(I confess, what with the feasting, shopping, caroling, and wassailing of the holidays I cannot collect my thoughts to write anything coherent longer than a couple of paragraphs. My apologies. -PB)

Taking Leave of our Common Sense

In a previous article I mentioned that politically, health care reform was not a big issue for me and I was instead more concerned about national defense and killing terrorists. I reiterate that from a purely utilitarian point of view, building, equipping, and manning a Carrier Battle Group is a better way to spend our national treasure than attempting to guarantee free health care for all. I know that as physicians we’re supposed to believe in medical care like foxes believe in chickens but there are more important things in life most of the time, for most people, most of whom don’t need that much medical care except on infrequent occasions. It is more the fear of not getting medical care that is driving the current electoral panic rather than any real risk that anbody is going to be left outside the door of the hospital for lack of insurance. While it is true that there is a small subset of the population who have no medical insurance, this doesn’t mean that the majority of them have no access. We act as if access can only be had if somebody else pays the bill but large numbers of the uninsured could afford major medical insurance and their own primary care (which is not expensive) except that they have other priorities. There is nothing preventing their access to medical care except their reluctance to divert money from other, more important discretionary spending.

That and a lack of primary care physicians but that’s not a problem that can be solved by giving everybody free health care. Even the insured have difficulty finding a doctor and waving a magic wand, declaring that the unwashed now have access, and even throwing a bunch of money at the problem is not going to materialize a couple hundred thousand primary care physicians out of nowhere.

The real question is whether somebody who doesn’t care about their health should get free health care courtesy of the public treasury. A pack of cigarettes costs around five bucks in my neck of the woods. That’s 150 bucks a month, to which we can add another couple hundred for booze and other irregular pleasures. With this kind of money changing hands even among the Holy Underserved, it is inexplicable why you or I should be asked to finance their routine health care except through some sort of quasi-extortion where the usual suspects pushing We-Swear-It’s-Not-Socialized-Medicine hold a gun to the patient’s head and threaten us with higher costs down the road if we don’t cough up some money now. Or look at it like a mugging where, to avoid getting hurt, we’re supposed to hand over our wallet without making any trouble.

The key concept is that primary care is not expensive and, under the care of a physician who has the time to think about a patient, it can be extremely effective in keeping chronic conditions stable or at least delaying the inevitable expensive interventions significantly. But only if the patients give a crap about their health which no amount of free health care will do a thing to encourage. In other words, a good predictor of how much or little expensive medical care you will eventually need during your life is the amount you care about your own health. If you care, you will pay for the occasional doctor visit even if you have no insurance and both take your medications (which are hopefully inexpensive generics) as well as take steps to modify your lifestyle. If you don’t care then you will ignore your doctor, decide that personal watercraft are more important than your blood pressure medication, and despite getting all the free primary care in the world you will still end up dying the death of a thousand interventions as you decompose slowly in the medical triangle trade. (Nursing home to Emergency Department to Intensive Care Unit.)

To smoke a pack a day in the face of severe emphysema or to choose booze over your antibiotics is to demonstrate that you don’t give a rat’s ass about your health. If you don’t, why should anybody else except because of the previously mentioned blackmail mentality?

Throwing Money Away

Primary care is dying in this country, largely because the the government which sets both the amount that doctors are reimbursed for their time as well as pattern by which private insurance reimburses, has decided that cognitive skills are less valuable than throwing a lot of procedures at the patient. Most of this is a lack of trust by parsimonious bureaucrats who reflect the general American character trait of preferring action to deliberation. A typical patient, if he gets a large bill from an internist who did nothing but ask a lot of questions, poke him a little bit, and then lean back in his chair staring at the ceiling while he thought about the case, feels as if he’s been cheated. After all, he spent an hour with the guy and he didn’t do a thing but change his medications a little and give him some advice.

The motherfucker didn’t even order any tests.

On the other hand if he presents to the Emergency Department and is loaded to the gills with intravenous contrast dye and then assaulted with every possible test and invasive procedure imaginable, the typical patient or his family will settle complacently into their happy zone convinced that now, finally, they are getting their money’s worth. Doesn’t matter that much of what is done is unnecessary or at least could have been replaced with a little bit of sound clinical judgement, nobody’s happy until they see some action.

This is not to say that people don’t want to spend a lot of time with their doctor, just that they don’t feel they should have to pay more than a couple of bucks for the privilege. Thinking is easy, after all. It’s not like the doctor had to do anything. The government has picked up on this philosophy and has subsequently come up with the perfect formula to save money which, as is typical when people who are qualified for nothing else but government come up with a plan, has resulted in large amounts of money being thrown away.

Consider the typical internist or family physician trying to keep the lights on in his practice. The amount that Medicare or Medicaid (and private insurance as they typically take their reimbursement guidance from the government) pays the doctor for his cognitive skills; the traditional history, physical exam, and clinical judgment, is so small in relation to both his expenses and his completely reasonable desire to make as least as much as a decent auto mechanic that he is forced to run a high volume practice. Of course, not every patient requires a long visit and certainly a more complicated patient can be given a little more time but when you are seeing thirty patients a day, you can see that it is impossible to give the truly sick and the multiply co-morbid the time that they need.

The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.

Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.

The Ticking Time Bomb

Having patients followed on a routine basis by a cadre of specialists is not only wasteful but dangerous. Under the team-based health care delivery philosophy, physicians are supposed to communicate with each other but, as talking to other doctors is generally non-reimbursable time, communication suffers for the same reason every other poorly-reimbursed activity suffers. The danger is that patients who are being followed by a disorganized squad of specialists will receive dangerous interventions and studies seemingly willy-nilly and, most importantly, are placed on long lists of medications, the interactions of which cannot possibly be fathomed except that someone has the time to sit down and spend an expensive half hour doing it. I regularly see patients with one-page medication lists taking three or four medications of the same class as well as medications that seemingly act at cross-purposes, not to mention having the potential for dangerous interactions.

I know perfectly well that many patients require this kind of complexity but after you see enough unexplainable altered mental status, coumadin levels (INR, I mean) through the roof, as well as the effects of everybody’s favorite loaded gun, digoxin, you sometimes wonder if anybody has ever taken the time to verify that yer’ demented granny really needs to be on 20 different pills.

Now, and I’m just thinking out loud here, what cardioprotective effects are we getting by keeping an 89-year-old woman on a beta-blocker, a statin, and an ACE inhibitor that are not completely offset by the possibility of side-effects and dangerous interactions with her other medications? It is this and other questions that need to be addressed and decisively answered by one doctor who has the time, via adequate reimbursement, to do it. The alternative is highly fragmented and slipshod care.

And no, it is not enough to expect the patient to keep track of these things. Some can of course, but it is very common for the multiply comorbid patient to know nothing more about his medications than their colors and shapes or that one is a water pill and another is for his “gouch.” In an ideal world, the only variable would be the compliance of the patient, not the confusion that results from trying to coordinate the care of various specialists.

Happy New Year

Another one has come and gone. One day, as the memory of medical school and residency fades and I have to devote most of my free time to moonlighting at Taco Bell to make ends meet under whatever silly health care reform comes out of the trailer parks, ghettos, universities, and other islands of provinciality and entitlement in America, I may grow tired of this blog. As I am, however, still going strong, I appreciate your taking the time to spend your time reading and I hope I can continue to provide you with a good reason for doing it. As always I appreciate all comments even the ones I have to delete.

Hey, we have rules on this blog. I had to go to a moderated comment format because of a few people with bad manners and I hope this hasn’t been too much of a burden. Not to mention that my spam filter catches about a thousand spam comments a day which leads me to this question: What on earth has Britney Spears done to deserve this kind of attention? Fully half of all the spam comments I receive promise to link me to naked pictures of her in all kinds of situations. I’m just not that interested. In fact, my interest in Paris Hilton, Anna Nichole Smith, and Anglina Jolie, the other members of the internet Gang of Four, is about a 0.001 on the ten-point pain scale.


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