My Private Knee

After three months of physiotherapy and rest and exercises and anti-inflammatory tablets had failed to fix my injured knee, an MRI explained why: the outer cartilage was torn and the inner was tatty. I saw a surgeon last Wednesday and on Friday he repaired what was reparable and removed what was not.
 
 
The next day I sat on my couch in small pain, enjoying a liberal dose of self-pity. I had time and excuse to sit and live slowly. I read the ‘paper. A fellow citizen wrote to the editor in praise of Medicare, our universal health scheme. Her small daughter fell acutely ill and she hurried to the public hospital, where the waiting area was crowded and the public address announced the arrival of a series of ambulances. The delays would be long. However the sick child was assessed in Triage as urgent, was seen and treated expeditiously and expertly. By morning she was well enough to go home and her mother took up the pen in praise and thanksgiving. ‘How lucky we are’, she wrote, ‘to have such an excellent public health system.’
 
 
A second letter to the editor told the opposite tale. The writer suffered a limb injury and attended a public hospital. His injury was disabling and unremittingly painful. It was rapidly recognised as in need of early surgery. That was two years ago. His case is classified in the category of Most Urgent (elective). Every three months since he has returned to the hospital for routine appointments, where the diagnosis and the urgency are confirmed. His letter ends with a lament: ‘How can we kid ourselves we have a health scheme where Most Urgent can languish for years?’
 

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The writer and I both suffered injuries. Both of us received expert advice that surgery was necessary. Mine was performed within days, while my fellow languishes for years. My injury was minor but it did not feel trivial. For three months it hurt too much to run. I turned to the bike and the knee felt worse. Soon I could not walk without pain. I watched the muscles of my thighs wither and I lamented. Those legs had been my pride. I contemplated a life without exercise and I knew I would not know myself.
 
 
How is it my leg improves by the day while a fellow citizen suffers a worse problem and waits interminably? I cannot doubt the sufferer subsists on medication which is neither curative nor safe. By now he is surely addicted to his opiates. Why the disparity? The answer is my private health insurance, which, by dint of thrift and belief, I afford. Not everyone is so fortunate.
 
 
Even an unbleeding-hearted economic rationalist would see the disparity as just that, an inequality. I believe there is a solution which is not a new idea, but a forgotten one. I recall a politician by name of Don Chipp who became Minister for Health in the Liberal Government in the days before Medicare was sanctified, beatified and became untouchable. Facing the disparity, Chipp proposed government would underwrite the private health insurance of the poor. All citizens would be insured, all would enjoy choice of surgeon and hospital, the private health sector would expand and prosper through efficiencies that Public Health can never match, investors would rejoice and the Liberals would be congratulated in the polls. Meanwhile Most Urgent Surgery (elective) would be performed within a humane frame of time.
 
 
That scheme, which bore some resemblance to Obama Care, never came to pass. Labor rejected the necessary Means Test as ideologically repugnant. Chipp moved out of his party and created a third force in politics, which soon became a chronic and disabling pain to Liberal governments. Decades later my fellow citizen, uninsured privately, suffers privately, where he could be cured.
 
 

Teaching an Old Dog Old Tricks

 

“Good morning, Doctor.’ The good-looking man is new to my practice. He offers a hand, shakes manfully, breaks no bones but leaves none unfirmed. His smile launches a promising relationship. ‘I’m new to Melbourne, doctor. Just moved here – for my studies.’

 

The man looks a young forty. I check his date of birth; he’s forty-nine.

‘What are you studying?’ – I ask.

‘Philosophy. Classic Philosophy, the greats, you know, Plato, Aristotle, Aquinas, Maimonides…’

He’s won me.

 

‘I used to be a lawyer. Made some money, made a family, four kids. Now it’s time for me. Time to pursue wisdom.’

‘Share it with me when you find it,’ I say.

He smiles.

 

‘Doctor, I wonder if you can help me out. Awkward situation. I’ve left my tablets in Sydney. They’ll arrive Monday next with the family. My doctor prescribed a short course of Temazepam for sleep. Exams next week and I can’t sleep. If I don’t sleep, I’ll fail. If I fail I’ll never find wisdom.’ The winning smile again.

 

 ‘What are the tablets?’

‘Temazepam, the weaker ones, the tens. I’m scared of anything stronger.’

‘Very wise. They’re habit-forming.’

The man looks shocked: ‘Habit-forming? Really? My doctor never mentioned that. I just want enough to get me through these exams. I finish in three weeks.’

 

 

The man and I spend a little time discussing Temazepam, natural remedies, his own preference for a long hard run (‘Wouldn’t you know, Doctor, my running shoes are still in Sydney?’) The man looks up at the marathon photos that cover my walls where other doctors show their degrees.

‘Are you still running, Doctor? Marathons? Really? Amazing!’

 

 

The man leaves my room with his limited prescription, leaving behind his protestations of delight, his vows he’ll be back, how lucky our paths crossed, he’s found a disciple of Maimonides, he wants me to be his new doctor.

 

 

A couple of patients later the receptionist buzzes me and pricks my balloon: ‘That new patient, do you know what he said about you, Howard?’

‘No.’

‘”What an amazing doctor! Still running marathons!” Says you are a scholar, an expert in Greek Physiology.’

 

‘You know what else he said?”

‘What?”

‘He said he left his wallet in his car. He said he’d be back in five minutes to pay. I asked him for his Medicare card, but that was in the car too. But he knew his number, he said, and I took it down. Thirty minutes and he’s not back. I rang Medicare: there’s no such number and they have no record of that name at the Sydney address he gave. I rang his mobile. “Optus advises the number you have called is incorrect or has been disconnected.”

 

 

Three years pass. Three years are not sufficient to heal a wound in trust.

Last week a new patient registers with Reception. He presents his Medicare Card, asking a series of questions:

‘What doctors are consulting today?

‘Who will I be seeing?’

‘How long has he been at this practice?’

‘I just need a prescription. I’ve lost my tablets and my wallet too. Can I pay with my credit card?’

 

 

The relatively new receptionist was not with us three years ago. She calls me: ‘Are you with a patient, Howard?

‘No.’

‘May I come in and talk with you?’

‘Certainly.’

The young woman is shaking: ’I think your next patient is lying. I think he might be the man who came here a few years ago and lied to you to get tablets.’

 

 

A phone call to the Doctor Shopping Line at Medicare. I give the Medicare number of the new patient. ‘We suspect he’s a doctor shopper’, I say. I give the new patient’s stated name. The Medicare person confirms the validity of the card and the truth of the name given. ‘We have records of that patient’s recent prescriptions. He’s had eighteen prescriptions since March first, every one of them for twenty Temazepam tablets, each prescription from a different doctor in your area. You might like to inform the patient of these facts, Doctor.’

 

 

Health is not a Human Right

I am about to make some shocking suggestions: 

Health is not a human right.

The Morrison-Turnbull budget cuts to Medicare Rebates are not completely bad.
Running in the dark this morning, I noticed the illuminated sign outside the local hospital. It read:

PRIVATE HOSPITAL.

 

I felt unhappy reading that. A hospital is a place where human beings help other human beings with their health. The meaning of a hospital cannot be realised with that label. ‘Private’ tells the reader that some humans will be admitted and others turned away. Privacy as a personal property might well have been eclipsed by the internet, but ‘private’ survives with this message, unkind to some, saying ‘keep out.’

 

If health were a right we’d need to outlaw Down’s Syndrome, premature death and disability. We would legislate and make ourselves ridiculous. The error of language here betrays an error of thinking. We cannot assert a right to health, but we can create a right to equal access.

 

I am a private doctor. I am a public doctor. The public is composed of private persons. I treat one person at a time, privately. That is, personally, confidentially; two humans together, doing what every human does in a lifetime: ordinary transactions of care.

 

Doctors generally share a number of characteristics. We are serious, careful, committed and proud. We are defensive of our liberties, self-righteous and voracious of cures. We are expensive; I mean someone, somewhere, always pays for cures. In its new budget the government has pegged Medicare rebates. This skewers doctors and patients: either the doctor loses or the patient loses. There is nothing new in this.

 

When Hayden-Whitlam introduced Medicare I bulk-billed everybody. I thought it was a wonderful thing that a person, be she rich or poor, might consult a doctor equally. I thought so then and I think so still. To assure doctors they would not lose, the Hayden-Whitlam Government set up a referee who increased the rebate in pace with the rising costs of practice. This was costly. So the government told the referee to stop indexing rebates. And I stopped bulk billing. Often patients found themselves facing a choice – see the costly doctor or feed the family. When this occurred all doctors I know abated their fees so the patient might afford both cure and food.

 

What a government does in tightening benefits is to create the need for a new force to operate in care. The force is not one of rights but of grace. The doctor and the patient gaze upon each other as we did through all history, unmediated by refunds and rebates, freer now of the obscuring presence of the insurer. Two humans in a situation of human need.

 

The words ‘Private Hospital’ jolt me. They remind me that health is not merely a matter of economics or of civil rights, but of civil opportunity.