A couple of weeks ago I wrote about Dr. Ezekiel Emanuel’s thinly veiled fury at the medical profession which seems reluctant to accept promotion to the rank of Puppet Captain of the health care ship. That is beginning to change, and this week’s issue of JAMA carries a brief manifesto from three physicians accepting the Captain bars and calling on all colleagues to do the same. The piece, titled “First, Do No (Financial) Harm”, is a succinct summary of health care’s new prime directive: First, Show Me the Money. Before recommending a course of treatment, doctors should first assess the patient’s financial capability. To deflect any remnants of ethical questioning, the authors suggest that assessment of financial status should be undertaken for all patients, not just the obviously poor. This in their learned opinion eliminates the appearance of discriminatory practice, and appearances are the major concern here, because this navigation strategy will have to be packaged by some Mad Men for consumption by the presumed stupid masses. [Note to EMR vendors: Perhaps financial prowess should be another vital sign that the nurse can collect during intake (e.g. how much can you afford to shell out of pocket? Nothing; Up to $100; Up to $1,000; Up to $10,000; Up to $100,000; No Limits), and decision support would be objectively provided by the EMR during Assessment & Plan. This should probably be added to Meaningful Use Stage 4.]
The example provided in the article is of course treatment of mild back pain, which requires no treatment. This, and MRI for headaches, or antibiotics for a cold, are the preferred examples to illustrate the benefits of cost consciousness by both providers and consumers. Nobody dares venture into the conversation that will have to take place with a cancer patient, other than Oregon, of course, which is mandating that this “conversation” takes place before the state will pay for anything. If the “conversation” did not result in the impoverished, sick, depressed and frightened patient asserting his or her “cultural values and preferences” to forgo expensive treatment (as all poor people should), the State will pull the plug anyway, thus empowering those who fail to be empowered on their own.
Let’s go back to MRIs and physical therapy for back pain which is a subject better suited for polite conversation. The authors provide us with a very thoughtful script on how a doctor would go about the difficult conversation of gently avoiding overtreatment of back pain. First you find out if the patient has any money in their wallet, then you proceed with the unrelated task of explaining that an MRI is clinically inappropriate. The latter can probably be skipped if the empowered patient doesn’t know enough to ask for an MRI. The next step is to tell the (poor) patient that beneficial treatment, like physical therapy is too expensive for him/her, and suggest self-care at home (an illustrated sheet of exercises should help). To round it up for those with no money and no real insurance, you could amicably suggest the patient’s “local yoga class”. This is how you “[o]ptimize care plans for individual patients”. The optimal care plan for someone living on the 10th floor of a housing project is most definitely a “local yoga class”. Marie Antoinette must be smiling in her headless grave.
A couple of years ago, my son’s friend, Kenny, got injured during a football game in his high-school senior year, and needed surgery on his knee. Since Kenny did not have a car, and even if he did he was in no condition to drive after surgery, my son drove him to the downtown clinic for post-op follow-up. Kenny came out of the exam room limping cheerfully since the nurse said that he is all good to go and does not need to come back. My son, having had his own surgical encounter with football’s unintended consequences earlier that year, was a bit surprised and asked where Kenny should go for his physical therapy. According to the friendly nurse, Kenny didn’t need any fancy PT. The boys walked out, one furious and the other limping and smiling sheepishly. I haven’t seen Kenny since that year and I don’t know if he is still limping, but this formerly bubbly and faster-than-the-wind running back has not shown up at the traditional, and immensely popular, Thanksgiving high-school reunion football games ever since.From the dawn of civilization to the current day and most likely well into the future, the rich and powerful in all social orders enjoyed better access to better medicine than members of the human species who are poor and powerless. Similar to disparities in other life-sustaining goods and services, enlightened governance systems have attempted to minimize (not eradicate) these differences in medical service provision due to an emerging sense of social justice and also because prosperity seemed to accrue to better nourished, better educated and healthier societies. A nation founded on the premise that individuals have an inalienable right to pursue happiness cannot weave social injustice into the very fabric of its existence, and expect to thrive. We know this, because we tried similar schemes before, and failed in what were arguably the darkest and most perilous moments in U.S. history.
Utilizing inherently trusted individuals to prevail upon the unfortunate that what seems like injustice is actually good for them in the long run, is not a novel idea. Substituting betrayal by physical healers in clinics, for indoctrination by spiritual leaders in churches, is a minor innovation. Internalizing and institutionalizing pure evil wrapped in misleadingly kind and gentle rhetoric, while inflicting much pain and suffering on countless human beings, is also a sure recipe for the ultimate destruction of the perpetrators no matter how righteous they believe they are. Doctors, who are tempted to accept compliance with the newly created Captain positions on the misguided health care ship, without questioning its opiate laden navigation route, are simultaneously terminating the medical profession’s days of glory. There will be no joy. There will be no trust. There will be no prestige. There will be no respect. And there will be no financial privilege. Captains of this doomed ship are a dime a dozen and they all reside below deck.
In order to protect privacy, names and locations mentioned in this post have been changed, as have certain physical characteristics, quotations and other descriptive details.