Wednesday, August 21, 2013

Leaning Forward, Rooted in the Past

As we get older, we become acutely sensitive to sounding like the old gomers we remember from our own youth, men and women who complained about how things had changed, and not for the better, how old values have been forsaken, and how the world is deteriorating.  
When we were young, we suppressed smiles at these remarks, thinking, oh, these old timers, complaining about progress.

Now, of course, we have a basis for comparison of old values of our own to the  new values and one can understand some of the old timer's dismay.

From the point of view of Mad Dog, much of this has to do with a change in the value of service toward a value of financially hard nosed reality.  In the case of doctors, one can talk about the value of putting the patient first, but if you do not put yourself first as the doctor, you will not survive to help any patient, say the new "thought leaders" who direct medical care delivery systems.

It's the same idea you hear when the flight attendant is giving the talk about what to do when the yellow oxygen masks drop down from the airplane ceiling--"If you are traveling with a child, put your mask on first and breathe before applying the child's mask." What she is saying is, you are not going to be able to help the child if you are unconscious from lack of oxygen. In the same way, if you do not ensure your own practice is on a strong financial footing, you cannot help your patients.

But in the case of the medical systems now being developed, Mad Dog thinks what he is seeing is the physician has the yellow mask clamped to his own face and is not inclined at all to think about putting the mask on that child, except as an after thought. 

Thus, the patient is kept in the waiting room and not allowed to go back to the exam room to see the doctor until all the paperwork is done, all the forms in place lest there be a chance the doctor's office will not be reimbursed fully.

There is the gastroenterologist whose secretary makes sure she collects the full $1,500 payment, cash, before she allows the patient to cross the threshold to the rear office for his colonoscopy.

There is the pharmacist who will not hand over the insulin, unless all the paper work is in order for payment, even it means the patient will have to go without it.

The patient in the emergency room is protected against the pay me first imperative because that is such a dramatic example--how can you let the man bleed out because he doesn't have his insurance card?

But there are much more pervasive and destructive forms of this sort of mentality--this is a business; we are not here to be heroes or saints or pillars of the community. We are in business and that is that.

So the new graduate doctor will take your phone call over the weekend, if you dial through the special line which will charge your phone bill $25 for the call, a fee send along to the doctor. It is the new airline model of medical care.  You pay for each blanket, each bag of peanuts, every time you go to the bathroom at the end of the airplane.  The basic service is transportation. Toilets cost money, and you pay for that.  Look over your hospital bill and see if that $5 aspirin and that $25 gauze pad don't look a lot like the $2 charge for using the bathroom on the airplane. 

At some point, the attention to the money end of medicine gets in the way of the relationship. 

Hemingway remarked how much easier dealing with people was in France, where everything was on a monetary basis, compared to Spain, where ideals of love and respect and duty got in the way of the simplest transaction. In France, he said, he tips a waiter well, and the next time he goes the restaurant, he gets a better table and prompt service.  In Spain, he could not even get a good hotel room for the bull fight weekend without establishing his bone fides as a true bull fight aficionado with the inn keeper. 

So, the idea of getting to know a patient, the idea of going to bat for a patient, for clearing the way for a patient through the medical maze may be ridiculously sentimental and may have no place in the modern, efficient mode of medical practice.

Oh, well, Mad Dog grows older and the world colder.

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