Tuesday, November 01, 2011


Health Care Reform Epiphony

When I was in medical school I had friends in law school. Late in our first years of training in our chosen fields, I had an epiphany. It was not at all about the information that we were learning, it was about the thought process. The medical students were being taught to think like doctors and the law students to think like lawyers. Both professions are, in most ways, about problem solving. There was a major difference in the problem solving processes taught.

In medicine we gather data, our history, physical exam, test results, and exploration. Along the way we are juggling the data and fitting to patterns. At some point we prescribe or perform a procedure to attempt to fix the problem. If the fix fails, we regroup and try again: gathering data, pattern fitting, trying to solve. All the human players are on the same team, the doctors, nurses, technicians, as well as the patient and the family: the enemy is disease or dysfunction afflicting the patient. Precision and speed are essential. Caring and compassion are essential as well.

In law the process has a different flavor. Although there is information gathering, the process is adversarial. There are winners and losers, and the battle goes to not necessarily to the best solution, but to the the best fighter. Perhaps justice is served, but all the combatants are bloodied. Surely there are "principles of law" that are based on millenia of sorting of human civilizations' wranglings with conflicts between people. But the lawyers thought process is taught about the minutia and techniques that win the battle, not for what is right, but how to win.

I watched as my law student friends became lawyers: arguing their points with ferocity and skill. I watched as my budding medical colleagues became expert in data analysis and complex human bio-psycho-social systems.

Tonight I had another epiphany.

It has been the in last forty-five years, and particularly the past thirty, that health care delivery has shifted and declined. I blame the decline on the shot-gun wedding of government/business with medicine. Under duress, medicine was forced to accept governmental intervention and control and subsequent business interference. The intrinsic thought process of physicians is incompatible with the legalisms of government and the imperatives of the marketplace. The medical model has been supplanted by a business model and legal process. I fear that the new generation of physicians will be taught to think like businessmen, lawyers, and politicians. I see it already.

My generation of physicians are retiring early, unable to practice as the physicians they were molded to be. Few physicians appreciate the interference and control of Medicare and the myriad insurers. The adversarial relationship is foreign to us: it just does not work for us. We are forced to argue with representatives over even the most trivial things.

This morning I was making rounds at the hospital. I needed to write orders, write a progress note, and obtain written consent from a patient for her blood transfusion. I had to search through racks of ninety-six (I counted) different forms to find these three sheets. Of course, half the chart information is not paper, but is in the computer. Despite the computerization there are over one hundred required forms. Thirty years ago there were less than half a dozen forms in the chart. Forms and paperwork are part of the legal mind-set, not the medical world.

I believe the ever-rising cost of health care and the ever-declining esteem and honor of my profession is a direct result of the spawn of that wrong-minded marriage.

Thank you for your insight and your perspective; helps us patients see what doctors have to cope with. It is rare to find someone with such integrity and rigor about their profession.
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