Imagine taking your car into the shop. You know the “shop?” The shop is the generic name for the place that takes temporary possession of your car and permanent possession of the contents of your wallet. Your car is running in fits and starts so you take it to the shop. The mechanic tells you that he’d like to start by changing the oil and, “we’ll see what happens from there.” Okay, you tell him with a little tremble of doubt in your voice.
You bring the car home and nothing’s fixed and so you bring it back. “Let’s try flushing out the transmission and if that doesn’t work we’ll change out the plugs.”
“Okay, you’re the expert, let’s do it.”
Couple days later and you’re back at the mechanic who, with a bewildered scratch of his head, offers, “Well let’s hook it up to the diagnostic and see what’s going on.”
“Huh? Why didn’t we do that from the start?”
Most mechanics don’t work that way and those that do usually find themselves in another line of work. Normally they do a diagnostic at the start, find the root cause and fix it. If they didn’t follow that protocol you’d be outraged. Doesn’t it seem reasonable to expect the same treatment when something in your own physical body goes a little south?
If your healthcare is in the hands of Kaiser Permanente that isn’t necessarily the case. Take my shoulder – please.
Last October, after doing some weight training and having a game of catch with my grandson I experienced some pain in my right shoulder. It wasn’t anything particularly new. Over the years I’ve had some pain in that shoulder and after some rest its calmed down and I’ve gone back to the normal routine. This time around the usual rest period offered little or no improvement so I went to my doctor, a new one actually, located in the Kaiser Pinole facility, about a five minute drive from home as opposed to my last who was a 30 minute drive plus a bridge toll away over in Vallejo.
At this point maybe I should shed some light on Kaiser. Kaiser Permanente is a health maintenance organization (HMO) which means that you have a one stop shopping environment, a sort of Walmart with a stethoscope. In an HMO you get a Primary Care Physician (known as a PCP – because nothing says America like acronyms) who acts as the gatekeeper to the rest of that shopping environment. Think of her as being like the Walmart greeter only this greeter doesn’t let you into the store without her okie dokie; and even then she’s pretty strict about where you can and can’t go. She might even just deem that you aren’t worthy to get a cart and go any further into the store.
If you go to your PCP and your complaint is beyond her scope then you do the ritual Kaiser dance. Depending on the problem it could just be a two step like a referral to the dermatologist for some skin cream or it could be a full on ballet. I just performed Swan Lake.
I went to my PCP and she looked at my chart with the furrowed brow that’s probably taught in medical school and told me what I knew; that I’d had a similar problem with the same shoulder nine years ago. I agreed and explained that I’d been diagnosed with frozen shoulder and instead of the suggested cortisone shot that the doctor offered I’d opted for acupuncture which fixed the problem in about 6 weeks.
Then she told me something that I didn’t know. “It says that the MRI showed a slight rotator cuff tear.”
“What? That’s the first I’m hearing about a tear.”
She explained that it might have repaired itself over time and, after tugging and rotating my arm and kneading the shoulder a bit she diagnosed (AKA, took a guess at) a case of tendonitis. My request for an audience with a shoulder specialist and an MRI was denied as I expected it would be and we agreed on dance step number two – acupuncture and a little bit of wait and see. She also prescribed some exercise.
I immediately started with the exercises which included movements that had me stretching my arm up over my shoulder and immediately the pain got worse and so, per the instructions, I discontinued them. A week later after my first acupuncture treatment there was some dramatic improvement as there was with the second. After the third there was a relapse and the shoulder settled into a game of on again, off again pain.
After the fifth acupuncture I emailed my doctor asking for a referral to a shoulder specialist; not just a shoulder specialist but one particular doctor who I was familiar with. She responded to tell me that the referral request had been made and instructed me to get an x-ray of the shoulder. I expected the x-ray, shook my head, rolled my eyes and mumbled a few curses because both I and my PCP knew that an x-ray would tell us that I have bones in my shoulder but wouldn’t reveal a thing about why my shoulder was hurting. But an x-ray is one of the required steps in the Kaiser ritual dance. In this case it was dance move number three.
A week later I was ushered to an exam room in the ortho department to be seen by a fellow named Norman, who is not only not the doctor I’d requested but is a Physician Assistant. In other words they were sending me to the second team. It would be nice if they gave you a copay discount for seeing a bench player instead of a starter.
Norman looked at the x-ray and told me that I had a touch of arthritis but it was not severe enough to cause the discomfort I was feeling. He thought that I probably had an impingement and offered me a cortisone injection. An offer of a cortisone injection is a required dance step in the Kaiser orthopedic ritual dance. Since Norman might be someone’s godfather but not THE Godfather it was an offer that I could and did refuse. That was dance step number four.
He then offered physical therapy and/or some prescribed exercises for impingement; exercises which prohibited any upward movement of my arm. It was on the tip of my tongue, “You mean don’t do the exercises that my own doctor prescribed two months ago?” I decided to err on the side of diplomacy and swallowed that question. I have a motto, “Don’t piss off your medical provider especially the one who might, in the near future, be aiming a gigantic needle loaded with cortisone at you.”
Norman brought up the tear that had shown up nine years previously and I told him that I wasn’t happy about that. He mumbled something that sounded like a guess that sometimes a doctor won’t dwell on something he might consider insignificant. Once again I had a snappy answer on the tip of my tongue. Something like, “What constitutes significant? A bigger tear? A bone protruding through the skin? Pregnancy?” And then I remembered, “Don’t piss off your medical provider…”
After some negotiation with Norman and a promise to him that all I want to do is to swim and do the household honey do’s and I wasn’t looking to be able to throw a 90 mile per hour slider or throw a football 50 yards he deigned to bestow me with an MRI. In fact, and this is the beauty part of Kaiser, he set me up for the MRI later the same day.
I went home and got ready for the MRI which meant I put on my sweatpants that have no metal parts, removed my chain, wedding band and watch and headed out to Martinez. I left my cell phone in the car, filled out the form that asked me among other things, what medications I was taking, was I claustrophobic and did I have metal in my body or a baby in my womb. I answered truthfully because who knows what happens to you in that tunnel if you’ve perjured yourself on that pre-MRI form. Do you implode or get sent to another dimension? Would I emerge from the tunnel and find myself in Ancient Rome for not telling them about my fillings and gold crown? Do yourself a favor and answer those medical questionnaires honestly.
The tech came out and called for the woman seated across from me who was dressed to the nines. Clearly this woman had never had an MRI or was either not given instructions or she just ignored the whole instruction sheet. As they disappeared down the hall I heard the tech say to the woman, “Take off everything except your panties.” Should’ve worn sweats and a t-shirt, now you’re going to have to get nekkid and step outside the building into that cold trailer where the MRI machine is located.
The other thing that went through my mind was, Oh God this rookie is going to take forEVER. A few minutes later the tech came out and told the receptionist that the woman would have to be rescheduled. “She’s claustrophobic.” My eyes shot skyward, “Thank you God.”
I was next up and the tech was clearly thankful because she could tell from the sweats and t-shirt that I’ve been in that tunnel before. A few quick instructions and they slid me into the tube where I had a nice little power nap.
Two days later I got an email from my PCP. “Good news, x ray of right shoulder revealed mild arthritis. I understand you declined physical therapy in the past, we can refer you at this time.”
At just about the same time I got an email from Norman. “The MRI shows that you have a small tear of the rotator cuff, measuring 4mm. Based on your exam you have good strength and motion of the shoulder and the tear is not limiting your motion. Next steps in treatment can be physical therapy or a cortisone injection (these guys are so hung up on cortisone that I’ve gotta believe they own stock in the company that makes that stuff). I do not think we need an ortho surgeon consult based on your last exam but that can be an option as well.”
After a slow burn I responded to my PCP who was a couple of steps behind in the dance, “That is no news. After consulting with the PA at Walnut Creek it was determined that arthritis is not the cause of the pain. I had an MRI done which shows a tear. I don’t know what else it shows because the PA didn’t specify.”
She responded, “I think he replied to your message. Please follow up with orthopedic. Please let me know if there is anything I can help.”
And then I responded to Norman, “If the tear is what is causing the pain then it seems I’m where I was 9 years ago. Will PT a shot and acupuncture repair the tear? I would like to be repaired please and not just continue buying time.”
Norman responded, “Sounds good. I will have my office contact you for an ortho surgeon consult.”
By now I’d lost count of the Kaiser dance steps I’d performed. I just knew that is was a hell of a lot.
When my appointment date arrived, I was, as my dear old dad used to say, “loaded for bear.” I was ready to give him hell.
The surgeon’s assistant ushered me into an exam room, handed me an introductory sheet that explained that the doctor had indeed graduated from medical school and then went chapter and verse into the protocol of shoulder surgery. She told me the doc would be in, in a few and as she headed out the door the youngish surgeon entered the room.
We shook hands and he asked me what my goals were for my shoulder. I told him that the main goal was to be functional around the house, “My wife is older than me and not as strong. I would like to be able to swim and do some weight training but that’s secondary. I just need to be able to use my shoulder.”
I’d gone into this appointment ready to unload on this doctor. I expected that I was going to have to cajole the man into granting me a surgical repair and in the end I had to do none of that. He reviewed the MRI with me looked at my chart and and then gave me a brief rundown on the preparation for surgery, the surgery itself and the recovery. We then set up a general time frame for the procedure.
I suppose that I could’ve complained to the surgeon about the obstacle course that I’d been put through but to what end? He knows the drill. I would’ve just been venting and you know my motto, “Don’t piss off your medical provider especially if he’s the guy instructing the anesthesiologist and holding the knife.”
What did it cost? With all of the appointments and procedures and acupunctures and dance steps and pushing back (and truth be told I didn’t push back hard enough) it cost me some high blood pressure, two months that I’ll never get back and 575 dollars. Five hundred and seventy five dollars it cost me to find out what I could’ve found out in a few days for half the cost.
By now you might be asking about that Bird Box Challenge thing in my title. That’s what Kaiser does. They take on a Bird Box Challenge by donning a systemic blindfold and then making the patient do the stumbling around. I had a doctor take a wild guess at my problem and she gave me exercises that are contraindicated for a torn rotator cuff. And then Norman was ready to give me a shot and shuffle me off to physical therapy after taking his own guess based on an x-ray that he acknowledged showed nothing significant.
Even after the MRI I had to push back because I guess that he was reading off the Kaiser corporate crib notes that were instructing him to go back to the cortisone and PT schtick. For all the good the shot and PT would’ve done he might just as well have referred me to a shaman. And who knows maybe they do have a shaman in one of their facilities. And I wouldn’t need a shaman to predict a hypothetical future of sinking three more months and a large chunk of my bank account doing PT only to end up in front of the surgeon.
Before I had Kaiser I belonged to a PPO plan and when I had an orthopedic issue I didn’t have to go through a PCP. I simply went to the Saint Francis Hospital Center for Sports Medicine which had as its clients, the San Francisco 49ers and the S.F. Ballet. These guys are the “A team.” They treat big fellows with shattered bones and high performance men and women with stressed and strained ligaments and tendons. Right from the start St. Francis would give me an MRI and a treatment plan.
So why does Kaiser have a policy of flying blind when the experts at St. Francis don’t piddle around? Good question. Only Kaiser knows but legend tells us its to save $$$ – theirs not the patient’s. And so since an MRI apparently is an expensive procedure you have to grab someone by the shoulders and give ‘em a good shake to gain entry into that sacred tunnel.
So what’s next? I’m going to have surgery in November so that my wife and I can do some travelling during the summer. The surgeon has no issue with that as long as I follow his instructions to keep me from turning a partial tear into a complete tear. Complete recovery will take up to six months and if I have to burn up half a year I might as well burn up winter.
I haven’t done it yet but I’m going back to my old PCP. That is a plus with Kaiser. You can fire your PCP just as easily as Trump can fire a cabinet member and you can do it just like he does it; over the internet without looking the person you’re discharging in the eye. And hiring a new one doesn’t need a Senate confirmation.
I feel like I should send my old PCP a letter of apology for dropping her in the first place. “I’m sorry Dr. P. I don’t know what I was thinking. It was my wife that made me change.” (Yeah I know that’s not very cool but I also blame the dog when I fart). You see, Dr. P. is a good gatekeeper. On reflection I didn’t realize the gem I’d had. She’s always managed to reduce the number of moves in my ritual dance. When I was working she noted that my company paid plan, in her words, “sucked,” and she arranged to do as many phone and email consults as possible, thereby saving me money. There was one occasion when I needed a procedure done and to make sure that everything went smoothly she gave me her personal cell phone number to contact her in case there were any problems.