21 August 2008
Some of my friends have told me it took them two years to adjust to life back in their home country. Hmm. Sounds like about the same amount of time it took me to adjust to life with baby! Actually, life with baby was a bit faster than that. It only took about a year for me to adjust to the new state of reality after my first child was born.
After baby was born, I kept putting off certain chores or things that needed to be done. At first, I had difficulty even getting out of the house. As soon as I got ready to go out, the baby would be hungry again. So, I’d feed her and change her diaper. It was winter, so I’d have to get her all bundled up again. And then, just as we’d be going out the door, there would be a noise and an odor, and my little bundle would need a major diaper change. Then, after the diaper change, I would look at my clock and realize it was almost time for her next nap. After the nap came more feedings, and before I knew it a whole day would have gone by, with nothing to show for it.
Things got a little easier as time went on, but I found myself still putting off major chores, waiting for things to "get back to normal". One day when baby was about nine months old, it struck me suddenly, like a lightning bolt: "This IS normal!"
What had happened, I realized, was that "normal" had changed. Now it was normal to have a little person in tow. Gone were the days of running errands without a little person in the car seat beside me, needing constant food, diaper changes, and various forms of attention. Gone were the days of hopping out of the car without carrying a 20 pound baby carrier. Once I accepted the new reality, that I had a little bundle in a car seat everywhere I went, and that I couldn’t do 20 errands at one time anymore, things were a lot easier. I learned to adjust myself, and my expectations of myself, to a new notion of what was normal.
So, now that we’re back in the USA, "normal" has changed once again. It’s time for my own, mental adjustment. Along those lines, I just broke down yesterday and signed a two year contract for an exorbitantly expensive and poor quality cell phone service. I guess I’ve just been being spoiled by being able to purchase affordable SIM cards and prepaid service in every other country in the world that I’ve traveled to, with no ominous questions about whether the particular service would work or whether the SIM card was set to destroy my phone if I failed to use proprietary components. It took me six full weeks of paying ten cents per minute for prepaid cell phone service to break down, accept the new reality, and sign on the dotted line for a stupid two year commitment. In my opinion, Americans get horrible cell phone service, cheap and poor quality phones, and pay what must be the highest prices in the world for it. And there’s nothing I can do about it! My friends sometimes are amazed that I don’t follow the news very closely. The truth is, I try not to worry about things I have no control over. What’s happening between Russia and Georgia, I’m sad to say, is something that I have no control over, so I try not to dwell on it too much. Same with the cell phones. I can only fight it so long. I bought the service. (Thanks, Uncle Sam, for deregulating the cell phone industry! I really appreciate that. It gives the powerless consumer so many options to choose from among the circling, large, cell phone company sharks, growing ever fatter from feeding on the poor consumers.)
But there are other things that I have more control over, and in which I still allow myself to be taken advantage of. Another cultural adjustment issue I’m having some shock about is the exorbitant prices Americans pay for everything. It’s also shocking that they pay those prices without batting an eye.
In fact, one of my sticker shock issues this week came from an annual eye appointment. My prescription hasn’t changed, but I couldn’t get new contact lenses without a new prescription because my prescription was more than a year old. My husband’s eye glass prescription hasn’t changed in more than 25 years, with the exception of now needing reading glasses, but he too must go for a new prescription every time he needs a new pair of glasses.
I’ve been going to the same Optometrist in the USA for about 25 years. I really like him. He has seen each of my children when they were toddlers. He remembers them. He does a good job with our prescriptions, getting them just right every time. And just this week, he charged us $168 apiece for our annual eye exams! If all five of us had gone, as we had hoped to do, the cost would have been $840!
That is $168 U.S. apiece . . . that’s Mei Jin (American money), not RMB! It was broken down like this: $79 for "established patient comprehensive eye exam," $60 for "contact lens conventional fee" (which means, for a contact lens "fitting"), and $29 for "optomap screening" (a high tech, computerized picture of the back of my eye).
I admit, I hadn’t asked the price ahead of time. And maybe I’m willing to pay a lot for really great care. But I was flabbergasted when, after the visit, I went to pay the bill.
My mom chided me for paying this much. She said she goes to Wal Mart because it’s cheaper and she’s happy with the care. I agree. I could have priced around and gone to the place with the cheapest price, and I didn’t. And also, as I thought back about it, I really wanted to go back to my "old" eye practitioner. For the last three years I’ve gone to different optometrists in the USA during each summer visit home, and somehow I didn’t have quite the same level of satisfaction with the particular contact lenses I was given. I didn’t feel I needed a detailed medical exam, as I would have gotten from an surgeon, but I wanted to go to someone I trusted. And that trust was built on a relationship rather than on credentials. Too bad perhaps he sees that relationship as built more around making money from me!
It was China that taught me how mercenary the medical profession can be. In China, it is normal to negotiate the price of your medical treatment, and doctors will routinely charge what they can get by with. But somehow, I was still in the middle here in the USA. It still takes me by surprise to learn that my caregiver is more interested in making money off of me than in making sure I get the best care.
I should have known better, though. I’ve long been convinced that each optometrist pushes the particular lenses that he happens to sell or which he gets the highest level of reimbursement for. Yep. That’s how jaded I am. If there are ten different lenses that would work for me, why not let me try them and see for myself which one works the best? Why else would they hesitate to give me my own copy of my prescription
and then let me research which brands of lenses fit the bill for me? Why not do what the dermatologist did, and give me samples of ten different sunscreens to see which one I liked the best?
Anyway, those suspicions aside, perhaps I’m willing to pay a high price for a "contact lens fitting" and "comprehensive eye exam" perhaps couple of years, with lesser levels of screenings in between. But it should be my choice. Indeed, that choice is exactly what position the extremely high price forced us into this week. My husband said that since he just had a detailed medical exam and had gotten new glasses last year, and because of the impact on the family budget of my having taken the children and myself, he would cancel his appointment. In other words, the result of my having paid so much for my care is that my husband is receiving none at all right now. Is that good?
Part of what’s so insulting about the eye office charging this kind of fee, also, is the fact that the optometry profession in the USA propagates lies to justify charging this exorbitant amount. If I hadn’t had experience in China and Thailand with the process of getting glasses and contact lenses, then maybe I’d be more gullible. But now I know better. Fitting a contact lens is not that complicated. When a technician in Thailand can take one look at me, tell me that my eyes are "medium" size, then use my glasses to measure my prescription, and charge $4 for the entire transaction, including the box of ten contact lenses, then you know that somewhere, somebody is raking in a lot of money, at my expense. Why does it cost $60 for this doctor’s technician to ascertain that my eyeball is "medium" size, probably right there in the middle 50th percentile of the entire world population? Why does this basic "eyeballing" of my eye size cost an extra $60, in addition to the $79 "comprehensive exam"? Sure. If somebody has a complicated eye, then I can understand charging them more, if there’s extra time and effort involved. But for an ordinary, normal person, charging this much extra is a racket.
This doesn’t just contrast with Thailand. In my observation, it doesn’t seem to be that difficult or expensive to get glasses in China, either.
In China, you walk in the optics store. They do an exam that includes looking through the machine with the lenses and being asked the "which is better, 1 or 2" routine. They do it until they get the prescription right. They check for color blindness, they use a light to look in the back of your eye, they do the air puff test for glaucoma. No, they don’t do the fancy computerized photograph of the back of your eyeball (which added $30 to the bill), but that’s the only difference I could tell. But, getting the prescription doesn’t cost a dime, if you buy your glasses at that shop.
So, after your eye exam in China, you then pick out your glasses and frame. And when you choose your lenses, you are given the option of lenses ground in a German lab and shipped in, lenses made in Japan and shipped in, or lenses ground in a Chinese shop. There is a range of prices ranging from Chinese made and functional, up to the most expensive lenses with all the coatings and treatments, ultra strong or ultra light, and imported from labs around the world. There is also a wide variation in price among the various frames, which range from the most expensive designer frames to the most basic plastic frames. The thing is, you are given the information and you choose. That’s exactly how my husband got his German (or Swiss? I forget) made, multifocal lenses, ultra lightweight, ultra thin, with safety coating (since he works in a chemical plant), and titanium frame glasses last year. We were given a lot of options and chose in the upper mid range in terms of price, but any of the choices offered would have corrected his vision adequately.
In the USA, in contrast, they try to keep the whole process mysterious and secret and make it as expensive as possible. They don’t tell you there are cheaper frames until after the sales job to sell the $600 frames has failed. They don’t show you the $50 frames until after the sales pitch for the $300 frames has failed. They don’t offer you safety lenses up front, you have to ask for them.
In fact, that lack of choice — the restrictions placed on my freedom to choose — is my basic gripe. It’s not that I mind paying extra for top quality care (or frames), if I choose to do so. Perhaps I would have willingly splurged on an expert "fitting" if I had been offered the option of the free versus the expensive version. What I really resent is the attempt to keep the process shrouded in clouds of mystery, a veil designed to keep the consumer ignorant of the fact that they are paying top dollar for something that is not top of the line. An effort to veil the truth that there are other options and that those other options might cost a lot less.
And yes, I have to say I have concluded that the care we receive in the USA is, generally speaking, not top of the line. Before I went overseas, I had bought into the notion that the USA had the best health care in the world. But then I experienced the "system" in other places, I realized that is just our national fantasy. Our health care in the USA is certainly more aggressive and more test-oriented than other places in the world. We have more bells and whistles and gadgets, but what really matters is whether the people who really need it receive the attention, as well as what is done with that information. Does that information translate into better care? It depends entirely on what is done with the information. Too often, the information stays hidden inside the doctor’s chart. That is not "the best". And, with all its tests and interventions and procedures and paperworks, our medical system surely must overall be the most expensive. It also has the most overhead. I think I wrote a blog entry once before which noted that Munchkin got an xray in a Chinese hospital on a wintery day, when all the windows were open and everyone in the building was wearing coats and gloves to keep warm.
There are a lot of ways to measure what is "the best". But "the best" is not strictly dependent upon getting "more" or getting "the latest treatment". Munchkin just needed a diagnostic xray and a splint. Her doctor in Guangzhou improvised the appropriate splint by using a popsicle stick and her roller blading wrist guard. It turned out that we didn’t need the newest elastomeric cast fiber for her broken wrist. Sometimes "the best" is, in fact, to admit that there’s nothing much that can be done and to receive compassionate palliative care.
Other times, it’s quite good enough to receive a much lower level of care. Like getting contact lenses in Thailand. All I needed was lenses. I didn’t need a comprehensive exam. I didn’t need someone with a doctorate degree. All I needed was a lens, and that’s what I got. And all I had to spend in Thailand, to get an appropriate level of care, was $4 U.S.. In the U.S., actually, I believe those lenses retail for $50, but to get that far I would have also had to have the "comprehensive eye exam" and the "contact lens fitting," so it would have cost me more than $200 for the same service in the USA. (This week, I did not purchase the contact lenses, so that has not yet been added in to my story here.) So my ranting question for the week is, "Why is it that in the USA, I have to pay roughly 50 times the price than what I pay in Thailand?" Yes! I said FIFTY TIMES the price. That’s x times 50. I can’t quite believe it.
You could respond that well, in the USA I’m being seen by a specially trained professional who makes sure that I don’t have glaucoma or degenerating retina. Hmm. Yes, that’s true. But does it take someone with a doctorate degree to screen for that? More importantly, why not leave it up to me to decide when I want to be seen by the doctor for that exam? Why be so condescending as to think that I am too stupid to make my own decisions about when I should receive a different level of medical care? (And corollary to this, why does the doctor bristle at my request for my record or my xray or my blood test result? Indeed, why does a testing lab think I’m not entitled to be told the result of a test I have paid for, that the information can only be communicated to my doctor?) Also, what if I can’t afford the $60 this time (indeed, as in this week, when my husband decided he couldn’t afford to get his eye exam just now)? What is better, to have a lower level of care that I can afford, or to deny me any care at all on account of the increased cost?
The other thing to note is, that this whole notion of someone else deciding what is good for me and then forcing me to live by their standard is just, well, so very American. Americans seem to run around the world applying their own ethnocentric viewpoint to decide what is "good," and then instructing everyone else in how they ought to do that. We could say that is what seems to be happening in our foreign policy, or school immunization policy (e.g. being varicella vaccine, which I asked for and was refused for my 2nd child but which is now mandatory for all school children in this state). But in fact, one of the funniest instances I ever saw was on the Lonely Planet Thorntree internet bulletin board for one of the countries in Southeastern Asia.
An American had made a six week journey overseas to Thailand, Cambodia, and Vietnam. Now the self-proclaimed expert, he proceeded to place instructions on an internet travel board about the etiquette and protocol of squat toilets. What made the post particularly hilarious was that he didn’t get it right!
So, that’s my rant for the day. I could call it a rant, but I think it more properly falls into the realm of health care ethics. Or perhaps it’s a matter of cultural adjustment to this very American idea of trying to regulate everyone’s lives for them and then making them pay extra for it. I think I’m adjusted relatively well to life back in the USA, but there are some things I am having to adjust to more than others!
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If you read this far, you get a prize. Namely, the photo that follows! David actually shot this on the wall of a restroom in a five star hotel in Shanghai. Enjoy! If you don’t understand what it’s about, let’s just say there’s a little joke. There’s a list that circulates around of items that "You know you’ve been in China too long when . . . ". One of the items on that list is when " . . . the footprints on the toilet seat are yours."
I hate to admit it, but after living in Southeast Asia for four years, the idea of American (sit-upon) toilets in public places seems really nasty. I’ve done my share of ranting about squat toilets. Sometimes I wonder if Asian men are capable of aiming at all. My husband says one restaurant he knows of solves the "aim" problem by putting ice in the urinals. This entices the men to practice their aim, as they earnestly try to melt the ice. I also sometimes wonder why, no matter how well the squatters are otherwise designed (with automatic flushers and even sometimes televisions at ground level), they always seem as if they were designed to splatter. Nevertheless, if I’m going to have to use a dirty toilet stall, especially when I’m helping a small child, I’d rather it be a squatter any day of the week! So yah, I have to confess. Along with horrible cell phone service, greasy food, and horrific prices, "sitter" toilets are one of the things I’m having to adjust to as well!