The American Medical System from an Englishwoman's perspective

I have always had an aversion to doctors. It's nothing personal. It's just that, given the option, I'd prefer not to have to see them. I avoided hospitals throughout my childhood and through much of my early adulthood. Maya was born at home. And then, a week before Iola was born, my luck changed. I'm still waiting for it to change back.

It began inauspiciously enough with an accident with a shopping trolley in Asda. I was heavily pregnant and not looking where I was going. The trolley ricocheted against a tower of baked beans, sending Heinz's finest scattering about the store, and I damaged my placenta. Cue: daily visits to the hospital for a week before an induced hospital birth for little Iola. I discharged myself the same day (it's hard to avoid doctors when you're on their territory) but we were back within a fortnight with the first of many hospital stays: bronchiolitis; suspected meningitis; more bronchiolitis; chest infections galore; breathing difficulties... We have arrived at Lancaster Royal Infirmary on foot, by car, by taxi, and by blue-flashing light ambulance from the Lake District. Less dramatically, Maya has caused me to visit doctors on nearly every vacation we have ever taken - I've hung about in surgeries in Madeira, Spain, Toronto, Skegness, Scotland, and Ireland with an assortment of eczema outbreaks, asthma attacks, minor accidents, and ear infections. (We've also helicoptered across New Mexico with a crash team on stand-by and the trauma unit waiting for our arrival... but that's a whole different and much less humorous blog).

We knew that the health system in America was going to be different to that we had experienced within the UK and as tourists in different countries. (Of course, our experiences in the UK were over a year ago, and much has changed thanks to the ConDemNation... but again that is a story for someplace other than here). We had hoped, with the blind optimism of the naive, that we might be able to avoid doctors as much as possible. When we looked at health insurance, we chose a mid-range plan, convinced that we wouldn't need more than a couple of doctors' appointments a year. If you have read any of my previous blogs, you will have some idea of the irony of this assumption.

We're fifteen months into our stay in Cambridge and I am gradually becoming competent in navigating the American healthcare system. It's a little like learning to use the A-Z of a city you would never willingly choose to visit.

1. Waiting and waiting rooms.
The worst waiting room system was at our local practice in East London. One could either book an appointment to see a doctor in at least a fortnight's time, or one could arrive, take a seat, and wait. My longest wait in the clinic, accompanied by a 6 month old Maya who had an ear infection, was five and a half hours. It wasn't great. But it was free and the waiting room was always filled with people. It wasn't the best clinic in East London and, from what I have heard, the clinic has been subsequently closed. I don't know where you would have to wait if you were ill in East London now.
Our local American practice runs a different business model. Firstly, you make an appointment. The telephone system works well: someone always answers the phone immediately and you are hardly ever put on hold. You feel that you are important: the telephonist is very polite and does the best that she can do to get you an appointment in the next day or two (this isn't gender neutral: the telephonist is always female). Admittedly, the best doctors book up a year in advance. Seriously. The doctor who is listed as my doctor was listed as one of the top 500 doctors in Boston. I've never met her. When I tried to get an appointment with her it was at 10.05am on  February 5 2014. I'm ok about that: I don't like seeing doctors anyway! But my children's doctor always has space to see them within the next 48 hours.

So, once you've made your appointment, you turn up at the practice at the allocated time. The practice is larger than the average cottage hospital. I suspect that you could spend several days walking around the corridors trying to find out where you need to be. Fortunately, there is a very sweet young man at the front desk who always wears a lovely sweater and a lovely smile. He asks how you are. I've learnt from experience that he isn't really interested in how you are, he's just being polite. He is very good at being polite. He'll ask you to sign a disclaimer, agreeing to pay undisclosed amounts for your child's imminent treatment. He'll take a copy of your insurance card, swipe your credit card, and cross reference the details with those that he has on his computer. He has a lovely smile when he asks if you would like to settle the outstanding amount from your previous three visits. I've found that it's useful to smile back and explain that your partner deals with such things. I'm not sure whether the company has spent a huge amount upon professional development so that he knows never to stop smiling, or whether he was born like that.

When he is satisfied that you have signed in the right place and that you are who you say you are, he'll direct you to the relevant part of the hospital. It's worth listening closely to the directions, or you might get lost. When you arrive at your bit of the building, another receptionist will leap into action. She (and it has always been a she) will ask you how you are but, again, she doesn't really want to know. She's also being polite (perhaps she went on the same training courses as the male receptionist at the front of the building). She'll tell you to take a seat in the empty waiting room, but a nurse (male or female) will arrive before you reach your seat. This is important. The reason why the waiting room is empty is that my clinic knows that waiting rooms are not healthy places to be if they have sick people in them. No-one wants sick people hanging around: they spread diseases (even with the dispenser of free face masks by the door and the hand sanitizer bottles fastened to the wall at 10 foot intervals). The nurse's job is very important: s/he is charged with keeping you out of the waiting room. You will either be sent to a private room where the doctor will see you in the next hour (we now take a bag of books, coloring pencils and a small snack with us whenever we visit the doctors), or s/he will advise you that the doctor is running late. In that case you will be told to get a coffee at the onsite cafe. It's run as a franchise. Having people waiting in a cafe is good business sense.

2. Getting past the nurse hurdle
Before you are allowed to see the doctor - even though you are now sitting in one of the doctor's rooms - you will be tested by the nurse. The nurses are sent on different professional development courses to the receptionist staff: they don't smile as much and they never ask you how you are. As professionals, they don't need to be as polite as the front of house staff. You can expect a little whirlwind of activity as the nurse measures and weighs you, takes your temperature and your blood pressure, and then leaves. The time after his/her departure is often a good time to unpack your snack and make yourself comfortable. It tends to be quite a while before anything else will happen.

3. Seeing the doctor
Eventually, the doctor will arrive. This bit is the same as in England. Same questions, same faces, same answers.

4. Going to the pharmacy
If you have a prescription, you will need to go to the pharmacy to collect this. Make sure that you have your insurance card and your credit card. We tend to go to CVS. It's nice there. You can buy anything from a vacuum cleaner to a winter coat or a bottle of perfume. The pharmacist will smile and ask you how you are... and h/she will be interested in your answer. You can talk to him/her for ages about how you feel, what symptoms you are experiencing, what is worrying you, and your plans for the weekend. They'll seem genuinely interested: perhaps that has been part of their professional development plan. After all, they're the ones who need to make the profit by selling you the drugs.

5. Cutting out the middle man
A lot of the people that I talk to don't go to the doctors anymore. They tell me that they get their advice and treatment from the pharmacist. In terms of the children, I'll continue packing a snack and a coloring book and spending a few half days here and there in a small room at my local doctor's practice... but in terms of my own health, it seems that the American system suits me just fine. It's nothing personal - I just don't like doctors.

On December 21, I was invited to the 23^rd Annual Interfaith Homeless Memorial Service, a service which is held annually on the shortest day of the year. 

It wasn't a great day for arriving anywhere early: the tail-end of winter storms from the Midwest has saturated Boston with torrential rain and I was sodden. On the positive side, it certainly gave me a glimpse of empathy: there's nothing warm and hopeful about Christmas lights and winter decorations when your trousers are wet and your coat leaks. I was feeling rather sorry for myself by the time that an angry man in a green sweater cursed me, pushed me to one side and vigorously rattled the locked doors. He sloped away before the doors were opened, leaving me standing there, sheepish and alone on the stoop, apologizing in my awkward English accent as a man quickly hurried me into the church – afraid, no doubt, that I might otherwise break the door down – and then returned to the music rehearsal.

There were four men, each smartly dressed in black, rehearsing the songs for the service. I took a seat in one of the pews near the back, feeling conspicuous as the only person to have (accidentally) arrived. The church was filled with gray cardboard headstones. Some were propped against pews, some were taped to the walls, some leant drunkenly against the altar. Each carried a person’s name. Each was hand decorated: rainbows and flowers, love hearts and splashes of bright color.

A woman came and sat next to me. She travelled all over America giving homeless people vouchers that they could use in Dunkin Donuts. She was very polite and smiled a lot. She told me that she didn’t particularly like eating donuts herself. She had once bought a man in San Diego a chicken quesadilla, but he had refused to eat it. I asked her if she knew anything about the headstones: she told me that each one represented a homeless person who had died in the Boston area that year. She didn’t know how many there were. She came to this service each year, and once there had been 260. But, she mused, last winter hadn’t been as cold so there would probably be fewer.

I misread the name on one headstone - No Man – and I felt a rush of anger. These people weren’t invisible nobodies, anonymous no-mans. They were people’s friends, sons and daughters, brothers and sisters, lovers, partners, parents, acquaintances. When I looked more closely, I could see the ‘r’, small and crooked and partially obscured by an enormous yellow felt-tipped sun, on Norman’s gravestone. He was one of 130 people to have died in the Boston area this year. During the service, each person’s name was read out and a candle was lit in their memory. Jeff Olivet, one of the musicians, reminded the congregation that, ‘We do justice to their memory by lighting candles but, God help us, we should be doing justice to them while they’re living!’ Throughout the service, people drifted in and drifted out like the ebb and flo of a tide. But, even at its fullest, the congregation held fewer people than the list of those that we commemorated.

There was one headstone which looked like one of Iola’s drawings: it was a square house with a symmetrical window on each side of a bright red front door and an inverted triangle for the roof. It was in remembrance to someone called Daniel. The woman next to me told me that the average age of a homeless person in Boston was eight years old.

The service lasted an hour, each group of recited names interspersed by a song from our four black-suited men. Each took a turn to sing a solo: a hymn called ‘It is Well with My Soul’, written by an American from the 1800s after he lost all his money and all his children were killed in a sinking ship; Leonard Cohen’s Hallelujah, which soon became a very loud rendition as more and more people from the congregation joined in with the words that they knew; an operatic performance of ‘Empty Chairs on Empty Tables’ from the musical Les Miserables (‘There’s a grief that can’t be spoken, there’s a pain goes on and on. Empty chairs at empty tables, now my friends are dead and gone’); and a rousing rendition of Leadbelly’s ‘Bourgeois Blues’ which, Jeff Olivet warned us, contained more than a little righteous anger.

I don’t think that I knew any of the people who were being commemorated: in Cambridge, people come and go and I’m not well enough established there to be able to put names to everyone’s faces, but I was welcomed anyway. The service ended with the congregation singing ‘Peace, Salaam, Shalom’. People rose to their feet and joined hands. It was a moving tribute to the people who had died and a powerful way to come together as a community. Afterwards, we were invited upstairs for a light luncheon and the opportunity to share and celebrate the memories of those who had died. The woman with the Dunkin Donut vouchers was one of the first in the queue. I lingered in the church for a while. A group of people had gathered around the piano and were having a raucous sing-a-long, the operatic baritone leading the way in a honky-tonk version of This Little Light of Mine, while an old man in a long tweed overcoat stamped the heel of his hand against the piano top. A woman leant towards me and told me that, if her friend had still been there among us, she would have been singing too.