How can American medicine be this bad?

I had a primary-care visit last week. I saw a system failing at the most basic levels.

I don’t see doctors much.

You may recall I had back surgery two years ago (a complete success, except my drop foot never recovered, ugh). For checkups I went every couple years to an old-school guy in Manhattan. He was a hematologist-oncologist who offered primary care out of a solo practice in a little office suite with the files in the back.

The place never changed. The visits didn’t either. His secretary called me into an exam room, I stripped down to my boxers and waited. His office was about five feet away. I heard him sometimes, calling in a prescription or talking to a patient.

He came in, wearing his tie and white coat. He took my blood pressure and drew my blood himself. He made me stick out my tongue, shined a light in my eyes, listened to my lungs. He prodded my stomach, looked at moles and, umm, checked my prostate.

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(The truth, even when it takes a rubber glove.)

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He checked his notes, asked about a couple of specific things and my life more generally. He discouraged me from riding a motorcycle. The visits usually took about half an hour, maybe a bit more.

He wasn’t warm, but he was in charge, and he was very much a physician. He clearly loved medicine, and he kept practicing even after he got cancer.

He took insurance, of course. If there was some problem with it, his secretary sent me a bill for the visit. Usually the bill was a couple of hundred dollars, maybe a couple of hundred more for the blood work, and in the end the insurance usually sorted it out. I kept him as my primary care doctor even after I moved out of Manhattan. I didn’t want to bother finding someone else, and I wasn’t seeing him all that often anyway.

But time marched on, as time does. He got cancer, and he got old. At some point I realized he was past 80 and possibly slightly demented. A couple of years ago he retired. So I didn’t have a primary care doctor. Eventually not having one seemed slightly embarrassing, plus I figured I was overdue for a physical.

So I made an appointment with a doctor at Optum, the UnitedHealth Group¹ division that has spent the last decade or so merrily buying up and consolidating groups of “healthcare providers” — I know, we used to call them doctors and nurses — in New York and everywhere else.

The date was a month or so out, which was fine; I wasn’t in any rush.

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(No, not Lumon! Optum! Easy mistake, though.)

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And so earlier this month, I drove to one of the many Optum medical office buildings scattered like forward operating bases at non-random intervals around New York City.

Like the others, this one has a big parking lot that’s always full. Inside it’s busy, filled with old people and sick people and old, sick people, as well as pregnant people — though I guess I’m allowed to call them pregnant women again. A few hints of Covid still remain, grimy forgotten reminders to stand six feet apart and wear masks.

I found the internal medicine suite, checked in, and in a couple minutes was waved into an exam room. A cheery woman measured me, weighed me, and took my blood pressure and pulse. I asked if I should get undressed. She said I didn’t have to.

A couple of minutes later the doctor walked in.

He wasn’t wearing a white coat. Or a tie. He seemed nice enough. And harried. He fiddled with his iPhone to set up a recording of the visit for transcription later — AI transcription, I assumed, though I didn’t ask. It took him a minute. Technology, he said. Technology, I agreed.

I stayed dressed. He listened to my heart. He listened to my lungs. Both fine.

Thus ended his physical examination.

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For the rest of the visit, he had two topics.

The first was my blood pressure. I don’t check it often, but at this exam, my blood pressure was running slightly high — the low-to-mid 130s over the low 90s.

I have no heart problems, a resting heart rate in the low-to-mid 60s, and I regularly work out hard on a elliptical trainer. I have no real family history of heart disease. My father never had heart problems. None of my uncles have heart problems.

I told him as much, or tried to. He wasn’t interested. He wanted me to buy a pressure cuff and test my pressure every day while changing my diet and make an appointment to see him six weeks later. If it didn’t improve by then, he would probably want me to go on blood pressure medicine, he said. A study had shown that doing so would lower my risk of heart attack and stroke.

I happened to know the study he was talking about. I’d read about it because I was wondering why I was suddenly seeing ads about “prehypertension.” I considered writing a piece about it.

It’s called SPRINT. It followed almost 9,000 people for a couple of years. It showed that in people over 50 who already had high blood pressure, treating their blood pressure more aggressively, to close to 120 instead of the mid-130s, reduced the risk of heart attack and stroke.

Makes sense. Except the average age of the SPRINT trial participants was almost 70. And they were already taking blood pressure medicines. They already had cardiovascular concerns. They were at a far higher baseline risk of heart problems than I am.

Once again, drug companies and public health types are working together to push treatments designed for patients at high or medium risk to the much bigger group of people at low risk.

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His other topic was (wait for it) vaccines.

At this point I had no choice but to ask him if he knew who I was. He said he didn’t; I said I was fairly well known for my views on the uselessness of Covid and flu vaccines. He didn’t try to argue the point. Instead he spent a couple of minutes talking about the pneumococcal pneumonia (Prevnar, brought to you by Pfizer!), tetanus, and shingles shots.

I heard him out. I might at least consider getting the shingles shot. There’s observational data suggesting it lowers the risk of dementia, though as Unreported Truths readers know, observational vaccine data is somewhere between mostly and entirely useless.

And that was pretty much it. He told me to stop by the lab downstairs to have my blood drawn and to make an appointment to see him again in six weeks. Sure, I said.

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(Medicine, back in the day! Okay, maybe this wasn’t such a good idea either)

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Fine.

Lowering my blood pressure isn’t the worst idea in the world, and those vaccines are recommended for people over 50.

But here’s what the doctor didn’t ask about or do.

I had been bitten by a tick a few weeks before and been seen at an Optum urgent care clinic. I had taken doxycycline. That visit had to have been in my records, but he didn’t ask about it.

He didn’t see the nasty scab it left, either, because he didn’t take my shirt off and look at me. He didn’t judge for himself my muscle tone (or lack) or my skin and its moles or sun damage.

He didn’t ask about my drop foot or the back surgery, either — even though those had to be in my records too, since Optum doctors performed the pre-surgical care and the surgery. To be clear, I didn’t expect him to be able to fix my foot. But the drop foot and the wasting of my calf muscle that has resulted is the worst medical issue I’ve ever had. I find not being able to run deeply frustrating. He didn’t even know about it. Nor would he have seen it had I not raised my pant leg to show him.

He didn’t ask me about my physical or mental health or my life, even in the most general ways.

Nope, what he cared about was what he could measure (and what Optum would measure him on): the blood pressure reading and the vaccines.

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I’m not surprised this doctor didn’t seem to care about me as a person. That’s not great, but on some level it’s to be expected. This was my first visit to a guy who probably sees dozens of patients a day in the most impersonal environment imaginable.

But I was surprised, and taken aback, that he didn’t seem to care about my body.

He didn’t seem like a bad guy, he was pleasant enough. But he didn’t seem like a physician, either. He was a functionary treating a chart according to an algorithm, not a doctor treating a patient after a decade of training.

At the end, he asked me if I had any questions. I’d actually expected a prostate exam. But I realized I couldn’t possibly mention it, I couldn’t ask this guy to glove up. Nope, I said.

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(Unreported Truths: more fun than a prostate exam! Unless that’s your thing.)

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I didn’t bother to make another appointment on the way.

I knew I wasn’t possibly buying a blood pressure cuff or coming back in to be given a prescription for medicine I don’t want or need. Still, I figured I could at least get my labs done.

But when I went downstairs, the waiting room for blood work was packed. I left without even giving my name.

I can’t imagine the next time I’ll be back for a physical.

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It’s not like my old doctor was running some high-end concierge practice. But he’d been trained at a time when scanning technology was far less advanced and physicians were expected to hear and see and touch their patients. And he’d built his practice at a time when a doctor could survive easily as a solo practitioner, before the cost of privacy-compliant medical records software and dealing with insurance companies made doing so next to impossible. He had the expectation he would see the same patients for years or decades, and he did.

He was treating patients, not charts.

But he’s gone now.

It’s Optum that’s won.

(If you have your own personal story of you’ve seen medicine change as a patient or, umm, provider, I’d love to hear it in the comments.)

1. There may be a more movie-villain company name than “UnitedHealth Group,” but I can’t think of it.