First of all, if there is anyone reading this diary who has not seen Keith Olbermann's passionate Special Comment from last night, please go and view it via DailyKos TV. I just finished watching it myself; frankly I fell asleep last night midway through. I am just, well, speechless. Thank you, Keith, for that passionate cry for reform.
Secondly, I am a primary care internist who, for the last three months, has been working in a Federally Qualified Health Center (FQHC) in the city of Baltimore. Maryland was recently ranked the wealthiest state in the country, per capita; we have the wealthiest counties in the country by many measurements. However, when ranked by zip codes, Baltimore City has several of the bottom 10 in the country. We have the "Best Hospital" according to US News in Johns Hopkins; right down the street is one of the FQHCs in the city that qualifies for loan repayment for doctors, based on being a medically unserserved area.
If this doesn't represent the criminal dichotomy of the US healthcare system, I don't know what does.
And, oh, the stories I could tell from the FQHC. I thought I had a lot to tell from my years of working with residents in my prior jobs. Three months has eclipsed all that in ways I frankly never thought possible.
So, on to my experience today.
With respect to patient confidentiality, I will need to keep this story to a minimum, but I will try to tell the essential parts.
I first saw this patient early into this new position; the patient has a number of social issues but, fortunately, actually has some insurance. The patient complained of abdominal pain and weight loss, among other things, and on the first exam, I found an abnormality in the abdomen below the liver. Blood tests revealed mild abnormalities in liver function, and I also sent the patient for an ultrasound of the abdomen. The ultrasoud report showed a "mass-like lesion in the gallbladder" and recommended a CT scan of the abdomen and pelvis, with contrast.
The fact that I had less than 10 minutes to actually tell this patient this bad news is another story in and of itself, but when he came in, I discussed it with him, and ordered the CT as recommended, which he got. This morning I found the report from the follow up CT scan on my desk, and it said there was an "abnormality" in the gall bladder suggestive of sludge, recommend ultrasound for further evaluation. WHAT??!!! I had specifically ordered the CT to "follow up on abnormal ultrasound" and it was done by the same radiology group.
Rather perturbed, I called the radiology group to ask about this report. I didn't get the doc who had read the scan, but was told that this would be referred back to him. Here's where it gets interesting. That doc said that, well, he had reviewed the scan (this was a rather short time later, IMO not really enough time to fully review either study) and said he would actually recommend another ultrasound to see if the lesion had "changed," and if it persisted then to get an MRI of the abdomen.
Flabbergasted, and with patients waiting myself, I said, "well, I've already made a surgical referral, thank you (very much for nothing, but I didn't say that part.)"
Here's the thing that gets me: radiologist make 2 to 3 times what I make at minimum without ever having to lay eyes on the patient or explain what the hell they are talking about. When I, as a primary care doc, send a patient for a radiologic study, I want information, not orders for further tests; but more and more, that's what we keep getting, as it seems many radiologists refuse to make a firm evaluation or recommendation. Of course, recs to keep ordering more and more tests keep their incomes up. Waaayyy up. And it keeps up the incomes of everyone else involved, including, but not limited to, the salespeople who sell the radiology equipment, the companies that make the radiology equipment, the radiology techs (who make damned good money, I'm not denying them their incomes, but there are people who do this work with associate degrees who can make upwards of 60, 70, 80K or more.) For that kind of money, I and my patients ought to get some useful information.
Keith Olbermann touched on this in his special comment last night, where he talked about the perverse incentives for physicians, and frankly other providers, to provide more services, but not necessarily better services. It behooves the radiologist to hedge for medicolegal reasons, something I'm not about to get into here, but it certainly also behooves them to put out a report recommending another test, and another test, and another test, because that's how they get paid. To what end, for the patient? Riddle me that, please.
Another thing that was pointed out last night, and was also pointed out by Abraham Verghese in a column he published in the Wall Street Journal last summer (sorry, don't have a link available) is that doctors, and frankly health systems, get paid more for doing to the patient than doing for the patient. As Keith Olbermann stated, in a system which is focused on quantity, not quality, of care, it is much easier for the doc, or any provider, to order a test or write a prescription than it is for the doc to take the time to sit down and talk to the patient about what is going on. And therein lies my incredible frustration with the FQHC where I am working - but that is, truly, a story for another day.
In the September issue of The Atlantic Monthly, author David Goldhill also wrote an impassioned piece about his family's interaction with the American system entitled "How American Health Care Killed My Father." Now, while I don't agree with his business based, market approach to healthcare, he brings up many important points in this article, and I believe it's an important read for understanding the system as it is. Several points in particular: he also points out the ridiculousness of a system that is based on treating disease rather than promoting health; he discusses how technology has brought costs down in every other area but not in health care (a point I believe is particularly salient with regard to what I ran into today;) and, frankly, some of the ridiculous disincentives that have come out of government regulations of healthcare, particularly in the area of Medicare which favors and reimburses procedures at an outrageous rate and puts little to no value on primary or preventive care. It's an important viewpoint into the current state of the American "healthcare" system - and yes, those quotes are quite deliberate.
We have a screwed up system, a system that is rotten almost to the core (and I had to think carefully about putting that word "almost" into that phrase,) one that needs fundamental reform in terms of how we even think about the term "healthcare" in this country. Getting poeple covered is critical but will.not.solve these underlying perversities. We need a fundamental rethinking of what it means to get medical care in our society. We need a fundamental re-emphasis on public health. Political carping about covering the undocumented will mean nothing when a major pandemic comes along and these people are unable to get care. Infectious diseases will not stop at their doorsteps just because they are here illegally. It will affect all of us.
And we need better information, we need access to information, and we need colleagues who can give honest advice even if it is risky.
We are in quite a quandary; the healthcare system is the only part of our economy that is "functioning" (apart from Goldman Sachs, clearly) but it is also killing us. Literally and figuratively.