End-of-Year To-Do List: Schedule Surgery?

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The old folks in our neighborhood are hard to operate on. They are suspicious. They ran away, years ago, from war and hunger and government officials making powerful speeches. They escaped places they loved, where they first had plenty, then enough and then nothing. They made the boat but the new land of opportunity was also one of educated opportunists and swindlers — the diplomas on my wall don't impress them. It takes a while to gain their trust.

Even then surgery is usually out of the question. Many of our local patients are in their 80s and still working. Our patient Tony, 82, is a gardener. He looks like a root: strong hands, twisted by arthritis, five-feet-nothin' and bowlegged. He's been listening to me recommend knee replacement for 10 years, but would never have the surgery. He takes the arthritis pills I give him, but leaves my physical therapy prescriptions on the counter ("Don't need no exercise, Doc. I work."). At most he'll take an injection when it gets bad. Even when he was limping, Tony would not even talk about an operation — until now. He came in two weeks ago and asked me to schedule his surgery.

Ira is about the same age; his shoulders, hands, hips and knees have all bothered him for years. Unlike Tony, he likes physical therapy. I've been warning him about letting the problems go too long, especially the numb hands, but since the '90s he has refused every procedure. About four months ago, something changed with him too. He requested surgery — first a shoulder, then the hands. He's been having an operation a month since then, quite happily. He still has another scheduled.

Why the rush? I've asked both men. And in two different accents, with two vastly different levels of political awareness, they say the same thing: "Because I don't know what's going to happen."

Among the changes my patients seem to believe in, in this twilight of our crazy decade, is a newfound need to talk about the bigger health care picture with their orthopedic surgeon. They love talking about the government plan, insurance companies, overseas surgery outfits, electronic medical records. Often, I enjoy it too. It can slow down office hours but it beats droning on about glucosamine. From many hours of chat with many patients like Tony and Ira has emerged one strong theme: "Get it while you still can."

Low expectations of America's medical future are now the rule in my patient population. Not with all the patients; the very well-to-do still show little concern for the future availability of care or what it will cost. But this group generally means business anyway; they've looked me up and are usually ready for an operation when they first come. The lawyers and teachers, similarly, don't seem too worried about losing access to my services anytime soon. And some fraction of patients always seems clueless about the world beyond the tips of their noses: they don't worry about insurance or anything else as far as I can tell.

But those patients in the middle — Medicare patients like Ira and Tony, the younger HMO types doing well but working harder and harder, the aging professionals dealing with their first serious pains — they seem to be of a new mind lately. So do the unemployed who foresee the day their COBRA benefits will end, and the still fully employed whose company plans in 2010 entail higher deductibles, higher copays and reduced benefits. Whatever their situation, these patients are less interested in therapy and anti-inflammatories, or in just waiting to see if the pain stops by itself. (Quite often it does.) They are signing up to "get it fixed" a lot more often than a year ago — an unintended and ironic "stimulus package" to my surgical practice from folks whose incomes have been seriously hurt this year. I'm grown accustomed to the year-end push for elective surgery from patients who have met their deductibles for the year, but many now are anticipating the end of health benefits altogether. No one I know is behaving as though they expect truly better health coverage by governmental guarantee.

Ira reads the papers like a hawk; Tony, not so much. But they are both worried that the days when they could afford an elective surgery with the doctor of their choice may be coming to an end. Tony and Ira ran small businesses in America all their adult lives; they understand budgets. They think the government is going broke — and in their early years, they've seen governments go broke before. They have seen big ambitious government plans do great damage, and so they maintain a deep suspicion of even the best intentions. I truly hope they are wrong, that the changes wrought by a federal health plan will not, to them, be familiar ones.