adventures in assembly-line medicine

[nibot]

Today I had my face sprayed with liquid nitrogen, a needle in my arm, a bizarre instrument in my ear, and some cuff pumping down on my arm... more or less simultaneously. Welcome to the world of assembly line medicine.

Wanting to exploit this brief period of full HMO health insurance coverage (courtesy you, the Californian taxpayer, as I am a full-time employee of the University of California), I went to Kaiser Permanente today to get some things looked at. I arrived at the building on Clairemont Mesa, parked, and bought a coffee ($1.70) and muffin ($1.65) from the kiosk outside. I was early, so I sat outside in the cool morning air and ate my muffin and drank my coffee amongst a bunch of medical types wearing scrubs. I got a refill for 50 cents and then ran inside to find my appointment.

An elderly woman wearing a badge that said "volunteer" sat at a kiosk labeled "information." On the third attempt, she understood my question of "Can you tell me where the stairs are, to the second floor?" It turns out that to use the stairs, one must exit the building and return via a poorly marked door that is clearly intended mainly as an emergency exit rather than a mundane means of conveyance.

Once on the second floor, I noticed the name of my assigned "primay care physician" listed along with a half-dozen others on the door. I queued up second in line to register. When he finished registering, the man in front of me turned around and ran into me. My coffee spilled. I was offered some kind of medical-issue tissues to mop up. I gave my insurance card and paid ten dollars. I then placed my medical card in a tray outside of a door, where it was picked up by some person further down the assembly line.

Soon my name was called and I moved down the line. A woman embossed my card into some paperwork, and simultaneously took my blood pressure, pulse, and put something into my ear that measured something else. She rattled off the numbers. Blood pressure. Good. Temperature. Good. Pulse. Good. That I had just imbibed 32 ounces of strongly caffeinated coffee and then run up the stairs was apparently irrelevent.

I was lead to an examination room to meet my doctor, Dr. O., a young and friendly man of Japanese ancestry. I liked him. He asked what I needed and I pointed to the freckel I suspected of malevolency and explained its story. He examined it briefly and then said, "This is somekindof latinnamedcondition. Let's get rid of it." He clicked his heels, disappeared briefly, then reappeared with some kind of contraption looking somewhat like a frosted fire extinguisher. With it he blasted the suspected malevolent freckle. I pointed to another anomaly and he blasted it too. Before he did this he said, "This doesn't usually scar too much."

Dr.O began packing up his things, thanking me for my visit, and so forth. I interrupted him with, "Do you think by any chance I could get some prescriptions renewed?" Dr.O said, "of course!" I asked for albuterol and flovent. He said, "Flovent we don't cover, but we have something else that does the same thing but has a different name." "Is it identical," I asked. "Yes," he replied. "Okay, I'll take it," I agreed, and Dr. O affably drew out the prescription.

Once again he began packing up his things, thanking me for the visit, and so forth, but I interrupted him and asked him to help me fill out my health history form for University of Rochester. This he did patiently and completely, carefully verifying all of the information from my other documentation before signing it, with a signature that was nothing more than a squiggle.

Again he began packing up his things, thanking me for the visit, and so forth, but I interrupted him and asked him if I could get one last thing. He was a very friendly and apparently competent man, but I felt it was very difficult to keep his attention. Maybe I should have outlined a list of everything I needed at the get go. Anyway, I asked for the next shot in the Hepatitis vaccination sequence that I had begun in Sweden, and I showed him the documentation the Swedish doctors had given me, saying they'd given me a shot of "HAVRIX" of a particular dosage. He said "sure," and gave me a piece of paper to give to the nurse at the next station on this assembly line.

Before we went our separate ways, I asked if I could get a summary of all of these things, like the name of the condition of the semi-malevolent freckle and so forth. "We don't normally give patients records of individual appointments," he said, "But you could write to our medical records department, and they can mail your records later." Instead, I asked him to write the information down in my notebook, which he did happily.

---

With no further cause to keep him, Dr. O then ran off to service other patients while I packed up my things. I could have written myself a few more prescriptions had I felt like it. Instead, I walked down the corridor to the next station, where I handed the nurse the slip of paper indicating the injection I was to receive. I half-expected to be handed the syringe and be told to inject myself.

There seemed to be some question regarding what injection to give me. I have a bright yellow passport-sized booklet that says "International Certificate of Vaccination" in big letters followed by "International Health Regulations (1969)" and "World Health Organization" and the WHO seal. All of this is repeated in French. It is an internationally recognized travel document used to document your innoculations, primarily from Yellow Fever. Without it, you risk being jabbed with a communal needle containing a supposed Yellow Fever vaccine, by a border guard somewhere in sub-Saharan Africa, should you travel there, or any other place where yellow fever is endemic.

In Sweden I got vaccinated against Typhoid and Hepatitis, and the clinician carefully wrote "HAVRIX I" in the "Nature of vaccine/Genre de vaccin" column to indicate the start of the Hepatitis sequence. Three injections are needed for full protection. ("Will they know what this is?" I asked at the time. "HAVRIX is the standard name for this, around the world," the Swedish clinician told me. I believe he was right.)

So back at Kaiser Permanente, the nurse squinted and turned my "international certificate of vaccination" this way and that. She left, returning with a syringe. "What is this?" I asked her. "Hepatitis B," she said. "Is that what HAVRIX is?" I asked. "I can't read it," she replied, in reference to the International Certificate of Vaccination. "It says HAVRIX," I replied, as it is clearly printed in block letters. "Is HAVRIX a Hepatitis B vaccine," I asked. The nurse fought with a yellow 8.5"x11" piece of paper labelled "HEPATITIS B VACCINE: what you need to know," a general information flyer for patient containing such bolded statements as "Hepatitis B vaccine can help prevent hepatitis B" and "How can I learn more? Ask your doctor or nurse." This did not inspire confidence.

I said I didn't know whether the HAVRIX sequence was for Hepatitis B or Hepatitis C. I know now, via the wonders of Google, that there is no Hepatitis C vaccine, but this didn't come up at the time. Obviously the "what you need to know" flyer didn't answer the question, and the nurse settled for the answer, "Dr. O says this is what you needed." So I got the shot.

"What was that," I asked.
"Hepatitis B vaccine," she replied.
"What's it called? Is there only one Hepatitis B vaccine?" I asked, recalling that in Sweden I had a choice of varieties.
"Hepatitis B Vaccine. That's what it's called," the nurse replied.

It turns out that Havrix is the world standard vaccine for Hepatitis A.

---

From there I was directed to the next stage of this medical assembly line, the pharmacy. I gave up on finding the stairs again and took the elevator down one floor. Seeing the massive frenzy at the pharmacy, I briefly thought of asking whether I could get my prescription filled elsewhere. I looked around for a place to ask, but the only place was the information kiosk with the elderly Volunteer who had had trouble directing me to the stairs. I submitted to the pharmacy queue.

Waiting for my prescription to be filled, I sat down in the waiting area and pulled out my computer to begin writing this story. I looked up and saw several prominent signs with the text, "Shoplifters will be prosecuted." An elderly gentleman moved over from his seat a few rows over to sit by me. He seemed interested in what I was doing on the computer, and also very interested in the take-out menu for Anthony's Fish Grotto, which he was poring over.

I closed the computer, and started chatting with the man. "What really burns me up," he said in a rising tone as he placed his finger on a particular line on the menu, "Is this." "Coffee for a dollar sixty. A dollar sixty for a cup of coffee!"

Later the subject veered onto the subject of San Diegans selling their houses and moving to the East or to the South where they could buy ranches for the sale prices of their modest San Diego homes. Then another elderly man joined the conversation. "You're telling me!" he said. "I bought my house on Kearny Mesa for $38,000. At the time I thought it was highway robbery, because it was built or only $14,000. But now my neighbor's house sold for $650,000!"

I felt a bit like jeddiespaghetti in his mommies club by now, but I saw my name on the electronic sign indicating that my prescriptions were ready, so I left the gentlemen.

A girl with a smile full of metal brought me baskets of inhalers. On the cash register there was a sign that said, "By California Law, all new prescriptions must include consultation with a pharmacist."

Three Albuterol, three of this other non-Flovent alternative, and a bill for $30, ten for the generic Albuterol, and twenty for the fake Flovent, a bargain by any measure. But I wanted to know what exactly this funky faux Flovent really was.

"Is this the same as Flovent," I asked.
"It's a cortical steroid." She said. "I mean, is it chemically identical to Flovent?" I pressed.

The girl hesitated.

"I know the answer, but I can't legally tell you," she said. "I am not a pharmacist."

I asked to see the pharmacist. The sign said that this was required by law anyway, but I had to demand it.

While I waited for the pharmacist, I read over a form from a dispenser located on the countertop. The top of the form has a little logo that says "Service Excellence Program — On The Spot Recognition." Then there is smaller text that says, "I want to commend your excellent service, and express my appreciation for a job well done. Please accept this certificate as an expression of my thanks." Then there are boxes for "Name of person being recognized (please print)," "Date of excellent service," "department," "location," and "employee number." Then about half the page is marked with lines, preceeded by the directions "Please legibly describe the performance of excellent service: NOTE: press hard with ballpoint pen, or type." At the very bottom, there is the text, "NS-7355 (4-97) WHITE — Recipient. CANARY — Supervisor. PINK — Service Excellent Center."

"Is this the same as Flovent," I asked the pharmacist, when she arrived.
"Yup. Except this is one puff every X hours, not two puffs," she replied.
"No, I mean, are they the same medicine but under different names?"
"Oh yeah, except you don't have to shake this one." She took the inhaler out of the package and demonstrated how to remove the lid, and how to hold it.
"Are they the same medically?"
"They are both cortical steroids."
"Dr. O said they were identical. Are they?"
"They're both cortical steroids. Except Flovent isn't covered."
"How do they differ?"
"This one is not covered," the Pharmacist replied, holding up my old Flovent, sounding somewhat exasperated. "Can you tell me why it is not covered?"

Finally she smiled, and answered directly:

"Because it is too expensive."

---

Information from the CDC:

Hepatitis A is a liver disease caused by the hepatitis A virus. Hepatitis A can affect anyone. In the United States, hepatitis A can occur in situations ranging from isolated cases of disease to widespread epidemics. Good personal hygiene and proper sanitation can help prevent hepatitis A. Vaccines are also available for long-term prevention of hepatitis A virus infection in persons 2 years of age and older. Immune globulin is available for short-term prevention of hepatitis A virus infection in individuals of all ages.

Hepatitis B is a serious disease caused by a virus that attacks the liver. The virus, which is called hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. Hepatitis B vaccine is available for all age groups to prevent hepatitis B virus infection.

Hepatitis C is a liver disease caused by the hepatitis C virus (HCV), which is found in the blood of persons who have this disease. HCV is spread by contact with the blood of an infected person.

[Hepatitis D] is a defective single-stranded RNA virus that requires the helper function of HBV to replicate. HDV requires HBV for synthesis of envelope protein composed of HBsAg, which is used to encapsulate the HDV genome.

Hepatitis E virus (HEV), the major etiologic agent of enterically transmitted non-A, non-B hepatitis worldwide, is a spherical, non-enveloped, single stranded RNA virus that is approximately 32 to 34 nm in diameter. HEV belongs to a genus of HEV-like viruses (unassigned genus).

[The two forms of Hep A protection — temporary 'immune globulin' or permanent vaccination via Havrix — are the various options I recalled being offered in Sweden. Reading over the information, I remember now. The CDC Travel Advisory for the Middle East recommended Hep A vaccination, as did the Swedish travel advisory for for the Middle East, which is why I got that vaccination. Hep B vaccination, on the other hand, was recommended only "if you might be exposed to blood (for example, health-care workers), have sexual contact with the local population, stay longer than 6 months, or be exposed through medical treatment" so we skipped it then. Therefore: Swedes right, Kaiser wrong. Nonetheless no harm in a Hep B vaccination. Just wasn't what I was after — not the second item in the Havrix sequence I asked for.]

Advice for future visits: Take Google with you to the doctor, and keep your own records.

[see also, non-adventure in swedish healthcare]

Comments

[wealhtheow.livejournal.com]

Whew! That's quite an adventure. I've hated Kaiser ever since they wouldn't admit my mother's good friend into hospital because he was "not sick enough" and his friends found him two days later, lying on the floor dead of pneumonia. So your encounter with minimal competence levels and assembly-line service sounds pretty typical. It is the ghetto healthcare institution.

[janviere.livejournal.com]

pharmacist?

Sounds no worse than a day in Tang. I hope the Hepatitis B vaccine won't do terrible things to you... but it shouldn't, since you should have been forced to get vaccinated for Hepatitis B to enroll at Berkeley.

[nibot.livejournal.com]

I hope the Hepatitis B vaccine won't do terrible things to you.

It's absolutely fine, and something I'd get anyway. The cavalier attitude towards medical accuracy and lack of attention to detail was just a bit appalling.

but it shouldn't, since you should have been forced to get vaccinated for Hepatitis B to enroll at Berkeley.

Nope.

[nibot.livejournal.com]

from http://www.uhs.berkeley.edu/students/immunization/hepatitisb.shtml :

Hepatits B Vaccination: Condition of Enrollment

The California State Legislature has mandated first-time enrollees at the University of California, who are nineteen years of age or younger, to provide proof of immunization against Hepatitis B as a condition of enrollment. If you will be under 19 on August 30, 2004, you must comply. The vaccine is a series of three doses: The second dose is given one month after the first, and the final dose is given five months after the second dose. Please follow the appropriate instructions below.

[janviere.livejournal.com]

That date is changed every year. I had to get it or prove that I'd gotten it when I started.

[nibot.livejournal.com]

I've had only positive experiences at Tang... I know people have their stories, but the Tang doctors always gave me plenty of their time and good treatment.

[nibot.livejournal.com]

Oh yeah, also, mainly it is a random story. I didn't think it was a terrible experience. They gave me things I needed, that were perhaps better than the things I thought I wanted. The anti-shoplifting sign in the pharmacy I find particularly amusing.

[probablevacancy.livejournal.com]

I really enjoyed this entry, Tobin, it sounds like the makings of the next Michael Moore movie.

[furzicle.livejournal.com]

I HIGHLY recommend keeping your own records. They will happily keep them for you, but you will never see them again. It's usually hard even to get doctors within a system to communicate with each other, let alone other offices.

[once-a-banana.livejournal.com]

I hope they didn't write goofy info on your imm. record after giving you the Hep B shot, since they thought it was at least your second one... you need three of those (I think it's one after 6 months and another a year after that). Sounds like you better scribble "Hep A" next to the line with "Havrix" to help educate your next immunizatin nurse...

[cheeseparade.livejournal.com]

This really is an interesting tale! My mom, an employee of the LA school district, also had a Kaiser HMO plan. Then they almost let my grandfather die from neglect, and my sister, from misdiagnoses , so we got the hell out of there. I really wish America had some kind of national healthcare system... sigh.