Wednesday, December 30, 2009

Materia Medica

The week between Christmas and New Year’s Day has proved to be very busy without any of the accomplishment that should be the reward of being busy. From the point of view of developing good “blog experience” it has been a disaster. Perhaps this is the week to deal with the inevitable topic of French medicine.

Following the American news from Paris is no easy task. The filter of the French newspapers casts most things transatlantic in a rather sallow light, and the (mainly American) Internet “news” sites threaten to give triviality a bad name. Yahoo “news” is generally unable to decide whether the more important story should be impending bankruptcy of the nation or the traffic violations of some starlet I have never heard of. Nonetheless I followed the meandering course of the “health care” bill with some attention and probably as much comprehension as anybody else—and in particular the senators—who has little actual idea as to what is in the bill. Its passage is neither the end of the republic as we have known it nor a glorious moment in humanity’s slow ascent from the quagmire of necessity to the fruited plain of grace—the two options apparently offered by senators McConnell and Reid respectively—but we all can surely agree that the process by which it has been achieved is a vivid emblem of our sad and seriously dangerous state of governmental dysfunction.

Inevitably the American “health care debate” has been the occasion of a good deal of journalistic comparison of the medical “models” (the preferred French term) of the United States and France. A similar comparative interest has several times been expressed privately, by French friends or acquaintances. Michael Moore’s Sicko, which offered a view of French medicine nearly as complimentary as its account of the American scene was critical, has not surprisingly enjoyed a certain smug approbation in this country. I have a generally dim view of Mr. Moore, not to mention of French smugness; but the messengers of unwelcome truth are not infrequently obnoxious.

The HEGP, or Hôpital Européen Geogres Pompidou. The most important word is the E-word, which differentiates this institution from...

The political ordeal we are experiencing in America at the moment really doesn’t have much to do with “medical care” per se. It is a question, rather, of the economics of medical care. It does seem likely that the new bill will significantly increase the number of Americans who have some level of medical insurance. That is, the bill will indeed have an effect on the financing of medical care. Its effect on actual medical care itself is a subject of speculation, but there is good reason to worry. Since I am not an expert in the economics of medicine I can but offer comparative comment, anecdotally of course, on medical care itself.

My extensive experience with American medicine has been, in a single word, good. During my entire working life I had access to “employer-provided” medical insurance that was adequate for me and my family, and I was living in places served by numerous general practitioners and specialists. My experience with Medicare I would have to describe as excellent, especially since it has been supplemented by a reasonably priced private policy that has left me with a maximal worst case liability of ten percent. As for my actual family doctor—Dr. Y. H. of the Princeton Medical Group—she is superb. She is superb once you get to her, that is, but getting to her involves infiltrating a wall of “helpers” about as porous as the front line of the Notre Dame football team.

...the HAP, or Hôpital Americain de Paris. Five medicos in search of a patient...

Two years ago, while in Paris, I developed what I experienced as a generalized malaise accompanied by shortness of breath. After a while it dawned on me that it was connected with the sensation of an irregular heartbeat. It was in fact the onset of atrial fibrillation, although I did not know that at the time. My daughter, quite concerned, turned to the Internet to find a cardiologist in our arrondissement—which happens to house the Hôpital Georges Pompidou. (In France, many of the academic specialists split their hours of consultation between private and hospital offices.) This man (Dr. E.) was able to meet me at the hospital on the following day, but that was not the first unusual aspect of the experience. When my daughter phoned him, he himself answered the phone. The only thing disturbing in an otherwise wholly positive experience was that he insisted on speaking English. He had spent some months at the Mass General in Boston, and his English was pretty good—just not quite good enough to keep him from petrifying me. “I zink I know what is wrong with you,” he said, after a brief tour of the stethescope. “Your hert, your hert iz not working any more.” He then pumped a horse-syringe full of some liquid blood-thinner into me, to hold me until I could get to a pharmacy for my own supply—all of which was a temporary precaution until the orally administered Coumadine could begin to take effect in a few days. To be absolutely sure that his diagnosis was sound he sent me immediately (meaning within a few hours) to another hospital where a friend of his (Dr. B.), another alumnus of Mass General and this time the owner of a fine Boston accent, recorded an echo cardiogram. Dr. E. then saw me for two more extensive follow-up visits in which he outlined for me the practical meaning of atrial fibrillation, which would require either the permanent re-establishment of a normal rhythm (not easily done) or a continuing pharmacological course of small doses of rat poison. For four extended consultations, including several electro-cardiograms and an echo cardiagam, the fee was three hundred euros, which I paid in cash, without any formal billing procedure, though I was supplied with the receipts that probably would have worked for at least partial Medicare reimbursement, had I thought it worth the while to face the American bureaucratic hassle of seeking it.

I’ve had two other occasions to visit the office of a general practitioner. Each resolved the problem that had led me to seek a doctor’s help and prescribed effective medicine. Each charged me seventy euros for the visit, again paid in cash, and without the hassle of elaborate forms, bills with malfunctioning return envelopes, and the other stuff I have become inured to at home. I had to see one other specialist, a urologist—my ailments all being, alas, age and gender specific. This man is another academic expert, and he was a bit more expensive—120 euros. This man did have a receptionist, but she played no part beyond the decorative in my medical transaction. An amusing feature of our encounter was that I concluded he must have seen me before. By curious chance his son took a Ph.D. at Princeton a few years ago, and the father attended the Commencement ceremony, at which I must have been the chief marshal! He told me how impressed he was that all the seniors were able to understand the Latin of the salutatory address! So, you can fool some of the people some of the time.

Prescription drugs are delivered free of a purchase charge to French residents who possess the indispensable carte vitale—a sort of combination social security and medical insurance document that is the “Open, Sesame” of the socialized French “model”. I have no such card, of course, nor do I merit it by paying the taxes that actually pay for the medicine. But since the over-the-counter cost of drugs here is seldom so much as a quarter of the American price, this hasn’t been an issue either.

My experience allows two other observations. The first is that French pharmacists are trained to a high level. Many ordinary Frenchmen turn with confidence to the pharmacist for colds and sniffles and routine aches and pains. I suspect that some of the people in the always crowded waiting room at the Princeton Medical Center could usefully do the same thing. The second is the private testing laboratories, which are numerous throughout Paris, offer a cheaper and certainly greatly more convenient way of accomplishing routine blood tests and urine scans than is generally available in America. At least in my experience the contrast with a couple of Quest labs I visited in America, where the sullen staff seemed only marginally competent, could hardly be more dramatic.

And on that note, a happy New Year to all!