspect these doctors assumed that I was, like their average patients at, done with my childbearing in my thirties, not desperately trying to start it. The waiting rooms were full of women with several children in tow. I looked just like these women, and on average each woman in the waiting room probably had at least two children. Just one problem: neither I nor any other patient is a perfect composite average. If health care providers only have the mental energy to live in an imaginary world of averages unless money can convince them otherwise, we are all in trouble, health care providers included. At that point most doctors could be replaced by machines programmed to dole out healthcare like an algorithm, without pesky human factors like racism and classism meddling with the treatment of patients to conform with guidelines. Perhaps we will all be better off when this becomes a reality.
Unfortunately we do not live in an imaginary world of averages. We exist in an infinitely diverse reality healthcare providers are tasked with managing to optimize our health. A good doctor makes an informed assessment about any given patient and provides appropriate care. I myself as a doctor in the past considered keeping certain patients in the hospital due to their apparent mental inability to be compliant with treatments. But when the tables were turned, and I was a patient the assessment of me was not towards over-treatment; but under-treatment. I simply did not matter, much less what I wanted in terms of my health or reproduction. None of this comes as a particular shock. If the events of the past year have proved anything, it is that America as a whole does not value certain lives. Why should American medicine be any different? The practice of medicine reflects cultural values. In Western Europe or Canada, where the general health of everyone is valued, patients are treated regardless of their ability to pay. In the US, patients may be treated in many cases according to their ability to pay.  A wealthy patient at Lenox Hill will be treated like an ATM machine. A poor woman like me will be treated as if she is simply in the way. Capitalism for better or worse, and usually worse, has shaped American medicine. So has racism. Bizarrely, individualism apparently has not, so when doctors see a penniless black woman like me, no matter how well educated, they do not practice drive by doctoring. They practice drive-away doctoring. They administer less and worst medical care. All the statistics gathered on health disparities show my case is not isolated, but part of a pattern within the medical system. The free market solution to these problems is that patients will doctor shop until they find providers that they are happy with. The American market reality when the wealth difference between blacks and whites is higher than that under apartheid in South Africa, blacks make up about 4% of doctors, and even one visit to a private physician can set you back $1000 as I found out; is that we, poor blacks, are not all going to get great health care. The free market does not solve all problems. In fact, in this case it creates them.
This summer we saw children ripped from their parents because of supposedly overdue water bills of a few hundred dollars in Detroit. We saw police not only killing unarmed civilians, but pushing pregnant women into the pavement, and beating up teenagers all caught on video week in and week out. Such events leave people like me wondering whether America values lives like mine at all. And if it doesn't why they can't it's officials simply tell me when I walk into a doctor's office or E.D. they will do their best to hinder my reproduction, and certainly not go out of their way to diagnose potentially life threatening problems like my thyroid disease even if I explicitly ask for it. At least that way I can cut my visit short and keep shopping the supposed free market for a doctor who actually cares. Due to centuries of state sponsored neglect of the education of certain populations, most of us living lives like mine lack the sophistication to understand that it is not only the policing system which actively devalues our lives as opposed to others. The denigration and devaluation comes not only from the police system but also the system that we have helped set up to guard life itself.