Thursday, July 17, 2008

Learning the ropes

A doctor remembers those heady days as a resident, and the education he received about health care in America.
Take my experiences in a Los Angeles hospital with kids who needed a surgeon. I would be on call, living in scrubs, trying to digest hospital chow. In the dead of the night, my pager would begin squealing, jarring me awake (if I was lucky to sleep in the first place). A number from an outlying hospital would flash on the screen. Stumbling out of bed to the nearest phone, I would learn that a child with, say, an open fracture of his leg needed to be transferred to our hospital since we offered "a higher level of care," which often meant an orthopedic surgeon who could treat the child.

Indeed, this is what happened one night. With the child on the way, I paged the orthopedic surgeon on call. Surgeons like information given to them concisely and directly. I ran through what I would say: "Sorry to wake you, Doc, but I have a 5-year-old male en route from a community hospital who has an open fracture of his right femur. According to the transferring physician, he will need to have a reduction in the operating room tonight. While we're waiting for you, we'll start morphine for pain relief and some Ancef (an antiobiotic) for infection prophylaxis." Then I waited for the phone to ring.

When the surgeon, a partner in a private Beverly Hills orthopedic group, returned my call, I was naive enough to expect some further questions about the child's history, requests for some laboratory work or more X-rays, and instructions on how to prep the operating room. Instead, his first question was: "What's their insurance?"

But I was not prepared for this question. I told the surgeon I would call back with the insurance information, which forced me to call the transferring doctor. I can't remember if the child was underinsured, uninsured or was insured by the state, but it didn't matter. When I called the surgeon back, he refused to come in. His group didn't cover "those kinds" of patients.

So there we were -- me, my intern, a nurse -- somewhere between late at night and early in the morning, alone. A broken child and his parents were on their way in an ambulance. We had promised to provide "a higher level of care," but the only doctor who could give that care just killed it. What was my plan? I was the doctor, after all. I had no idea.

In the end, all we could do was give the child morphine (a lot of it) and antibiotics, hoping we could keep him comfortable. Still, every time he moved just a little, he howled in pain. We hoped he wouldn't lose his leg to some flesh-and-bone-eating infection. And so we waited until morning, when we would ask our teaching attendants to delicately negotiate with the surgical group to please come in and take a look.

What did I learn that night? Certainly nothing about the preoperative and postoperative management of children with femur fractures. No, I learned how even in the dead of night, in the presence of a child suffering, the bottom line can override the Hippocratic oath.

Such is our peculiar institution called American healthcare. [...] You can blame insurers for their reimbursement games, the American Medical Association for lobbying to maintain the status quo, lawyers for bringing frivolous lawsuits, or drug makers for blocking international imports to keep prices high. The list goes on and on. But in the end, put it all together and it's a system, a monstrous medical-pharmaceutical-legal-actuarial-industrial complex that's leaving a lot of people behind.
Don’t wait for this to start affecting you before you start caring, because as this nation’s wealth continues to migrate away from the many and into the hands of the few, it’s just a matter of time before a doctor, a hospital or your insurance company refuses to help you in your time of need.

UPDATE: The results of the monstrous medical-pharmaceutical-legal-actuarial-industrial complex’s work:
Despite spending $230m (£115m) an hour on healthcare, Americans live shorter lives than citizens of almost every other developed country. And while it has the second-highest income per head in the world, the United States ranks 42nd in terms of life expectancy.
Does the free-market approach to healthcare still sound like a viable option to anyone whose livelihood doesn’t depend on its continued existence?

It’s simple, really. For-profit health insurance companies will never put your health ahead of their profits. Ever. You will never be as important to your insurance company as money is. Your insurance company doesn’t want to spend a lot of money on you. It would rather and is more than willing to Let. You. Die.

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