Wednesday, November 24, 2010

Dealing with Medical Issues

One of the most intimidating aspects of spending a year abroad is the prospect of dealing with a foreign medical establishment. Everything is different. Expected wait times, dealing with insurance, doctor-patient relations. I knew that it was impossible to go a whole year without some medical issues, and sure enough, in the first 3+ months, we've had our share.

I should point out that I viewed my potential interaction with medical treatment in Israel both as a consumer, and as a researcher, as my Fulbright project involves working with the Israeli HMOs on medical record security. So I approach each health challenge with some degree of curiosity, along with the anxiety that always accompanies such experiences. When I injured my wrist (described below), my host at Tel Aviv University, Ran Canetti wondered if this was my way of embedding myself in this issue, the way I became en election judge when working on e-voting.

Our first interaction with the Israeli medical system came when Benny managed to split open his foot running through the apartment. We were worried that he needed stitches because the cut would not close. Coincidentally, I had a meeting with one of the doctors at the Maccabi headquarters that day. Maccabi is the largest HMO in Israel and services over 2 million patients, just under 30% of the population. Ann and I spoke by phone, and she decided to take him to the Maccabi clinic near our house. They dressed and closed the injury, but when Ann was ready to pay, they were surprised to learn that we were not registered with Maccabi, and they said they did not have a mechanism to collect payment. The doctor wanted Benny to be re-examined a couple of days later, but the administrators at the clinic said that we could not be seen unless the children were registered.

Ann called me on my cell phone during my meeting at Maccabi, and a few minutes later, the clerks at the clinic were speaking with a senior official from their HMO. However, they were adamant that unless we were registered, they could not treat us, and apparently going over their head had no impact. Meanwhile, I obtained the number of a private doctor for Benny. Ann called the doctor who informed her that he did not see patients outside of the HMO, but that she should just get into a cab and ask him to take her to Magen David Adom, which provides emergency medical services and runs an ambulance service. I can just picture the wide open eyes of a Tel Aviv taxi driver as a frantic, American mother enters with her wounded child and asks to be taken to Magen David Adom. That cab ride would probably put him in more danger than his injury. We began looking for another private doctor, but in the meantime, Benny's foot healed.

Having a general purpose clinic right near our home is a great feature of living in a city like this, but not if they won't treat you, and I did not like our chances when it came to sneaking each kid in until it was time for payment and then being kicked out. I figured that this only works once. So, I went to the clinic and was forced to wait about an hour in the waiting room before I could meet the head administrator and request to register our family in the clinic. She said that only Israelis can be registered. I pulled out the childrens' and my Israeli passports and said that we were in fact Israelis. She frowned as though this was not what she was expecting nor hoping for, and sat down at her computer. After punching her keyboard for a few minutes, she looked up and said that I have to go to the bituach leumi, which means national insurance before I can register myself and the kids. I tried in vain to argue with her, but she said that without a visit downtown to the bituach leumi, there was nothing she could do.

I know the drill in Israel, so I decided it was worth wasting a few hours, or maybe days, of my life to take care of this. I called the bituach leumi office several times before I managed to speak with someone, and that person told me that it would not be a problem. She said I should bring my letter from Tel Aviv University regarding my appointment, all of our passports, Israeli and American, my Fulbright award notice, and anything else I could think of. I realized that what she was saying was that I would probably not be greeted with cooperation, and that I need to be prepared to make my case.

Feeling like a lawyer heading to argue his first case before the Supreme Court, I collected all of the relevant materials and headed downtown to the bituach leumi offices. The entrance to the national insurance office, once I got past security, was a complete mob scene. I was mentally prepared to spend my day there and to deal with a slow uncooperative bureaucracy, but I was still taken aback. There were people everywhere. I wanted to get in line somewhere, but I could not find a line. I saw a security guard, and I asked him where I'm supposed to go for . . . but before I could explain what I wanted, he stated that he was just security and had no idea. I decided that this was one of those moments when I had to put my manners and all of my cultured upbringing aside. I looked at the part of the mob that seemed to be going most aggressively in a particular direction and decided that this is more likely to be the right mob than the other ones. I started squeezing my way to the front. People yelled at me and asked me to get behind them, and I said that I just had a question. People replied that they all had questions. That made sense, but I pushed on ahead. Several times I was yelled at, but I just yelled something back. After about 45 minutes, I ended up near the front of the mob, and I managed to approach the desk. I explained why I was here, and of course, I was told that I was in the wrong line, and she pointed to another collection of people at the other end of a long hallway.

I went down there and discovered that there was a number dispensing machine. So, I took a number. I looked up at the board with the numbers, and saw that my number was several hundred higher than the displayed number. So, either they already called my number a while ago, or something was wrong. I asked one of the people waiting what the deal was with the numbers, and he explained that everybody is keeping track of when they came because the number dispenser is not working. I asked him how in the world I'm supposed to know when it was my turn. He looked up and yelled very loudly, "Who is last?" And some woman in the back yelled, "I am". He turned to me and said, you are after her. Over the next hour, people showed up and they seemed to know what to do. They yelled "who is last?" and got the reply. And thus, when it was finally my turn, I went right after that woman who had responded initially. Peculiar system, but it works.

When I finally got to meet the clerk at the bituach leumi, I started explaining that I'm a visiting professor on a Fulbright, and I pulled out all the evidence and laid it out. He asked me what I wanted, and I said that I and my children are Israeli citizens, pulling out further evidence, and we wanted to register with Maccabi. He looked at me and said. "That's impossible." Just like that. I knew that I was expected to argue with him, and I did not want to let him down. But, nothing worked. I asked to see his supervisor, and he said that he was the supervisor. I was feeling desperate, so I said to him, "Here's the situation. I'm in this country for a year. I have three young children. What am I supposed to do if they get sick?" I know that Israelis are super-sympathetic to children. I even showed him their picture on my cell phone. He said that he was very sorry, but that there are private doctors who will see them if they are sick. I said that when I called on the phone, the person told me that I should bring all this stuff, and that it would work out. He rolled his eyes and launched into a lecture about how the people on the phone are college students in Beer Sheva who don't know anything, and how frustrated he is with them always giving out wrong information on the phone.

I gave up and left.

Shortly after that experience, I injured my foot playing soccer. At first I thought it would heal on its own, but when I was still limping 3 weeks later, I decided to have it seen. I asked around, and a friend of mine recommended a private hospital in Herzeliya called the Herzeliya Medical Center (HMC). I called them up and made an appointment to see an orthopedist. He was American and seemed very good. He ordered x-rays, and told me I had a bone contusion (bruise), and that I was fine, and I could do anything but use pain as a guide. It was a good interaction and not that different from how such a doctor's visit would go in the States. Furthermore, the HMC accepted my Seven Corners health insurance that I received as part of the Fulbright program.

But, luck was not on my side. A couple of weeks ago, I fell off of my bike riding to work. I missed the ramp from the sidewalk because I was looking to see if any cars were coming, and I happened to go off the curb over a sewer drain, which was a bit high up. My front wheel collapsed, and I hit the ground hard. I put out my left hand to break my fall, and when I finally got up, my hand and wrist were killing me. I went home and immediately drove to HMC. Lucky for me, there was a hand surgeon there. Unlucky for me, he was not nearly as nice as the orthopedist who saw my foot. I ended up spending 6 hours there, about 3 minutes of which were with the doctor. He made me wait outside in the hall while he met with other patients and performed surgery. I was told that he had squeezed me into an already overpacked schedule, and I was grateful, although I was not happy about the service I was getting. In my brief meeting with him, he told me that the x-ray was inconclusive, but that he did not see a fracture. However, he thought I may have broken my scaphoid, a small bone that usually required surgery to repair. He said that I should wear a brace all the time, and that he wants more x-rays in 2 weeks to determine whether or not there is a fracture. I was supposed to take it very easy with my hand.

So, for 2 weeks, I wore the brace, did not ride my bike, and took it very easy. I was optimistic that the bone was not broken because after a few days, the pain went away, and there was only the discomfort of wearing the brace all the time, even to sleep. On Sunday, I went back to have the repeat x-rays taken, confident that I would be told I was fine. The doctor was not there, so I left my cell phone number for him to call me with the results. Ann and I had plans at a very nice restaurant that night. As we were leaving the house for dinner, my phone rang, and it was the doctor. He said that he saw a line that looked like a fracture. He asked me where I lived, and I said Tel Aviv. He said that in that case, he wanted to see me again next Sunday because he was not going to be in Tel Aviv until then. And he hung up. I was in complete shock. If my wrist was broken, shouldn't it be in a cast? Am I supposed to wear the brace? There's no way I'm waiting a week to take care of this.

Ann and I went to the dinner, and while I enjoyed the food, I was absolutely miserable. I faced the prospect of 6 of the next 7.5 months in Israel in a cast, possible surgery in this country, and an unpleasant recovery. I was particularly disappointed because I had convinced myself that my wrist was fine before that call came in.

The next morning, I made my mission to find the best hand surgeon in Israel and see them right away. In hindsight, nothing could be more naive. I pulled out all the stops and wrote to everyone I knew here in Israel asking for recommendations. Several people started making phone calls on my behalf. The big breaks came from the doctors I had met here as part of my research, including a private doctor and some doctors at Maccabi. I also had an orthopedic surgeon in Baltimore and my uncle who is a famous doctor on the case. By the end of the day, I had the names of two well regarded hand surgeons who practiced in Tel Aviv, among other places.

I called one of them, and the earliest appointment I could get was for December 21. I begged and pleaded and explained the urgent nature of my situation. I had a potentially broken wrist with no cast on. I needed to be seen by a specialist ASAP. The receptionist would not help me. So, I googled the doctor and found her email address through some of her research publications. I wrote her a long desperate email, invoking my professor position at Johns Hopkins, hoping that she would make the association with medicine. But, she never answered. In the meantime, I called the other doctor and sent her a similar email message. The other doctor, Dr. Hagar Patish responded to my message in the afternoon and said she could see me the next evening at her house where she has a clinic. Bingo!

I had to go back to HMC to pick up the x-ray so that I could bring it to Dr. Patish. Tuesday morning, I drove to Herzeliya and retrieved the CD containing the x-ray. The receptionist there told me that there was a report with the x-ray. I said that I knew that, and that I had spoken to the doctor. She suggested putting the report in the case with the disk. On my way to the car, I opened the report to read it, and to my surprise, it said "no fracture found" and it was signed by a radiologist. What?!?!? A wave of relief swept over me, but I still was a bit nervous. What was that doctor who called me talking about? Tuesday night could not come quickly enough.

I don't remember much about Tuesday (yesterday). All day long I was preparing for the meeting with the hand surgeon. I was barely able to eat. At 4:45 pm, I drove Benny to soccer practice and then proceeded to enjoy an hour of Tel Aviv traffic as I headed to the doctor's house. Ann went to get Benny when his practice was over. Dr. Patish greeted me warmly. She asked me some questions and then pulled up the x-rays on her monitor. It was the friendliest experience I can ever remember having with a doctor. She showed me every aspect of the x-rays, and pointed to a line on the scaphoid on the first set of x-rays. She said that this line could indicate a fracture, but that strangely, the line continued past the bone, so maybe it was just something on the picture. She then pulled up the x-rays from two weeks later and we went over them. She took several minutes and told me that she saw no evidence of any fracture, and that she was pretty comfortable ruling out a broken scaphoid. She said that if there were a fracture from the first x-ray, two weeks later it would be magnified. She then performed a physical exam (does this hurt? does this hurt?) and said that she was even more certain that the wrist was fine. She also said that I absolutely should have been in a cast immediately after that first set of x-rays. If the scaphoid was broken, and there was reasonable evidence that it might be, it would be very serious not to have it in a cast. Yet more evidence of how much of a loser that first doctor was, and a lesson to me about finding the right doctor early when something serious is going on.

After the examination, we launched into about a 40 minute discussion of electronic medical records, about my research, patient privacy and about her opinions of medicine in Israel versus the US. Finally, I asked her if she could take the Seven Corners insurance or if I should pay and then get reimbursed from my insurance back home. She responded to me, "You are my guest here." At first I did not understand, but then she explained that she was not going to charge me for the visit. I was embarrassed and muttered something like "Are you sure?" and tried to protest, but she would have none of it.

Only in Israel.

On the drive home, I was just amazed at the quality of treatment I had just received. No doctor had ever explained to me my condition and all the potential ramifications as clearly or thoughtfully as she had. She showed me the x-rays and discussed them as though I were a medical student and she was my professor. And in the end to not charge me. I know from some of my phone calls on Monday that most orthopedists in Israel when treating a foreigner as a private patient charge 800 shekels (a bit over $220) just to say hello.

I'm not thrilled about the prospect of dealing with whatever medical issues come our way in our remaining time in Israel. But, the knowledge that there are doctors here like Dr. Patish, even if they are hard to find, is very comforting.