Insider/Outsider

There's this interesting thing about medicine and medical care that a lot of people probably don't know about. If you're an "insider", you get vastly different access than if you're an "outsider". I can't say for sure the care is different because this is hard to measure objectively (i.e. from the non-provider perspective). I know when I was inpatient at the hospital where I worked, I got the private room on the carpeted unit where they put rich people, famous people, and board members with boo-boos. My care was not super but this was because it was a non-teaching service on a weekend and the attendings were bickering about what service I should be on (admitted to GI but turned out to be GYN). Hence I had no diet orders, only about half the meds I needed, and had to wait until someone could be compelled to take charge so I'd get orders on my chart*.

I'm going to describe some of the experiences I and people close to me have had as insider and as outsiders on the other side of that desk. I'll try to stick to the circumstances I have first hand knowledge about. But first, let me define "Insider" and "Outsider". It's pretty simple really. You're an insider if you work at that hospital, if you work in any medical professional capacity in what counts as a particular provider's network (socio-professional, not insurance), or if you are married to, seriously committed to, or a close relative of one of the above. For example, my mom was a nurse in the Boston area for most of my life. This meant that I was given insider status at not only the hospital she worked for, but at hospitals she had worked for and hospitals with staff who knew her.

An outsider is everyone else.

Here are a couple of scenarios that allow for somewhat direct comparison of access and care for insider and outsider patients.

Cat attack 1
In 2000, my huge cat Max decided to get unfriendly with me. He's always been extremely aggressive with other animals, so he was limited to only supervised trips outdoors. We were in my yard on one such day when he started acting strange. I decided play time was over and picked him up to take him in. Big mistake. He attacked me, biting and scratching my arms and hands...mostly the right hand. I had several bites on my thumb and two fingers, one of which bites went straight through the finger. Needless to say, I freaked the hell out. My then husband Bob helped me wash up, noticed how badly chewed up I was, and drove me to the hospital he worked at. I was taken in the back entrance and seen immediately. While there, I was seen by an ER doctor and a hand surgeon who performed minor exploratory surgery on my finger to make sure none of the tendons had been hit in the cat attack. I was given a dose of IV antibiotic, some IV fluid just for the hell of it, and discharged with scripts for oral antibiotics and pain meds. I got great discharge instructions including careful step by step details on how to clean and re-bandage the wounds. I was also given dressing change supplies and several doses of each medication to take home with me.

Cat attack 2
In Spring of 2002, my sister was bitten by a neighbor's cat who was fighting with her kitty on her porch. She had no idea if this cat had it's shots and the cat snunk its teeth in deep on her right hand low, near the wrist. She drove herself to the ER, was triaged slowly, seen late, and asked by the nurse "so we have a cat scratch?"

No one even cleaned my sister's the wound. She was given no IV antibiotic in the ER, and her discharge instructions consisted of "come back if it gets worse" even though they knew she lived alone and would have to drive herself back with an infected arm if it "got worse". She called me and I had driven up to see her during the day. When the hand looked like a fucking Jimmy Dean sausage that evening, we went back to the ER. As luck would have it, a nurse who knew us was on triage. She had been friends with our mother. I had worked with her occasionally when I was floated down to the ER at the hospital my sister, brother, mother, and I all worked at years before. Her name was Mary. Mary saw that it was me and my sister and took my sister in back. She then switched off triage so she could be my sister's nurse. My sister was given IV antibiotics, several bags of IV fluid (warmed before being connected so she wouldn't get the cold IV arm), and was promptly admitted when her blood cultures came back positive.

Doctor's office:
When I was married to the doctor, our primary care used to waive our office co-pay as a "professional courtesy". As soon as my primary care found out I was separated, I had to start paying my co-pay again even though my yearly income had gone from a shared $100,000 plus to a single $15,000.

Today:
My hip went out of joint again last night. That's what I'm assuming is going on with it because that is what it feels like. And oh good lord does it hurt. I can't walk or even sit very well (I'm taking breaks every 30 minutes to lie down) but it is better than it was last night which was extremely painful even lying down. Last time this happened (in late April), I saw my primary care a day later. She had an x-ray done which was unremarkable except for the fact that the tech was stunned by how far my leg would bend (it's all that whoring, is what I wanted to tell her but decided my brand of humor is probably kept to myself). It took over a week for my primary's office to call me with the results and to tell me if this happens again, my doctor wants me to see someone from ortho.

I called my primary back today and explained that hey, it happened again and ow. Her nurse called me back and asked me to make an appointment with one of two local ortho guys. She asked if my preference was local or somewhat less local. I said "My preference is whichever is better". She said she didn't know. The more local was the one it would be better for me to see, she said. I looked him up. He's older, very new to the local practice, just transferred from Rhode Island, is a third generation surgeon (yuck), and had recently lost a medical malpractice lawsuit against him.

While I was waiting all day for my primary's office to call back, I e-mailed a faculty member who does research with sports medicine people here at my university. She got back to me shortly after I (reluctantly) made the appointment with the malpractice guy. She forwarded me a reply she received on her inquiry from her research colleague, a professor who is also a physical therapist.
He wrote:
She should get into see Dr. ______, the smartest ortho I know. He is in _______, and should be listed... Also, my parents have his number....Please tell [PFG] to feel free to call me at home in the evening if she has any questions, either before this Friday or after the 4th, as I will be away

Now that's a recommendation.

So now I have two appointments. One with the local guy for next week and one with the professor recommendation guy for August 2. Acceswise, so far the local guy is quicker, but this is quite likely because he has no or few patients of his own at the moment. He's only been in that practice for about a month. You can bet your ass I'm calling the prof tonight to thank him for the recommendation and to let him know I have an appointment for a month from now. Let's test my insider hypothesis and see if talking to him doesn't get me a quicker appointment.

* = In my experience on the other side of the desk, in this scenario, the unit secretary can be your BEST friend. If you're family or friend of a patient who's been waiting hours for orders, go talk to the clerk. E.g. "Hi. I'm so sorry to bother you. My dad's in room 612 and I wanted to see if his doctor called back yet. No? That's too bad. Ok, well, I'll try to run down to the cafeteria to get myself a snack before he calls back. Does he usually take a while, because I was going to eat downstairs so my dad doesn't see the food, he's starving and I don't want to eat in front of him. Oh, can I get you anything while I'm down there?" You can even ask him or her very politely if s/he could please see about expediting at least diet and med orders. Unit secretaries/clerks have ways to make the doctors call back, and nurses at least used to be able to take phone orders for one or two things before the doctor makes his or her way in off the golf course to write a full set of orders.