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| drawing by Suzanne Dunaway |
My patient Gayle
lived hand to mouth with an Italian mechanic boyfriend, her sole income selling
homemade preserves at the weekly village market. She decided to consult me after
giving up on her National Health Service General Practitioner: she’d been
experiencing gnawing abdominal pain for months, then started having bloody
diarrhea. It was obvious that she needed colonoscopy to figure out what was
going on, and fast, but how was she to get one? Her local public hospital had
an eight-month waiting list, and she couldn’t afford €900 to have it done in
the private clinica I usually
recommend.
Gayle asked around and found a
cut-rate private operator who quoted her €250. I turned thumbs down at her
doing such an invasive procedure with someone I didn’t know – I’ve seen too
many colonoscopies gone wrong. Sometimes the doctor got only halfway up the
colon and turned back. Other times he or she saw polyps but left them in place
instead of removing them, or omitted biopsies that need doing. In the worst
case, a hole was poked right through the bowel wall.
Next I asked my trusted gastroenterologist
colleague whether he could get her hospitalized on the public ward where he
worked. He rolled his eyes and told me his hospital was so short of beds that
an ulcerative colitis patient of his was parked at that very moment in the Emergency
Room hallway with a high fever, passing bloody diarrheal stools every hour,
waiting for a hospital bed to open up and in the meantime getting no treatment
at all. No chance that my patient, who was sick but not at death’s door, could
get admitted.
For decades, there’s been a
tug-of-war on between full-time National Health Service hospital doctors who
want to supplement their salaries with private practice, and governments that
aim to keep public medicine strictly public. An uneasy compromise lets hospital
docs see paying patients, but – theoretically – only inside the hospital. This
has been dubbed intramoenia, Latin
for within the walls. If you get a colonoscopy on the public system you’ll pay
next to nothing, but unless you arrange it a year ahead of time you’ll feel
every painful twist of the tube. If you do your colonoscopy privately in the
same hospital, with the same gastroenterologist, in intramoenia, an anesthesiologist will be glad to knock you out for
the duration.
In their battle to hold on to outside
offices, the physicians have found strange bedfellows in the left-wing hospital
workers’ trade union, which opposes on principle the mixing of public and
private medicine on hospital grounds. Both groups have been appeased by a
sleight-of-hand redefinition of “hospital grounds” that can stretch to include offices
anywhere in town…
Back to Gayle. My trusted colleague
eventually came up with a splendid solution: he referred her to his own trusted
colleague who did the exam on intramoenia
three weeks later for €450, about what Gayle and her boyfriend could scrape
together. The diagnosis? Crohn’s disease, which now that it had been diagnosed
could be treated perfectly well in the public system where she doesn’t have to
pay a penny. Much of my professional life is spent helping patients run this
kind of daily slalom between public and private medicine. Quite a job in its
own right.
*****
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