Ask not for whom the Bell tolls…

On Monday morning, I realized that the left side of my face wasn’t working. It had felt a little tight on Sunday afternoon, but I blamed that on a weekend outdoors in the wind and sun. But on Monday I was unable to close my eye properly… it looks pretty creepy. As does a one-sided smile or dribbling my coffee.

Dr ChatGPT gave me a likely diagnosis of Bell’s Palsy. We went to the GP, who squeezed me in without an appointment, and he confirmed the diagnosis but sent me to the Emergency Department for a brain scan “just to make sure.”

At the ED, we waited about 3 1/2 hours to see the Dr, who agreed with me that the scan was unnecessary… I had all the symptoms of Bell’s Palsy and none of the symptoms of anything more sinister. He wrote prescriptions and sent me on my way.

We’re in the middle of a health system crisis here in NZ. There’s not enough money to give everyone what they want. And the money that is spent could be apportioned and prioritized differently depending on who you ask. My interaction (anecdotally) confirms all this.

Disclaimer: I am a rich white guy in a rich white suburb, with a background in the way the health system works, etc. Therefore, my experience would be at the top end of experiences people have.

First, this was an almost unqualified success. All my carers were easily available, seemed knowledgeable and kind, and I’m as confident as some internet searching can make me that I got the right diagnosis and optimal treatment. I don’t have private insurance… this was all in the publicly funded health system.

I said “almost” unqualified success. Here’s the qualifications. I can point to multiple system problems that I think reduced the efficiency of the whole endeavor. If these thoughts bear out and exist for others, there’s a lot of savings to be made and satisfaction to be improved.

1) Funding disparity for urgent care. My presentation falls perfectly into the urgent category. Not life-threatening, but scary (my face doesn’t work!), and the internet told me it was important to start treatment as soon as possible. My GP couldn’t get me an appointment till the next day (which is already way better than it is for many people in NZ). But we insisted a bit and they squeezed us in on the spot. Awesome service, but we disrupted their schedule which contributes to overwork and just puts friction in. My subsidized copay at the GP is $60. At the private urgent care a few miles away it’s $160 just to walk in the door, so from my perspective it was easier and cheaper to muscle into the GP. Perhaps because of the extra pressure of seeing me in a hurry over lunch, the GP was unwilling to just treat, and instead made a probably unnecessary referral. A publicly subsidized, properly equipped urgent care with appropriate triage (including the authority to refuse subsidized visits if it’s really a GP issue) would have been perfect for me.

2) Something cultural making him unwilling to treat. The GP seemed competent and confident in my case, calling it a 101-level, not complex at all. But he still felt the need to send me off for a scan instead of sending me home with a prescription. We don’t have the litigation and malpractice insurance problems of the USA, but somehow the GP needs to feel even more empowered to just treat me. Instead I took up a slot in a busy emergency room and wasted an afternoon.

3) Availability of diagnostic facilities outside the ED. Given that I have a referral for a diagnostic scan but am clinically stable, why was the ED the only place to send me? Better allocation of hardware and personnel away from the ED, and perhaps better contracting between the public and private providers like the US VA has done so well, might have resulted in a less expensive interaction.

4) Patient-centered tweaks in the ED itself. When you walk in, there’s three windows. The first one inside the door is where you go second, after visiting the one in the center. There is a sign way up near the ceiling explaining all this. But we watched two dozen people come in and all go to the first window, like we did. Each time the clerk there paused, listened politely as the patient began their story, and then sent them the three steps over to begin again. Although I know that time-and-motion efficiency experts can be just phenomenally useless, it sure felt like that workflow could be examined to the benefit of both patients and staff. And if that workflow, how many others?

5) Time and money consequences. Sending me to the hospital resulted in a 7-hour adventure, including an hour plus in the car (remember gas is $10 per gallon), a $20 parking fee, and fast food for dinner. None of that is a huge deal for me, but I don’t have childcare to worry about and I make my own work schedule. The long ED wait meant that the bargain pharmacies were all closed when we got out, so I had to pay the full $20 copay for my prescriptions at an after hours place. Again, for me not an issue, but those copays are a proven problem for surprisingly many people. The previous government abolished the prescription copays, but Mr Luxon and his Coalition partners have reinstated them. There were consequences for the system staff too… all the documentation was generated twice, and then transmitted among providers, blah blah blah.

After my first couple doses of prednisone, I can already see a tiny improvement… my mouth can manage an almost Mona Lisa level of exuberant grin. Most people recover fully, and this affliction doesn’t usually come back. Fingers crossed (which I can still do on both sides)!