Healthcare 1
Medicine is a wonderful profession. The body of knowledge that in necessary to practice rationally is huge, interesting, and constantly evolving. That science is coupled to humanism when patients, often strangers, come to the physician and share the intimate facts of their lives and their troubles. It is a rare privilege to be allowed into another human personal realm. It is a challenging and complex task to apply scientific principles to the subjective states of the human organism
The press and popular literature tends to focus on the problems of medicine in America such as cost, impersonal interaction between physician and patient, and the side effects of the ever increasingly potent medications. We don't hear much news about the many miraculous things that medicine can do. The placement of new lenses in the eye to relieve the blurring of cataracts is simple and almost perfect. Cancer is still with us but it is increasingly being cured. I have been cured of two lymphomas. Cardiac surgery prevents heart attacks, valvular disease and arrhythmias. Antibiotics cure what were often fatal infections a hundred years ago like pneumonia. Vaccines prevent many childhood illnesses. Old arthritic joints can be replaced with smooth functioning new ones. Medicine is an incredible success story.
Medicine does have problems. The cost of health care in America is twice as much as other developed countries and the outcomes are worse. The physician-patient interaction has become impersonal and driven by algorithms often ignoring the individual's needs. And the ever more successful and potent treatments have ever more severe side effects. Each of these topics are the subject of many books. I am not a health care economist nor am I a medical historian, but I am a physician who practiced medicine over the last 40 years and watched some of these problems arise.
Business entered medicine in the early 70s and its influence has been growing since; mostly a detrimental influence. In Kurt Vonnegut's book, God Bless You Mr. Rosewater, one of the leading characters says that in law school every student was taught to keep their eyes open for situations where money was changing hands, and catch whatever fell during the exchange from one hand to another. As medicine became increasingly successful at curing many of our problems people became willing to pay for it, and like the sharks they are joked to be, the lawyers and MBAs smelled money and swarmed into the medical staff offices.
When I started at the hospital where I worked for most of my life, in the emergency room, the emergency department was run by one of my partners, a physician, along with the head nurse. They had a secretary. Above them was the hospital administrator and above him five nuns. That was it. And the nuns didn't get paid. Thirty-three years later when I retired in 2010, there were uncountable administrators between us and the now non-existent nuns. And we were doing the same job we did 33 years earlier. Administration had no noticeable impact (not entirely true because there was some negative impact) but since most of the income came from the money generated by us seeing patients, we were supporting a useless cast of dozens. Why were there so many and what did they do? Well, administrators need someone to oversee. Since administrators were not physicians and not licensed to practice medicine, they can't really oversee or manage doctors. So they hire people to whom they can give orders. These people need to do something so they make things up to do. To be fair, some administration is needed. Someone needs to keep track of the financial side of the business and the physical plant of the hospital. But, truly, managing nurses, respiratory therapists, physicians, lab technicians, etc. are better done by each particular group. But this new group of 'health care administration' needed something to do and this idle time led to all kinds of painful, misguided administrative plans, only one of which I will share in this essay because it illuminates a whole host of problems that have arisen in modern medicine.
In order to speed up the flow of patients through the emergency room the administration decided (with the consent of the majority of my physician partners but not with my consent nor the consent of several others who were not interested in making more money) that we would begin a system they called Rapid Medical Triage (RMT). This system consisted of was having a nurse practitioner briefly see a new patient while they were in the waiting room before they saw a physician, take a brief history and an even briefer physical exam and guess what testing they were going to need. The nurse would order the lab and x-rays so that the wait time for test results would be shortened once the patient saw the physician. This assumed, of course, that the 'shoot from the hip' judgement of the nurse practitioner was right on target. The justification for RMT was to move people through the ER faster, because patient often complained about long wait times. No one asked them if they would prefer a longer wait or a more accurate, thoughtful diagnosis and treatment.
The physicians job is to gather data and think before they act. In the emergency room, often we end up acting before we have all the data. Early in the history of emergency rooms they had trouble finding physicians to work in emergency rooms because they had trouble finding physicians dumb enough to make so many decision with such little information. But, when we have time, we do like to read the patient's medical records, take a history, do a physical exam and develop a plan to diagnose and treat whatever the problem is. The RMT plan of ordering tests before the evaluation of the patient was complete was backward and wrong and many of us said so many times. After we were outvoted and RMT begun, I asked to do a study of how many lab tests and x-rays were ordered before and after RMT was instituted. The hospital refused to give me access to the data. They make money off lab and x-ray as well as by seeing more patients. They didn't want people to know that information, that they may be getting more lab and x-ray than they needed in the name of efficiency. So, money trumped patient care. I knew RMT was the end for me. I left not long after this system was put in place. It was eventually stopped for unclear reasons, probably because, in my opinion, it constituted malpractice. To be fair, I was getting older and working in the emergency department means night work which was increasingly hard, so retirement wasn't entirely because of RMT, but that and other administrative aberrations made it difficult for me to stay.
The invasion of medicine by MBAs helped convert medicine from a profession to a business over about 30 years. Many physicians were complicit in this transformation. Money talks. But if you paying the bills you would like to be part of the conversation.
My plan is to write at least three more blogs on medicine. The next will be about the physician-patient relationship, the third will be about the problems caused by modern medicine, and last will be about illness as memory.
The press and popular literature tends to focus on the problems of medicine in America such as cost, impersonal interaction between physician and patient, and the side effects of the ever increasingly potent medications. We don't hear much news about the many miraculous things that medicine can do. The placement of new lenses in the eye to relieve the blurring of cataracts is simple and almost perfect. Cancer is still with us but it is increasingly being cured. I have been cured of two lymphomas. Cardiac surgery prevents heart attacks, valvular disease and arrhythmias. Antibiotics cure what were often fatal infections a hundred years ago like pneumonia. Vaccines prevent many childhood illnesses. Old arthritic joints can be replaced with smooth functioning new ones. Medicine is an incredible success story.
Medicine does have problems. The cost of health care in America is twice as much as other developed countries and the outcomes are worse. The physician-patient interaction has become impersonal and driven by algorithms often ignoring the individual's needs. And the ever more successful and potent treatments have ever more severe side effects. Each of these topics are the subject of many books. I am not a health care economist nor am I a medical historian, but I am a physician who practiced medicine over the last 40 years and watched some of these problems arise.
Business entered medicine in the early 70s and its influence has been growing since; mostly a detrimental influence. In Kurt Vonnegut's book, God Bless You Mr. Rosewater, one of the leading characters says that in law school every student was taught to keep their eyes open for situations where money was changing hands, and catch whatever fell during the exchange from one hand to another. As medicine became increasingly successful at curing many of our problems people became willing to pay for it, and like the sharks they are joked to be, the lawyers and MBAs smelled money and swarmed into the medical staff offices.
When I started at the hospital where I worked for most of my life, in the emergency room, the emergency department was run by one of my partners, a physician, along with the head nurse. They had a secretary. Above them was the hospital administrator and above him five nuns. That was it. And the nuns didn't get paid. Thirty-three years later when I retired in 2010, there were uncountable administrators between us and the now non-existent nuns. And we were doing the same job we did 33 years earlier. Administration had no noticeable impact (not entirely true because there was some negative impact) but since most of the income came from the money generated by us seeing patients, we were supporting a useless cast of dozens. Why were there so many and what did they do? Well, administrators need someone to oversee. Since administrators were not physicians and not licensed to practice medicine, they can't really oversee or manage doctors. So they hire people to whom they can give orders. These people need to do something so they make things up to do. To be fair, some administration is needed. Someone needs to keep track of the financial side of the business and the physical plant of the hospital. But, truly, managing nurses, respiratory therapists, physicians, lab technicians, etc. are better done by each particular group. But this new group of 'health care administration' needed something to do and this idle time led to all kinds of painful, misguided administrative plans, only one of which I will share in this essay because it illuminates a whole host of problems that have arisen in modern medicine.
In order to speed up the flow of patients through the emergency room the administration decided (with the consent of the majority of my physician partners but not with my consent nor the consent of several others who were not interested in making more money) that we would begin a system they called Rapid Medical Triage (RMT). This system consisted of was having a nurse practitioner briefly see a new patient while they were in the waiting room before they saw a physician, take a brief history and an even briefer physical exam and guess what testing they were going to need. The nurse would order the lab and x-rays so that the wait time for test results would be shortened once the patient saw the physician. This assumed, of course, that the 'shoot from the hip' judgement of the nurse practitioner was right on target. The justification for RMT was to move people through the ER faster, because patient often complained about long wait times. No one asked them if they would prefer a longer wait or a more accurate, thoughtful diagnosis and treatment.
The physicians job is to gather data and think before they act. In the emergency room, often we end up acting before we have all the data. Early in the history of emergency rooms they had trouble finding physicians to work in emergency rooms because they had trouble finding physicians dumb enough to make so many decision with such little information. But, when we have time, we do like to read the patient's medical records, take a history, do a physical exam and develop a plan to diagnose and treat whatever the problem is. The RMT plan of ordering tests before the evaluation of the patient was complete was backward and wrong and many of us said so many times. After we were outvoted and RMT begun, I asked to do a study of how many lab tests and x-rays were ordered before and after RMT was instituted. The hospital refused to give me access to the data. They make money off lab and x-ray as well as by seeing more patients. They didn't want people to know that information, that they may be getting more lab and x-ray than they needed in the name of efficiency. So, money trumped patient care. I knew RMT was the end for me. I left not long after this system was put in place. It was eventually stopped for unclear reasons, probably because, in my opinion, it constituted malpractice. To be fair, I was getting older and working in the emergency department means night work which was increasingly hard, so retirement wasn't entirely because of RMT, but that and other administrative aberrations made it difficult for me to stay.
The invasion of medicine by MBAs helped convert medicine from a profession to a business over about 30 years. Many physicians were complicit in this transformation. Money talks. But if you paying the bills you would like to be part of the conversation.
My plan is to write at least three more blogs on medicine. The next will be about the physician-patient relationship, the third will be about the problems caused by modern medicine, and last will be about illness as memory.
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