The past 8 days have been unexpectedly difficult ones for me. I spent the balance of them, until Tuesday morning, with a bandaged splint on my right arm, extending up to my elbow. Cutting through the mostly dry and well sanded parking lot of Northampton High School, just down Milton Street from my apartment in the Baystate neighborhood of Florence, while pondering abstractly on the nature of my rejection of the Christian doctrine of the Trinity and my opposition to the idea of Divine intervention in the material universe, the worn heel of one of my old Air Force desert flightline boots suddenly hit a lone patch of black ice, crystallized near the opening to Milton Street from the day's snow melt at the lot's edges. Before I could realize what was happening, I landed flat on my butt on the concrete. Fortunately or unfortunately, I reflexively laid out my open palms in the split second in which I fell, to break the fall and spare my spinal cord the full shock of hitting the cold hard concrete. That shock was largely absorbed by my right hand, and, as I pulled myself quickly off the surface of the parking lot, I immediately realized that this hand had sustained a relevant injury that I could feel as I attempted to bend my fingers and clinch my fist.
It turned out that I had sustained a non-displaced distal fracture of my right radius, the anatomical term for a broken wrist. It has been the most peculiar injury, even to the extent that I have had no previous experience, at age 40, with broken bones. On the night that I fell, the pain gravitated from my wrist up my arm to my elbow, a throbbing that drove me to pop down two Ibuprofen tablets and hope that I'd be able to sleep. By morning, the pain had subsided, and there was no obvious bruise and only a minimal amount of swelling with one slight but obvious and painful lump on the underside of my hand near my thumb. I held out hope at the urgent care certain where I was treated that it would only be a slight sprain. An x-ray revealed, however, that I had a clean crack right across the radial head where the radius meets the ulna and the carpals of the hand (i.e. the wrist joint). The urgent care clinic splinted my injury and referred me to an orthopedic practice for casting.
Acknowledging that the whole purpose of my splint was to immobilize the bone and the wrist joint per se to avoid further injury, my initial inclination, in view of the fact that I could still clinch my fist and hold a knife, was that I would continue to work at least until that injury was cast. In fact, I missed an hour and a half last Wednesday, not so much because of my injury as because the accumulation of ice on my street made it unsafe for me to leave my apartment as normally at 6:30 in the morning. I worked almost forty hours wearing my splint, during which time I continued to perform almost all of the duties I normally perform down at the meat store where I work, short of using a mallet with my right hand (it was an interesting experience learning how to pound chicken cutlets with my left hand). I even found myself delivering groceries to the vehicles of customers with my injured hand. This coming Tuesday, when I consult my orthopedic practitioner for my first follow-up x-ray, I will, of course, discover the extent to which my exuberant efforts to continue to lead a normal working life in the week after my fall may have intensified my injury.
The most peculiar thing about the week between my fall and getting casted was the fact that I rarely experienced any pain, however much stress I placed on my arm. The physician who had initially evaluated me at the urgent care clinic suggested that I should not use Ibuprofen to address pain from the injury but instead use Acetaminophen (i.e. Tylenol) and even offered twice to prescribe something stronger (e.g. Acetaminophen with codeine or Oxycontin). I politely declined to accept her offer on the grounds that my injury really didn't hurt very badly. My inclination, moreover, had been that, if anything I was doing might result in the intensification or dislocation of the injured bone, then it probably would have resonated as an instance of severe pain!
At this point, a few comments on the nature of the medical process, the complications arising from dependency on labor income, and the subordinate matter of civil liability for both personal injuries and medical malpractice are in order. First, I am not sure that the way that I decided to deal with my injury was perfectly ideal in terms of the use of medical resources. A little under two years ago, I suffered an abscess in my back arising from an infected sebaceous cist. At the time I was insured through the University of Massachusetts where I was a graduate student. The insurance plan operated as a health maintenance organization (HMO), where all meidcal problems were to treated under one roof or referred for subsequent treatment outside of the health clinic. After an initial consultation and prescription of antibiotics for treatment of my cist failed to yield any improvement, I showed up in the clinic with a heavily swollen patch of skin on my back. The physician who evaluated me took one look at it and concluded that he would have to operate at that moment. Following the operation, I underwent an extended series of post-operative visits to change dressings and evaluate the progress of the wound. If I remember correctly, neither the surgery nor any of these visits inflicted on me any expenses more costly than a $20 co-payment per visit. I am not sure that the practice was acting, to some degree, in an overly zealous manner by compelling me to disrupt my work routine in order to show up two to three times a week over a month after my surgery, but the most significant personal expense arising from the entire process concerned only my lack of paid sick leave and lost wages from the disruption of my schedule, motivations that eventually prompted me to cut the post-operative treatments short and "wing it" with my recovering wound. By and large, whether this represented an efficient use of medical resources, at least with respect to my own needs, I was very satisfied by the organization of my health insurance plan and its responsiveness to my need for medical care.
Presently, I have a health insurance plan sponsored and paid in full by my employer. All things considered, it is a fairly good plan at mitigating expenses from treatments, even to the extent that I encounter higher co-payments for treatment than under my former UMASS plan. To a somewhat greater degree, the organization of the plan relies on my efforts to manage my own health care needs through a single primary care physician. I had such a physician briefly at UMASS but was unable to retain him when I left the university. Now, by contrast, I have come to rely on urgent care clinics for all of my acute medical needs. Obviously, the isolated treatment by an urgent care clinic for a single broken wrist is not an overwhelming problem. On the other hand, reliance on urgent care facilities is not a good way to manage long term care on problems like hypertension (i.e. high blood pressure), which I fear that I may have to deal with in the near term! While my health insurance provider, thus, seems to be reasonably good at organizing medical resources to reduce either urgent care or emergency room visits as a recurring phenomena for individual patients, it is more than a health insurer can be expected to do ensure that patients take the adequate steps to organize their own long term health care issues in the most cost effective manner. Ultimately, this is a responsibility of the patient, the effects of which will be manifest across a broader health insurance network if individual patients, in the aggregate, do not follow through in ways that will ensure cost savings in the long run for the insurer. That is to say, I may not bear a significant responsibility for seeking out medical attention for my wrist from someone other than the primary care physician that I have listed with my insurer (who I have yet to actually meet a year after I selected him), but I do bear responsibility for not treating the medical process as an ongoing, preventitive endeavor.
Beyond my concerns about the organization of health care processes, one subordinate issue in my treatment, alluded to above, struck me as I was writing this post. Notably, it is significant that, even though I was not reporting any pain at the time when I visited the urgent care facility, the physician who treated me volunteered to prescribe high powered pain medications to me. At the present time, the Commonwealth of Massachusetts is dealing with a widespread public health crisis in the abuse of prescription pain medications, leading, at least in some circumstances, to abuse of and addiction to heroine. To be clear, I am not seeking to impose blame on my treating physician for the prescription medication abuse problem in Massachusetts, but it seems clear that medical professionals are confronted with a quandry in the treatment of conditions inducing pain that can be readily addressed with pharmaceuticals and I am not certain that it is entirely safe for the profession to err on the side of progressive treatment in such circumstances. Certainly, physicians enjoy a much greater range of available pharmaceutical preparations to deal with the discomforts of patients suffering from broken bones, infections, and chronic conditions (e.g. cancer-related pain). Perhaps at some point in the near future, physicians in Massachusetts will be able to prescribe marijuana for certain chronic conditions, if state legislators and regulators finally get around to obeying the expressed mandate of the Massachusetts electorate on this issue (i.e. we approved medical marijuana by ballot initiative 2 years ago). Moreover, the administration of medications to reduce the pain experienced by patients is a relevant component in the business of treating diagnosed medical conditions. However, given wide variations in the strength and addictive nature of certain pain medications, it probably makes more sense for medical professionals to allow patients, in most circumstances, to self-medicate using over-the-counter (OTC) analgesics, particularly Ibuprofen and Acetaminophen-based products, subject to the appropriate use instructions on OTC labels, and reserve prescription medications for circumstances involving chronic conditions and, more generally, acute conditions requiring hospitalization or other significant measures. In any case, insofar as I had indicated experiencing little to no pain from my breakage, I do not think it was entirely appropriate to be offered vicodin for the taking just because it might make me feel a little better than an extra-strength Tylenol.
This leads me to a legal question. Notably, under what circumstances might physicians and medical practices become civilly liable for the prescription or failure to prescribe pain medications? In the former circumstance, the evolving corpus of medical malpractice law seems to indicate that there is some basis for physicians to be held liable for the prescription of pain medications leading to patient addiction when an accepted standard for medical care of particular conditions is transgressed by an individual physician. In my view of this, I am still somewhat spell bound why physicians would be tempted to err on the side of prescribing pain medications for particular conditions even when a patient is not reporting significant pain. There is, of course, the recourse to compassion as the motivation for physicians to go above and beyond in treating patients with broken bones, nasty lacerations, and severe infections, but, maybe by virtue of a certain lacking of emotional sensitivity on my part, I just do not comprehend how physicians could open themselves up to possible malpractice litigation out of sympathy for the real or perceived suffering of a patient. Rather, from my standpoint as an economist, I am inclined to interrogate the market motivations for the over-prescription of pain medications. That is to say, I find it at least plausible that physicians over-prescribe pain medications because they perceive that the failure to offer pain medications to patients experiencing potentially painful conditions must impact the ability of the physician to retain or otherwise attract new patients, even at the level of a medical practice with multiple physicians. Such a situation might be patterned in some game-theoretic manner, incorporating the expected risk of addiction from given medications and the expected risk of diminished long run compensation to physicians failing to offer pain medications, especially in circumstances when a patient within a demographic where the probability of abuse is very high actually asks the physician to prescribe a pain medication.
One last thought on the medical profession in the U.S, derived from my present experience and from past experiences of treatment for acute but relatively significant medical conditions: there are few professions in the U.S. where economic myopia is at least tolerated if not rewarded as it is in the provision of health care. In making this observation, I do not mean to argue that the physicians who treated me, either at the urgent care clinic that I went to initially or to the orthopedic practice that cast my injured wrist a few days ago, proceeded with a cavelier indifference toward the costs my medical condition would inflict on me. In some degree, a condition like a broken wrist is probably somewhat technologically simpler that numerous other conditions (e.g. cancer care) where new, state of the art medical procedures and technologies are now available to be offered to patients. My point is, however, that, given the market structure of American health care, the medical profession needs to be more attentive to the costs of given treatment regimes relative to the income level of patients and the potential effect that a prolonged medical disability is likely to have on the patient's income.
Again, the problem here may have much less to do with the medical profession itself than with the institutional environment of labor markets in the U.S. against which it is situated. For my part, a short incapacitation from a broken wrist is unlikely to bankrupt me. The actual treatment costs will be largely borne by my insurer. Moreover, I can accept the fact that my condition is going to demand follow-on orthopedic care, including more x-rays - I am actually quite enthusiastic about this insofar as I really do want my wrist to heal as rapidly as possible and without complications. On the other hand, I would be much more likely to obey a strict regime restricting the use of my right hand and right arm if I enjoyed some form of compensation to ensure that I remain out of work and not over-stressing my arm. The more painful point is that I will end up sinking my federal and state tax returns to pay for monthly living expenses rather than contributing to my long term savings. Clearly, I am going to lose a good amount of labor income and potential savings, and possibly a week of paid vacation time, as a result of this injury. If, in the end, this comment devolved into an advertisement for short term occupational disability insurance, I did not actually mean for it to do so, but my level of frustration with my combined physical and financial inability to do all the things I want to do right now and my inability to rationally attribute blame to someone else prompted this result in exasperation!
Closing on the point of attributing blame, I still have the issue of that one little patch of black ice at the end of the Northampton High School parking lot. In theory, I guess I could secure an attorney and sue the Northampton School Department for negligence in failing to maintain an ice free driveway or, in the very least, failing to put up any signs warning of icy surfaces or prohibiting use of the parking lot as a means to traverse the distance between Elm Street/Route 9 and Milton Street. On the other hand, in that event, I used the parking lot to get where I was going for one simple reason - it was the most ice-free space available in a year in which we have had, until now, very little snow but a profusion of freezing rain/ice events! The sidewalk maintained by the School Department skirting the outside of the High School property was a proverbial ice-skating rink, as was the road surface at the beginning of Milton Street. All things considered, the School Department deserves at least some credit for maintaining the parking as dry and well sanded as it is and as it was on the night I fell. No one can absolutely ensure that all surfaces will be ice free in a winter like the one we are having. Moreover, my inability to provide any witnesses on a night in which I fell in total isolation from any other human beings in a fairly isolated suburban corner of town would make it difficult for me to corroborate any claims that I fell on school property and that the school was responsible. In the end, all that I can say is that, notwithstanding my best efforts to stay on dry ground and avoid ice, accidents are accidents and I will have to simply deal with this one.
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