Monday, January 4, 2010

"The doctor will see you now......bwahahahahahah"

Perhaps you've noticed. When you visit your PCP (primary care physician), your time schedule and the doctor's time schedule are not in sync. This is the reason that you have ample time to fill out your entire medical history, beginning with your polio shots from third grade and then additional time to read and review a Sports Illustrated or Better Homes & Gardens issue from 1994.

Then, just as you are fully engrossed in learning about the Nancy Kerrigan/Tonya Harding dust-up, a nurse flings open an unmarked door, bellows your name and briskly leads you to a very public hallway scale where you are weighed, despite the fact that you still have your clothes on, are carrying a coat and toting a briefcase with a laptop inside; nurse clucking and scowling ensue. Then, you are taken to a small, chilly room, your blood pressure taken (more clucking and scowling) asked to disrobe, don a paper gown, not to be confused with anything Halston would design, and told, "The doctor will be right in". This is the medical equivalent of the phrase, "Of course I will respect you in the morning."

You spend enough time alone in this chilly room, in your non-insulated paper gown to discover and read more not-too-recently issued magazines--usually vintage 2003 to 2006 -- and to have various parts of your body react to the chill; depending on your gender, either enlargement or shrinkage.

Then, just as you are absorbed in an investigative Newsweek report about Dick Cheney having accidentally shot a fellow quail hunter in the face, in comes the doctor, looking confident but somewhat harried. There is brief small talk, a question or two, a quick look down your throat and into your ears and tah-dah, you're done. "What, what, wait; I forgot to ask about that burning sensation when I pee." Too late. You peek out the door one way, then the other, clutching the paper gown so as to keep your dignity, but the doctor is gone and, in that gown, there never was any dignity.

The nurse tells you that the burning sensation is "very common in people your age" and to try "cutting out spicy food." Total time at the doctor's office, two hours and twenty minutes; portion of that time with the doctor, twelve minutes.

However, if you have an appointment with a specialist, particularly some arcane medical specialty such as "Reproductive Organ Cosmetic Surgery" (I'm not making this up), you barely have time to hang your coat, grab a complimentary cup of Irish Mist Mocha Java and begin searching for reading material before you are graciously escorted into the inner sanctum. There, you are asked to disrobe so that the body part of interest is available for convenient inspection. You are provided a warm terry robe and the doctor and his or her assistant whisk efficiently into the room almost the moment you loosely knot the sash.

The specialist listens attentively, types notes in a laptop, clicks from screen to screen checking your medical history and the net present value of your previous procedures. Then, only after you have completely covered the reason for your visit and your vision for the eventual outcome, the doc carefully examines your present condition, followed by providing a thorough explanation of the procedure alternatives, likely outcomes and risks. There is a tasteful discussion of price ranges for the procedure and some clever banter about "lifestyle improvements". The doctor suggests that you call later if you have questions. He or she will take the call personally. You get dressed and you are done. Total time at the doctor's office, 45 minutes; portion of that with the doctor, 35 minutes. Who needs magazines?

Your primary care physician likely sees 30 or more patients every day and earns about $170,000 a year, less if he or she has a lot of Medicare patients.

The specialist may see six to 12 patients a day, three days a week and do procedures one or two days a week. The specialist will earn $400,000 a year at the low end and $1,000,000 (or significantly more) at the premier end of the income scale.

Let's see, the math indicates....divide the bigger by the smaller.... carry the 15.... add a decimal....hmmm......Wowzer! If you want to be a rich doctor and quickly pay off that pesky $200,000 student loan, then a specialty is for you. (By way of full disclosure, my oldest is a general surgery resident M.D. hoping that when he finishes his specialty training that there will be sufficient diseased gall bladders, inflamed appendixes, etc. to put him in the higher end of the income bracket).

Much as I appreciate financial success, especially among my own, there is a way big problem for America in the financial disincentive to become a PCP, family doctor, internist or geriatrician, each a category that falls well below the highly-compensated specialty clique. For those of you haven't been paying rapt attention and haven't already seen the hitch in this ointment (or maybe it's the fly in this git-a-long), here's the deal: the accepted wisdom is that America needs lots more PCP's, geriatricians, family practitioners and internists and fewer specialists but the current free market system works directly against that goal. Oh-oh.

If you are a Baby Boomer, you should be particularly uneasy. Should you reach the age of 65--and that begins to occur in 2011 for the oldest Boomers--you have an 80% chance of then living to 85+. Somewhere around 65, your body's biology begins to change measurably, much the same way that your biology changed markedly during junior high school, morphing you from child to a nearly-grown slightly crazed sex addict with acne and additional hair. Growing old reverses some of those changes. Providing appropriate medical care to geriatric patients is similar to providing appropriate pediatric care to children. The skill set for either is different than it is for treating young and middle-aged adults. For most readers, your doctor has very little, if any, training in geriatrics because our medical schools do not require it.

The number of geriatric patients in America is currently growing. In 2011 it will begin an 18-year slow motion explosion as the Baby Boom turns into 77 million cranky old sex addicts with multiple medical complaints, worn out body parts but less hair. There won't be nearly enough trained geriatricians--and I'm talking about a huge gap because the number of geriatricians is shrinking--to provide appropriate care. The end result will be millions of misdiagnoses, over-medication (already a troubling problem), unnecessary and expensive procedures (likewise) and a reduced quality of life for millions of Boomers who would otherwise do quite nicely with correct care.

The free market does many things very well. For instance, flat-screen, high definition TVs are becoming more affordable, in a classic case of free market creative destruction, foreign auto companies have run Detroit into the ditch (where the gummit should have left it) and department stores have something "On Sale until Midnight Tomorrow" 24/7, etc. However, in the realm of health care, the free market does a lousy job in a number of areas, including the one that determines how many of what kind of physicians we have, in spite of what we need.

The current proposed health care legislation takes some teeny weeny steps in the direction of addressing this problem. The loyal opposition (also known as Republicans) decry these modest proposals as "a gummit takeover of the health care system" and innocently look the other way while some of their nuttier supporters liken it to the policies of the Third Reich.

Should we fail to modestly change our current health care system, thanks to the loyal opposition, the irony will be that eventually, Mitch McConnell, Jim DeMint or some other loyal opponent will be misdiagnosed by a well-meaning but inadequately trained physician. The aging legislator's "advanced dementia" will actually be symptoms of clinical depression, poorly trimmed toenails and a urinary tract infection, none of which Aricept will improve. As a current example I give you Senator Robert Byrd who has been repeatedly misdiagnosed as "not quite dead yet". A geriatrician would have spotted the reality several months ago.


Observoid of the Day: It's not really winter until all of the kudzu has turned brown.


  1. I could be wrong, but I think a free-marketeer would say health care costs should be contained by the end-user performing an internal cost/benefit analysis for each transaction. Ideally, hundreds of millions of users doing this for all health care transactions would naturally drive down costs.

    I say ideally because I don't know empirically whether this is true or not. Its not really ever been tried in any country in the modern medical era (to my knowledge). Which I find strange, because its without a doubt proven to be the most efficient method of cost control in every other single industry that I know of (this includes technical, non-technical, essential, and non-essential industries). It's weird to me that most don't want to give this idea the time of day.

    I haven't handed a receptionist more than a $35 co-payment for anything in 8 years. That includes numerous PCP, specialists, drugs, and even surgeries. I really couldn't care less how much my doctor charges me. Limitless consumption of a scarce product should drive up costs, and its proven to be true in our system (and others).

    I suppose that central-planning is the other option for cost control, but we do have empirical evidence available for that - and its just not very convincing to me.

    OECD Health Care Costs Per Capita - % Change from 1990 to 2007:

    11.) UK 211%
    17.) US 159%
    19.) France 149%
    21.) Japan 129%
    23.) Canada 123%

    Its very true that we are not successfully controlling costs - but it doesn't appear to me that anyone has figured it out either. Maybe nobody has tried the only method that will work?

    I know its not a perfect idea and there are plenty of reasons why it would be difficult, but I just can't see any reason why I should be forced to buy insurance from my employer and have no say over what type of coverage I have.

  2. When one arrives at the hospital with a a pulse of 20 and blood pressure of 300/180, pausing for "an internal cost/benefit analysis" and then foregoing treatment because the analysis suggests against it, seems unrealistic. But, then again, I don't think like an economist. Very few with a burst appendix or multiple myeloma do either. Cost/benefit analyses work very well for boob jobs and tummy tucks but are slippery when it comes to true health care.

  3. No, emergency visits are probably not going to be helped much by a transparent market. At least not directly (but if I cared that hospital a. charged me 35% more than what I later found out hospital b. charges for the same procedure - then I might drive next door to hospital b. next time, forcing hospital a. to lower their prices).

    But I also think you used more extreme examples. It might help with MRI's, cat-scans, x-rays, testing, non-urgent specialist visits, elective surgeries, etc.

  4. I give up. I can only hope that I am dead before your group takes over health care. But first, I've got to do that cost/benefit analysis on death vs. the alternative. Isn't Milton Friedman dead? Apparently, the analysis augered in death's favor. Milton would never go against the numbers.