Ah, Internet reading, the posts you inspire. Also, ah, Internet reading, how common threads turn up in different places. In this case, the common thread — from size acceptance advocates, from chronic pain patients, from frequenters of sexual health haunts — is the advice to “just fire your doctor” if they aren’t meeting your health care expectations.
First off, I absolutely agree with the sentiment behind the advice. When I enter into a provider-patient relationship with a physician or nurse practitioner or midwife, I am seeking professional, expert health care advice and services, yes, services I usually cannot provide for myself. However, guess who has the best overall knowledge of me? That would be… me. As such, given that I am seeking advice and services about health care applied to me, I bring some expertise to the table too. I respect my providers’ knowledge. Any providers who refuse to respect my knowledge about my own self — my history, my body, my priorities — are not good providers for me. I should be able to “fire” each and every one of them and to seek services elsewhere.
Except, it isn’t always that easy.
For people without insurance and/or with limited incomes, health care in the US (and in other places, I’m assuming, but this is my frame of reference) is expensive, sometimes prohibitively so. While I’ve been fortunate to have medical insurance for most of my life, there have definitely been times when I could not have afforded a second visit to another provider — at least not inside any kind of short time frame, should appointments even be available.
Even with affordable insurance, there are sometimes limits to how many different providers one can see. For example, I am currently permitted to change my primary care provider one time per plan year. Any time I want to see a specialist, I need a referral from said primary. (Which can be an issue if, say, my primary care provider disagree on what is wrong with me and whether consulting a specialist is necessary. Then it takes one extra doctor — and one extra copay — to get to the doctor I wanted to see in the first place.)
In cases like those, my realistic choice was between settling for sub par treatment and settling for no treatment. In cases like those, I have, at times, been willing to tolerate unprofessional treatment — judgment about my weight, mental health, or sexual history — in order to obtain the services I need in the shorter term. It’s not pretty, but there you have it.
Additionally, some health care issues are urgent. When I am, say, gushing pints of blood out my vagina, “firing” the ER doctor is not the most accessible option.
Then there are mobility and availability issues to consider. Some people live in rural areas, where the “next doctor over” is ten or twenty or fifty or a hundred miles. For people without independent transportation, there’s a limit to how far they can reasonably travel — round trip — in a day. Hell, for people with reliable cars, there’s a limit to how far they can drive — taking off work, if they can, perhaps unpaid — to see a second health care provider. For people with chronic pain or bodily mobility issues, those can be limiting factors as well.
When all’s said and done, some of us just plain run out of health care providers. I mean, I have health insurance, and for regular office visits — urgent care, advanced imaging, and surgical care notwithstanding — I can basically afford my copays as often as I go now (somewhere between two and four times per year for non-acute care). I live in a good-sized city, though it’s not a major metropolitan area, and it is in a Western state — meaning that distance between cities and to the nearest major metro area is rather enormous compared to my experience with states east of the Mississippi.
But I also have endometriosis. Specifically, I have microscopic endo with chronic pelvic floor involvement. In lay terms, I have an odd presentation of endo sufficient that it confuses — explicitly or in practice — all the endo specialists in my good-sized city. (I say “or in practice” because there was one doctor who was sure he had my magic solution — but who couldn’t figure out why I wanted more endo management than, “Congratulations, your fertility should be perfectly intact. You’re one of the lucky ones.”) There was one awesome pelvic floor physical therapist, but getting my insurance to cover enough visits (apparently they do not understand that some folks may require physical therapy for chronic conditions as well as acute ones) was an endless barrage of paperwork red tape and phone call runarounds. And anyway, she moved away.
I’m very loyal to my current nurse practitioner, but objectively, there are a lot of reasons why she’s not the best for me. She’s not an endo expert, and she’ll be the first to admit that she’s old — more to the point, that no matter how hard she tries to keep up with the various new developments of her patients’ health care needs, things often change faster than she can process, let alone memorize. Even more to the point, she prescribes too few pain meds and won’t refer me either of the two pain management clinics here in town. (According to her, one is unlikely to prescribe any opiates without an opiate contract. The other is likely to be freer with the prescription pad but unwilling to pursue other avenues of pain management. My independent research, though limited, suggests that her assessments are — more likely than not — accurate.) Additionally, while she does not berate me for my weight, her office requires that she discuss it with me at my physical every year.
Could I “fire” my nurse practitioner? Certainly — though if I do so, I’m stuck with whichever new provider I choose until August 2013.
Should I “fire” her, though? In the abstract, I really couldn’t say. I mean, if someone came to me, cited my NP’s same shortcomings in their own health care provider, and said they were dissatisfied with the quality of their health care, I could neither disagree nor fault them for their assessment of the situation. Even for myself, whatever else I could or might say in my NP’s defense, I continue to have health issues that are insufficiently managed.
Am I going to do it? No, flat out. It is true, technically, that I could find another health care provider who helps me better than she does — and that I could do it on the very next try. That said, my “on the ground” experience here suggests that I’m actually four to five times more likely to find someone who does a worse job of things. And, given the various real life limitations going on, four to five years is a long time to wait to make “firing” my provider actually pay off.