Monday, July 09, 2007

Michael Moore's Sicko: a Review

In the opening segment of Sicko, we learn of a man who severed the top of his ring finger and top his middle finger. The man did not have insurance and was told that he would have to pay $12,000 to have the ring finger made whole again and $60,000 for the same for the middle finger. He chose only the former and presumably gave the middle finger to the hospital.

As Moore makes clear early on though, this is not a film focused on the uninsured. For the first half of the movie, Moore is primarily concerned with insured Americas who were “swept into the cracks by the insurance industry”. As with all of his films, Moore takes Stalin’s infamous, but true, maxim to heart. "One death is a tragedy; a million is a statistic." The film is emotionally compelling. It is also funny, albeit in a Kafkaesque sort of way. For example, one woman tells how she was involved in serious head on collision, knocked on unconscious, taken to hospital while still unconscious and then told by her insurance company that she must pay for the ambulance ride because she did not get it pre-approved.

The film does have its faults. Nuance has never been Moore’s strong suit and he never fully grasps the issues at hand. Moreover, the bulky quintessential American does have a talent for telling lies of omission; the omitted Roger Smith interviews being the best case in point. In Moore’s telling of tragic story of year and half year old Mychelle Williams the aforementioned shortcomings come together. This is a court summary of what happened to her.

“On May 6, 1993, at approximately 5:30 p.m., Dawnelle Barris (hereafterBarris) brought her 18-month old daughter, Mychelle Williams, to the emergency room at Martin Luther King/Drew Medical Center (hereafter King/Drew) by ambulance. Mychelle was a member of the Kaiser Foundation Health Plan (hereafter Kaiser), but was taken to King/Drew because it was the nearest emergency medical facility. She had suffered episodes of vomiting and diarrhea, was lethargic, and was having difficulty breathing. Her temperature was 106.6 degrees, her pulse and respiratory rate were abnormally fast, she had abnormally low pulse oxygenation, and she had infections of the middle ear in both ears.

Mychelle was transferred to the pediatric emergency room, and examined by Dr. Trach Phoung Dang. He believed her fever might be caused by bacteria in the bloodstream. He noted signs and symptoms consistent with sepsis, a life-threatening bacterial infection that he knew requires prompt treatment with antibiotics. Nonetheless, he did not rule out sepsis or begin antibiotic treatment. Although he concluded that a complete blood culture, which could have detected sepsis, should be done, he did not order it because he believed that he had to obtain authorization from Kaiser. Kaiser had developed a program called the Emergency Prospective Review Program (EPRP) to deal with situations where a Kaiser member is brought to a non-Kaiser facility for emergency medical care. Its purpose was to facilitate the transfer of such patients to a Kaiser facility.

On the night of May 6, Brian Thompson, a Kaiser physician, was handling phone calls that came in under the EPRP. At approximately 7 p.m., Dr. Dang spoke by telephone to Dr. Thompson to arrange for possible transfer of Mychelle. Dr. Dang discussed her condition and indicated that he thought blood tests, which would rule out a bacterial infection in the blood, should be performed at King/Drew. Dr. Thompson instructed him not to perform the tests, saying that the blood work would be done at Kaiser. Apparently still concerned about the delay in treatment, Dr. Dang telephoned Dr. Thompson again, and repeatedly suggested starting the blood work at King/Drew. Again, Dr. Thompson instructed Dr. Dang not to do so. Dr. Dang noted in his chart that “Dr. Thompson at Kaiser did not want me to do any blood test.”

At approximately 8 p.m., Mychelle suffered a seizure. She became increasingly lethargic and nonresponsive. Dr. Dang treated her symptoms of fever, dehydration, breathing difficult, and seizure, but did not administer antibiotics.

Shortly after 9 p.m., Mychelle was transferred by ambulance to Kaiser. At 9:50 p.m., within 15 minutes of her arrival, Mychelle suffered a cardiac arrest and was pronounced dead shortly thereafter. A blood culture performed as part of an autopsy was positive for streptococcus bacteria, which is readily treatable by antibiotics. The death certificate listed cardiac respiratory arrest caused by septicemia, or sepsis, that had been present for 10 hours.

Moore puts the blame squarely on Kaiser’s shoulders. He implies in the movie that it was Kaiser’s refusal to allow the blood test to go ahead that led to the toddler’s death. No one outside perhaps Dr Dang shares this opinion and the important question as to why Dr Dang was unwilling to go head with the blood test irrespective of what the Kaiser official said goes wanting for an answer in the movie. Truth be told, both sides where equally guilty. They literally passed the buck back and forth while the little girl died, but there was no official denial of coverage. No side had blinked by the time the little girl had died.

At trail, Dang testified that although he was cognizant of the fact that sepsis was a possible cause of the girl’s condition, he thought the cause was an acute asthma attack. An expert for Barris, Mychelle’s mom, blew Dang’s story apart. The expert noted that the medical record and Dang and Thompson’s conversion showed that Dang believed that it was sepsis. The expert also noted that irrespective of what he thought, it was standard practice to administer antibiotics just in case it was sepsis. The jury found for the plaintiff. The majority of the blame was assumed by Dang and the county.

Kaiser is now using Dang’s discredited testimony to undermine Moore’s account.

"Fourteen years ago, the treating physician at the King/Drew Medical Center incorrectly believed that he was treating a patient having an acute asthma attack. He had several phone conversations with one of our physicians. Neither physician discussed the possibility that the child was suffering from a grave blood infection. During the course of those conversations, given the asthma misdiagnosis, the Kaiser physician believed that necessary tests could be conducted at Kaiser once the child was stabilized for asthma and transported to Kaiser. As a result of the misdiagnosis, the child ultimately succumbed to her blood infection. We offer our deepest sympathy to her family. ….

We regret that none of the physicians involved recognized that the child had a life-threatening infection and not asthma. The movie claims we denied coverage of treatment by the doctor at the county hospital. That was not true. The issue was a misdiagnosis followed by the wrong treatment. The movie is inaccurate in its portrayal of that sad case.

This was essentially a tragic case of medical malpractice.”

Kaiser is trying to paint a case of medical malpractice arising out of corporate greed as a case of medical malpractice arising out of a misdiagnosis. What they are saying is, of course, complete and utter bullshit. Indeed, if you are to believe Kaiser “neither physician discussed the possibility that the child was suffering from a grave blood infection [i.e., Sepsis]” even though there were repeated requests made to Kaiser to have her tested for exactly that.

One can only hope that Kaiser’s efforts backfire. The insurance industry and their allies in the Bush administration have long maintained that medical malpractice suits are driving up costs and this has detrimental costs for all concerned. The cost of such lawsuits, many they argue illegitimate, needs to be capped. After all, medical error can never be fully eliminated and there is no fool proof method for preventing illegitimate lawsuits for succeeding from time to time. The Mychelle Williams case turns this talking point on its head. Mychelle Williams did not die due to medical error. The cause of her death was that no one was willing to say the buck stops here and get on with treating her in a timely manner. A reasonable conclusion to draw from this and other cases like it is this. If liability was ridgely capped, the insurance industry would be able to calculate the potential costs of not providing standard medical care and this would lead them to build into their business a rubric for determining when it is in their best interests to provide standard medical care when it was advisable to encourage malpractice or even engage in it . In other words, it would mean more Mychelle Williams.

The other half of the film is less memorable. The much criticized survey of health care systems outside the US has gotten far more negative publicity then it deserves and has only served to distract from the moral backbone of the film. The survey should be taken for what it is, namely Moore’s flippant response to the scaremongering tactics used by those opposed to “socialist medicine”. Besides, all is fair in love and Moore. What struck me about survey as noteworthy was not its superficiality, but rather the fact that not all of those that are interviewed are terribly sympathetic. As a Canadian, I was not happy to lean about the American health care refugee, or her older Canadian friend with benefits. I imagine the defenders of the French system where similarly not thrilled to learn that one of there own took a three month fully paid doctor prescribed vacation partying in the French Rivera. These are trivial complaints though.

The criticisms of Moore’s Cuba adventure carry more weight. However well intentioned the cause, when one gets right down it Moore provided a dictatorship with great PR. That said, the fact that the Castro regime was able to score so many points when given the chance reveals just how broken the US system is. No other western country would be as vulnerable.

1 comment:

Anonymous said...

good review.