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My breast has fallen off. Can you reattach it?
April 24, 2012 10:16 PM   Subscribe

Since she is not truly an emergency patient, she is triaged to the back of the line, and other folks, those in immediate distress, get in for treatment ahead of her. She waits on a gurney in a cavernous green hallway. The “chief complaint” on her chart at Grady Memorial Hospital, in Downtown Atlanta, might have set off a wave of nausea in a hospital at a white suburb or almost any place in the civilized world. It reads, “My breast has fallen off. Can you reattach it?” (via Boing Boing)

This is an extremely distressing story. Be cautious.
posted by Joe in Australia (103 comments total) 40 users marked this as a favorite

 
I don't know if I'll ever get that image out of my mind.
posted by lunasol at 10:26 PM on April 24, 2012


This says a lot about American culture, even moreso than American healthcare. In Canada, it is almost inconceivable that a woman with breast cancer would lose her job for seeking treatment. The employer would get slapped down so hard their subsidiaries' heads would spin. It isn't just a matter of whether Americans have health insurance or not. If you have it but can't use it, why even have it? All the Obamacare in the world won't help someone who's living paycheque-to-paycheque without adequate sick leave and in a work culture that discourages wellness through the threat of termination.

This is an important interview and excerpt, and I'll bet it'll be an important book. My mind boggles that this doctor is a pariah among other doctors.
posted by ten pounds of inedita at 10:35 PM on April 24, 2012 [44 favorites]


Heartbreaking and infuriating.
posted by deborah at 10:38 PM on April 24, 2012


She wasn't in pain or distressed which is good. The most disturbing mastectomy account you will ever read was written in the 19th century, called "Fanny Burney's mastectomy letter", about a procedure done without anesthesia. (previously)
posted by stbalbach at 10:38 PM on April 24, 2012


As a lifelong Atlanta resident I've always been taught exactly what the article says. Avoid Grady at all costs, unless you are shot, stabbed, or snake bit.
posted by Megafly at 10:38 PM on April 24, 2012 [4 favorites]


This broke my heart. :(
posted by These Birds of a Feather at 10:48 PM on April 24, 2012


USA! USA! USA!



[This crap really makes me sick, how can more than 1/2 the country not see what's going on?]
posted by bottlebrushtree at 10:54 PM on April 24, 2012


This is sickening. I don't understand how people can be so blind.
posted by fshgrl at 11:32 PM on April 24, 2012


how can more than 1/2 the country not see what's going on?

They can see what's going on. In particular, they can see that it's not happening to *them*.
posted by Tell Me No Lies at 11:58 PM on April 24, 2012 [48 favorites]


Articles like this do not help to change minds. Instead, it is just another good example of bad spin.

This doctor blames the increased incidence of triple-negative breast cancer in black women on "the racial difference in the prevalence of the estrogen receptor". He then blames this difference on dietary choices.

All well and good to this point, but then he continues on to blame produce deserts. In Atlanta? No. I lived in south and west Atlanta neighborhoods. Fresh produce is quite available year-round, in supermarkets, at independent markets, even from trucks parked on street corners. Not to mention the wide availability of some of the best and cheapest veggie plates at soul food diners, both licensed and not.

With one miscue, one demonstrably false point, this doctor destroys his credibility entirely among the opposition. Sure, the choir says, "Amen", but outside, the response is "Bullshit, doc!"
posted by Ardiril at 12:31 AM on April 25, 2012 [3 favorites]


Not to mention the wide availability of some of the best and cheapest veggie plates at soul food diners, both licensed and not.

Do poor people eat out in the USA? Because here in the UK where I assume benefits are comparatively generous compared to the US, they certainly don't pay you enough to eat at a diner -- licensed or not. Eating out at any level just takes up too large a proportion of your weekly income to be even contemplating it.
posted by PeterMcDermott at 1:13 AM on April 25, 2012 [4 favorites]


Ardiril, he's basing his argument mostly on nationwide statistics. Even if his anecdotal evidence about Atlanta food deserts doesn't match your anecdotal evidence about them, I don't think that invalidates his entire point.
posted by fermion at 1:16 AM on April 25, 2012 [8 favorites]


My mom died of metastatic breast cancer on the 14th. I can say that this story echos loudly for me.

Not because of the lack of insurance. My mom had excellent Medicare and PPO supplement.
Not because of race. She was white.
Not because of going to a hospital like Grady. She went to neighborhood hospital with a good reputation. It was no University of Chicago but it was good.

She died because of fear, misdiagnosis, believing in a doc without question, and not knowing where to turn.

From going through her stuff this week, I found her "symptom notes". They go back to 1994. In 1999 she had duct surgery. See since 1994 she had bleeding out of her nipple, underarm lump, vertigo, and just overall not feeling right. Her primary said it was some duct thing so he did surgery.

In Nov 2004 she was diagnosed with stage IV metastatic breast cancer. I went through her test results, CT, and PET.

Stage IV ductal carcinoma. Right breast removed.
Lymph invasion (removal of lymph nodes).
tumors in adrenal glands, spleen, 4 in the spine--thoracic and sacral, lower lobe lung tumor, and tumors too numerous to count in her liver. She did immediate radiation and then seven years of EVERY treatment except hercepton available. She lived five years beyond anyone's expectation and a year beyond her final "terminal" diagnosis.

From what she told me, the doc didn't even have to feel her to tell her she had breast cancer and expect metastasis. That shouldn't happen if someone goes to the doctor and had her symptoms.

I saw my mom severely decline since January. I saw her look exactly like a skeleton, I saw her mobility taken away out of the blue and not even her oncologist took it seriously enough to test her with an MRI. "take her to the ER" was her oncologist's directive. We just got BACK from the ER after what I thought was severe pneumonia. Chest xrays said it was some fluid but not sure what it was. She was tested for pneumonia and treated with 3 drugs. One doc said it wasn't pneumonia at all. The other said it was. The last didn't give us an answer. She went home in a week and said she never felt the same. She asked me DAILY when would she feel better? When would her cough that sounded like pneumonia stop? When would she feel better overall? She started to ask me to get her a boatload of sleeping pills because she wanted to die. This wasn't living.

I called the doctor again asking WTH is up with the diagnoisis. She said bring her in for MRIs up the wazoo, blood, etc. It would be 9 hours of back and forth testing, drinking barium, etc. I guess she didn't hear me the first time when I said she couldn't walk. I mentioned hospice directive for a week. Doc finally gave in on April 1st.

Monday April 10th she signed over her power of attorney to me and her DNR with hospice staff witnessing. She was beyond weak and walking. She told us she wasn't urinating anymore after going over her symptoms. She said she had so much pressure in her belly that it was hard to breathe. I knew that her kidneys were shutting down and her liver was too.

Tuesday she was bed ridden.

Wed, she was on oxygen 24/7. She said goodbye to my son--he's 3.

Thursday morning we had a pretty good time talking bullshit, what's on tv., gardening. I went home by dinner to get my son. In 1/2 hour my dad called. She was unconscious and death rattling.

Friday--death rattling, No urine output, blue hands, cold hands.

Saturday morning she was still rattling. Hospice came at 11. My dad told me to go home and take a nap with my son so I could be with him for a bit (he was missing me). I got a call an hour later. My mom died.

I know this is in NO comparison to what this woman in the story has been through or what Grady patients go through. Or for anyone else with less than adequate insurance or worse--no insurance.

But if you take away the barriers of economics, both women had fear of what would happen to them, their family, their job (although my mom didn't work). And that shouldn't be. There should be no fear---period. I can't imagine every nuance of what my mom and this woman in the story went through during their disease but I can say I saw how afraid my mom was of dying when her time was coming. Both were braver than I could ever be and they deserved better.
posted by stormpooper at 1:20 AM on April 25, 2012 [82 favorites]


Because here in the UK where I assume benefits are comparatively generous compared to the US, they certainly don't pay you enough to eat at a diner -- licensed or not

McDonald's. And like-KFC-but-halal chicken takeaways, which blanket low-income areas
posted by mippy at 1:34 AM on April 25, 2012 [1 favorite]


This doctor blames the increased incidence of triple-negative breast cancer in black women on "the racial difference in the prevalence of the estrogen receptor". He then blames this difference on dietary choices.

Stating these things contribute differently is not apportioning blame. You can state facts without it being a blame game.

And he explicitly doesn't state that black women have different cancer to white women:

There is no difference in the proportion of black and white women with progesterone-positive or HER2-positive disease. So if we are to focus on the 12 percent disparity, we must look exclusively at the racial difference in the prevalence of the estrogen receptor.

Does this suggest that skin color stands for some biological difference?

Not really.


He points to the different ways that black women and white women experience menarche and differences in their diet, and how those differences occur at the intersection of race and class:

You observe the same problems among poor whites, and you don’t see them among wealthy, well-educated blacks.

I cite the CDC data from the 1960s because they measure the racial differences that are driving the breast cancers we are diagnosing today. This disparity has since widened, and if we trace it, we can project the differences in breast cancer rates and prevalence of triple-negative disease for decades into the future.

This extrapolation produces a deeply disturbing picture: the black-white gap in the onset of menstruation and body weight has dramatically widened, which means that the disease disparities will widen also.


I thought this was a very insightful article and I hope the book is as good. Did we read the same article or what?
posted by Jilder at 1:45 AM on April 25, 2012 [8 favorites]


...how can more than 1/2 the country not see what's going on?

Oh, they see it. But, in typical, vindictive American fashion, they blame the patient for not making good choices in their life.

Up until it happens to them.

Then, they become special snowflakes that "the system" has victimized, all the while maintaining their vindictiveness toward all the others in the same situation.
posted by Thorzdad at 4:52 AM on April 25, 2012 [23 favorites]


This was an appalling and horrifying article. The sacrifice of watching your own flesh putrify because you have to hold it together for your family for years? That is incredibly brave. I can't imagine how much pain she must have endured. And I can't quantify how insanely and badly broken our medical system is, when this kind of thing happens at all. What the fuck, seriously, USA? I'm pretty sure even the stoic Puritans and their vaunted work ethic didn't intend for the city on the hill to be tainted with the horror of stories like these.

.
posted by jetlagaddict at 4:57 AM on April 25, 2012 [7 favorites]


A lot of doctors who truly focus on evidence based medicine were excoriated before the weight of data silenced their critics, and although this case is often exagerrated, I work with someone who used to walk out of the lecture theatre if Barry Marshall walked in.


I work in a medical field and the very thought of automastectomy nowadays is anathema, maybe in my grandmother's generation.


but a real test for us Mefites is in the solid fact that annual PAP tests are not necessary for women who have not had a large number of sexual partners and are in a monogamous relationship. That's simply a waste of your health resources. While the USA boasts one of the best survival rates in the world for this Ca it's clear from this article that if it were broken down by social class, it would make for pretty ugly reading.

So the Edna's will continue to spend 9 years hiding the stench of a rotting breast....
posted by Wilder at 5:00 AM on April 25, 2012


I am 24. I have not had "a large number" sexual partners and am currently in a year and a half long monogamous relationship. A PAP test last year caught HPV and abnormal cells. If I hadn't had the pap test, I wouldn't know about either of those things. I hardly think a preventative test like a PAP smear is what's keeping women from getting accurate diagnoses and keeping our health care system from mustering the resources to give women with breast cancer adequate treatment, and I think it's pretty ridiculous that you're pointing to that as the issue.
posted by ChuraChura at 5:28 AM on April 25, 2012 [6 favorites]


We admit Edna Riggs into the hospital, to get the tests done and to start antibiotic treatment of the infected wound. We could have done the workup without admitting her, but I fear that she will leave the system as abruptly as she entered. Psychological and emotional support are legitimate reasons for admittance, though most insurance companies and Medicaid would disagree.

Most? Or all? How have we gotten to the place where insurance people get to make our medical decisions?
posted by Obscure Reference at 5:55 AM on April 25, 2012 [2 favorites]


If I hadn't had the pap test, I wouldn't know about either of those things.

And that's *exactly* the point Wilder is trying to make. Just because it turned out to be a good idea for you to have that test (and I'm glad you did!) does not make it a good idea that *every* woman age 18 and up get a PAP test.

If the test took literally zero time, cost literally zero dollars, and had literally zero side effects, then it might be a good idea to have annual, or hell, monthly tests. But they do not. They have real costs, they take real time, and they have risks. And you have to weigh those costs and risks against the benefits of catching particular illnesses at an earlier stage -- and if treating them at an early stage is helpful. What if they don't progress?

And, yes, on a single person level, you may well be condemning a person to death from a disease that could have been stopped earlier. But, if you test everyone, save that person, and one dies from complications, and one dies because of lack of resources to treat a different condition, because we're spending time and money on PAP smears, then, well, we've condemned twice as many people by insisting on the annual tests!

That's what evidence based medicine is about. That's why we say anecdote does not equal data. You can always find a person who says "Well I took X and now I'm fine." It's when you look across thousands of people who took X, and thousands who did not, that you will find out what the real effect -- and real cost -- of taking X is.

And, in the case of annual pap smears across the entire population, it is very clear that the real costs of that test are not justified by the outcomes. More women, and more people, are hurt by doing so then helped. Some are hurt directly, some indirectly by treatments for conditions that were best watched, some indirectly because they money and time spent could have been used on a more effective procedure. Over the population, it's a bad idea.

We let the impartial numbers speak, even if we have some personal evidence against. We don't have infinite time or money. All procedures have risks. We want the best outcomes we can get -- and it will, in some cases, be a worse outcome for the individual.

And, in case you think this is just a female issue, the *exact* same argument is playing out over annual PSA testing for males. One of the kickers there is "you're treating a cancer that will kill that 75 year old man in 30 years. What is the cost -- in time, money, and quality of life -- of that decision?"
posted by eriko at 6:18 AM on April 25, 2012 [25 favorites]


Well that's a depressing article, especially considering all the money and effort poured into keeping things the way they are.

Here's hoping that SOMETHING comes out of recent healthcare reform attempts, and it doesn't get declared a failure and an untouchable issue for the next twenty years.
posted by Artw at 6:22 AM on April 25, 2012


I can't get over the evil catch-22 of employer-offered health insurance: your treatment is covered, but you can't take time off work for it because you'd lose your job, which would mean that you wouldn't be covered any more. Oh, and you wouldn't have anywhere to live either.
posted by Joe in Australia at 6:24 AM on April 25, 2012 [20 favorites]


And then I think about how the NHS is being dismantled because the Conservatives* actually WANT a system like this.

* and useless hanger-on party.
posted by Artw at 6:28 AM on April 25, 2012 [3 favorites]


Joe in Australia: "I can't get over the evil catch-22 of employer-offered health insurance: your treatment is covered, but you can't take time off work for it because you'd lose your job, which would mean that you wouldn't be covered any more. Oh, and you wouldn't have anywhere to live either."

Also, if you use the insurance to cover an illness that is likely to be expensive over time, the insurance company will pressure your work to get rid of you, so you'll stop being covered and they won't have to pay out for the full treatment.

(Similarly, sick days. A lot of companies offer them on paper, but if you use them, you're kissing your career goodbye.)
posted by Karmakaze at 6:36 AM on April 25, 2012 [2 favorites]


How have we gotten to the place where insurance people get to make our medical decisions?

It has been that way for years, and in any health care system that is going to be functional, that is going to happen, because there simply is not enough time or money to do everything.

Seriously. Rationing care is exactly what they do. It is what they have to do -- and it's not just insurance companies, it's all payers. Single payer, public-private, multi-payer, non-profit, for-profit. They all ration care by saying "We will cover A and B, and if that doesn't work, C, but not X. If you want to try X, you pay for it."

There is a certain point where, across the population, the cost of treatment becomes enormous and the results of that treatment become weak. This is the "cost-outcome" ratio, and it is critical in any healthcare system -- any of them -- to work. You want to make treatments that are effective and cheap very widely available. You want to make treatments that are ineffective and expensive unavailable. And, of course, the hard part is there is a gradient between costs and between outcomes.

Now, the problem with for-profit payers is that they want to spend as little, and take in as much, as possible. Thus, they have a different economic motive that you, so they may decide that expensive treatment X isn't worth paying for, not because of effectiveness, but because of the impact on profits. However, if they are effective at managing costs correctly, this may actually be a win overall.

The core problem with the US multi-payer job-based system is that there is no incentive for long term prevention. You won't be with the same payer all of your life. So if I, for-profit payer X, cover lots of things that make my population healthier in the long term, for-profit payer Y will get the benefit, because that's where large parts of my population end up when they change jobs.

Single payer systems have an economic interest in preventative care. It's why, as a rule, they have better cost-outcome ratios than multi-payer systems. And that, kids, is the core problem with US healthcare today. We do have (if you are covered) great outcomes -- if you are covered and can afford it, the US healthcare system is very, very good. But the costs we pay are incredibly high compared to other nations, and of course, we have the worst rationing of all, which is a large percentage of our population gets basically no healthcare whatsoever.

It's why I believe that, in the end, we will have single payer -- or, well, no payer.
posted by eriko at 6:38 AM on April 25, 2012 [18 favorites]


Here's hoping that SOMETHING comes out of recent healthcare reform attempts, and it doesn't get declared a failure and an untouchable issue for the next twenty years.

It may become a failure -- I think ACA/Obamacare is a very flawed answer -- but the trend is clear. It won't be untouchable for 20 years. Too many people will be dying for that to happen. People will start caring when they realize that the 20% who can't afford healthcare are in fact 50% and climbing.
posted by eriko at 6:40 AM on April 25, 2012


Excellent article that nicely sums up healthcare in America. It boggles my mind that so many of my fellow citizens (including too many colleagues) are adamantly opposed to even incremental change like Obamacare, much less the drastic reforms that are really needed. All too often it boils down to concern that it will affect the bottom line in some way.

I look forward to reading his book; I might even buy several copies to leave around work in the hopes that others might read it and put a little thought into their opions on the healthcare system in this country.
posted by TedW at 6:41 AM on April 25, 2012


In case anyone else is interested in the book, here is the Amazon link, and here is an article that Dr. Brawley wrote for CNN.
posted by TedW at 6:46 AM on April 25, 2012 [3 favorites]


With one miscue, one demonstrably false point, this doctor destroys his credibility entirely among the opposition. Sure, the choir says, "Amen", but outside, the response is "Bullshit, doc!"

Let's cut to the quick: The next argument the opposition makes, at least in their own mind, is: They chose to eat an inferior diet. They are *inferior* people. What a shame, but they did it to themselves.

This is the nicely packaged counter-thesis that conservatives have in their back pocket for every occasion. Who wrote that easily accessible thesis and who does it serve?

One foundational idea in conservative rhetoric in this country is the idea that there is a "they" and an "us". Seriously fuck that idea. It is transparently rooted in bigotry and philosophies of racial superiority even when proponents deny it or the targets are "the poor" or "feminazis" or homosexuals or whatever "inferior" group is being villified. We are all Americans and we can do better. We have the resources to do better but not the will.
posted by Skwirl at 6:47 AM on April 25, 2012 [6 favorites]


My best friend Mark came to visit me in Atlanta from South Bend, Indiana. While he was visiting me, he had a very severe, very unexpected, psychotic breakdown that caused him to attack and try to harm me. I hadn't seen him in five years and didn't know how bad his mental health had become. I did know that he didn't have insurance, and so I took him to Grady.

The hospital is exactly like the doctor describes in the article. It is a warehouse of broken, forgotten people, right in the middle of downtown Atlanta. It is a modern-day Bedlam. Possibly the only thing worse than seeking medical treatment at an indigent hospital is seeking psychiatric care at an indigent hospital. This is the place where the cops drop people after their insanity has motivated them to beat someone to death with a wrench. It’s where the mother goes when she leaves her baby in the car because she has to go to work and can’t afford daycare. And when her shift ends, the tiny baby won’t wake up. She’s a criminal now and Monica Kauffman ends the story of her with the standard “She was taken to Grady Hospital for further evaluation before being turned over to police custody.” If they take these people, I think, maybe they will accept Mark, a visitor from South Bend with no insurance and a head full of fire.

I spend 11 hours in the locked psychiatric ward at Grady (13-B), waiting for Mark to be treated. Later, I wrote a very long story about it; here's an excerpt that maybe will give you an idea of what it was like. I apologize for how lengthy this is. Mods please delete if necessary. This episode was, until very recently, one of the most traumatic things I'd ever experienced.

*

“13 B,” says the yellow sign stenciled on the locked metal door. The armed security guard unlocks the door and we step inside. After describing Mark’s condition to a very nice Haitian man ensconced behind bullet-proof glass (“Oh my,” he keeps saying, “Oh my!”), we take our seats in the Waiting Room of the Damned. I’m clearly the only non-patient here. Across the room from me a dirty man in his 40s balances a Styrofoam container of meat and rice on his lap. He stares at me, methodically tearing off strips of the Styrofoam and eating them. A very old woman approaches us. “Would you smoke?” she asks.

“I’m not sure we’re allowed to smoke in here,” I reply. The woman is wearing a housecoat, like my grandmother.

“No, honey, I know that! I’m gonna go outside and have me one.” Outside of the locked door outside of the metal detector outside of Matthew with his gun outside of the green tiles of the first floor hallway outside into the sleet with her housecoat and her illness and her cigarette. Outside. I offer her a cigarette. “Pall Malls?” She looks at me like I’m insane. “Oh no, honey, I can’t smoke no Pall Mall!” She turns from me and begins scooting the empty chairs around, lining them up and rearranging them.

A man in the corner moans, a low, constant, sexual sound that he repeats the entire 11 hours that we spend in this room. A woman leans against the plastic surrounding the nurse’s station. She stares at us, the new people in the room, and cries and cries. I realize I am looking at the most frightened person I have ever seen. There is nothing left of this woman at all save for her fear. It has obliterated everything else. She’s wearing flip-flops and a kind of peasant blouse and nothing else. No pants, no underwear. She cries unceasingly, not moving, staring, terrified, clutching an American Heritage dictionary to her like a talisman or a life vest.

We sit like this for several hours, not talking, and then suddenly I cause a minor stir when my phone rings. It’s my realtor, calling to get the go-ahead for the house inspection. I have to take his call. As I answer the phone, a large man moves from his perch across the room and sits down right next to me, though there are plenty of other empty chairs. He’s so fat and so close to me that our legs are touching, and I can feel this awful heat coming off of him. I am trying to focus on my realtor, trying to remember that there is something other than where I am, trying to get him off the phone quickly. Out of the corner of my eye I see the man next to me reach into the front of his pants with both hands. He pulls them out of his pants and he’s holding double handfuls of his own feces, like wet sand, like fistfuls of change he’s taken from his pockets. The realtor asks me what time on Tuesday and I instinctively duck to the side, away from the man and his awful sharp smell. The fat man raises his hands above his head triumphantly and flings open his fingers and his shit falls on me in warm little drops. This causes the other people in the waiting room to begin screaming, yelling, howling. Suddenly the room is filled with noise and people moving and the Haitian is running out of his cage towards us hollering no no no in his beautiful patois.

“Robin? What’s happening? Where are you? Are you alright?” It’s my realtor. I tell him I’m fine that Tuesday’s fine that everything is just fine. I hang up the phone and the Haitian dabs me with wet paper towels. “I’m sorry, so sorry,” he says. I look at Mark, who’s been pretty much comatose the entire time. He’s staring at me, crying, appalled. “Robin?” he asks miserably.

I begin to cry and fold Mark into my arms. I’m holding him and he is just clinging to me. I know what he wants to ask me.

“You are not these people,” I whisper to him over and over, rocking him back and forth until the doctor comes for him, “You are not these people.”
posted by staggering termagant at 6:54 AM on April 25, 2012 [46 favorites]


I'll leave the conversation about health care to y'all, but I wanted to give some perspective on Grady as a hospital.

I live in Atlanta and am a mental health professional who works with folks who come out of Grady's ER. The thing about Grady is that it is this city's absolute safety net; if you are poor, if you don't have insurance, if the nicer hospitals won't look at you, you can go to Grady. As Megafly says above, if you are shot or stabbed within 100 miles of downtown Atlanta, there is nowhere else you want to be than in Grady's level 1 trauma care. Grady's center on Ponce de Leon is one of the top three HIV/AIDS treatment centers in the country. Grady does an immense amount of community-based clinic care, bringing basic medical care to people who don't have transportation (Atlanta has shit public transit) to get outside their neighborhood. When you hear about people who get their primary medical care from emergency rooms, you're hearing about Grady. From the perspective of social services and working with underserved populations, Grady is a necessity in a city that doesn't do a great job with poverty.

And yet, Grady struggles to stay open. It has been mismanaged in the past, used as a political football by the county governments who fund it, and federal cuts in Medicare/Medicaid reimbursements have caused the hospital to close dialysis clinics and cut staffing positions. I feel sometimes like people wish Grady would just go away because it blemishes the PR position that Atlanta is moving forward and everyone's above average (because we cheat on our No Child Left Behind exams).
posted by catlet at 6:56 AM on April 25, 2012 [14 favorites]


> As a lifelong Atlanta resident I've always been taught exactly what the article says.
> Avoid Grady at all costs, unless you are shot, stabbed, or snake bit.

Well, that's certainly what white, suburban, non-Atlanta residents (you don't even live inside the perimeter) who would never go to Grady in the first place like to say. It's certainly why they work so hard to defund the only medical care available for many who actually live in Atlanta. But hey...looking 20 miles down I-75 certainly makes it easier to vote for parties and policies to shut down inner city and rural health care and shift it to the suburbs, with the bonus that the same folks also vote for parties and policies that make sure the inner city and rural poor have no affordable way to get to those funded facilities. But hey...go ahead and condescend away.
posted by kjs3 at 7:02 AM on April 25, 2012 [5 favorites]


I also want to say that from the moment I stepped into Grady everyone -- from the intake person in the ER, to the armed security guards I dealt with, to the man who triaged Mark when we got in the ward, to the doctor who ultimately saw us -- treated us with dignity and kindness. It was remarkable, and so humbling.

What the doctor in the article says about racism at Grady is true. Many of the people Grady serves are black, and completely disenfranchised. Every single person I dealt with at Grady was black (I'm not using the term "African-American," here, because many of them had accents that identified them as Haitian, or African). And so here come these two completely terrified white people, two people who largely by virtue of their race have no idea what it means to be disenfranchised in any regard, and who have never, ever seen anything like where they are now. What a perfect opportunity for the people there, who experience it every day, to take revenge on a broken system by being unkind or dismissive of us. "Yeah? It's awful, isn't it?" I imagine them thinking. "How do you like it?"

But no. I could not have made it through that experience without the considerable help and kindness of these exhausted, underpaid people. I will never, ever forget them.
posted by staggering termagant at 7:05 AM on April 25, 2012 [26 favorites]


I hardly think a preventative test like a PAP smear is what's keeping women from getting accurate diagnoses and keeping our health care system from mustering the resources to give women with breast cancer adequate treatment, and I think it's pretty ridiculous that you're pointing to that as the issue.

I am a college-educated middle-class woman who knows the importance of PAP smears. I had tested positive for HPV two years ago, and knew that regular screening was necessary to monitor that.

However, last year I was also employed only as a temp. I had health insurance via my temp agency, and was lucky to have it; but the only time I could get the aforementioned PAP smear was during business hours. If I asked for the time off to go to the doctor, I could in fact have gotten it - but I would also be out the $60-75 I'd lose in income from taking time off, plus the co-pay from the insurance. And at that time, I really needed the hundred bucks. So I crossed my fingers and figured I'd wait just a little longer.

Fortunately, I was able to wait only a year, until I'd gotten a better job with a much more humane time-off policy (they've honestly been PRINCES about the time off I've needed coping with a broken foot), and my last pap came back negative and I'm also HPV-negative. So I was lucky. But I also know that sometimes, health insurance and knowledge just plain isn't enough.
posted by EmpressCallipygos at 7:16 AM on April 25, 2012


As a British it seems absolutely bizarre to me that you would a) be able to choose your hospital b) choose it based on cost rather than location/specialism. (There's an episode of The Simpsons where Marge breaks her leg and Homer has to pick a hospital - I never got what that was about for years.) When my friend got sectioned, she went to the local hospital. When I broke my foot, or had to go to A+E because I was feeling suicidal, I took the one with the shortest bus-route or taxi ride. When I hurt my head and ribs following a slip at home and didn't feel better at work the next day, I went to the city centre/university hospital down the road that is, apparently, THE place to go if you have sick children in the North West, because it was nearer. I can't even explain to you how far out of my sphere of experience this kind of story is.
posted by mippy at 7:21 AM on April 25, 2012


“You are not these people,” I whisper to him over and over, rocking him back and forth until the doctor comes for him, “You are not these people.”

Hey, I appreciate that you took a risk by sharing a personal thing with us here, but this closing line struck me as incredibly callous and I wish you would rethink it, or tell me I misunderstood it. You had to comfort your friend by telling him he was somehow better than the other people at the emergency room? They were in the emergency room. You saw them at their most abject and desperate. There is really no reason, but a couple of incidences of good luck which could be revoked at any time, that you, your friend, I, or anyone else cannot be "these people."
posted by milk white peacock at 7:24 AM on April 25, 2012 [6 favorites]


You had to comfort your friend by telling him he was somehow better than the other people at the emergency room?

"And this is why, in a moment of what was obviously incredible mental stress for you, you decided to be a bad person. I wish you had decided otherwise."
posted by mightygodking at 7:27 AM on April 25, 2012 [7 favorites]


"You are not someone who is alone and abandoned, warehoused. You have someone with you who loves you. It is not hopeless."

Think about it how you would feel if you were Mark and watched your sanity evaporate, and then were taken somewhere that suggested that how you would "end up" would be like that, locked in a ward by yourself for days at a time, with no one to come for you, or remember you, or advocate for you. You would be utterly terrified. I was trying to tell him that he was not going to end up like that, not that he was better than anyone else. There but for the grace of God go all of us.
posted by staggering termagant at 7:31 AM on April 25, 2012 [15 favorites]


When I broke my foot, or had to go to A+E because I was feeling suicidal, I took the one with the shortest bus-route or taxi ride. When I hurt my head and ribs following a slip at home and didn't feel better at work the next day, I went to the city centre/university hospital down the road that is, apparently, THE place to go if you have sick children in the North West, because it was nearer. I can't even explain to you how far out of my sphere of experience this kind of story is.

The one and only major-emergency kind of emergency room experience I had came about 15 years ago, when I was having some major abdominal pain. Fortunately, I was with someone (it was a date, natch) who literally carried me down to the street, flagged down a cab, and brought me to the nearest hospital emergency room, where I was examined and tested and finally diagnosed with an ovarian issue and whisked into emergency surgery. I'd recently taken on a new job with health insurance, so was relieved that that wouldn't be an issue.

Which is why I was so puzzled to see that I got a letter from my insurance agency one month later, stating that something about my hospital stay wasn't in the network, so my insurance wasn't going to cover it. When I called the insurance company to ask for clarification, they said that apparently, the anesthesiologist was out of my policy's network. And, because I hadn't gotten a referral from my general physician prior to receiving treatment, they couldn't cover it.

"So, wait," I retorted. "You're telling me that as I was being brought to the ER because of abdominal pain, and being brought into emergency surgery, that I should have stopped everyone, called my doctor at six am, and gotten a referral?"

....After a very long pause, the insurance rep meekly said that they would drop their objection and pay the charge.

But this happens a lot. There's always some one weird little thing that even when the rest of your coverage is in-network, there's one tiny thing that isn't, and it's impossible to keep track of it all. When I broke my foot, I made sure I went to my regular doctor, who sent me to an orthopedist who was in my insurance network, who also made sure that my physical therapist was in my insurance network -- but when I was receiving my cast, I learned that the manufacturer of my cast was not in my insurance network, so I would have to pay for the cast on my own. Even though I had done all the due diligence to keep it in-network. It must happen a lot, though, becuase the cast manufacturer has a much cheaper rate for people paying on their own than they did if they were paying through insurance.
posted by EmpressCallipygos at 7:35 AM on April 25, 2012 [5 favorites]


Similarly, sick days. A lot of companies offer them on paper, but if you use them, you're kissing your career goodbye.

The big trend is the concept of Personal Time Off, or PTO days. In this scheme, your vacation and sick days are lumped together as a single block of time for you to use. However, it typically isn't a "two weeks of vacation plus 5 sick days" calculation. Typically, your new PTO allotment will only equal the number of vacation days you used to have. Your additional sick days are not included in the calculation. So, in the end, you've actually been shorted days.
posted by Thorzdad at 7:43 AM on April 25, 2012


It scares the hell out of me that Canada is trying to go down that road.
posted by Stagger Lee at 7:46 AM on April 25, 2012 [1 favorite]


My appendix burst when I was six - the doctor told my mum it was wind, my mum didn't feel confident in questioning the doctor, so I went home and didn't think about it when the pain went away.

When I went out and then came in crying because I tried to drink Cherry Coke and turn cartwheels and now my stomach HURTS, I was in hospital and in surgery within two hours - if they'd waited three, I'd have died, because once it burst they had thirty minutes to get it sorted out. If my parents had had to fanny around finding out which was the hospital they could afford, I'd be dead. If they were worrying about whether it was enough oif an emergency to risk the cost of taking their daughter to A+E, then I wouldn;'t be here either. They kept me in for a week, I got a month off doing PE, and that was the end of it. No money, no insurance.

Of course, were this America, my parents could have also sued the GP. But I know what I'd prefer to have happened.
posted by mippy at 7:47 AM on April 25, 2012 [1 favorite]


Five minutes after I read the excerpt, I was reading the book. (Bought & downloaded to my Kobo. Without getting out of my pyjama pants. Gee whiz, I love living in the future.)

The US healthcare system fascinates and mystifies me; I really struggle to understand *why* it exists. It's such a towering edifice of cruelty and blind greed, so systemically broken, that I can't help but keep searching for reasons why you all created it and keep it going. There must be some powerful motivation, some deep-seated philosophical explanation that, if I only understood it, would explain many other things about your society.

230 pages into Brawley's book, I have learned many things about how cancer treatment works and how the medical system works and how drug companies work.

But the *why*... it still escapes me.
posted by Mary Ellen Carter at 7:47 AM on April 25, 2012 [2 favorites]



Similarly, sick days. A lot of companies offer them on paper, but if you use them, you're kissing your career goodbye.


Can you explain the sick day thing? Here if you're sick, you phone in to work and then take the day off. If you're long-term sick, that's different and you'd probably be put on half-pay or something, but there's no such thing as specific sick days. What if you get the flu - you don't get paid? I've got a chronic illness (and I'm a migraine sufferer) and when I joined the company they asked me if I might need extra holiday to cope with it.
posted by mippy at 7:49 AM on April 25, 2012



My appendix burst when I was six - the doctor told my mum it was wind, my mum didn't feel confident in questioning the doctor, so I went home and didn't think about it when the pain went away.

When I went out and then came in crying because I tried to drink Cherry Coke and turn cartwheels and now my stomach HURTS, I was in hospital and in surgery within two hours - if they'd waited three, I'd have died, because once it burst they had thirty minutes to get it sorted out. If my parents had had to fanny around finding out which was the hospital they could afford, I'd be dead. If they were worrying about whether it was enough oif an emergency to risk the cost of taking their daughter to A+E, then I wouldn;'t be here either. They kept me in for a week, I got a month off doing PE, and that was the end of it. No money, no insurance.

Of course, were this America, my parents could have also sued the GP. But I know what I'd prefer to have happened.
posted by mippy at 7:47 AM on April 25 [+] [!]



I would be dead for precisely the same reason if not for public health care. At approximately the same age I spent a week on antibiotics and morphine for the same ailment, after my parents insisted on the surgery. If money or access had been factors, I would be dead.
posted by Stagger Lee at 7:50 AM on April 25, 2012 [1 favorite]


Here if you're sick, you phone in to work and then take the day off. If you're long-term sick, that's different and you'd probably be put on half-pay or something, but there's no such thing as specific sick days.

Ahahahahah oh bless. I have a friend who is working a food service job (a nice place for fast salads and whatnot) and her boss had to be convinced by the other workers to drive her to the ER for stitches when she sliced her hand chopping veg. I think she got a day off on worker's comp. But she doesn't get sick days.
posted by jetlagaddict at 7:52 AM on April 25, 2012


(Sorry that may have come off as sarcastic but it wasn't! It's just that I'm so angry at her workplace, at the system that allows us to pretend like this is functional, and all of it. I have sick days, which I can do by the hour if need be. I don't have many friends with that kind of luxury.)
posted by jetlagaddict at 7:54 AM on April 25, 2012 [1 favorite]


When I called the insurance company to ask for clarification, they said that apparently, the anesthesiologist was out of my policy's network.

I had my gall bladder removed a few years ago. My surgeon was in network. His assistants? Nope.

The hospital I stayed in was in network. The doctor who came in every day and coordinated my care was not. Nor was the MRI machine I was repeatedly wheeled into that was right down the hall.

So, yeah, if you can you should definitely ask about this stuff in you ever need any serious kind of care.
posted by Cyrano at 7:55 AM on April 25, 2012


I managed to slice my hand making a sandwich and I got sent to the hospital by work. Seriously, how do you know in advance how many times you'll be sick over the course of a year?
posted by mippy at 7:55 AM on April 25, 2012


Can you explain the sick day thing? Here if you're sick, you phone in to work and then take the day off.

In the US, employers assume that employees are all liars who will phone in sick when they aren't and limit the number of paid days you can be sick. For example, I accrue 4 hours of sick time every two weeks. If I need to be sick for more than that they stop paying me.

No it doesn't make sense, don't try to make it make sense.
posted by Bulgaroktonos at 7:56 AM on April 25, 2012 [3 favorites]


There must be some powerful motivation, some deep-seated philosophical explanation that, if I only understood it, would explain many other things about your society.

"Better this than knowing that some lazy person somewhere is getting free healthcare with my tax dollars."
posted by dirigibleman at 7:59 AM on April 25, 2012 [10 favorites]



In the US, employers assume that employees are all liars who will phone in sick when they aren't and limit the number of paid days you can be sick.


I found the same thing in low wage, private-sector jobs in Canada. They treat you like crap for being sick, and I'd catch myself playing up the symptoms on the phone, putting the extra cough and phlegm into my throat, regardless of symptoms. Awful, and without paid sick days you end up losing money while you sit in med-clinic waiting rooms all afternoon just to drop 15$ on a doctor's signature to say that you are in fact sick.

Now, with a public sector union job, if I'm feeling unwell I send an email or phone to my boss telling him I'm not coming in, and booking it as general illness. Any other explanation is voluntary. With paid sick days and the freedom to use them, I have a bit more dignity; and surprise, now I find the time to do my annual preventative checkups, get immunizations and everything else.

It's not as easy as public healthcare, we need jobs that actually allow us to take advantage of that healthcare. Even in a public system, access to healthcare hits the poor the hardest, and the poor need it the most.
posted by Stagger Lee at 8:01 AM on April 25, 2012 [1 favorite]


I've taken annual holiday when I've felt unwell in the head, just because it's one of those things that's difficult to explain to your boss - you feel like you're just pretending to be sick, or something. But then we have four weeks' annual holiday, not counting public holidays, so it's not as painful.
posted by mippy at 8:04 AM on April 25, 2012


More of a practical answer to the "how do sick days work" question:

It depends on the employer. Here in the U.S, many employers offer a set number of day as "sick leave" - say about five or so. If you're sick with a flu or something, you can claim one of those days on your time sheet, and you will be paid for that day even though you didn't turn up to work. However, if you go over that number of days, then either you will have to file for short-term disability (if your company offers that as an option) or go unpaid (if they don't).

But many employers don't even do that. When I was a temp, I did have health insurance through my temp agency, and I did get a weeks' worth of "bonus pay" if I worked a set number of hours in the year; in theory that weeks' worth of pay was meant to reimburse me for any and all vacation time, sick leave, or what have you that I accumulated over the preceding year. But at the time I'd actually taken the sick leave/vacation time, I didn't get paid; and waiting until December to get reimbursed for a days' lost pay in June is awfully hard, so there were a lot of times I went to work sick.

And then there are employers who don't even offer that.

This is one of the things that "obamacare" was supposed to fix - compelling more businesses to offer health insurance and a few sick days. But the Republican party has dug in its heels on that score.
posted by EmpressCallipygos at 8:07 AM on April 25, 2012 [1 favorite]


but keep searching for reasons why you all created it and keep it going.

Deep down, America has this feeling that weakness or failure, even the kind that is caused by viruses or cancers, is your fault and you should be ashamed of it. If you had only done X, this terrible thing (being killed by racist white people, dying from lack of healthcare, being poor) would not have happened to you. But it did, and therefore you are at fault, and if the rest of us help you, why, we're just enabling your lack of moral fibre.

It's the dark side of the democratic/meritocratic ideal; if anyone can make it big, and you don't, then it must be because you didn't try hard enough, so fuck you, loser.

It's deeply immature and destructive, but surprisingly hard to kill.
posted by emjaybee at 8:10 AM on April 25, 2012 [34 favorites]


ChuraChura: I'm sorry you feel my point was somehow invalidating your positive expereince of a PAP:
I hardly think a preventative test like a PAP smear is what's keeping women from getting accurate diagnoses and keeping our health care system from mustering the resources to give women with breast cancer adequate treatment, and I think it's pretty ridiculous that you're pointing to that as the issue.

Abnormal cells do not always mean something bad is going to happen and indeed in treating them something even worse can happen, it's all about balance of probabilities and about the fact that a more invasive medical ethos does not always equate to better outcomes. Your "right" to an annual PAP is taking resources away from areas we know to be more successful in treating illness and death.

I honestly didn't think I needed to explain that but I do see that if you are brought up in a culture where having an annual smear test is as automatic as brushing your teeth, then anyone questioning the validity of the frequency of it might surprise you, but that's the whole point of solid evidence.
posted by Wilder at 8:15 AM on April 25, 2012 [1 favorite]


In the US, employers assume that employees are all liars who will phone in sick when they aren't and limit the number of paid days you can be sick. For example, I accrue 4 hours of sick time every two weeks. If I need to be sick for more than that they stop paying me.

It's a slightly similar system here in Singapore. We get a certain number of days of annual leave, and certain number of sick leave days. We can't take sick leave without a medical certificate (so sick leave is usually referred to as an MC), so on days when I'm so giddy I can't stand up without passing out, walking 2 blocks and across 2 roads to the doctor's wasn't an option, and I'd have to take urgent leave. This is allowed, but frowned upon.

If I exceed the number of sick days I'm allowed, then I have to make up for it with my annual leave and/or pay. Happened once when I broke my leg very badly and couldn't go to work as there was a curved staircase to negotiate at that time, and my surgeon, knowing the place, was adamant I didn't try to climb it till my leg was fully healed. I wound up taking a month more medical leave than I was allowed, so HR called me and arranged to have my pay and leave docked to make up for it.

But the health system here is still pretty good. Co-payments are common, but doctor's and hospital bills here are not insane and - for citizens - subsidized by the government. I vaguely recall my leg op was around 3k and bills for an airconditioned, 4 bed ward was less than $200 per day (it's gone up to about $200 per day now).
posted by Alnedra at 8:19 AM on April 25, 2012



I honestly didn't think I needed to explain that but I do see that if you are brought up in a culture where having an annual smear test is as automatic as brushing your teeth, then anyone questioning the validity of the frequency of it might surprise you, but that's the whole point of solid evidence.
posted by Wilder at 8:15 AM on April 25 [+] [!]


It's not that simple. Western society has some baggage where women's health is concerned. In that environment it's really important to distinguish between "this procedure isn't necessary for your health," and this "this procedure isn't valued."
posted by Stagger Lee at 8:20 AM on April 25, 2012 [4 favorites]


In various surgical conferences I hear the odd comment about "ball-breaking" "Go-Getter" "agressive" US surgeons and the opposite for anyone who isn't in favour of the latest invasive procedures (NOTES anyone? Why not take every appendix out via mouth or vagina, sheesh, it's the biz!) but for the most part you hear people asking, N=?. eventually when N=enough to assure the scientific community that on balance of probabilty there are real advantages to adopting something then there's kind of a critical mass.

A lot of the focus these days is on new approaches that do better but cost significantly less, like short stay and day-case surgery, enhanced recovery programmes, patient education, etc., I noticed that over the last few years of our local School of Surgery Core Trainees Prize day a big shift in emphasis away from presentations of the weird & wonderful case study, super-dooper new piece of kit that costs the earth, and towards more cost-effective and efficent ways of improving healthcare. Thankfully an economic recession can only encourage this trend, in the same way that war encourages improvements in trauma care.

This is all obviously skewed by Big Pharma, money & ego, if you throw enough money at some medics they will do what you want them to do even if by that they do harm. But when we are talking about increasingly scarse health resources as we are now in the UK, it terrifies me that we are adopting more US methods of healthcare management.
posted by Wilder at 8:27 AM on April 25, 2012


Thanks Stagger Lee for that, I could of course as eriko did reference the PSA testing of men which probably causes even more harm....it's strange to reflect that in my professional life here in the UK I'm a bit more gender-blind than I am in my private life and I value the feedback.
posted by Wilder at 8:29 AM on April 25, 2012 [2 favorites]


I have a friend who is working a food service job (a nice place for fast salads and whatnot) and her boss had to be convinced by the other workers to drive her to the ER for stitches when she sliced her hand chopping veg. I think she got a day off on worker's comp. But she doesn't get sick days.

At the fast-food job my son works days at, the employees are required to arrange another employee to take their shift if they are sick. Plus, they must bring a note from their doctor attesting to the illness if it goes longer than a single shift.
posted by Thorzdad at 8:36 AM on April 25, 2012


stormpooper - There should be no fear---period.

I am sorry. My mother had a different but similar situation. She had the best access to medical professionals, working directly with the head of the Oncology Department, but it didn't matter. When the time came we did in home hospice (not really recommended). The last weekend she was conscious, when I got to her she begged me to kill her. I promised her I would.

I stayed up all night trying to find a way to do it with as little pain as possible and with me not ending up with a murder rap. I could not find a way. I demanded the doctor come see us and that he increase her meds. That put her out and she passed several days later at a hospice facility.

She was scared and at that point I wish there had been no fear. I wish that there was a better way. I also wish she had gotten the chance to meet my son. Take some comfort that your mother got to say goodbye to yours.
posted by daniel9223 at 8:36 AM on April 25, 2012 [2 favorites]


and while we're on it, regular smears are very much a good thing, we only disagree about the regularity.

I do understand why there was a huge outcry recently when a male researcher suggested the same for mammograms and I suspect that argument will really test the limits of evidence based medicine and social policy/gender issues.

we are moving into a more personalised era in medicine, (if we can afford it) and right now my favorite colorectal surgeon inputs his patient data into the registry that most UK colorectal surgeons subscribe to and tells them, "in your exact presentation I have an 8.7% mortality rate". Something like that doesn't actually cost a lot, is far better in gaining informed consent, and improves outcomes across the board for the same surgery.
posted by Wilder at 8:42 AM on April 25, 2012


Western society has some baggage where women's health is concerned.

I see that, so let's change it to men then... it used to be that at 30 all men would get an annual PSA. Great, right? Problem is that the test isn't that great, often gets a lot of false positives, and even worse, sometimes the treatment is worse than the ailment itself.

Despite the fact that in individual cases it saves lives, over the course of hundreds of thousands (if not millions) exams, the safer route is to wait until men (in general) are older and even then to only do it once every few years.

It's tricky... What we've essentially created is a system which values the individual tree so much, that the safety of the forest is no longer considered. And it's a very cold and heartless concept to think that the steps we rationally need to take is to start tending the forest, even if it means losing a few trees that otherwise would not be lost.

Not to say I'm defending the "Republican" stance, or that of the money-grubbing insurance companies... but there's got to be a middle ground somewhere that takes best interest of both the forest and the individual trees, and because of salacious and misguided rants like "ObamaCare is socialism" we haven't even started looking for it yet.
posted by Blue_Villain at 8:45 AM on April 25, 2012 [1 favorite]


Thorzdad: "The big trend is the concept of Personal Time Off, or PTO days. In this scheme, your vacation and sick days are lumped together as a single block of time for you to use. However, it typically isn't a "two weeks of vacation plus 5 sick days" calculation. Typically, your new PTO allotment will only equal the number of vacation days you used to have. Your additional sick days are not included in the calculation. So, in the end, you've actually been shorted days."

Yeah, that's what they did at my job. The thing is, every time you take an "unscheduled" PTO day, that's a tick mark on the calendar. Unscheduled meaning not requested and approved several days in advance, preferably two weeks in advance. (How often do you know you're going to have the flu two weeks from this Wednesday?) If the tick marks approach the number of days that used to be called "sick days", then you have an attendance problem on paper, and an attitude problem in the eyes of management.
posted by Karmakaze at 8:51 AM on April 25, 2012


Here in the UK in most medical disciplines taking more than 12 days sick without doctors certification in one year triggers a review by your line manager. Part of that review is to ascertain whether you're getting burnt out but it's mostly to protect the institution.

My cousin, who stacks shelves in a supermarket, and who has a pretty complex kidney issue is often let go from jobs because of the amount of time she needs off sick, even when that is hospitalisation/certified but we're talking about 2 months in 12. They couch it as "not getting on with your co-workers" because she could probably sue & win if it were because of her illness but she is seen and managed regularly by one of the best teams in the UK on the national health service.

I find these threads some of the saddest on Metafilter, sure some of the boyzone old ones used to make me angry and losing several wonderful contributors to them really bugged me, but the routine acceptance of the stress inherent in not having access to healthcare, thinking that Enda's life for 9 years was probably as bad as some people's experience under slave labour conditions, and it has become so politically weighted that there really doesn't seem to be any light on the horizon for millions of your fellow citizens and many of you, is just sad beyond words.
posted by Wilder at 8:52 AM on April 25, 2012 [6 favorites]


Wilder - I'm in a white-collar job, but I remember how difficult it was talking about health issues when I was a temp, and easier to get sacked for no good reason. My experiences of minimum-wage jobs were pretty poor in terms of staff welfare/employee-boss relations, and I'm sorry that your cousin has to have that extra stress.
posted by mippy at 8:56 AM on April 25, 2012


Cyrano: I agree that all things being equal that it behooves you, with this current state of affairs, to figure out if every last jot and tittle of your medical care is in-network. But my issue was that it's hard to find the time to do that legwork if you are being whisked into emergency "we must do this now or else you could die" surgery at 6 in the morning on a Saturday.

Better still, though, if you didn't have to try to track down whether even your anaesthesiologist's secretary was also in the network or something.
posted by EmpressCallipygos at 9:13 AM on April 25, 2012 [3 favorites]


All well and good to this point, but then he continues on to blame produce deserts. In Atlanta? No. I lived in south and west Atlanta neighborhoods. Fresh produce is quite available year-round, in supermarkets, at independent markets, even from trucks parked on street corners. Not to mention the wide availability of some of the best and cheapest veggie plates at soul food diners, both licensed and not.

I don't think you are doing it on purpose, but you're not really thinking through the day of a poor person. Imagine a single mother with two kids. In Atlanta. Without a car.

You wake up, probably at 6 am, hours before work because Marta is notoriously unreliable. You try to make something for your kids before you leave, if you have time. After an hour and a half ride and walk to work, you are on shift with a few 15 minute breaks. Lunch time is officially frowned upon, if one is even given at all. Your second job is from 2pm to 8 pm — both jobs you work keep you under 40 hours so they can deny you benefits, but you're just glad they will work with you when the shifts schedules don't work out.

By the time you get home at 9:30 or 10, if the buses are on time, you clean up a little bit, and spend 30 minutes worrying about bills, or God forbid, watching television to get your mind off things. But really all you can think about is that you have to be up and do it all over again in 6 or 7 hours.

So, why didn't this person take the extra hour or two to go to the grocery store, and another hour to prepare a healthy meal, or spend the money go to out to eat? Because they don't have the time or the money to consider such options, and even if they could scrape by and get that done, you're asking them to make choices that well off consumers are too lazy to make.

Living even a mile away from shopping centers without a vehicle is like living in a desert, whether you want fresh produce or not. It adds a minimum of 30-45 minutes to any errand, which is a lot to someone who is suffering from the poverty of having no money and no time.
posted by deanklear at 10:20 AM on April 25, 2012 [20 favorites]


I suppose this is as good a thread as any to link to my old roommate's account of his experiences in the ER at Washington DC's Grady equivalent.

Highlight: For the next two hours I lay there in bed 13 (or was it 14?) unnoticed, untreated. On several occasions I hollered “excuse me” out into the room in vain hopes of getting a nurses attention. Occasionally a nurse came or went, but none so much as looked at me. Never once did I spot anyone who looked like a doctor. I needed a blanket. I needed a pillow. I needed water. Something for the pain. Forget about diagnosis or treatment. Basic things. Things I would have had if I’d stayed at home.

This is what happens when, as catlet describes above, you turn hospitals and medical care for the poor into a political bidding chip. Sell the hospital off to the lowest bidder, cut the staff, watch as the private companies you bring in to do the management fail again and again. It's okay, that's just the care that those people deserve. As if nobody knows that there's better care available if you're insured, conscious, and aware enough to ask. Meanwhile, the poorest hospital can't even afford a freaking blanket.

Apparently, between this story and the one yesterday about debt collectors in ERs, this is my week to be even more enraged than usual at the state of health care here. Seriously, I'm shaking and seething now.
posted by ActionPopulated at 10:22 AM on April 25, 2012


One of the recent frustrations at my employer is the clock-watching. I have been an hourly employee for the year I've worked here. However, recently the company decided to crack down and get super clock-watchy.

I used to be able to plan a doctor appointment at around my lunch hour, go to my appointment, and if it took longer than my lunch hour, I could just stay a little late or take a short lunch the next day to make up the time. This was something my boss was agreeable to, and it worked out fine. She would check my time for the week, I'd make it up, no big deal.

Since the crackdown (which came from executive management), I still try to plan my appointment around my lunch time, but I cannot make up the lost time because "we don't have flex time". So that leaves me with having to use my PTO, of which we get 5 days per year. PTO can only be used in 1-hour blocks. So if my appointment only took me 1-1/2 hours, I either have to lose the half hour of pay, or use up a whole hour of PTO. I cannot make up the half hour from my next day's lunch break, because we are now required to take off our entire lunch hour.

The company also tries to deprive us of benefits as quickly as possible. Because of being hired mid-year, I only had (prorated) 3-1/2 days of vacation time for the entirety of 2012. I have already used 3 days this year because of visiting family with our new baby. My last half day of vacation was eaten up because I was sick with a bad sinus infection a couple of weeks ago, and had to take off two days. That wiped out all of my remaining PTO and vacation time.

We are also expected to clock in early at the beginning of the day to "be at our work stations" on time, but the clock rounds the time up to the top of the hour, so we don't get paid for it. It doesn't round the clock back if you're a minute late, and that counts against you as an "occurrence". Traffic is not excusable. (Living in Metro Atlanta. Right.) At the end of the day, if you clock out after your usual end time, the clock rounds back to the hour.

Fortunately, the company doesn't (yet) require a doctor's proof that you were sick unless you're out more than three days at one time.

And in the current economy, I'm "lucky" to have this job.
posted by Fleebnork at 10:24 AM on April 25, 2012 [3 favorites]


US Healthcare: rich special snowflakes in freezers; poor ones in produce deserts
posted by Wilder at 10:43 AM on April 25, 2012 [1 favorite]


On a recent Real Time, one of the conservative guests brought up the talking point that if you're diagnosed with breast cancer in the US, you're much more likely to survive than if you're diagnosed in the UK.

"if you're diagnosed"
posted by heathkit at 10:45 AM on April 25, 2012 [3 favorites]


Even given the last bit, I'd want to see stats on that.
posted by Artw at 10:55 AM on April 25, 2012 [1 favorite]


In Canada, it is almost inconceivable that a woman with breast cancer would lose her job for seeking treatment.

My aunt was out of work for more than a year and had no income due to breast cancer, in Canada.

We have good single payer healthcare. But we don't have good provision for people too sick or disabled to work. Many Canadians have no sick days whatsoever; I once met a woman who didn't believe that sick days (a day off when you were sick with no loss of pay) were real - no one had those.

But what we face in Canada is inequality in employment benefits (sick days, prescription drug coverage - that's a huge one, dental and optical coverage - I haven't had a tooth cleaning in 15+ years) - not the basic healthcare inequalities that the US faces.
posted by jb at 10:58 AM on April 25, 2012 [1 favorite]


Even given the last bit, I'd want to see stats on that

One source
Another
posted by pjaust at 11:01 AM on April 25, 2012


Hmm. That's actually kind of shocking.
posted by Artw at 11:02 AM on April 25, 2012


from the BBC link: "White Americans, who are on the whole wealthier and therefore more able to afford the insurance which underpins the US system, were up to 14% more likely than others to survive cancer. "
posted by jb at 11:18 AM on April 25, 2012


One source
Another

The "Another" was behind a sign-in wall, and the BBC article referenced data that was 20 years old. I'm not a betting man, but I'd be willing to wager large sums of money that the tools to diagnose cancer have improved on nearly the same scale that tvs, computers and cellular telephones have in the same time.

Treating cancer is a completely different story, but considering that they've just recently identified that "breast cancer" may actually be different types of diseases, not just cancers, means that we're still just shooting arrows in the dark and hoping to hit cures with them.
posted by Blue_Villain at 11:19 AM on April 25, 2012 [1 favorite]


I have a friend who is working a food service job (a nice place for fast salads and whatnot) and her boss had to be convinced by the other workers to drive her to the ER for stitches when she sliced her hand chopping veg. I think she got a day off on worker's comp. But she doesn't get sick days.

My other aunt (I have a lot of them) was permanently disabled because her boss would not allow her to go to the hospital for treatment after an accident at work; another co-worker had convinced him that she was malingering.

She is now on permanent disability: she barely lift her arms. Her injury would have been treatable if she had received immediate attention.

I think the government should sue her employer for the money it will take to support her for the rest of her life.
posted by jb at 11:22 AM on April 25, 2012 [3 favorites]


In my experience (thus, anecdotal), here in the U.S. my various health care providers have always required an annual pap smear to renew oral contraceptive prescriptions. No exam, no birth control. I need my birth control, so I've had to have an annual exam for nearly a quarter century.
posted by Occula at 11:24 AM on April 25, 2012 [2 favorites]


Staggering Termagant, I'd like to read the rest of your story about that experience. It is staggering and awful and amazing. Please let me know where i can find it.
posted by aacheson at 11:30 AM on April 25, 2012


Occula I sincerely hope you're wrong! here in the U.S. my various health care providers have always required an annual pap smear to renew oral contraceptive, where the hell is the sense in this???? Christ what your health provider is effectively saying is that because you are sexually active you have frequent sexual partners which is a ridiculous assumption to make.


Waiting times for breast cancer surgery were historically long here in the UK and we didn't have enough dedicated breast surgeons. General surgeons here were genuinely general as specialisation was not as distinct as in larger US centres. Only this year has vascular surgery become a specialty in its own right (4th April written into law) and so vascular surgeons are no longer expected to take the GS all comers in the ER, allowing them to literally hone their skill and get better outcomes.

Breast surgeons want the same but that will be a few years coming, if ever, they are only now coming off the general take in most hospitals ;- most dedicated breast surgeons I know do three sessions (1/2 day) lists a week so would not see the numbers their US colleagues might see in a year. But every District General Hospital has a breast surgeon. Also several breast surgeons here only do small numbers because they also do the general surgery take, so basically any hot abdo that comes in the door. In this case their results will not be as good as people who do the bigger numbers and we are now moving to delivery of healthcare by outcomes and evidence. I'm involved in these changes and they will take time.

The new programmes of targets about wait time from Dx will not yet have fed through to the statistics so I have no trouble in imagining that survival rates are better in the USA at the moment, but what I would observe is there will not be the kind of socio-economic demarcations about who gets access to the surgery.
posted by Wilder at 11:36 AM on April 25, 2012


sorry I withdraw my previous remark to Occula, I suppose they feel they are also playing the numbers game... but what a waste of resources...
posted by Wilder at 11:44 AM on April 25, 2012


No, Virginia, cancer care in Europe doesn't suck, contrary to what a recent paper implies
posted by homunculus at 11:50 AM on April 25, 2012


In my experience (thus, anecdotal), here in the U.S. my various health care providers have always required an annual pap smear to renew oral contraceptive prescriptions. No exam, no birth control.

Yep, that's pretty common but it should have changed in the past year or two (here are the current US guidelines--in fact, the dude who's the subject of this article has a very good article in CNN just this past month explaining the changes).

The US has finally signed on to the 'no medical reason for a Pap every year' in place of 'get 'em while you can and tie it to something they need' which was essentially the previous recommendation. We shall see how long it takes to trickle down to practicing doctors, though.
posted by librarylis at 12:02 PM on April 25, 2012


All well and good to this point, but then he continues on to blame produce deserts. In Atlanta? No. I lived in south and west Atlanta neighborhoods. Fresh produce is quite available year-round, in supermarkets, at independent markets, even from trucks parked on street corners. Not to mention the wide availability of some of the best and cheapest veggie plates at soul food diners, both licensed and not.

He also mentions Detroit, where he grew up. Which I imagine was some years ago.
posted by narcoleptic at 12:03 PM on April 25, 2012


There is apparently still at least one food dessert in West Atlanta, which is about to be filled by a Walmart. I admit to spending more time north and east, but there are certainly parts of those, such as East Lake, where it's a long walk to the nearest place that sells produce, so I don't think it's that far-fetched that there are still folks with limited access, especially given the state of MARTA.
posted by hydropsyche at 12:12 PM on April 25, 2012


There may be food deserts, but West Atlanta is not, there are a handful of grocers in less than a mile radius that have produce and its a fifteen minute marta trip to the Sweet Auburn Curb/Farmer's Market and a 30 minute marta ride to the absolutely fabulous Dekalb Farmer's Market (which takes EBT).

That article is just a pr piece about a bunch of politicians hard at the thought of filling some empty retail space after Publix left but a huge vacant building remained. Its not that they couldn't find a grocer, its that they couldn't find a grocer big enough to fill that huge space.
posted by stormygrey at 1:53 PM on April 25, 2012


People who think US cancer survival rates are better should really read the link Homunculus provided. It links to this article: Survival rates are not the same as mortality rates from which I will quote a few paragraphs that really cleared things up for me:
In England women are screened by mammography every three years starting at age 50, yet in the United States the American Cancer Society recommends women are screened by mammography every year starting at age 40. For a woman diagnosed with breast cancer in 2001, the five year survival rate in the US was 89.1%; in England it was 80.3%.
"Well", I thought, "doesn't that mean they do things much better in the US?" No. Because a higher survival rate doesn't necessarily mean people with cancer are living longer:
Let’s say there’s a new cancer of the thumb killing people. From the time the first cancer cell appears, you have nine years to live, with chemo. From the time you can feel a lump, you have four years to live, with chemo. Let’s say we have no way to detect the disease until you feel a lump. The five year survival rate for this cancer is about 0, because within five years of detection, everyone dies, even on therapy.

Now I invent a new scanner that can detect thumb cancer when only one cell is there. Because it’s the United States, we invest heavily in those scanners. Early detection is everything, right? We have protests and lawsuits and now everyone is getting scanned like crazy. Not only that, but people are getting chemo earlier and earlier for the cancer. Sure, the side effects are terrible, but we want to live.

We made no improvements to the treatment. Everyone is still dying four years after they feel the lump. But since we are making the diagnosis five years earlier, our five year survival rate is now approaching 100%! Everyone is living nine years with the disease. Meanwhile, in England, they say that the scanner doesn’t extend life and won’t pay for it. Rationing! That’s why their five year survival rate is still 0%.
Huh.
posted by Joe in Australia at 4:08 PM on April 25, 2012 [13 favorites]


@Joe. Amazing perspective and thanks. I'm still shocked (as well as oncologists) that my mom survived SEVEN years with chemo treatment for metastatic disease. I know your stats are based on average, but for some, they beat the curve. However, for me, if I were 74, I don't know if I want to beat the curve. My mom kept a calendar of their appts. I was shocked at their doc visits (my dad is 80 with heart and kidney issues). There were months they both went to the doc DAILY. I would say fuck that, ya know? But to each is own. I know my mom was afraid of dying. I know she wanted to see me having another child (not going to happen). I know she wanted to make sure I was going to be ok. So everyone has their reason to live. But for me, if I was 74, with that state of disease, seeing that my only child had a baby and life was "complete" it's time. But at the same time, I'm sure when the time comes, I'll be terrified of dying. I'm a baby now at 40 when it comes to needles, so who am I to talk?

I think the focus in general, should be on euthanasia at the patient's will. Cancer will never be solved--it's too lucrative. Hospice is great but medically and ethically, there is so much they can do. I can tell you that the loss of control was the most depressing thing I saw with my mom. The loss of her mobility, vision, biological control----but also the hallucinations that come with death. She should have had a right to bow out when she was ready, under complete control. Everyone says we do it for our pets without a second thought, I don't know why people don't open their minds to it for humans.

Then again, humans can't even comprehend birth control/right to life options without going into a tizzy so there you go. It will never be solved.
posted by stormpooper at 4:20 PM on April 25, 2012 [1 favorite]


My mind boggles that this doctor is a pariah among other doctors.

Dr. Brawley is no more a pariah than Secretary of State Clinton is. He's the Chief Medical Officer and Executive Vice President of the American Cancer Society, he's a full professor at Emory, and he co-chaired the Surgeon General's Task Force on Cancer Health Disparities, and he's served on a variety of very influential advisory committees in federal health agencies (CDC, FDA, NIH).

His perspective on PSA screening gets pushback for the very reasons that we're seeing argument in this thread about the frequency of Pap screening - people have great difficulty divorcing their own experience of finding a real problem early (the experience of being a true positive) from the statistical certainty that overfrequent screening results in a false-positive rate with its own profoundly negative consequences for the individual and for the population.

In the face of a threat, doctors, being human, prefer doing something to doing nothing - they prefer overfrequent to underfrequent screening. But even at a high rate, false positives are a rare event from the perspective of the patient and physician - individual docs and patients don't see the cumulative effect of the unnecessary surgeries or the associated cost. Dr. Brawley is not only a skilled clinical oncologist, he has a rare grasp of population health and biostatistics and the gift of explaining the import of biostatistics in human terms.

(False-negatives also have an impact - they incorrectly reassure people with disease and delay treatment - but, obviously, screening at longer intervals delays treatment for everyone with disease, too, so the real trick of managing screening is the balance among the human and financial cost of false positives, the benefit of early intervention for true positives, and the financial cost of screening in light of what other interventions the same money could buy.)
posted by gingerest at 4:25 PM on April 25, 2012 [1 favorite]


Wilder, I just wanted to confirm what Occula was saying. That's the reason I started getting annual PAPs ... because I want to keep my prescription for birth control.
posted by ChuraChura at 5:25 PM on April 25, 2012


To the "out of network" issues at hospitals: I have a history of a serious DVT after surgery and traction. Subsequently, I'm supposed to be on the alert for any of the symptoms.

After being trapped in a delayed airline for a long time, I noticed when I got home that one of my ankles and calves was swelling and changing color. I called my internist and send him a cell phone pic and asked if I should just elevate it or what, and he said "Go to the hospital, now."

Well, I've played this game of hospitals and insurance before, so I called the insurance first. Asked them which hospital I should go to, to make sure that the er visit would be covered by my insurance.

Went to the hospital they wanted me to go to, which is not the hospital where my internist practices. Ok. Fine. Got there, they got me in, got me back, did a sonogram thingy, gave me a shot of something, and sent me home to keep my feet elevated.

While at the hospital, I paid the out of pocket fees and the deductible for the policy. (Around $500.00)

Imagine my surprise when I received a bill for $2700 because the doctor and the sono tech were out of network.

It has been two years. I'm still fighting with them about this. I will be goddamned if I'm going to pay an out of network fee when I specifically asked both the insurance company and the hospital staff if they were in network.

The doctor, who was already compensated $1800 for her 5 minute cursory review of a sonogram, sent the bill to collections. I have faxed the collection agencies the EOBs showing that the doctor CANNOT collect that fee, because she cashed the check from the insurance company, the letters from my insurance showing that it was preapproved, I did everything I was supposed to do, and they are still hounding me, every single day, 3-4 times a day sometimes, to get me to pay.

I've gotten it taken off all 3 major credit reports twice, because even those vultures think this is a ridiculous charge and that I don't owe it.

I have a stellar credit record, and I've stopped answering the phone at my house. My son can't pick up the phone because of the things these people will say to a small child. The only way I can make this stop is to pay a fee I don't legally owe because as the person at West Asset Management said; "You can't win. It doesn't matter what you send us. Our fax machine feeds into a shredder. We will not stop calling until you pay this full amount."

It's companies like West Management that make me wish I had invested in small tactical nukes.
posted by dejah420 at 6:36 PM on April 25, 2012 [4 favorites]


dejah, do you have a lawyer who can send them a letter about suing for harassment if they don't stop? Consumerist.com features similar stories now and then and at least with other creditors, commenters say that it has worked for them.
posted by emjaybee at 6:55 PM on April 25, 2012


dejah420: "It's companies like West Management that make me wish I had invested in small tactical nukes."

If your state allows single party recording, answer the phone and record yourself telling them they may only communicate with you about by mail. Send a letter in follow up. Log each and every call they make after that point. Every one is worth $1,000 in small claims court. (or real court)

Alternatively, you could hire an attorney to handle the legal work and possibly collect a significant amount of money given how often they are calling you. It sounds like they've already racked up a fair bill, so rather than be annoyed, be happy that you may well be able to sue them for enough to ruin their year. Be sure to hire someone well versed in FDCPA cases if you go that route.
posted by wierdo at 7:06 PM on April 25, 2012


Grady saved my life and they deserve better than to be underfunded and understaffed. I went into Grady because I couldn't breathe. A team came round, talked to me, made sure I got x-rays, tapped on my back. In the end, they drained about a liter of fluid from my lungs. They do very good work.
posted by who squared at 8:51 PM on April 25, 2012 [3 favorites]


Fair Debt Collection Practices Act.

More on the FDCPA.

Even more (Warning: howstuffworks.com).
posted by dirigibleman at 9:34 PM on April 25, 2012 [1 favorite]


Stormpooper, your story broke my heart. I hope you get some peace. You were there in your mom's final days and I expect she took comfort from that.
posted by wenestvedt at 7:08 AM on April 26, 2012 [1 favorite]


Thank you Wenestvedt. It is still very surreal. To me, it doesn't feel like she's gone. I don't like that feeling either. Feel free to mefimail me if you want to chat (or even just to say hi). :)
posted by stormpooper at 6:04 PM on April 26, 2012


And, in case you think this is just a female issue, the *exact* same argument is playing out over annual PSA testing for males. One of the kickers there is "you're treating a cancer that will kill that 75 year old man in 30 years. What is the cost -- in time, money, and quality of life -- of that decision?"

It's not the exact same argument. Prostate cancer and cervical cancer are totally different diseases. The majority of men diagnosed with prostate cancer are older than 55 and yes, have very slow-growing cancers that would not kill them within their natural lifetime. The majority of women diagnosed with cervical cancer are younger than 55, and while cervical cancer certainly isn't the most aggressive cancer, it's not something that you can live with for 30 years without treatment.

The standard treatment for early-stage cervical cancer is simple hysterectomy, and the side-effects w/r/t sexual health are only discussed in terms of fertility. The standard treatment for early-stage prostate cancer, while not prostatectomy, still often results in erectile dysfunctio, so offering Viagra is typical. Look, I am all for preserving the sexual health of 75 year old men, as long as we don't sugarcoat the potential implications of removing the uterus of a pre-menopausal woman whether she wants to actually have babies or not.

I'm 38 and have been monogamous for ten years. I'd never had an abnormal pap in all my years of going to gyns before. I don't really fit any high-risk categories and wound up going three years between checkups recently (still within guidelines!) Can you guess where this is going? Well, I was lucky, because while the initial diagnosis of carcinoma in situ turned out to be too optimistic, I got away with minor surgery thus far (my six-month checkup is next month.) A cone-shaped piece of my excised cervix contained a tiny invasive tumor but had blessedly clear margins.

That's not really why I was so fortunate, though -- it's because I'm a good risk, a college-educated woman with a decent job and health insurance with multiple hospitals close by. Other women with the same level of cancer get a different story, a different prognosis, few options, major surgery, a fat hospital bill. I'm actually very much in favor of many principles of evidence-based medicine. I do think that the current system in the US tends toward expensive, ineffective overscreening in many areas. But the institutionalized racism and classism and sexism sure does diminish all the money saved by convincing some wealthy CEO that he doesn't need an EKG for fun each year.
posted by desuetude at 12:49 AM on April 28, 2012 [2 favorites]


Study raises doubts over treatment for prostate cancer
The study compared surgical removal of the prostate gland – radical prostatectomy – with "watchful waiting" (doing nothing). The results show that surgery did not extend life. A leading British specialist, who asked not to be named, said: "The only rational response to these results is, when presented with a patient with prostate cancer, to do nothing."

posted by Joe in Australia at 2:03 AM on April 29, 2012


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