Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain…
And the great star early drooped in the western sky in the night,
I mourned, and yet shall mourn with ever-returning spring…
But this is not a eulogy, it’s about my recent encounters with Medicine and its current practices during my friends’ illnesses. The doctors were excellent except for the Emergency Room where some were okay and a couple were truly horrible. The best I can say is that I didn’t hit one of them [which says more about my restraint than his just due]. Which brings me to what I want to talk about. There were two main forces at work in our hospitals and medical systems that are diametric antipodes – struggling with each other in every single medical encounter.
At multiple points along the way, each of them needed to be in the hospital for diagnostic reasons, but apparently that’s a poor use of hospitals these days so we had to haul these two very ill men all over hell and half of Georgia [literally] to get the tests needed for diagnosis as itinerant outpatients. And there were numerous examples of ‘we can’t do this test [we need] until we do this other one [that we already know the result of]‘. The tentacles of managed care utilization review spreadsheets were everywhere, usually unnecessarily obstructive, and drove us all nuts – concretely interfering with decent care. Consults that could’ve been done in a few minutes took days to schedule and coordinate with others doctors. The impact of the forces of restraint in medical spending were certainly apparent every day, everywhere.
On the other side of the coin, the waste and unnecessary expensive medical tests took my breath away. It was worst in Emergency Rooms where CAT Scans and MRIs were ordered as if you had to have one or more just to prove you’d been there. It felt like a mixture of fee churning, CYA, and defensive medicine – more like the primary purpose of an ER was to generate revenue rather than tend to the sick. That was true in the hospitals as well. There are rigid protocols for everything perverted to drive up costs rather than contain them [their original purpose]. I’ve been mostly blessed with health, so my stint on the "consumer side" of modern healthcare was more up-close than it has ever been, and left me with a bad taste in my mouth – both the outside influence of managed care restrictions and rules and the outrageous waste, expense, and excesses of the hospital corporations/PHARMA/etc. I felt something between shame and rage much too often in this last month for my liking. There are other things that need feeling when you’re losing your friends.
I tried to keep what was going on in my life out of what I was writing about Integrative or Collaborative Care, but on rereading, I think I failed at that. What I read sounded like perverse systems theory drivel with people jockeying for position. Even though I was a reluctant soldier, the best system of medical care I ever worked in by far was the US military on an overseas base. Part of that was because it was a healthy population. Part of it was because there were very few, if any, sociological problems – by definition, everybody was employable and employed, pretty much on the same level. But another piece was that it was genuinely Collaborative Care, Integrative Care, whatever you want to call it when there is a team of medical personnel working together. We were all in a centralized location, knew each other, ate lunch together, were paid the same, etc. If you needed some help, it was just down the hall. I was an Internist then, but the Psychiatrists were an integral piece of that system.
The second best systems were the two megalithic City/County Charity Hospitals where I did my training [one now closed]. They were always on the brink of bankruptcy, underfunded, chaotic, and staffed largely by sleep deprived trainees. The patients were indigent and with a ton of pathology, but the healthcare was good, including psychiatry – collaborative. I would include the charity clinic where I now work in that group, though services are limited.