The Columnist Manifesto

I relearn an important lesson about managed care: the squeaky wheel gets the grease.

I was sick today and had to deal with my HMO.

Maybe it was always true, but it is certainly true now, under managed care: when your pain doesn't impress them, make it their pain. One would like to think that you could just say what your symptoms are and then get the correct amount of attention. I have no problem with triage. When I have a medical problem I need treated without an appointment, if my problem can wait, then fit me in later after the more urgent cases.

But you get the feeling that under our current system of managed care, the triage system bases its decisions only in part on your medical condition, and in part on your willingness to fight over the phone.

The problem begins with the phone tree itself. Any time you call a clinic, there seem to be two levels of non-medically-trained people that managed care interposes between you and a trained health care practitioner. There's a general receptionist and an appointments coordinator. They seem to have received training in how to sound all medical and professional over the phone, and when they ask why you want to see the doctor, you naturally want to tell them. This can be a mistake, because it feeds the misperception that they will be impressed by your situation and help find a way to get you treated quickly. In fact, their real job is to put you off until the next opening with your regular doctor, in about six weeks.

Question: "did your medical receptionist course teach you whether the large pulsating welt that developed on my arm in the past three hours could safely wait six weeks?"

You will often have to demand to speak to the "duty nurse" at least twice in order to get a person with actual health-care training (as opposed to health care management training) on the phone. Then things start to happen.

In my case, when I described the symptoms to the nurse, together with my own self-diagnosis, she agreed that it should be dealt with today. She was going to talk with the doctor and get back to me.

Two hours later I called again. The nurse said, "the doctor and I were just about to discuss your situation, when he got a phone call. I'll get right back to you."

An hour and fifteen minutes later, I called again. The nurse said, "we're taking these one at a time, and we haven't gotten to yours yet." I said, in a not unfriendly, but firm way, "look it's pretty clear what these symptoms are, and they're getting worse by the hour."

At that point, I decided to proceed on two separate tracks. I got in my car and headed off to urgent care walk-in clinic. On my way, the cell phone rang. It was the nurse. Based on the information I had previously given her over the telephone, which she relayed to the doctor, the doctor had gone ahead and phoned in a prescription for me. End of story.

I have mixed feelings about this story. I actually like my doctor, who is a practitioner in the new mode of patient empowerment -- tell the patient what you know, and give advice, rather than hiding the ball and being overbearing. It was certainly convenient to have the prescription phoned in based on what amounted to a description of symptoms mixed with a self-diagnosis that sounded right to the professionals on the other end of the line. And yet, as I popped my pills, I had a bit of disquiet in the back of my mind... shouldn't he at least have looked at me?

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