posted by meowser
Part 1 is here.
Part 2 is here.
And thanks to Michelle for getting the ball rolling on the subject of “compliance” — that is, Following Doctors’ Orders (or else?).
In America (and I’m guessing most other countries too?), nobody is required by any law to do exactly what doctors tell them to do. Hell, nobody even has to see a doctor in the first place if they don’t want to, even if it means they’re delaying getting a problem checked out that will be more expensive to treat if they wait. And without violating any HIPAA regulations, I can tell you flat out after many years of creating medical records that people refuse recommended treatments all the time. I do a lot of ER reports, and the following scenario is extremely common: Patient presents to the emergency department. Doctor thinks patient should stay and have some tests run, maybe have some IV antibiotics or other medications. Patient says sie wants to go home. Doctor tells patient sie really should stay, and that sie runs the risk of dying or becoming much sicker if sie leaves. But patient is still permitted to sign out AMA (against medical advice) and go home if sie wishes.
And what do you think doctors tell patients when they do sign out AMA? “Okay, but don’t come back again if you get really sick, because you didn’t listen to me”? No. They say, “Return to the emergency department if there are any problems.” Because it would be completely ludicrous for them to say, “Well, asshole, you had your chance at proper medical treatment and you blew it,” right?
And yet, that’s what frequently happens to fat people who seek medical attention. They’re “ordered” to lose weight, more often than not they either fail to do so or gain back whatever they do manage to lose, and they’re told, “I can’t do a thing for you unless you lose all the weight I told you to lose and keep it off.” You’d think by now that more of them would get a clue that almost no one loses 50 or 75 or 100 or more pounds permanently through diet and exercise alone — except possibly for a few people who start out being extreme binge eaters and/or binge drinkers and don’t have a long dieting history, or who have made getting and staying thin their full-time job and never EVER cave in and eat anything “bad” or miss their two-hour (or longer) daily workouts even with the most wracking knee injury or virulent case of bubonic-boogie flu. And that’s just not reality for most of us. But the idea that most people have limited control over their weight hasn’t gained a whole lot of traction yet despite the staggering pile of evidence in its favor.
So we fatasses who remain fat — i.e. almost all of us — constantly run the risk of being labeled “noncompliant” by our doctors just because we exist. And the vast buttinsky contingent that exists here (though not, of course, exclusively here) just loves to bleat about how expensive we are compared to them because of our stubborn “refusal” to slim down. (Although I note with more than slight puzzlement that these are usually the exact same people who think their perfect habits are going to carry them through to their 100th birthdays — exactly how is it “inexpensive” to your fellow Americans to live to be 100?) They love to say things like, “Well, if you’re not following doctors’ orders, you deserve to have to wait your turn behind those of us who are trying to be good.”
To which I always say something like this: “If you’re going to rank people as a lower priority for care because of not following doctors’ orders, what on earth makes you think you won’t be next?“
I’m one of those radical fruitcakes who thinks “imperfect” people deserve health care just as much as the Goody-Twelve-Shoes Club does. Because let’s face it, even the Goody-Twelve-Shoes Club has people in it who have pasts. How can anyone know that those 10 years of chain-smoking, or hard drinking or drug abuse, won’t come back to haunt them later? I and my fat ass never did any of that, so nyaah, all you smug former party animals. The GTS Club thinks it’s reserving its bared fangs and spittly hissing for people who are still doing those things right now, but believe me, the people who used to do that stuff won’t be far behind if we start holding out on people for being “bad.”
Michelle’s post was about a doctor who was having a hissy-pissy because his dialysis patients were drinking water when they were thirsty against his orders. Yeah, that’s all it took to bend his antlers; he talks about them “chugging gallons of milk or juice” at home, but I’ll bet my next Hot Lips fruit soda that the offending amounts of liquid were much smaller than that. (The comments on that post are terrific too; highly recommended reading.) So he wants all patients to do exactly what their doctors tell them to do, and no backtalk? He really wants to go there? It got me thinking about a whole pile of potential behaviors, none of them especially outrageous, that could possibly get a patient labeled “noncompliant” under a system that makes “good behavior” a prerequisite for care:
- Smoking pot. (It always astounds me how many pot smokers who don’t smoke tobacco think the smoking-is-noncompliance stick will never be used on them. With THIS government? Hah.)
- Not wearing your compression stockings when it’s 100 degrees out and the air conditioner is busted.
- Eating something that’s not on your 1800-calorie diabetic, soft foods only, no seeds, 2 grams sodium, low cholesterol, low residue, low fat, low oxalate, low protein diet. (Yes, people are actually given diets that ridiculous to follow at home.)
- If female, not having children young so as to ward off postmenopausal breast cancer.
- Staying coupled to someone who keeps flaking on you when you need to be driven to and from appointments.
- Self-discontinuing a medication because you don’t like the side effects, or not filling a prescription because you don’t feel comfortable taking that drug, or forgetting to take the drug as scheduled.
- Not having mammograms or prostate exams or colonoscopies or DEXA scans (for bone mineral density) as often as your doctor recommends, for any reason.
- Playing with or helping out the kids or grandkids when the doctor has told you to rest.
I’m sure you can think of others.
Heck, I even think people who do stuff I personally find objectionable — like screwing around in the car instead of watching the road and getting into an accident, or yelling at their employees to the point of making them come down with stress-related illness — shouldn’t get down-triaged for care. Because people aren’t perfect, and no amount of withdrawing care is going to make them so.
But let’s get real. We’re never, ever going to have a health care system in America where everyone pays and only the GTS Club gets full care. Because in case nobody’s noticed, this country, more than any other, is crawling with celebrities and other wealthy people. Many of these people don’t have the world’s most perfect health habits, or aren’t what doctors would consider “ideal” weight. Can you imagine an NFL linebacker being refused care for being too hefty? I can’t. Sure, do that knee replacement on him! It’s not like he’ll beat up on it tackling people for a living or anything. And if they don’t consider him to be a waste of a perfectly good prosthesis, there’s no reason *I* should be if I ever wind up needing it, when all I’m going to do is walk on it.
Chain-smoking movie stars? Alcoholic rock stars? No problem, they can hop right on in. There’s no way on earth they won’t be able to, even under UHC. And there’s no way on earth they’ll be told, “Quit right now, or no health care for you.” If they ever were, they’d scream bloody murder. If Michael Jackson could find one doctor to remove his entire nose and another to give him fucking propofol to use at home (something no mere mortal would ever, ever be allowed to leave a hospital with), there’s probably no limit to what you could find a health care provider to do if you’ve got the scratch. Yeah, they’re really going to outlaw all that stuff here and enforce all those laws to the letter when they’re already not enforcing laws that already exist. And I’m Malibu freaking Barbie.
That’s why I’m not putting a lot of stock in the idea that under UHC, we fatasses are all going to be “ordered” to lose lots of weight for good, no matter what it takes, or not get care. As it stands right now, they’re saving buckets of dough by millions of us never going to doctors because we’re not allowed to or can’t take the abuse. Can you imagine the expense of having WLS performed on every single “obese” person? And all the followup care? It would make all our current “fat related health care expenses” look like Slurpee money. (Not to mention the fact that Shaq et al would just refuse.) There are about 300 million of us, and they can’t even prevent all the convenience store owners from selling cigarettes to 13-year-olds in a country this size, even with a federal law in place prohibiting it, because it would be too expensive to crack down on all of them round the clock. If the idea is to make everyone “compliant” to save money, they don’t even want to know how much that’s gonna cost them.