Raymond Chandler attacks US healthcare in newly-discovered story

Authored by theguardian.com and submitted by Crowji
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It’s All Right - He Only Died was found in The Big Sleep author’s archives with a note underlining his contempt for doctors who turned away poor patients

A lost story by Raymond Chandler, written almost at the end of his life, sees the author taking on a different sort of villain to the hardboiled criminals of his beloved Philip Marlowe stories: the US healthcare system.

Found in Chandler’s archives at the Bodleian Library in Oxford by Andrew Gulli, managing editor of the Strand magazine, the story, It’s All Right – He Only Died, opens as a “filthy figure on a stretcher” arrives at a hospital. The man, who smells of whisky, has been hit by a truck, and staff at the hospital are loth to treat him because they assume he will be unable to pay for his care. “The hospital rule was adamant: A fifty dollar deposit or no admission,” writes Chandler.

Gulli said the story was one of the last things Chandler ever wrote – it is believed to have been written between July 1956 and spring 1958. Chandler died in 1959. “He’d been in and out of hospital, he’d tried committing suicide once, and he’d had a fall down the stairs,” said Gulli. “The story mirrors some of his experiences of that time. It’s about what he calls a ‘transient’, a homeless man who gets hit by a truck and who finds himself in a hospital that is reluctant to treat someone who can’t pay the bill. And of course there’s a twist at the end.”

The Strand is publishing the story this weekend, complete with an author’s note from Chandler in which he reveals his fury at the US healthcare system. The doctor who turned away the patient, Chandler writes, had “disgrace[d] himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long-acquired skill might help or save”.

According to Chandler scholar Dr Sarah Trott, the story is “a prime example of Chandler as social critic and visionary in American literary history”, and unlike anything else Chandler wrote, with its serious tone, “bordering on sinister”.

“The story’s unsympathetic dialogue, paired with Chandler’s damning assessment, in itself unique, suggests a deep personal dissatisfaction with American healthcare, where the amount of money a person carries can dictate the level of care they receive,” Trott writes in an assessment of the story also published in the Strand. “It is a contemporary life-or-death story; a cautionary tale about the problematic nature of assumption and appearance in a ‘cash-is-king’ society, and a disturbing commentary about the American dream, where the competition to remain employed means not running a hospital ‘for charity’, even if it requires denying medical attention to a seriously ill patient.”

Trott called its publication timely, given the current situation with US healthcare, pointing out that Chandler was a British citizen until 1956, and would have had experience of the contrasting service of the NHS. “It feels relevant today,” agreed Gulli. “Things don’t change.”

Gulli, who has previously unearthed stories languishing in archives by major names including William Faulkner and HG Wells, said that he had given up on finding anything new by Chandler.

“I was very pessimistic,” he said. “You don’t see all the times I’ve found something by a great writer and it’s not that good, it would be a minus on their reputation.”

He speculated that Chandler might have decided not to publish the story because it was so different from his Marlowe tales. “I think perhaps, since this was unlike anything he’d ever written that he might have decided not to publish it,” he said. “To me, this shows the activist side to Chandler, particularly with the author’s note. This was not Marlowe showing up some of the LA phonies, this was Chandler penning a social message.”

thereisafrx on November 16th, 2017 at 16:59 UTC »

Resident physician here; the problem with the U.S. healthcare system isn't physicians. It's the creep of businesses and extraneous activities into hospitals that keeps adding expenditure. I wish I could find the figure but there was an amazing graph in the New York Times a few years ago that showed the effect of "skimming" in healthcare from the early 1990s (almost none) until 2015 and it was a >200% increase. An example of this is people get hired for administrative positions, they have a nice cush job, get great healthcare because they work for a healthcare company, and then don't want to leave so in order to justify their existence a new form is created or a new departmental activity is instituted. Over time this has resulted in huge flocks of employees working in hospitals, who have absolutely no connection to healthcare whatsoever and do not generate any definitive income for the hospital (hospitals make money treating patients, and if they make more money doing something else then they are not and should not be a hospital). In the system where I work, we have assistant associate vice presidents for nursing outreach; wtf does that even mean? From a healthcare standpoint, dollars earned through patient care go to pay these people's salaries. Where do those dollars come from? They come from the academic hospital charging your private insurance $1500 for a bag of normal saline in the ED; that bag of normal saline also pays for the next 50 bags of saline that the ED will give to people with no insurance who come to the ED for a cough or sore throat, and the ED isn't allowed to turn them away because one time, 10 years ago, one person got turned away with a sore throat and they turned out to have throat cancer which went un-diagnosed and then a lawyer caught wind of it and sued the hospital for multiple millions (despite the fact that if that patient had had a primary care physician, it still most likely wouldn't have been diagnosed because lots of people my colleagues see for mouth/throat cancer show up with a recent rapid strep test at an urgent care clinic and a script for 10 days of augmentin).

Do I sound jaded? Sure. I knew what I was getting into when I signed up and it's part of the process to work your ass off for little pay, but you don't realize how bad it is until you start getting into the thick of it. It simply doesn't make sense from a happiness standpoint to become a physician anymore There are literally hundreds of people at my institution whose jobs could be deleted and it wouldn't affect patient care one bit. Half of these people spend all their time telling physicians what they can and cannot do, coming up with regulations that are more reactionary than based on evidence.

Now, for the economic aspect of going into medicine, I haven't really seen anyone touch on the opportunity cost of becoming a physician. My colleagues from college have been working since the late 2000s, most of them with nice engineering jobs, starting families, 401ks, buying houses, etc. I am one of the lucky ones to have a spouse who is also a physician (in training) and we have two kids and managed to scrape enough together to buy a house. We aren't saving anything, however, and are living paycheck to paycheck. This means that we won't start saving for retirement until one of us finishes training in a few more years.

Meanwhile, all of my friends who did the smart thing and got a real job right off the bat, have been working for 9 years already and have 9 years of contributions and growth to 401Ks, most have gotten raises and promotions and so are making mid 100ks. I am in a surgical subspecialty and my colleagues who are finishing are seeing first contracts in the 200-300 range; this may seem like a lot of money but to pay back your loans most payment plans are income-based, so the monthly payment is around 2500-3000 if you have, like me, around 250k-300k in loans. Monthly, your after-tax income is around about 15k. Take away student loans, malpractice, etc. and you have about 10k per month. You could easily get this kind of money doing a degree in computer science, going to work for a tech company, and being a code monkey (avg salary at a company like google or facebook is mid-100sk after 5-10 years). This is the same timeline but you don't spend 10 years of your life (4 of med school, 3-6 of residency and 1-3 years of fellowship) getting verbally abused, waking up at 5 AM and working until 8 PM 6 days a week, missing birthdays, family events, and only getting 3 weeks off a year (which, also, most residency programs will give you 7 days off, from Monday-Sunday, and the Sunday before your vacation starts you're on call, so you start your vacation sleeping for a day).

Finally, the last point I wanted to make is that most of the people making healthcare policy are lawyers and politicians; VERY Few of these people are physicians and actually know what it takes to take care of a patient well. Most of the policy nowadays is based off of bullshit hospital rankings that only look at complication rates (which are easily fabricated, another example is a physician I worked with who had a templated note for all of his patients that said the same thing, no matter what, he then maintained a shadow EMR where all the complications and actual patient care happened, so when JCHO came to inspect and do chart reviews everyone looked great with no complications. Ha, what a fat lie).

tl;dr - becoming a physician is not cush. At all. Our income is proportional to the opportunity cost of delayed employment. If I work my but off as a surgeon, don't see my family at all, and make $500k/year it's because I fucking earned it and I'm going to smack you if you think I'm part of the problem.

Younghoe_Koo on November 16th, 2017 at 14:53 UTC »

Blaming doctors just shows how misinformed people are. In most hospitals, the doctors do not decide who is seen and who isn’t. The hospital itself dictates the prices and who receives care.

WithOneSipOfTea on November 16th, 2017 at 14:50 UTC »

Living in Jacksonville, FL ... I can’t tell you how common place this is. I get turned down and told “we are not accepting anymore Medicaid patients” almost immediately when I ask if my insurance is accepted there. This really upsets me because you know for a fact they’re not accepting anyone because the only places that do are PACKED FULL. 24/7. The wait times there are backed up 2 months sometimes. Your only option is the emergency room to get meds if you’re sick, or a doctors note. God forbid you need anything done. If you have a job and get sick, they ask for doctors notes, but your PCP can’t schedule you a visit until way after you needed the note.

Edit: I’ve only contacted places that said they accepted. Sorry about forgetting that detail.