A tale of two wounds
By Daniel M. Ryan
I have two old wounds in my body. Both of them have required medical attention, and both have permanent aftereffects, as a reminder to me. One of them is in my left forearm, as a result of an accident involving a stepladder, and one of them is in my tooth, the first upper-right molar. They differ in terms of the level of treatment I had gotten for each.
My forearm was broken in two places: a "spiral" fracture right near the elbow, and a fracture in the wrist. The treatment I had gotten for it was an operation, with full general anesthetic. My tooth had a hole right through the top enamel, to the point where I could shove a toothpick (to poke an abscess) or a glop of toothpaste into the interior of it. The treatment I got for its rot was a regular filling. The permanent aftereffect in my left arm is a displacement of the "funny bone" nerve, somewhat restricted movement of the wrist and rotation of the forearm itself, a screwed-in plate which sometimes creaks when I exercise the limb, and, until I had it removed, further restriction of my wrist movement because of a screw in the wrist. The permanent aftereffect in my rotted tooth is a general thinning of the enamel, which is part of the original wound, and a chip out of the front of it, where the enamel has worn the thinnest. For both wounds, I have enough post-treatment symptoms to remind me not to be so reckless with my body.
The specifics of the wounds certainly make for a difference. So does the expensiveness of treatment for each.
The operation on the arm cost north of $40,000 – I saw the bill for it. The associated physiotherapy, which was also of high quality, cost the government substantially more. The entire tab, except for phone privileges while at the hospital (24 bucks), was picked up by OHIP, Ontario's government-run heath-care system.
The filling cost somewhere around $150.
It's true that the difference in cost of treatment is a consequence of the difference in the wounds. An arm broken, in the way I managed to mangle mine, is a more serious wound than a rotted tooth, by any sensible metric except (perhaps) for pain. As a result of getting the "best of treatment" for my arm, and the "worst of treatment" (barring a tooth pull, and omitting the fact that the filling has held quite nicely) for my tooth, I find myself on a bridge between the old-style health-care system and the present one. I could have had the full root canal, or crown, treatment had I afforded or rated it, which would have prevented the front chip on that back tooth forming – maybe. I could certainly spend some time dreaming of such an outcome, even if the dream would not have quite matched the reality had I coughed up for the full deal.
Unfortunately, my dreaming is limited by the aftereffects of my broken arm. There is no way that I could prove that the treatment I had for that broken arm of mine was anything less than the best. Any complaint I could muster to that end could easily be waved away by noting that I wasn't the only patient in the ward, and that a physician is incapable of performing miracles. And yet, as noted above, I have permanent aftereffects. The creaking is the result of the strengthening plate put in by the operating physicians; it was put there to make sure my spiral fracture knitted back properly. The movement of the funny-bone nerve was, most probably, a consequence of putting the bones back together. I have some scar tissue from a cut right through my left triceps, which obviously resulted from the surgeon in charge cutting into my arm to put in the plate and straighten the arm out. The (minor) restrictions in movement, and stiffness in my wrist, are obviously the effect of me breaking the thing in the first place.
Since these aftereffects in my left arm are obviously results from receiving the best of care, I have little reason to complain about them.
They, along with the aftereffects in that tooth of mine, have gotten me wondering, though. Had I only been entitled to a basic treatment – a cast, followed with a do-it-yourself handout in place of professional physiotherapy unless I could put up the coin for either or both – would the aftereffects from my arm being treated in that way, been more limiting to me now?
My arm would have been immobilized in a cast for the same amount of time. According to a doctor that I buttonholed while in the hospital, though, had I gone for the simple cast treatment, my arm would have healed in a somewhat crooked manner, which would have meant that my range and functionality would have been restricted relative to what I face now. The same conclusion results from omitting the professional physiotherapy; what are now minor restrictions would undoubtedly have been major ones. I may have run the risk of weakening my arm, if not re-breaking it, had I enthusiastically undertook amateur's self-physiotherapy. I definitely have received a benefit as a result of the expensive option, relative to what I would have ended up with had I gone for the cheap option. (Believe it or not, I could have, even though it would have meant going against medical advice.)
The aftereffect on my left triceps, and the one resulting from the implanted plate, though, both imply that there is a tradeoff with respect to this wound. How much restriction of functionality would I put up with in exchange for: my triceps being left to heal naturally; and, no plate around my left elbow?
It's an interesting question, and it's one I have no answer for, since I don't know how stiffened up my arm would have been had I bolted out of the hospital early. (I could have; the cast was put on when I had gotten to the emergency room.) The fact that someone in my shoes would face this trade-off, however, does mean that I have scope to…complain.
In fact, I do have scope to complain, had I been the complaining sort, about my tooth. Had I gotten the more expensive dental option, though, I could have complained anyway. There's no guarantee that any kind of treatment, apart from pulling the thing out, would have prevented further visible (or feelable) rot, and if I had had it pulled out, I could certainly complain about its loss. No matter what treatment I had gotten, I could still complain, with memory of my life, pre-wound(s), as the psychological backing for it.
What would differ, though, would be the credibility of such complaints. Had I complained about the stiffness in my left arm after receiving the simple cast-and-homekit treatment, I would gain a sizable audience, because I could point to "cheapskate government" as the cause. If I complain about the residual stiffness, muscle damage and creakiness of my arm as it is now, though, my complaints would be far less credible, because they are clearly the aftereffects of a more comprehensive treatment. Unless…
…I blame the doctor!
Such is the effect of a "complaint-driven" system. If I have something to complain about, I might as well complain away, because a "complaint-driven" system gives me a free ticket that might score me a jackpot, as well as folk-hero notoriety. As a result, complaints, no matter how frivolous, always appear when trade-offs do, because there's no cost attached to rolling the dice in that way. It's better than the lottery, because the lottery makes you pony up the cash beforehand!
Such is the result – one that the taxpayers, and worried greybeards, are beginning to see in the exponential growth of health-care system costs – of a "complaint-driven system" whose drivers are yes-men.