Kabuki Medicine

In one month I have had Mary as a patient four times. I have also noticed her roaming restlessly through the department on days when some other resident had the bad luck to pick up her chart. I would not be exaggerating if I said that she has been a patient in our department thirty times this year and the Lord only knows how many times at other Emergency rooms in the area. She is a huge consumer of emergency services and no one dares tell her to pound sand when she presents with one bogus complaint or another because one day, after crying wolf for her whole life, she is really going to be sick and if she dies the usual compassion fascists will descend on us like self-righteous harpies.

Thus do we regularly ignore common sense and, putting on our best kabuki faces, take every episode of chest pain, abdominal pain, shortness of breath, and near-syncope completely seriously pretending that we have not spent hundreds of thousands of the taxpayer’s dollars ruling out everything except drug addiction. It would be more cost effective if we just gave her perscriptions for all the oxycontin she wanted provided she limited her visits to once a month. Instead we enact the the traditional Kabuki drama where she assumes the role of a patient and we pretend to be her doctors. We stamp and posture, reciting our ritualistic lines while she demurely assumes the character of someone we actually can treat. Five acts later we discharge her, plus or minus a six-pack of vicodin, depending on how badly we want to get her out of the department.
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File this under getting what you pay for. Putting asided the usual policy wonkery, the real problem of American medical care is the complete absence of common sense. Mary is not unique. She is just a very visible symbol of a society that is ridiculously risk averse and consequently ridiculoulsy over-doctored. In a perfect world, someone would meet her at the door and say, “No. You are not getting drugs here.” If she departed chastened from our door and died…oh, let’s just say from a perforated bowel… a reasonable jury, assuming the case ever went to trial, would decide that it was a darn shame but understandable given her pattern of abusing emergency services.

Of course this would never happen. In the real world we are cautious to the point of foolishness, at least if we equate foolishness with a cavalier disregard for money.
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Consider, as one example, the typical cardiac work-up and the vast sums of money wasted every year on diagnostic testing and empiric treatment of patients with ridiculously low pre-test probabilities of being sick. (In other words, they are not sick.) A young male with no risk factors for heart disease should not need a complete cardiac work-up when he presents with chest discomfort as it is almost certainly going to end up being musculoskeletal pain, reflux, or anxiety. And yet the patient inevitably gets the whole enchilada including an expensive stress test and occasionally an admission if he is deemed to be unrealiable for follow up (because if he is told to return in the morning for his stress test, forgets, and dies three years later it is our fault). Now, it may come to pass that one day, out of ten thousand thirty-year-old otherwise healthy men you will isolate the one who does, in fact, have early coronary artery disease…but then you probably would have picked him out just from the history and review of systems. I don’t deny that if I were that one guy I’d be pretty happy that our system is structured to spend billions protecting against lightning strikes but the fact remains that we are spending billions with a very little to show for it in actual treatment or prevention of morbidity.

My point? I am getting tired of saying it and I will soon stop. Because of the highly litigious nature of American society, there is no incentive to exercise common sense. In fact, there is a perverse incentive to spend money like drunken Marines in a brothel because there is no allowance in American medicine for mistakes. The standard of care has become absolute zero-defect which costs money…but the key is that our system is so adept at shifting costs that it always appears to be somebody else’s money.

Potemkin Medical Care
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Cuban health care is so good that thousands of Americans risk their lives every year on flimsy boats and makeshift rafts in a desperate attempt to make it across the shark-infested waters of the Straits of Florida. Many perish in the endeavor and the 90-mile strait is littered with the floating corpses of uninsured Americans, many still attached to their now empty home oxygen cyliinders.

Ha ha. No, not really. Still, as the idee fixe of the pseudo-intelligentsia is the efficiency and general superiority of Cuban health care it is only a matter of time. We’ve all heard the mantra. The Cubans, it seems, spend a twentieth per capita of what we spend on health care but, mirabile dictu, have better outcomes and better access to medical care. Michael Moore, a man who knows as much about medicine as I know about making documentary films (i.e. nothing), has even made a movie based on this premise.
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Leaving aside the fact that Cuba is a Soviet-style dictatorship where the official statistics are manipulated to show the Dear Leader in the best possible light, ignoring for the moment that Cuba has the usual three-tier medical system of every worker’s paradise (one for the apparatchicks, one for the proles, and a Potemkin hospital or two for the tourists), and even forgetting the inexplicable love of the American left for a dictator and a society from which people are willing to risk death fleeing…leaving aside all of this I just want to know why, in a society with a per capita income of just 300 dollars per year they manage to spend so much money with so little to show for it.

The per capita income in the United States is about $40,000 per year or about 130 times that of a typical Cuban. Cuban doctors make about three hundred dollars per year or about half of what the typical American family, even those in the dependocracy, spend for cable television. Cuban nurses probably make what my young children get as an allowance. Since labor costs are the biggest expense in health care both here and in Cuba, I just want to know why the Cubans are spending so much money on health care and still have a life expectancy less than the United States. Something doesn’t add up. Cuba is 130 times poorer than the United States and yet, in relative terms spends five times as much on health care.

Oh my long-suffering readers, do not yearn for Cuban-style medical care in the hopes that it will be cheap. It’s cheap for Cubans because Cuba is a third world country where everyone is poor. In Cuba a doctor might be willing to work for fifty bucks a month but in the United States, any enterprising teenager can make 20 times that amount working as a taco jockey. In other words, unless you plan on making everyone poor, good luck getting people to work at the hospital wiping yer’ grannies ass or coming at night to admit a patient for the kind of wages it would require to Cubanize American medicine.


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