I stood up as a very tall young man walked into the examining room, didn’t introduce himself, shook my hand, and as he sat down, his booming voice uttered one word:



It reminded me of the time in 2006 I was in Grand Marais, Minnesota, the night before I went to Isle Royale National Park.  I was at the casino eating dinner, since that was the only place open, and the waiter walked up and uttered one word.



I remember repeating the fish’s name, interrogative, and he replied that it was the special. I’m not sure if I decided to have it, but I do remember his introduction.  

I went to the urologist’s lab a week prior to get my annual PSA test.  I am more concerned about my PSA than I should be, but I remember the adage that the probability in percent  of a man’s having at least microscopic prostate cancer is equal to his age.  In addition, my father had it, and he took an expensive medication to control it.  My only biological brother doesn’t write me often and may not have been checked in years, so I don’t know anything there. 

I arrived at the office for my appointment 20 minutes early to check-in, the check-in line out the door, and only one person working.  I joined a few old people there, and while waiting, I heard a daughter ask her mother-patient questions that the latter needed to have repeated and wasn’t sure of the answer.  The receptionist had a problem couple she was helping, and explaining the iPad check-in took time.  Life is sometimes difficult for those of us digital non-natives.

Eventually, it was my turn, and fortunately, I was checked in quickly and given two pieces of real paper on which to write down my medications.  Before I even got to the third line, I was called: “Michael?”  

While I usually introduce myself to younger people by my first name, I don’t like being called it in public by people who are a third to half my age and don’t know me.  It wasn’t worth saying anything, but whatever happened to basic formality? Perhaps if we were more formal in our speech and treatment of each other, we Americans might be less polarized.  Or not.  Just sayin.’

The nurse told me that “James” would be seeing me.  I didn’t know a James, and I started running through my head my doctor’s first name.  On my way to the inner sanctum, I had to get weighed, so I took my phone and wallet out of my pocket, stepped out of my shoes and got on the scale.  I lost 13 pounds two years ago, kept it off, and am proud of it.

I was put in a room to wait for “James,” saw my doctor’s first name (David) on a business card, and within a couple minutes, the tall man entered.

I was so stunned by the start, I couldn’t think of anything to reply to  “Questions?”  

I should have asked, “Who are you?” But, I read the “PA” on his badge.  I could have then asked, “Where’s David?” But obviously I was going to be seeing a PA.  I stammered, much like Ralphie does in the movie “A Christmas Story,” near the end, on Santa, he clams up and finally says, “A football?”  with my version of the pigskin:  “What was my PSA?”  

Tappety tap, mouse clicks.  Then, “When was it done?” Answer—with plenty of time for it to have been sent here and written on a piece of paper that you could have taken in your large hands in here and given me the result immediately instead of tappety, tap.  I stared at the wall and finally learned it was a good 1.8.  

I liked my physician, David. He’s a major player in the local and state medical community plus being a principal investigator for the practice.  I was once a player in my local and state medical community but never a principal investigator, although I tried to get my colleagues to investigate errors, but that didn’t work out.  

I have called the office and been on hold, where I heard about the great cutting edge, literally and figuratively, care is given.  It’s truly impressive, as is the information given to patients, hearing, “Knowing is better than not knowing.”  But, I didn’t know why I wasn’t seeing David but a PA.  I realized that being a retired physician counts for little these days, either in a medical office or outside of one, where first responders, nurses, and therapists carry the day and docs are good for ….well, let’s face it—being donors, bashed as a group, or occasionally being asked to give a curbside or trailside diagnosis. I had several questions, and while some were answered, it wasn’t the same.  I got my exam and some recommendations.  David told me a lot more.

The next thing I knew, I was walking out of the office, aided by a sign pointing to the exit, which was needed, because I needed to be in the left lane or else walk into somebody’s office. I remember thinking that the sign needed to be permanent, because it was necessary and the temporary one looked tacky in this 21st century office.

I had been looking forward to telling my urologist that I was off diazepam, that I had both discovered and used it successfully for a nasty condition. I tapered it myself, after one internist suggested as I got older I had more of a fall risk taking it, which was true. I tapered it faster when my next internist ignored my refill order. Don’t get severe pain today, because physicians are scared of the feds coming down on them for opioids and other controlled substances scripts, even when diazepam is not an opioid.  We went from pain as a 5th vital sign to don’t ever give opioids. I’ve been on this pendulum before.

I never got to talk to my urologist about the fact that some of my issues arise from other medications I am now taking.  This stuff happens at 70. I wanted to talk to him, because “Knowing is better than not knowing,” unless one is an old man with a stable condition and can be put off on a mid-level practitioner, rather than the physician.  I never did that when I was in practice.  I saw people, I returned their calls myself, I gave mountains of free advice and care, and I was a chump in another era.  But I was available, for better or for worse; for worse, if I were sleep-deprived, which was often. My office didn’t require people to make more than two 90 degree turns or walk more than 10 meters from the waiting room.  We didn’t need signs showing how to leave the sanctum sanctorum.  

It’s a different world.  

I wrote David and said I had missed him and had looked forward to seeing him.  I never got a reply.  That hurt.  It takes 24 seconds to send a polite blow off email.  I timed it once.  I sent an email to James deciding to take the medication we discussed, and several days later screwed up logging in to my patient portal, getting my account locked.  I waited and sent a couple of emails, and nothing happened.  A call finally settled everything, and I was told an email for me was on the portal, except it wasn’t.  Three days later, I got a three emails giving me a password to my account. Not being a digital native, I just thought it was a bad system, but digital is always better.

I thought that the bill would be less because I saw the midlevel and didn’t have a urinalysis, which I wanted to have.  It is, after all, a urology office.  One colleague told me that my bill would be the same. We were both wrong. It was $150 more than the prior year, when I saw the physician AND had not only a urinalysis but an ultrasound. My followup care charges in 1992 were $35. By medical inflation, they should now be $90. It was $350 for what I described above. We’ve lost something in 21st century medical care.  We are arguing as a nation as to who should and should not have care and how it is paid for.  Fair enough.  We need to do more, in my opinion.

But how the care is delivered is not unimportant. Knowing is better than not knowing.  And there is still important magic given by physicians who actually take time to see patients. That time matters.  Knowing matters. Laying on the hands matters.  I didn’t fully understand that when I was in practice.  I do fully understand it now.

And we have yet to fully address quality of care.  That’s for the 22nd century.

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