Posts Tagged ‘health care’

MEDICAL DELIVERY: A TALE OF WOE

Monday, August 6th, 2012

“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)

References
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.

MEDICINE: QUANTITY IS NOT QUALITY

Monday, July 23rd, 2012

To reiterate from a previous posting (1), so-called healthcare is not synonymous with medical care. The difference is not mere semantics. “Healthcare” is cutting your toenails. Medical care is treating a cancer with surgery then radiation then chemotherapy.

Recently, a fellow named H. W. Brock . . . neither a Medical Doctor nor a biobehavioral scientist but a financial type . . . wrote a piece claiming a resolution to the problematic situation of delivering medical care in the USA.(2) His resolution? Increase the supply.

Unfortunately for Mr. Brock, his postulates are invalid. As he confuses”healthcare” with medical care, he confuses quantity with quality.

The elements of his so-called supply-sided resolution? 1) Federal training of more physicians. 2) Financial aid for physicians-in-training. 3) Financial incentives for physicians going where shortages exist, medically and geographically. 4) More foreign-trained physicians. 5) Reformation of medical malpractice. 6) Fewer redundant diagnostic tests. 7) More nurses and other para-medical personnel replacing physicians. 8) Promotion of cheap, “retail”, quasi-medical shops.

As always, the devil is in the details. Let’s look at Mr. Brock’s recommendations.

1 & 2) Training more physicians may be a good idea, but who’d be financing the training? With monies from where?

The individual states? The concept of state-based financing is nothing new. State-based budgets, however, are strained . . . California, for example, is broke. Increasing state-based funding for training more physicians seems rather unlikely.

Who’s left? The federal government? The concept of federal financing also is nothing new. It’s been on-going for years through Medicare and other programs; e.g., Title VII of the

“Health Professions Educational Assistance Act” of 1976. Okay, why not just increase it and expand it?

Wait! Congressman John Boehner recently stated flat-out, “We’re broke!” . . . not that a lack of funds usually stops federal spending. Under ObamaCare, for example, Big Government ironically will spend tens of millions that it doesn’t have to train “physicians’ assistants” under “Expansion of Physician Assistants Training (EPAT)“. Meanwhile, current funding for training physicians through Medicare is being slashed. Music to your ears, Mr. Brock?

Stop! Look! Listen! Those who love individual liberty never should forget that government . . . especially Big Government . . . is a dangerous servant and a terrible master. “He who pays the piper calls the tune.” The federal government already is directing American medical care through Medicare and Medicaid. How would Mr. Brock block further empowering its dictatorial control over physicians via increased financing of their training?

Now, who’s left? Private enterprise? Only Big Business could afford financing medical training on a meaningful scale. What would be any reward to any business, say, to offer scholarships? What would be “the catch” for the physician?

3) Rewarding physicians financially for going where shortages exist, medically and geographically, also may be a good idea. Who should do the rewarding? The federal government? Individual states? Under-served municipalities? Private enterprise? Governments already do, to some extent. What must the physician promise in return for increased funding? Mr. Brock might consider that using oneself as chattel for a mortgage is unconstitutional.

4) Importing more foreign-trained physicians may sound like a good idea economically. Is it a good idea medically? On average, is an American-trained physician more competent than a Grenada-trained physician who passed the examination designed by The Educational Commission on Foreign Medical Graduates . . . even without the time-honored cheating?(3) Under whose knife would Mr. Brock care to put himself when his is the life at stake?

5) Reforming medical malpractice, unquestionably, is a good idea. America has become a nation imprisoned by lawyerism. Too many laws; too many lawyers; too many lawyer-politicians; not enough law . . . think the now-disgraced, lawyer-politician John Edwards or the honest companies bankrupted by greedy lawyers (4).

Who’ll perform the legal reform? A federal government dominated by lawyers? On what constitutional grounds . . . not that the federal politicians and bureaucrats care about the Constitution unless it suits them to do so? The fact is that both physicians and lawyers are licensed by the individual states not by the federal government. Isn’t reform a task for the states . . . but, ah, the ease and joy of central versus provincial (i.e., state-based) control; eh, Mr. Brock?

6) Who can argue against reducing the number of redundant diagnostic tests and procedures? Aren’t many of those tests ordered, however, to preëmpt unfounded lawsuits?

Defensive medicine aside, Mr. Brock neglects to tell us The How. Rap physicians’ knuckles? Fine physicians? Imprison them? Execute them? Nothing as quick and simple as negative versus positive control; eh, Mr. Brock?

7) Allowing nurses and other para-medical personnel to masquerade as physicians may increase the supply of “healthcare-related” services but can it maintain quality of service? Nurses aren’t trained to make diagnoses. Sorry, Mr. Brock, it’s true. With all due respect to nurses, essentially, they’re necessary, valuable, and hopefully caring technicians trained to carry out physicians’ orders. With the use of improving technologies, as time passes, they may become competent to do more. Even so, should nurses and other para-medical personnel operate with no medical supervision? Moreover, who, ultimately, should be responsible . . . medically and legally? Mr. Brock gives us no clue whom to sue.

During the days of the now-defunct Soviet Union, its dictators boasted having an ample supply of “physicians”. . . well, not exactly physicians but physicians-in-name; what we in the USA now call “nurse-practitioners”. The average Soviet citizen rarely was attended by a legitimate physician . . . only the politicians, high-level governmental bureaucrats, and military officers. Do we Americans really want the Soviet-style medicine that Mr. Brock is promoting?

Furthermore, will lower fees compensate for lower quality? Even if they do, won’t those lower fees gradually rise towards the fees charged by real physicians?

8) Promoting cheap, “Wal-mart style” quasi-medical shops to handle “common minor ailments” . . . shops already appearing in supermarkets . . . staffed by quasi-physicians acting in isolation from real medical support undoubtedly will increase availability of “healthcare-related” services. Mr. Brock neglects to state, however, who determines what is a “common minor” ailment. The customer? The nurse? The assistant to the absent physician? The check-out clerk? As a financial type, Mr. Brock might keep in mind that there’s a cost to everything. How about your life, Mr. Brock? Still a good value?

No, Mr. Brock, your “solution” won’t resolve the situation-in-question. Fortunately, however, there is a valid resolution, and it comes from biobehavioral science . . . not from the pseudo-science of economics nor from the polemic of politics nor from the mumbo-jumbo of mysticism (www.inescapableconsequences.com).

So, what’re the odds favoring us Americans resolving scientifically the current dilemma in delivery of medical care? After all, we have the way. We have the means. Ah, but do we have the will? What say, Mr. Brock?

References
1) Categories/Biology & Medicine/”Healthcare” Reform/ ‘Healthcare’ Is Not Medicine”.

2) Brock, HW: “A Supply-Side Solution for Health Care”. Barron’s, 23 July 2012, page 30.

3) Lyons, RD: “Cheating On Exams For Doctors Causes Alarm”. The New York Times, 03April 1984.

4) “The Tort Bar Burns On”. The Wall Street Journal, 23 July 2012, page A12.

“HEALTHCARE” IS NOT MEDICINE

Monday, September 6th, 2010

Walter Reed Army Medical Center (WRAMC) has several divisions, one of which is Walter Reed Army Institute of Research (WRAIR). Entering the Army as a Captain in the late 1960’s, I was assigned to WRAIR as a Research Psychiatrist.

Instead of being stationed at “The Main Section” in D.C., I was stationed at “The Annex” in Silver Spring, Maryland. The facility had been a girls’ school expropriated by the Army during WWII. Dedicated to research, unlike at The Main Section, the atmosphere among officers and enlisted men was relatively cordial and informal.

One afternoon, I stood chatting with Gerry, a draftee assigned to the Department of Psychiatry, one part of the Division of Neuropsychiatry. The young man obviously was quite intelligent and well-educated. We’d been chatting about nothing in particular when the conversation drifted to our respective, future plans.

“What are yours when you leave?” he asked.

“Academia,” I replied. “Continue my research . . . UCLA, in fact. Yours?”

“Harvard School of Public Health.”

“Really? Why not medical school?”

“I can see that you can’t.”

“Can’t see? Can’t see what?”

“The future! It’s right in front of you. In fact, it’s already begun . . . Medicare and Medicaid. I’m here to tell you, Doctor, that, someday soon, the federal government is going to control you guys, and I’m going to be one of the controllers. You’ll be saluting me, so to speak.”

“Yeah, right!” I replied, dismissing his prediction.

“That is right. Guys like me will be controlling guys like you . . . physicians, I mean . . . and all the rest in medicine, as well. I’ll be one of the experts doing the controlling. Who knows? Maybe, I’ll even be in Congress. With all due respect, you’ll be doing exactly what I tell you to do . . . Sir.”

His arrogance notwithstanding, I wandered to my office wondering if Gerry could be right. Some years later, I learned how right he was.

How did it happen? How did self-styled, bureaucratic “experts”, few with any medical training, become the controllers and physicians the controlled?

The causes have been multi-dimensional. One was via the manipulation of language. Words became politicians and bureaucrats’ weapons against physicians and patients. Words have power. Words can kill.

In his classic novel, 1984, George Orwell eloquently described how governments simplify language and pervert it to fulfill their own, tyrannical goals. He called it “newspeak”. Those in the federal government have borrowed a page from Mr. Orwell’s book and applied his ominous depiction to all four cornerstones of American society . . . government itself, law, education, and medicine.

Prior to Medicare/Medicaid, the federal politicians exerted little control over physicians. Medicine was a “cottage-industry” with hundreds of thousands of independent offices. These independent physicians collectively held too much power over too large a segment of the economy to suit the politicians. Smashing that power became a top priority for vote-hungry politicians; make voters dependent upon politicians not physicians for medical care. One element of their strategy would be through words . . . propaganda. Through words, reduce the prestige of physicians; thereby, reducing their power. How? Lump physicians together with everyone else in medicine from nurses and technicians then include outright charlatans such as chiropractors.(1) Instead of physicians practicing medicine, medical doctors would be merely one category of “providers” among many delivering “healthcare”. The strategy succeeded.

Ask yourself the following, three questions: 1)What comprises “healthcare”? In Webster’s New Collegiate Dictionary (1977), the term, healthcare or health care, doesn’t appear even. Whence came it?  2) How does “healthcare” differ from medicine?  3) Does the distinction matter?

1) As the term denotes, “healthcare” refers to caring for one’s health. It’s amorphous, is largely a personal responsibility, and  includes everything from washing your hair to brushing your teeth to cutting your toenails. Accordingly, a “healthcare-provider” includes anyone or everyone who promotes himself or herself as rendering advice, assistance, or instruction in the care of one’s own health. Simply put, “healthcare” is not medicine.

2) In contrast, medicine is the healing art based upon science the mission of which is the relief of suffering caused by disease and trauma. Its practitioners are known as physicians; those whom they diagnose and treat are known as patients. Traditionally but not currently, physicians must have gained a Doctor of Medicine and be licensed as such in the state in which they practice. Traditionally, para-medical personnel included nurses, technicians, and certain classes of therapists. Medicine was among the learned professions. At its best, for its practitioners it was to be more a calling than a business . . . something akin to the priesthood. The sole obligation of the physician was to the patient not to a third-party such as the government or a “healthcare plan” or even society as a whole. Communication between physician and patient was to be sacred and kept confidential except in cases of malpractice litigation.

3) The distinction is not mere semantics. If not coined by them, the term, healthcare, was seized by politicians, bureaucrats, and profiteers to concoct a deliberately confusing, inconsistent system of medical delivery that they themselves could control for their own respective, pecuniary benefits. The consequence has been that, instead of becoming scientifically-based and scientifically-driven, the medical system has become politically-motivated and politically-manipulated with money and power as the controlling variables. The nightmare of ObamaCare represents Gerry’s dream come true. It brings with it a new host of euphemisms guaranteed to confuse. As I described in the non-fictional Healthcare Reform D.O.A. (now out-of-print; 1994)* and more recently in the fictional/non-fictional Inescapable Consequences (2009), there is a better way.

So, in any discussion of medical services, let us force the politicians and bureaucrats to define their terms. Let us remember always . . . words can kill; and, in this case, you, the patients, are the victims.

* Nominated for two national awards by The American Risk & Insurance Association.

1.  Theoretically, the underlying principles of chiropractic are nonsensical. Operationally, chiropractors injure 30% of their customers, on average (See, for example, Hurwitz, EL, et al: “Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study.” Spine 30:1477, 2005.). Worse, some of these injuries are fatal; chiropractic “manipulation” has been documented to cause death from dissection of the vertebral artery (See, for example, Chen, WL, et al: “Vertebral artery dissection and cerebellar infarction following chiropractic manipulation”. Emergency Medicine Journal 23: e1, 2006.). Re-labeled “chiropractic physicians”, these “healthcare providers” receive the same governmentally-mandated prestige as genuine medical doctors.