Just pay attention, and think about what's happening.
After a brief phone conversation with me, my doctor contacted the hospital with which his practice is affiliated to have them schedule my colonoscopy. I first heard from the hospital (let's call it Joe's Bar and Surgery) via a letter. It consisted of a page of single-spaced, dense type, stating the date, place and time at which I was to present myself, followed by lengthy, complicated instructions. I didn't do a formal literacy level test, but I'm accustomed to estimating and I'd put it at tenth or twelfth grade. That means the majority of people would not be able to process it.
The requirements are not only complicated, but quite onerous. Your last meal is breakfast the day before. After that, you are restricted to "clear liquids," which they don't exactly define, although they do give some examples -- jello, strained fruit juice. At about dinner time the night before, you have to drink some extremely nasty tasting stuff called sodium phosphate, which gives you instantaneous severe diarrhea. (It's actually marketed as a laxative, but I can't believe anybody would consume it voluntarily.) The diarrhea winds down in three or four hours. The next morning, you have to do another shot of poison, drink some water, and then have nothing -- not even water -- until after the exam. As a bonus, you get to experience another three hours of diarrhea while you are starving. I was scheduled to show up at 3:30 pm, so I spent a long day in mortal combat with my hungry id. Oh yeah -- you must have someone to drive you home. They won't let you leave without an adult escort, even if you promise to take public transportation. Fortunately, my brother works nearby so I had a solution. Not everybody does, of course.
Joe's did have someone call me, not so much to go over the instructions as to make sure I didn't have any counterindication for this, such as a drug allergy or severe chronic alcoholism or heroin addiction. I suppose that some people, perhaps most, have the chance to go over the procedure with their primary care physician ahead of time, but since we already know that immediately after a physician visit, people do not know 50% of what their doctor told them, I don't know how helpful that is.
I arrived at Joe's endoscopy center at 3:30, as required, and sat in the waiting room until 3:50. Okay, that's not too bad, usually physicians keep you waiting for at least half an hour. They had me strip and put on the notorious hospital jonny, then lie on a gurney and wait. A nurse came briefly to insert an IV, and I had the opportunity to ask her if they had a lot of no-shows for this procedure. The answer is yes.
So there I am, in infantile pajamas, in bed, in what is indistinguishable from a hospital ward. Other patients were lined up there in areas separated by curtains, but for the most part the curtains were not drawn and everyone was out in the open. Some of them were inpatients who were very sick. I lay there for 50 minutes, ignored, with nothing to read -- I didn't have my glasses anyway -- in the official clothing and posture of an invalid, on an invalid's furniture. This humiliation may appear pontless, but it's actually essential. Without the ritual redefinition of my social role from that of middle aged professional and free citizen to that of helpless infant (aka patient), it would not be possible for a man to insert a long tube into my anus and snake it through my digestive tract.
For those who are considering going through this, the procedure itself was much less unpleasant than you might think. They heavily drugged me and I really wasn't aware of what was going on, although I was conscious enough to see the video, which was sort of interesting, although my memory of it is fairly hazy.
So, here are my conclusions and questions for further research.
1) There are many barriers to people getting this procedure, in addition to the financial barrier, which is substantial. (My understanding is that the full cost is about $1,000. Even with good insurance, my co-pay is $100.) There is the need to fast for two days, the very unpleasant purging, and of course the need to take at least one day off from work. I did go to work the day before, but it's hard to be fully productive when you are starving.
For people who have difficulty understanding the instructions, or find them intimidating, there must be a strong temptation to just forget the whole thing. And I wouldn't be surprised if many people who take the first dose of sodium phosphate decide not to go through with the second one. Many people must succumb to temptation and cheat on the fast, as well. So I would be curious to know:
a) What percentage of people just don't show up for the appointment? What characteristics of patients, geography, and methods of communication by providers are associated with no-show rates? What kinds of actions (what we call interventions) can increase attendance?
b) What percentage of people do show up, but have made less than adequate preparations? What percentage of procedures are compromised by failure to properly clean the colon? Again, what kinds of communication and supports could help people succeed at this quite onerous requirement?
I presume that some research has been done on these questions, but it's pretty obvious to me that Joe's, at least, doesn't have the answers yet.
2) I don't see why people going through such procedures can't be granted more dignity. I can tell you that there is nothing unique about colonoscopy in the way that people who undergo it are systematically infantilized. Why must everyone don the same baby's smock, always with that dull gray check pattern, and the back open with your ass blowing in the breeze? Why can't the nurses manage the flow of patients so that people aren't asked to change until just before the procedure, and why can't we wait in a comfortable lounge, sitting on chairs, reading four-month-old issues of Popular Mechanics, instead of lying in bed among the suffering and the doomed?
When I was hospitalized some years ago following major surgery (long-time readers know this tale, which I never quite finished and suppose I must), after five or six days I convinced the nurses to let me wear doctor's scrubs instead of a backless smock. There was actually no medical reason why I shouldn't, as it turns out. And the cost to the hospital laundry was the same. The result? I felt like a grownup again. I got to wear a shirt, and long pants, just like the big kids. I think it helped me get better.
Monday, September 11, 2006
You too can be a medical sociologist
Just pay attention, and think about what's happening.