we want this? why?
http://www.opinionjournal.com/extra/?id=110006785There's No Place Like Home
What I learned from my wife's month in the British medical system.
by DAVID ASMAN
Wednesday, June 8, 2005 12:00 A.M. EDT
"Mr. Asman, could you come down to the gym? Your wife appears to be having a small problem." In typical British understatement, this was the first word I received of my wife's stroke.
We had arrived in London the night before for a two-week vacation. We spent the day sightseeing and were planning to go to the theater. I decided to take a nap, but my wife wanted to get in a workout in the hotel's gym before theater. Little did either of us know that a tiny blood clot had developed in her leg on the flight to London and was quietly working its way up to her heart. Her workout on the Stairmaster pumped the clot right through a too-porous wall in the heart on a direct path to the right side of her brain.
Hurrying down to the gym, I suspected that whatever the "small" problem was, we might still have time to make the play. Instead, our lives were about to change fundamentally, and we were both about to experience firsthand the inner workings of British health care.
We spent almost a full month in a British public hospital. We also arranged for a complex medical procedure to be done in one of the few remaining private hospitals in Britain. My wife then spent about three weeks recuperating in a New York City hospital as an inpatient and has since used another city hospital for physical therapy as an outpatient. We thus have had a chance to sample the health diet available under two very different systems of health care. Neither system is without its faults and advantages. To paraphrase Thomas Sowell, there are no solutions to modern health care problems, only trade-offs. What follows is a sampling of those tradeoffs as we viewed them firsthand.
As I saw my wife collapsed on the hotel's gym floor, my concern about making the curtain was replaced by a bone-chilling recognition that she was in mortal danger. Despite her protestations that everything was fine, her left side was paralyzed and her eyes were rolling around unfocused. She was making sense, but her words were slurred. Right away I suspected a stroke, even though she is a young, healthy nonsmoker. Over her continuing protests, I knew we had to get her to a hospital right away.
The emergency workers who came within five minutes were wonderful. The two young East Enders looked and sounded for all the world like a couple of skinhead soccer fans, cockney accents and all. But their professionalism in immediately stabilizing my wife and taking her vitals was matched with exceptional kindness. I was moved to tears to see how comforting they were both to my wife and to me. As I was to discover time and again in the British health system, despite the often deplorable conditions of a bankrupt infrastructure, British caregivers--whether nurses, doctors, or ambulance drivers--are extraordinarily kind and hardworking. Since there's no real money to be made in the system, those who get into public medicine do so as a pure vocation. And they show it. In the case of these EMTs, I kick myself for not having noticed their names to later thank them, for almost as soon as they dropped us off at the emergency room of the University College of London Hospital, they disappeared.
Suddenly we were in the hands of British Health Service, and after a battery of tests we were being pressured into officially admitting my wife to UCL. As we discovered later, emergency care is free for everyone in Britain; it's only when one is officially admitted to a hospital that a foreigner begins to pay. I didn't know that. But I did know that I was not about to admit my wife to a hospital that could not diagnose an obviously life-threatening affliction. And even after having given her an MRI, the doctors could not tell if she had a stroke.
Now, the smartest thing I did before we left the hotel was to delay the ambulance driver long enough to run back to my room and grab my wife's cell phone. With that phone I began making about a thousand dollars worth of trans-Atlantic calls, the first of which was to the world-renowned cardiologist Dr. Isadore Rosenfeld, who I'm lucky enough to have as my GP. As it turned out, not only did Izzy diagnose the problem correctly, he even suggested a cause for the stroke, which later turned out to be correct. "There's no reason for her to have a stroke except if it's a PFO." I didn't know what Izzy meant, but I wrote down the initials and later found out that a PFO (a patent foramen ovale) is a flap-like opening in the heart through which we get our oxygen in utero. For most of us, the opening closes shortly after birth. But in as many as 30% of us, the flap doesn't seal tight, and that can allow a blood clot to travel through the heart up to the brain. Izzy agreed that I should not admit my wife to UCL but hold out for a hospital that specialized in neurology.
As it happened, the best such hospital in England, Queen's Square Hospital for Neurology, was a short distance away, but it had no beds available. That's when I started dialing furiously again, tracking down contacts and calling in chits with any influential contact around the world for whom I'd ever done a favor. I also got my employer, News Corp., involved, and a team of extremely helpful folks I'd never met worked overtime helping me out.
Suddenly, a bed was found in Queen's Square, and by 2 a.m. my wife was officially admitted to a British public hospital. The neurologist on call that night looked at the same MRI where the emergency doctors had seen nothing and immediately saw that my wife had suffered a severe stroke. It was awful news, but I realized we were finally in the right place.
That first night (or what was left of it) my wife was sent off to intensive care, and the nurses convinced me that I should get a few hours sleep. We found a supply closet, in which there was a small examination table, and the nurses helped me fashion fake pillows and blankets from old supplies. The loving attention of these nurses was touching. But the conditions of the hospital were rather shockingly apparent even then.
The acute brain injury ward to which my wife was assigned the next day consisted of four sections, each having six beds. Whether it was dumb luck or some unseen connection, we ended up with a bed next to a window, through which we could catch a glimpse of the sky. Better yet, the window actually opened, which was also a blessing since the smells wafting through the ward were often overwhelming.
When I covered Latin America for The Wall Street Journal, I'd visit hospitals, prisons and schools as barometers of public services in the country. Based on my Latin American scale, Queen's Square would rate somewhere in the middle. It certainly wasn't as bad as public hospitals in El Salvador, where patients often share beds. But it wasn't as nice as some of the hospitals I've seen in Buenos Aires or southern Brazil. And compared with virtually any hospital ward in the U.S., Queen's Square would fall short by a mile.
The equipment wasn't ancient, but it was often quite old. On occasion my wife and I would giggle at heart and blood-pressure monitors that were literally taped together and would come apart as they were being moved into place. The nurses and hospital technicians had become expert at jerry-rigging temporary fixes for a lot of the damaged equipment. I pitched in as best as I could with simple things, like fixing the wiring for the one TV in the ward. And I'd make frequent trips to the local pharmacies to buy extra tissues and cleaning wipes, which were always in short supply.
In fact, cleaning was my main occupation for the month we were at Queen's Square. Infections in hospitals are, of course, a problem everywhere. But in Britain, hospital-borne infections are getting out of control. At least 100,000 British patients a year are hit by hospital-acquired infections, including the penicillin-resistant "superbug" MRSA. A new study carried out by the British Health Protection Agency says that MRSA plays a part in the deaths of up to 32,000 patients every year. But even at lower numbers, Britain has the worst MRSA infection rates in Europe. It's not hard to see why.
As far as we could tell in our month at Queen's Square, the only method of keeping the floors clean was an industrious worker from the Philippines named Marcello, equipped with a mop and pail. Marcello did the best that he could. But there's only so much a single worker can do with a mop and pail against a ward full of germ-laden filth. Only a constant cleaning by me kept our little corner of the ward relatively germ-free. When my wife and I walked into Cornell University Hospital in New York after a month in England, the first thing we noticed was the floors. They were not only clean. They were shining! We were giddy with the prospect of not constantly engaging in germ warfare.
As for the caliber of medicine practiced at Queen's Square, we were quite impressed at the collegiality of the doctors and the tendency to make medical judgments based on group consultations. There is much better teamwork among doctors, nurses and physical therapists in Britain. In fact, once a week at Queen's Square, all the hospital's health workers--from high to low--would assemble for an open forum on each patient in the ward. That way each level knows what the other level is up to, something glaringly absent from U.S. hospital management. Also, British nurses have far more direct managerial control over how the hospital wards are run. This may somewhat compensate for their meager wages--which averaged about £20,000 ($36,000) a year (in a city where almost everything costs twice as much as it does in Manhattan!).
There is also much less of a tendency in British medicine to make decisions on the basis of whether one will be sued for that decision. This can lead to a much healthier period of recuperation. For example, as soon as my wife was ambulatory, I was determined to get her out of the hospital as much as possible. Since a stroke is all about the brain, I wanted to clear her head of as much sickness as I could. We'd take off in a wheelchair for two-hour lunches in the lovely little park outside, and three-hour dinners at a nice Japanese restaurant located at a hotel down the street. I swear those long, leisurely dinners, after which we'd sit in the lobby where I'd smoke a cigar and we'd talk for another hour or so, actually helped in my wife's recovery. It made both of us feel, well, normal. It also helped restore a bit of fun in our relationship, which too often slips away when you just see your loved one in a hospital setting.
Now try leaving a hospital as an inpatient in the U.S. In fact, we did try and were frustrated at every step. You'd have better luck breaking out of prison. Forms, permission slips and guards at the gate all conspire to keep you in bounds. It was clear that what prevented us from getting out was the pressing fear on everyone's part of getting sued. Anything happens on the outside and folks naturally sue the hospital for not doing their job as the patient's nanny.
Why are the Brits so less concerned about being sued? I can only guess that Britain's practice of forcing losers in civil cases to pay for court costs has lessened the number of lawsuits, and thus the paranoia about lawsuits from which American medical services suffer.
British doctors, nurses and physical therapists also seem to put much more stock in the spiritual side of healing. Not to say that they bring religion into the ward. (In fact, they passed right over my wife's insistence that prayer played a part in what they had to admit was a miraculously quick return of movement to her left side.) Put simply, they invest a lot of effort at keeping one's spirits up. Sometimes it's a bit over the top, such as when the physical or occupational therapists compliment any tiny achievement with a "Brilliant!" or "Fantastic!" But better that than taking a chance of planting a negative suggestion that can grow quickly and dampen spirits for a long time.
Since we returned, we've actually had two American physical therapists who did just that--one who told my wife that she'd never use her hand again and another who said she'd never bend her ankle again. Both of these therapists were wrong, but they succeeded in depressing my wife's spirits and delaying her recovery for a considerable period. For the life of me, I can't understand how they could have been so insensitive, unless this again was an attempt to forestall a lawsuit: I never claimed you would walk again.
Having praised the caregivers, I'm forced to return to the inefficiencies of a health system devoid of incentives. One can tell that the edge has disappeared in treatment in Britain. For example, when we returned to the U.S. we discovered that treatment exists for thwarting the effects of blood clots in the brain if administered shortly after a stroke. Such treatment was never mentioned, even after we were admitted to the neurology hospital. Indeed, the only medication my wife was given for a severe stroke was a daily dose of aspirin. Now, treating stroke victims is tricky business. My wife had a low hemoglobin count, so with all the medications in the world, she still might have been better off with just aspirin. But consultations with doctors never brought up the possibilities of alternative drug therapies. (Of course, U.S. doctors tend to be pill pushers, but that's a different discussion.)
Then there was the condition of Queen's Square compared with the physical plant of the New York hospitals. As I mentioned, the cleanliness of U.S. hospitals is immediately apparent to all the senses. But Cornell and New York University hospitals (both of which my wife has been using since we returned) have ready access to technical equipment that is either hard to find or nonexistent in Britain. This includes both diagnostic equipment and state-of-the-art equipment used for physical therapy.
We did have one brief encounter with a more comprehensive type of British medical treatment--a day trip to one of the few remaining private hospitals in London.
Before she could travel back home, my wife needed to have the weak wall in her heart fortified with a metal clamp. The procedure is minimally invasive (a catheter is passed up to the heart from a small incision made in the groin), but it requires enormous skill. The cardiologist responsible for the procedure, Seamus Cullen, worked in both the public system and as a private clinician. He informed us that the waiting line to perform the procedure in a public hospital would take days if not weeks, but we could have the procedure done in a private hospital almost immediately. Since we'd already been separated from our 12-year-old daughter for almost a month, we opted to have the procedure done (with enormous assistance from my employer) at a private hospital.
Checking into the private hospital was like going from a rickety Third World hovel into a five-star hotel. There was clean carpeting, more than enough help, a private room (and a private bath!) in which to recover from the procedure, even a choice of wines offered with a wide variety of entrees. As we were feasting on our fancy new digs, Dr. Cullen came by, took my wife's hand, and quietly told us in detail about the procedure. He actually paused to ask us whether we understood him completely and had any questions. Only one, we both thought to ask: Is this a dream?
It wasn't long before the dream was over and we were back at Queen's Square. But on our return, one of the ever-accommodating nurses had found us a single room in the back of the ward where they usually throw rowdy patients. For the last five days, my wife and I prayed for well-behaved patients, and we managed to last out our days at Queen's Square basking in a private room.
But what of the bottom line? When I received the bill for my wife's one-month stay at Queen's Square, I thought there was a mistake. The bill included all doctors' costs, two MRI scans, more than a dozen physical therapy sessions, numerous blood and pathology tests, and of course room and board in the hospital for a month. And perhaps most important, it included the loving care of the finest nurses we'd encountered anywhere. The total cost: $25,752. That ain't chump change. But to put this in context, the cost of just 10 physical therapy sessions at New York's Cornell University Hospital came to $27,000--greater than the entire bill from British Health Service!
There is something seriously out of whack about 10 therapy sessions that cost more than a month's worth of hospital bills in England. Still, while costs in U.S. hospitals might well have become exorbitant because of too few incentives to keep costs down, the British system has simply lost sight of costs and incentives altogether. (The exception would appear to be the few remaining private clinics in Britain. The heart procedure done in the private clinic in London cost about $20,000.)
"Free health care" is a mantra that one hears all the time from advocates of the British system. But British health care is not "free." I mentioned the cost of living in London, which is twice as high for almost any good or service as prices in Manhattan. Folks like to blame an overvalued pound (or undervalued dollar). But that only explains about 30% of the extra cost. A far larger part of those extra costs come in the hidden value-added taxes--which can add up to 40% when you combine costs to consumers and producers. And with salaries tending to be about 20% lower in England than they are here, the purchasing power of Brits must be close to what we would define as the poverty level. The enormous costs of socialized medicine explain at least some of this disparity in the standard of living.
As for the quality of British health care, advocates of socialized medicine point out that while the British system may not be as rich as U.S. heath care, no patient is turned away. To which I would respond that my wife's one roommate at Cornell University Hospital in New York was an uninsured homeless woman, who shared the same spectacular view of the East River and was receiving about the same quality of health care as my wife. Uninsured Americans are not left on the street to die.
Something is clearly wrong with medical pricing over here. Ten therapy sessions aren't worth $27,000, no matter how shiny the floors are. On the other hand my wife was wheeled into Cornell and managed to partially walk out after a relatively pleasant stay in a relatively clean environment. Can one really put a price on that?
Mr. Asman is an anchor at the Fox News Channel and host of "Forbes on Fox." This article appears in the May issue of The American Spectator.
