Saturday, July 22, 2017

Death Panels

During medical school, I had a preceptor who worked at a county clinic serving the least fortunate in Vallejo, California. He once said that the experience working at the clinic "is how Republicans are born." This, coming from him was, of course, tongue in cheek. But, he has a point. The front lines of medical care in this country bring to light the vast and substantial inadequacies in the health of the people, in this country.

I could go on, and on about the policies and political decisions that have brought us to this point -- I have no shortage of opinions in this area. I feel compelled to express and assert what is tantamount "end-user experience expertise," leading to a greater insight than most -- yes, it comes from simply being a doctor and working where I work, but also from the many jobs I've worked over the years. I've spent time as a business consultant in health care. There have been large swaths of time spent un- and under-insured.  My opinions are formed from a perspective imbued through the seasoned lens of wanting better health -- for all of us. I have no concern for the shareholders of private insurance companies, hospital systems and pharmaceutical companies. It has been shown that capitalized medicine only works for those with capital.

And, while I happen to believe that access to health care is a right, it is a discussion that should be had in the public arena. I believe it is, undeniably the right thing to do. It is also the best thing for this country, to ensure a future with citizens that can contribute to the greater good, where preventable diseases and unexpected traumas don't ruin a life -- physically, and financially. It is paramount for national security -- we are a nation that depends on our brain trust,  we need healthy brains.

There is another side, a darker side -- one fraught with sirens that call out to all first responders, true public servants, hospital clinicians and especially physicians, it is a desirable chorus that we must fight against, must resist. It stems from a rampant lack of individuals taking personal responsibility for their actions compounded by the desperate situations that come from a lifelong pattern of this. While all of our lives have aspects of uncertainty woven into them, there exist decision tree patterns in this world which, to a (un)certain degree lead to predictable outcomes. One may fall into many different careers in their life, but one does not just fall into being a physician. This is a decision tree with relatively predictable outcomes. The schooling, training and the sheer length and intensity of it all offer many off ramps and outs along the way (mixing metaphors feels sloppy, but I'll allow it this time.) I paused at a number of off ramps along the way, I've even explored some side streets here and there, only to get right back on. Neglect of the body --.> disease. Some of us just ignore an insidious disease like diabetes mellitus. They keep on going despite the pancreas all but giving up its endocrine function, walking around with blood sugars in the triple digits for years straight, all the while the little tiny blood vessels and tiny little nerves in their eyes, feet and kidneys are being fried with acid, killed over time with an absoluteness that makes this one decision tree even more assured in its outcomes. They will lose their eyes, toes and kidneys if their diabetes remains uncontrolled.

There are other algorithms that people follow, such as allowing oneself to be consumed with anger and deflect all responsibility outwards -- this person often uses more resources and is more "trouble" and time consuming than ten other patients combined. Sometimes this person comes in as a drug seeker, with manipulative means that have been honed to put the doctor in a corner, forced to fight against improper opioid administration. A patient with no fear of respiratory arrest, but "all body pain" rated 10/10 can be a 45 minute, desperately fought discussion teetering on straight argument, depending on the patient. It is hard to have compassion for this patient. They take time away from other patients that need attention. Infuriating situation, at times. Other times, a patient isn't fighting to further their addiction, but simply to have a warm bed and food. There are keywords which mandate a relatively expensive workup, and at times can land a stay longer than six hours in the ED to a few nights up on the floor. While these misallocation of precious and fleeting resources are disturbing, it is more understandable than the patient who has a dilaudid deficiency.

I mentioned the sirens earlier. These sirens feed on these types of patients, lurking behind us during rounds and whisper things in our ears that are evil -- judgemental, unempathetic, shortsighted thoughts that can entice people to broader plains of falsely founded bias and even bigotry. I actively fight this siren's call.

It is easy to focus and imagine the patients above, and how they waste such a disproportionate amount of our resources. But let me be absolutely clear, the ratio of these patients vs those who find themselves in the hospital fallen from historically tried and true decision trees, is actually very low. I see people, on a daily basis who, even in the eyes of a capitalist, hardcore, Reagan worshiping and Grover Norquist adhering Republican -- are valuable contributors to society who don't have access to reasonable preventative, much less affordable acute, emergent care. These people aren't the squeaky wheel, unlike the patients that remain in my mind, the ones that the sirens keep bringing up, reminding me of their greedy and incautious ways.  Just like the image of the "welfare queen" buying steak at the grocery store invalidates welfare programs, regardless of how many real, needy people, people who chose to climb a decision tree that shouldn't leave them destitute, outnumber the "welfare queens."

Listen, it is not as if I think an installation of government run, one-payer, "socialized" health care is the panacea to this problem -- but, I personally think that it would be, in general, an improvement. I could care less about political allegiances. I just want decision based not on short term, privatized profits, as they are now.

This is a national security vulnerability.

Sometimes I think that if the poor state of this country's people were framed in a way that would hurt the military-industrial complex, the Pentagon may actually advocate for a better system. I suppose that outsourcing our military to a population from overseas would be their preferred plan of action. Afterall, it seems that the political powers that be are preoccupied with ensuring that we have less access to care, in the name of political infighting, real life consequences be damned. If they're buying shares of private health insurance companies, maybe I should too, after all my student loan payment plans are next on the chopping block.

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