I’ve been hard on American medicine. Americans are overtested, overdiagnosed and overtreated, I’ve argued, because physicians and hospitals in our capitalist culture care more about profits than patients. In 2019, I touted Medical Nihilism by philosopher Jacob Stegenga. Most medical interventions work poorly, if at all, Stegenga contends, and many do more harm than good; we should therefore resort to tests and treatments far more sparingly. Stegenga’s diagnosis and prescription seemed sensible to me.
But two episodes, one big and one small, have forced me to reconsider my medicine-bashing. First, the pharmaceutical industry, which I have accused of greed and dishonesty, created safe, effective vaccines for COVID-19 with unprecedented speed. I felt overwhelming gratitude when I got my second Moderna shot in March. Then, on Memorial Day, I got emergency surgery on my stupid right elbow. Here’s the story of that latter episode.
Every winter for the past 25 years, I’ve played hockey on frozen ponds in and around Cold Spring, New York. (That’s why I called my old blog “Cross-Check.”) Checking isn’t allowed, but sometimes we run into each other by mistake. Also, cracks and air pockets in the wild ice trip us up. I wear a helmet, padded gloves and shin-and-knee pads, but I don’t wear elbow pads, despite repeated admonitions from teammates. I hardly ever fall down, I assure my buddies, and elbow pads chafe me.
Last January, I fell and banged my right elbow so hard that it bled through my jersey. In late February, playing on treacherous ice, still without elbow pads, I fell and banged the same elbow. A week or two later the elbow swelled up and reddened. In mid-March, my primary doctor in Hoboken, N.J., where I live and work, said I probably had bursitis, inflammation of the bursa, a fluid-filled sack that lubricates joints.
My doctor referred me to an orthopedic surgeon in Hoboken, whom I’ll call Orthopedist No. 1. I saw him on March 24. After taking x-rays, which revealed no fracture, he confirmed that I had bursitis. He drained my elbow, gave me a cortisone shot and advised me to ice the elbow after exercise and to compress it with an elastic bandage. My elbow felt and looked better for a couple of weeks, then it swelled again. To my alarm, my right armpit also puffed up.
On April 21, I returned to Orthopedist No. 1, and he assured me that my elbow bursitis was unconnected to the swelling in my right armpit, where I have a lymph gland. If the armpit puffiness persisted, he said, I should have my primary physician check it out; as for my inflamed elbow, the bursitis would probably go away on its own with further icing and compression, although it might take a while.
My girlfriend, a Manhattan snob, bugged me to get a second opinion from a doctor in New York. On May 10, I saw Orthopedist No. 2, whom her doctor had recommended. Unlike Orthopedist No. 1, Orthopedist No. 2 thought the swelling of my armpit was caused by an infection in my elbow. She recommended a bursectomy, surgical removal of the elbow bursa.
Surgery!!?? This was just a little bump! No bigger than a golf ball! I’d never had surgery before, and I didn’t want to start now. Friends who’ve had surgery for sports injuries have never been the same afterward, or so it seemed. I also distrusted Orthopedist No. 2. Surgeons always want to cut us, right? Moreover, she did not accept insurance; I’d have to pay her in full up front for her services.
The morning after I saw No. 2, I took off the bandage she had wrapped around my arm, and a cloudy fluid oozed out of a hole on the tip of my elbow, where No. 2 had poked it. This discharge, a mixture of pus, bursa fluid and blood, was alarming, and disgusting. But I used my left hand to squeeze more fluid from my right elbow, as if it were a giant pimple, and the swelling and soreness subsided. My elbow felt better.
Nevertheless, at my girlfriend’s insistence, over the next week I saw three more Manhattan specialists: Orthopedist No. 3 (recommended by a friend of my girlfriend); Wound Specialist (to whom No. 3 referred me); and Orthopedist No. 4 (to whom Wound Specialist referred me). None liked the look of my elbow, which now had a hole in it; all recommended surgery. But they said I could treat the bursitis with antibiotics and get surgery later if my elbow got worse. Orthopedist No. 3 put me on sulfamethoxazole/trimethoprim and cephalexin, which seemed to work, or so I convinced myself.
On May 29, after two days of feeling feverish, nauseous and achy, and at the urging of my primary physician, I checked into the emergency room of the Hoboken University Medical Center. Blood tests revealed a low white-blood cell count and elevated liver enzymes; these results, plus my fever and chills, were consistent with sepsis, according to the emergency-room doctor. She immediately put me on intravenous antibiotics and checked me into a room.
I ended up spending four days in the hospital getting intravenous antibiotics and countless tests. I saw six different doctors in all. My temperature never rose above 101, and tests never revealed bacteria in my blood. But Orthopedic Surgeon No. 5, who took charge of my case, said I definitely had sepsis and needed surgery. On Memorial Day, while I was under general anesthesia, he operated on my elbow. He removed the bursa and surrounding tissue and shaved a bone spur off the tip of my elbow.
I left the hospital on June 1 with a five-inch incision that wrapped around my elbow and was held together by about 40 metal staples. The doctors debated whether I should stay on intravenous antibiotics after my discharge; that would require me having a port stuck in my arm. Eventually, to my relief, I was put on a powerful oral antibiotic, linezolid, for 12 days. That medication cost me $840, because the prescribing doctor didn’t alert my insurance company in advance, but I’m hoping I can get reimbursed.
On June 12, Orthopedist No. 5 removed the staples from my arm, and soon I was proudly showing friends and family my surgical scar. So, what did I learn from this episode? It reminded me that medicine is hard. My problem was simple, “boring,” as Orthopedists Nos. 4 and 5 put it, compared to the complex bone fractures and tendon tears that they often handle. And yet my elbow still presented uncertainties that led different experts to reach different conclusions.
In retrospect, perhaps, Orthopedist No. 1 should have realized that my elbow, given the swelling in my right armpit, had become infected, or so No. 2 said. Orthopedist No. 2 should not have poked my elbow so hard that the skin broke, or so No. 3 said. Orthopedists Nos. 1–4 should have ordered blood tests to check for infection and Nos. 2–4 should have pressed me harder to get surgery, according to Orthopedist No. 5, who operated on me.
But No. 5 also blamed me for dithering for so long. I have asserted that Americans are overtested, overdiagnosed and overtreated. If anything, I was undertested, underdiagnosed, undertreated, but that was largely my fault. I told all the physicians I saw in Manhattan that I wanted to avoid surgery, and so they didn’t push for it. They said staying on antibiotics was an option, at least temporarily.
Another point: I have accused physicians of being profit-driven. If Orthopedist No. 1 had been greedy, he would have pushed for surgery, but he didn’t. Wound Specialist, who spent a half hour meticulously cleaning my wound and packing it with antiseptic gauze, never even billed me or my insurance company.
None of the physicians I saw before my hospitalization was incompetent. Nor was anyone at Hoboken University Medical Center, where I ended up getting surgery. The hospital, which has recently undergone changes in ownership, has pretty bad online reviews. They remind me of a recent article in the New Yorker, “The Death of Hahnemann Hospital,” about how health care corporations are so intent on squeezing more profit out of hospitals that they are hurting patients.
But the care I got at the hospital was superb. Was it because I am a fully insured white man? Or because—hoping, I admit, for special treatment—I told some of my caregivers that I am a professor at a local university and a journalist? Maybe. These factors surely didn’t hurt. At any rate, the physicians and nurses at the hospital were all competent and kind.
My ordeal has forced me to acknowledge the downside of my distrust of experts. At one point, after the gauze that Wound Specialist had pushed into my elbow wound came out in the shower, I actually considered repacking the wound myself. I was inspired by a book I had just read, The Innovation Delusion, which celebrates people who repair their own cars and computers instead of relying on experts. I came to my senses after watching a horrifying YouTube video of a guy packing a wound in his belly caused by a spider bite.
So, when should we doubt experts? When should we trust them? There is no surefire formula, no algorithm, that can resolve this question for us. We must agonize over cases one by one, never forgetting our own fallibility. I stand by my critiques of psychiatry, cancer medicine and health care in general. The U.S. spends far more on health care per capita than any other country while ranking below many countries in longevity and other health measures. American health care needs fixing.
But I have more respect for medical experts now than I did before the pandemic and my elbow problems. The next time three specialists in a row tell me I need surgery, I’ll get surgery. I also have more respect for the wisdom of my hockey buddies. When I hit the ice next winter, I’ll be wearing elbow pads.
This is an opinion and analysis article; the views expressed by the author or authors are not necessarily those of Scientific American.
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