Friday, November 27, 2009

Gingerbread Breasts

I’ve never been able to agree with those who contend that health care should operate strictly along free market principles, and that allowing it to do so without government involvement or competition is the best way to promote health care reform. I don’t believe this because it’s never worked that way before, and the very nature of health care precludes it from operating as a free market entity.

The fact is that you can't look at health care as a marketplace subject to the same market forces as buying a home appliance. The key difference is that health care is accessed differently than other markets. For example, it’s your insurance plan that often dictates your choice of physician or hospital, not your informed consumerism. Your insurance plan may not be your choice, but the only one offered to you by your employer or the government. If your needs are urgent, your choices are often circumscribed by time, geography, and the need for specialty services. The vast majority of expenditures on your behalf go through a single gatekeeper (your personal physician) rather than an individual having free choice of costs, products, and options to review at their leisure. I don't know that I can support the idea of heath care operating as a pure free market system, not because there's anything wrong with the free market, but because health care cannot by its very essence operate in that way except in a very limited realm of choices and services. An employer choosing which health plan to offer employees can do so using free market principles; the employee's use of that policy cannot.

But health care can work as a free market for those procedures that are purely elective, like cosmetic plastic surgery. There was a time in medical school that I wanted to be a plastic surgeon. It was during my first year, when we were rotated through community hospitals for the purposes of getting acquainted with clinical medicine. (In reality, it was an excuse for the University to charge us a whole lot more money for the privilege of wearing a lab coat once a week and pretending you were something other than a rank freshman dissecting preserved cats in biology class.) By chance, I was taken in by Dr. Michael Hynes, a plastic surgeon in Kansas City. He would let me watch surgery and follow him during rounds, all heady stuff for a teenager.
I still remember the first surgery I ever got to scrub on. It was an amputation of the lower leg for persistent problems with circulation and non-healing wounds, and he had asked my friend Todd Gwin and I to assist. Our “help” had consisted on holding the leg down by the ankle while he worked some kind of surgical magic just above the knee. We were watching him, fascinated by what he was doing but not yet with enough knowledge to actually figure it out, when he quietly said, “Okay, take that leg and hand ot off to the nurse.”

Todd and I looked at each other in the space between our surgical masks and our scrub caps.


“Yeah, take it off the table and put it on the cart behind you.”

What we hadn’t realized is that he had just detached the lower leg from the rest of the body. Looking at each other with disbelief and a trace of fear, we slowly started to lift the leg up and could not understand why the rest of the limb from the knee up didn’t come with it. We thought that maybe we had just not lifted it high enough, but not matter how many inches we took the leg above the table the rest of the body stubbornly refused to come along for the ride. And then we were holding this disembodied, waxy leg, now cool to the touch with it’s blood supply severed, looking at it with utter disbelief and in total ignorance of what we should do with it.

“Taking it away today would be good.” Dr. Hynes stayed bent over his work.

So as the rolling table was on my side, Todd shifted to weight of the leg to me. While nurse aides and other caretakers have a keen sense of what it feels like to lift the dead weight of an adult human body, most of us really have no idea. We pick up molded plastic bloodied limbs at the Halloween store to decorate our homes and think it’s something like the real thing. The truth is that the human body is heavy and awkward, that the sprawling limbs and floppy head defy all the rules for lifting weights as a consolidated compact mass. This is all a polite way of saying that I had no idea how much a human leg weighed, and I almost dropped it. By the time I had gotten it over to the cart, I recognized that I should have some kind of profound thought, but nothing came to me except a very clinical, “Whoa, that’s a leg.” Which, I suppose, is precisely the point.

Dr. Hynes was a great guy. While he may have done lots of cosmetic work, most of what I saw was reconstructives…facial fractures, skin flaps, rebuilding pieces and parts. I thought it was fascinating (still do), and that this was what I wanted to do for a living. That was, until I learned that in order to become a plastic surgeon I would have to voluntarily submit to five years of butt-whipping and genital-licking to be a top general surgery resident, and then try to weasel my way into two additional years of the same as a plastics fellow, and suddenly three years of shift-based, not-on-call Emergency Medicine residency seemed a much better deal. And while the ER has been a great ride, that’s still one career decision I regret.

But back to the free market, the glories of capitalism, and the shameless pursuit of ersatz perfection. The hospital where I work will be placing an advertisement in the November 30th issue of the Daytona Beach News-Journal. Entitled “Ten Procedures Specially Priced for the Holidays: ‘Tis the Season for a New You,” it pictures a gingerbread man complete with a list of elective plastic surgical procedures and prices, with arrows pointing to the relevant part of the pastry individual. A facelift is $4,000, and new nose is $2,800, and a mere $3,000 gets your ears pinned back to the sides of yur head. (Interestingly, the most common plastic surgical procedure performed on gingerbread dismemberment and decapitation, or biting off the arms, legs, and head…is actually not listed as an option, probably because it’s free.) The ad mentions that gift certificates for these procedures are great stocking stuffers, because there is nothing more your beloved wants than a gift that says there’s something fundamentally wrong with you and I’m willing to pay real money to make it go away.

(I showed the ad to a friend of mine who actually is a plastic surgeon. He looked at the picture, thoughtfully pulled down his glasses down over his nose, and with all professional seriousness noted, “$2,920 is pretty good for a couple of decent breasts.”)

It took little effort to think through the ramifications of this proposal. Take the breasts. The line from the printed price to the appropriate part of the gingerbread man pointed to a single red hot where the right breast would be. (Since the gingerbread man also had a bow tie, we’re still a little confused about the gingerbread gender.) So the first question to answer is if the price was for a single breast, because that’s what it pointed to, or for a set of two. And then we wondered what kind of breasts you got for $2,920. Saline or silicon? Paper or plastic? Mix and match?
What about size? Was that the full price to go from A to DD, four sizes up? If you only wanted to go up two sizes, say from a C to a DD, is it only have the price? And why was the price an odd number, like $2,920? If you spent the extra $80 and made it an even $3,000, did you get some kind of bonus item like an extra nipple?

(I don’t have any really good plastic surgery breast stories. The only one worth telling is the time I was out with friends, everyone got a little drunk, and one of our more generously endowed nurses decided it would be educational for us to see just how good a job her plastic surgeon had done on her breasts. So she flashed, and I looked, and the pathetic combination of age, alcohol, and clinical acumen in me meant that I actually was noticing the exemplary symmetry and the lack of obvious scarring rather than the intended humongous perkiness of the effort.)

I do think sales like these are a good idea, and not just because they help jump-start the local economy. I know that personally, when I was “on the market,” as it were, I could easily spend at least this much money in meals, movies, and jewelry just trying to get a good long look at a single set of breasts. Imagine spending the same amount of money, and then getting to own them? What a deal! That is, as long as they don’t run off with the undercarriage.

1 comment:

  1. Personally, biting the ears off chocolate Easter bunnies is a favorite way to go, then the tail, then..... ha ha loved the blog, as always!!! :-) dark-haired persons who decapitate chocolate Easter bunnies rule!