No skin off my nose, pal

As the narrator of this tale, or the plaintiff in a related medical malpractice nuisance suit, I have the great advantage that you won’t need to squint or strain to see the fingernail sized permanent divot on the bridge of my nose. You can see what I’m peeved about at a glance, even in low light.

This lifetime scar gives me instant credibility as the teller of this particular story, and a bit of pathos too. Juries like pathos, if they shudder to imagine having been subjected to the same thing the plaintiff was forced to undergo.

It’s always a mistake, of course, to believe that a gratuitous scar on one’s face, inflicted by a doctor who has not performed the medical procedure he prescribed, the one authorized by insurance, is a legally cognizable injury.

Let the lawyers fight it out, I say.

“Is this scar going to fill in?” I asked the confident doctor three weeks after the surgery, a single gouge deep into the bridge of my nose, to remove a basal cell invisible to the naked eye, a large round wound which was then cauterized instead of stitched.

“No, that’s about as good as it’s going to look,” he said, with admirable candor.

My next question was based on the four or five previous Mohs surgeries I’d had to remove much more visible, deeper, more advanced basal cells (the most benign form of skin cancer). Each of these surgeries had taken several hours, as opposed to the 30 minute procedure his surgeon had done on my nose.

“I was supposed to have Mohs surgery, which removes one thin layer at a time to preserve as much healthy tissue as possible and minimize scarring. Your surgeon basically took a small, sharp ice cream scoop and scooped out all the surrounding tissue in one pass, down to the cartilage,” I said.

“Yes,” said the doctor. In that moment I didn’t have the presence of mind to say anything more. I suppose my psychic efforts were focused on not cauterizing the good doctor’s nose right then.

The doctor’s attitude about the prominent scar in the middle of my face was a slightly impatient “no skin off my nose, pal.” His body language said “are we done here? Any more rhetorical questions?” He thought for a moment then told me about a powerful prescription cream that reduces scarring.

“But your insurance won’t pay for it,” he told me a moment later. The kindly doc then sent his nurse off to find a few of the free sample tubes the pharmaceutical company rep had left him a case of. The cream, which came with no instructions except his nurse’s “apply in a very thin layer”, seemed to irritate the scar which became increasingly uncomfortable until I stopped using the stuff.

In the debate over “socialized” medicine we often hear the critique about the “rationing” of medical care not provided on a competitive, profit-driven “free market” basis. Healthcare, in Communist nations like Great Britain, Canada, Japan, France, etc. is rationed, we are told, because everyone is presumed to be equal when it comes to health care and so there is often a line for some procedures. While it’s true that the wealthy can skip the lines, even in those countries, by going to a private doctor, health care for most is still “rationed”. Here, under our system, the level of care you are “entitled” to is rationed by your ability to pay a monthly health insurance premium. The more you pay, the higher the quality of care you are entitled to, the less rationing you will be subject to.

Here in America every doctor, even the kind orthopedist I’ve visited a couple of times for the arthritis in my knees, knows exactly the level of your insurance coverage as you sit discussing medical options. “Unfortunately, your insurance won’t pay for it, though it works very well to keep the knee pain-free for six months or so while you strengthen the surrounding muscles,” she said of an injection she proposed. She nodded when I told her I’d be on Medicare soon, hopefully. Medicare will absolutely pay for the shot, she told me with a smile.

A cardiologist, who revealed himself as a mask-shunning Trumpist during the pandemic, billed almost $12,000 for each of the four procedures I had on veins in my calves. He’d told me confidently “your insurance will cover it.” My insurance paid him almost half. Not a bad hour’s work for those first three veins. I had a mirthless laugh when I got my “Explanation of Benefits” for the fourth and final venous ablation. He’d billed $12,000 and received zero. His office, apparently, had failed to renew the authorization to be paid. I guess their lawyers will have to fight it out, and good for them both.

A doctor working for a patient with low-cost health insurance (dictated under the ACA according to your declared income, the only choice a low-income patient has is to accept the offered insurance or reject it — and have none), knows exactly how much of the amount his office bills will be paid by the insurance company. This dermatologist motherfucker had every incentive, based on the small fraction of his billed Mohs surgery fee he’d receive, to get me in and out of his office as quickly as possible. Thus incentivized, I was in and out quickly. Even though the surgeon couldn’t see the tiny spot he was supposed to remove.

He called in the dermatologist for a quick consultation, they looked at the photos of the two biopsies (the second had been necessary because the first was done in haste) and concluded it was there, just next to that broken blood vessel. I had a strong reflex to hesitate, as if in a moment of precognition.

“If you can’t see it clearly, I’d rather wait a few months until it’s visible,” I said with mild panic, knowing that these slowly growing cells can be there for a long time with no terrible effect. The confident dermatologist told me that they concurred, knew exactly where the basal cell was and that there was no need to put off the surgery. Like a schmuck, I sat back and let the surgeon hurry to gouge out the entire surrounding area, taking out a circle of healthy tissue to ensure he got the basal cell.

I was in and out of the office in just over a half hour, less time than even the first phase of Mohs surgery usually takes, as I know from experience, having had the procedure now five times out of six. Cah-ching.

As for Dr. “No Skin off My Nose”, what are the odds that a patient with a scarred face, given one more small scar for good measure (and to maximize the good doctor’s billable hours) will have the ability to coherently make a case that a doctor who prescribed surgery A, had that surgery (as well as a skin graft to minimize the scar) authorized by the patient’s insurance and then provides surgery B, including the burning of the flesh around the unnecessarily large wound, deserves a little shit, from his medical ethics board and a payment from his malpractice insurance carrier for the nuisance he inflicted (I have pain at the site of the surgery months later, in addition to the small crater) to the guy whose nose he brutalized?

It may take me a little while longer, but this slick, confident operator needs his smug fucking face cauterized too, just a little. No? After all, it is really no skin off my nose.

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