“An error lurking in the roots of a system of thought does not become truth simply by being evolved.”
– John Frederick Peifer

Forward: Will Mr. Obama’s “Patient Protection and Affordable Care Act (PPACA)” improve the American system of medical delivery, or will the nation slide from American-style medical care into Soviet-style “healthcare”?  Given the data from its model, RomneyCare in Massachusetts, the answer is the latter.(1) The following is a highly abridged excerpt from the semi-fictional novel, Inescapable Consequences; “The Doctor” and “Uncle” are two of the characters therein.‘Tis the kind of tale likely to be told and retold millions of times:(2)

The patient, a thirty-eight-year-old, married, obese, mother of three had a past psychiatric history of a single brief psychotic episode ten years previously, treated successfully with complete remission and without recurrence. Her recent health had been good until the current presenting complaint of several days duration characterized by abdominal pain with nausea and vomiting.

The morning prior to admission to the hospital, she had complained to her husband of a slight sore throat and a persistent mild but increasing nausea. She had declined to accompany the rest of the family to services at church. Upon his return, the husband found the patient still feeling ill. Her nausea had intensified somewhat, and she continued complaining of diffuse, dull abdominal pain.

Through his employer, the husband subscribed to a “healthcare-plan” issued by a “health-maintenance organization” or so-called HMO, the premium representing a significant portion of his wage. He telephoned the number provided by the HMO for such occasions, receiving only a recorded message with the usual disclaimer instructing him to telephone “911” if he, a layman, determined that the situation was a life-threatening emergency. Then, pursuant to the subsequent instruction by the recorded voice, he left his own brief message with his telephone number.

Approximately one hour later, a woman identifying herself as a nurse returned his call. She had no records of the patient available. As best he could, the husband described his wife’s current complaints and past history including her psychiatric history.

Addressing him by his first name, the nurse quizzed him primarily about his wife’s past psychiatric history, neglecting her present illness.  She then suggested that he telephone the following morning, Monday, to schedule a regular appointment.

He informed the nurse that, since his wife had been feeling increasingly ill for several days, she herself already had called for that regular appointment. The soonest that the receptionist would agree to schedule one was three weeks hence.

The nurse replied by advising him, nevertheless, to try again the next morning and to inquire whether there had been a cancellation. She also prescribed bed-rest and a diet of clear liquids.

Concerned about the typically long wait at the Emergency Room of the HMO, he asked if he could take his wife to a nearby ER. The nurse answered, “You’re free to do whatever you think best, but we can’t authorize an Emergency Room visit ‘out -of-network’.”  Her parting words reverberated in his brain like car-brakes without a lining. “Have a nice day.”

Late that afternoon, his wife was feeling no better. He decided that he would drive his wife to the Emergency Room of the HMO and hope for the best. Upon arriving, he registered his wife with the clerk, who told him that there would be “a considerable wait”.

One hour later, a nurse approached them in the waiting room for a “screening evaluation”. After a brief conversation, she said that she did not believe that his wife’s symptoms warranted a visit to the ER but that his wife would be seen “in due course”. Three hours passed. Feeling as sick as she looked, his wife was pleading for him to take her home. Instead, he took her to the Emergency Room at their local hospital, the financial risk be damned.

There, the clerk advised him that, if his HMO should decide, in its sole opinion, that the patient’s case was not a true emergency, he himself would be responsible personally for all charges. He agreed. He allowed the clerk to take an imprint of his credit card.

Another hour later, a nursing aide escorted them into an examining room. She recorded the patient’s vital signs, noting a slightly rapid pulse and a slightly elevated temperature.

Another thirty minutes of waiting. Then, a man in a white coat with a stethoscope entered. He introduced himself as “Dr. Faki”. Neither patient nor husband understood that Dr. Mohandas Faki was not a physician with an M.D. from an American medical school but a nurse with a Ph.D. from a foreign nursing school, nor did either understand the right to be attended by a physician not a nurse.

The husband again reviewed the course of events and again made the mistake of mentioning that his wife tended toward anxiety and did have a past psychiatric history. Upon hearing about the patient’s psychiatric history, as had the telephonic nurse before him, the “doctor-nurse” focused his questioning in that area.

He then performed a brief physical examination, noting only a slightly injected pharynx and mild, diffuse, abdominal tenderness. He ordered some routine studies by the laboratory “stat”. The couple returned to the waiting room.

Two more hours passed. The nursing aide reported that the results from the laboratory returned as “non-specific” and that the doctor-nurse had said that they should return home then see the patient’s “healthcare-professional” the next day. At no time did a doctor-doctor examine the patient.

Having returned to their home, by late that evening the patient’s husband could see that his wife’s condition was deteriorating further. Her nausea had intensified. She had vomited. Her abdominal pain had intensified. Emotionally, she was becoming distraught.

Her husband tried calming her while he himself was feeling increasingly anxious. Risking the punitive cost, he decided to try a different Emergency Room. He happened to choose a hospital where Uncle’s nephew, The Doctor, held surgical privileges.

Viewing her presenting appearance, the hospital-staff quickly registered the patient then wheeled her into an examining room, where a nurse performed an initial screening. By then, the patient was complaining of increasingly severe abdominal pain in the right upper quadrant. Her skin was cold and clammy to the touch.

The surgeon-on-call that evening already was working on another case in the Operating Room, so a nurse telephoned The Doctor. He ordered her to prepare the patient for immediate surgery, including typing and cross-matching three units of blood, and hastened to the hospital.

By the time that he arrived, the patient was in the Operating Room but going into shock, which the staff, none of whom was a physician, feverishly was attempting to reverse. The Doctor hastily changed from “civvies” into “scrubs”, washed, gowned, and gloved. He took a moment to evaluate the situation before beginning an exploratory laparotomy while the nurse-anesthetist was doing her best to maintain the patient’s vital signs; no physician-anesthesiologist was available. Everyone but the patient was breathing the air of desperate urgency. On her own, she was breathing hardly at all.

Entering her abdominal cavity, The Doctor quickly discovered the cause of the patient’s trouble; a gangrenous gallbladder, now-ruptured. He began to correct the condition by cleansing the cavity of the spilt bile and pus. In the midst of his doing so, the woman suffered a cardiac arrest. Instantaneously, the cardiac monitor screamed its piercing alarm, an unnerving “bleeeeeee . . . .”.

Following a series of frantic efforts, the nurse-anesthetist admitted failure. “We’ve lost the patient,” she reported meekly, gazing fixedly at the floor.

“We?”  The Doctor angrily shot his question at her; his expression, grim; his emotion, impotent rage.

Masking his feelings, he reluctantly entered the hallway, where he found the patient’s husband pacing like the proverbial caged animal. He approached the man slowly and introduced himself. With a quiet compassion in his voice, he informed the husband that his wife had died.

He then attempted to provide what little consolation he could offer. It was difficult for The Doctor to find the right words; actually, to find any words. What could he say?  The wife’s dying had been avoidable. It never should have happened. The medical system had failed her directly and her husband indirectly.

The Doctor’s efforts at sympathizing were in vain; the husband remained disconsolate. The Doctor stood silently while the suddenly-widowed man sobbed.

Then, the tears stopped. Shaking his head, the man looked at The Doctor with a compassion of his own. Paradoxically, he began offering consolation to The Doctor, apologizing for the system foisted upon the country by politicians for whom he himself had voted. Looking into The Doctor’s eyes, he noted tearing.

Whereas the husband felt apologetic, The Doctor felt ashamed, not for himself as much as for his profession or what was left of it. “The medical profession . . . my profession . . . no longer controlled by physicians but by politicians, bureaucrats, lawyers, and profiteers. The consequences? Casualties. This man, his wife, and I are three of them,” he whispered silently to himself.

The husband gently took The Doctor’s hand and held it.“Go home, Doctor . . . get some sleep. You did your best. It wasn’t your fault.” He predicted that, with his wife’s death, the HMO would agree that his wife’s illness had represented a real emergency, after all.

 The Doctor put his other hand on the husband’s shoulder and gave it a slight squeeze. He turned and walked away, leaving the bereaved man behind with his grief-stricken widowerhood bestowed by a system of managed costs euphemistically characterized as “managed care”.

On his way to the locker-room, The Doctor stopped at the desk to request that an aide stay with the husband while the secretary summoned the husband’s brother from home. The secretary said that she would try but that the hospital was understaffed, as usual.

At the moment of the husband’s shock and grief, The Doctor had not wished to disabuse him of his financial fantasy. The Doctor predicted that the HMO would deny the charges, claiming that, in spite of its staff erroneously having told the husband by telephone and at their ER that his wife’s condition represented no real emergency, she should have stayed to be seen “in-network”. He assumed that the charges would force the husband into bankruptcy. Oh, the man would rant and rage and threaten legal action, but, given current law protecting the profiteers, he would find no lawyer to take the case “on-contingency”, and he ill could afford hourly fees.

As for The Doctor’s fees? He would never receive a penny. “The people’s right to ‘healthcare’ . . . their right to my labors . . .” would be his only response, silent and ineffectual.

That night, The Doctor managed to get an hour or so of sleep. Then, he was off to make rounds at the hospital; then, to see patients at the office.

Given the schedule of fees dictated by the government and by the various governmentally-promoted “healthcare-plans”, caring for many of those patients also would generate little financial gain, if any; caring for a few of them would generate financial losses; caring for all would risk unfounded lawsuits filed by unscrupulous, avaricious lawyers.

Months later, The Doctor’s prediction would prove valid. The premiums that the husband had paid to his HMO were for naught when an actual need arrived. His HMO had denied care by delaying care then had forced him, the subscriber, to take the financial fall. Ironically, the same day that the man filed for bankruptcy, the HMO filed a fifteen percent rise year-to-year in its profits.

© Gene Richard Moss (2009)

1) “RomneyCare 2.0″. The Wall Street Journal, 06 August 2012, p. A12.

2) Already, under “Expansion of Physician Assistants Training”, the PPACA is directing tens of millions of dollars to training paramedical personnel. Meanwhile, under Medicare, funding for physicians-in-training and payments to physicians-in-practice are being slashed.

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