Any system that results in benefits is intrinsically vulnerable to being abused. It’s just in the nature of things. Systems are created to deal with a group problem, but when benefits are involved, individuals flock to become members of the group, and it grows. Likewise, those financing the system focus on the abuse rather than the system’s intent. That’s in the nature of things too.
My father, like many first-generation-American-born children, was a devoted patriot. He teared up if someone read, "Give me your tired, your poor, Your huddled masses yearning to breathe free" and was first in line to volunteer when we declared war on the Axis powers. I think he always felt guilty about being pulled out of that line and assigned to a munitions plant because he was a chemist. Yet once a year, he became something of a lunatic when he did his taxes – no sympathy for those huddled masses in April. They were just people who "didn’t want to work." His early heart attack terrified him, and he never returned to work. His campaign to get medical disability filled his mind [and ours] – back to the huddled masses he went [though the April lunacy was unchanged].
I was surprised at the balanced efficiency of the military medical system. But there was one part I hated – Medical Board it was called. I had noticed as a resident at the VA hospital that the patients were service connected for medical conditions that surely had nothing to do with being in the military, but didn’t know how that worked. In the service, I learned. When you retire, you go see all the doctors who write up reports, and then a Medical Board makes that determination. So I had to see all these retiring 40-somethings and write a report. My problem was that just before I was invited into the Air Force, there had been a realistic reform of the system. So these burly soldiers came expecting benefits for their aches and pains along the way, and the Air Force just didn’t do that anymore. "If you were healthy enough to serve, we’re not going to declare you a cripple the day you retire" was the new order of things. The retiring saw that as a personal decision I had made. I learned the meaning of both "shooting the messenger" and "the squeaky wheel gets oiled" in those days.
I could tell these stories until the end of time, but I’ll just add couple more. When I left the military and came to a psychiatry residency, I had a stipulation – I wouldn’t rotate at the VA Hospital. I recanted down the road, and it wasn’t about not liking vets. I was one. It was those damned Medical Boards. My residency was during the end of Viet Nam, and we were discovering once again that war can make some people very sick. PTSD can be a showstopper. I saw it in friends and patients. Supervising residents working in the outpatient clinic at the VA, I became something of an expert separating the really ill from the hordes of applicants. I had a resident who thought I was too tight-assed. So he and I put on our jeans and bandanas [I wore a tie-dyed t-shirt and my old fatigue jacket with insignia but not the rank], and off we went to the VA on a field trip. In the huge parking lot, we encountered activists handing out brochures with the diagnostic criteria for PTSD on the front. Inside they told what to say and what not to say. When we got back to the car, there was one under each wiper blade. After that, that resident became the hard-ass and I had to take the other side to undo some of my little lesson. Did I mention, it’s just in the nature of things?
I was drawn to analytic training because the psychoanalysts were the best clinicians. They heard the music I wanted to learn to hear. As would be my fate, my analytic training program spanned the DSM-III [1980], 1976 to 1984. I didn’t use my health insurance for my own analysis though it was covered back then. It didn’t seem right, but I didn’t tell my classmates [or analyst], because it was such a hot topic – insurance coverage for analysis. My otherwise super-reflective teachers and fellow trainees were uniform in explaining why it made perfect sense. Of course it made absolutely no sense, but I wasn’t about to have my pathological egalitarianism analyzed. Like I said, it’s just in the nature of things when benefits are involved.
I live in a place with an indigenous population dating to the country’s founding. The area was long the center of the moonshine trade, and the tradition persists – meth labs, prescription pill abuse. etc. I’ve mentioned that I surrendered the pain pill part of my DEA registration because I got so tired of being hit asked for narcotics. I’m the only person in our clinic that will prescribe Benzodiazepines, and we have a way to be sure that the patients aren’t seeing multiple doctors for prescriptions and are told if patients sell them by the local constabulary. When I explain to patients why I made it impossible for me to prescribe narcotics, they all say exactly the same thing – obviously ill people, the indeterminable, and drug seekers alike. "It’s a shame that people who really need this medication have to suffer because of the bad behavior of others." It is a shame. But it’s in the…
I probably shouldn’t talk about this topic very much, because I actually do have unanalyzable pathological egalitarianism, and the reason is revealed in the second paragraph for all to see. But I can say something about the process. It involves the universal mechanism I call simplification of people. We all know the drill. When angry, the infuriating other becomes a flat character – a mostly bad guy like in the movies. In fact, we love those kind of movies, such a relief from everyday life and the complexity of real human beings to see the world as filled with good guys and bad guys. When I was a kid, the movies were easier – hat color was enough to provide the key in the first scene. Nowadays, we don’t find out for a while that the good doctor is a cannibal, or the cop is a mobster. But a morning watching cartoons with the grandkids shows us that the out front good versus evil paradigm is living and well. Anyone who treats the mentally ill [or looks at their own interior] encounters this dichotomy every day.
So the evil, greedy doctors are just people milking the system for their own gain. Don’t we read about Medicare fraud in the paper every day? Didn’t those greedy analysts bill for endless therapy? See! Or. to reverse the process, those unprincipled Managed Care bean counters are having a field day because mental health coverage is so easy to cut. They’re filling the pockets of their companies at our expense, at the patient’s expense! and we don’t have the biomarkers that other specialties have to fight back. Didn’t I just read that people are killing themselves waiting for appointments at the VA. So it’s Greedy Doctors v Greedy Insurers. Patients out of the picture. Kill the messenger! Squeak! Squeak! It’s a shame that people who really need this medication have to suffer because of the bad behavior of others. It is a shame, but it’s in…
The only way I know to get people out of the simplifying other people mode is encounter. When put in the same room for a long time, waring factions can sometimes be engaged in seeing the complexity of the other – it’s a central principle of couples therapy and diplomacy. A waring couple in a room with a neutral other can sometime recall whatever love means and move towards each other. But don’t try it in a courtroom where benefits are on the table, the simplification of the other gains the upper hand. Why – didn’t I see a case just like mine on 20/20 [or Dateline, or Dr. Phil] just last night?
So my neurotic hangups about the problems of being special are very real. I can’t play the look-at-my-credentials card, even when Sandra asks directly. It’s not in my bag of tricks [2nd paragraph hangover]. I’m willing to compete on the open market only based on what I do. That’s actually not totally sane, but at least I know it. But in terms of the topic on the table, there is one thing that I feel solid about. Managed Care has way overdone it with psychiatry. I dread seeing a truly homicidal or suicidal patient because the resources have disappeared. Hospitalizing someone is now impossible. The same is true with grossly out of control psychotic patients. Psychiatric treatment for severe illness is non-existent except for meds. I wish the people protesting at the APA would give equal time to the Behavioral Health Insurers so people might get the treatment they actually need – "shooting the messenger" and "the squeaky wheel gets oiled" come to mind.
Cognitive disconnects abound in our world. The tragedy of the commons is played out daily in all parts of society. The clergy talk about doing good with our money, and oh and by the way, I need a raise, longer vacation, and how about a new car.
Various parts of medicine clamor that they are the one and true savior of our bodies and our souls. Front line doctors speak of the importance of a history and then boast of being able to tell what is wrong with a patient in seconds resulting in them seeing 70 plus patients per day.
That patient churn has resulted in a reduction of fees and doctors respond by claiming poverty and the right to protect their income by excluding all of those who do not posses a MD. Those with life experience and graduate work in other areas need not apply.
Insurance companies need to make a profit, but are a cost plus business due to state regulations. The result is often to make their products more costly in the name of cost control. We need this test before that test so as to be sure you need the second test, which you will get because the doctor is paid per test.
Pharma is a world unto itself taking literally the results from less than under 100 people, extrapolating this to the whole population, and calling this science. All the while the doctors claiming to be scientist accept any new thing the drug rep brings in the door, as long as they bring lunch.
Politicians work together to try and bring some type of positive result to this issue and “leadership” will not allow a win for the other side claiming they have a constituency that will not benefit. Trial lawyers are large contributors to one party, and the party claims they are protecting the little guy.
Five years ago right before my wife retired they received mental health benefits as part of their insurance package. The daily mailing were outrageous with questions of did she feel sad, was she over worked etc. Yes she felt this and much more since she worked for a political hack whose only function was to slow the system and not allow anyone to take credit for any accomplishment.
Today we are left with a totally dysfunctional system where the truly sick are not treated because they cannot be churned. Lawyers are paid at the public trough to fight the very doctors trying to provide care for those who are truly in need, and every April I am told how fortunate I am to pay even more in taxes.
Steve Lucas
Dr. Nardo,
This isn’t to open the box on your “pathological egalitarianism”, it really is just a thought about taxes and the poor. I don’t know your history, yet I know that you’ve seen the level of poverty I am going to describe at your clinic; it isn’t the worst by far, but enough so that I have had people tell me that it doesn’t exist in America.
1970’s, 1 adult and 4 kids living on $70 a week. We had a home that my father paid the mortgage and the heat bill for, plus his insurance covered several dental visits. We didn’t receive social welfare except for free lunches at school and we didn’t have a phone or transportation. There was very little access to medical care, but we were pretty healthy so that didn’t really matter. I still remember years of being hungry every single night. I’d say that was the worst.
With this background, I find it odd that people equate helping the poor by paying taxes. It isn’t that the poor don’t benefit from things like clean water, a free education and roads. But these are the same things all benefit from. And, even though I see a need for emergency aid in many situations for the poor, I also see if for anyone that suffers a major setback in their lives.
Yet, I would say that the idea of throwing money at the poor through government, actually does them a major disservice because it allows successful people to assuage their guilt over poverty, government to use this guilt to extract even more money from them while giving crumbs to the poor, and both to ignore what almost all of them really need. And that is, someone who has been successful in life to actually give a d^mn about them and be in their lives even if for a short time. Please correct me if I am wrong, yet it isn’t one of the great deciding factors in the positive outcome of life of a child that has lived in horrific conditions, the presence of one caring adult. I see it no differently for the poor.
Steve – excellent post.
Perhaps we are seeing here the monetization of life. The consequences are the erosion of professional identity and the commodification of patients. A useful overview is given by the legendary sociologist Jane Jacobs in her book Systems of Survival. She draws a contrast between the guardian ethic (professions) and the commercial ethic. When the commercial ethic invades the professions, then the things you describe will happen. It boils down to the familiar adage: No man can serve two masters. The imperatives of managed care are incompatible with the traditional professional standards of disinterested beneficence to patients.
Dr. Carroll
Excellent point, I had not thought of the problem from that prospective, but it explains a world where as we say in business, you bottom line any action.
Steve Lucas
After reading Dr. Carroll’s comment I came across this post:
http://loathingbioethics.blogspot.com/2014/05/how-to-exploit-patient-with-mental.html
I am also reminded of the celebration of the psychopath in business. They are touted for their focus and lack of empathy, but as seen in the book Snakes in Suits, leave a trail of broken people and careers.
As a business person I am troubled by the use of the word economics. Often this is simply a substitute for increasing sales to reach an income level for higher ups. The reverse of this is structuring a transaction not for efficiency, but to maximize profits, often for one individual.
Our large universities in every state lead through example, leading the way in questionable behavior Students graduate with an ingrained “corporate culture” of keep quiet and take every advantage of every situation.
The clergy no longer speak of ministry but of job security and contractual obligations, always about how the congregation is obligated to pay them regardless of their performance. I have a job; I have a contract, sue me to get rid of me.
The law long ago used the excuse of a defense for every person to scam public funds for fruitless defenses of hardened criminals. All the while low level criminals are processed through the system and jailed when they would be better served in a supervised system where they can receive the mental health treatment they need.
When we monetize every aspect of our life from our extra value meals to professional services, we cannot expect medicine to be any different than society in general.
Steve Lucas
Dr. Carroll,
Thank you very much for providing me with a historical and sociological foundation for my thoughts. Having worked in both fields, I was always positive I did/do not want to see what I call the “business mindset” in medicine. And to clarify, it is the current, prevalent business mindset that I have issues with. Business doesn’t have to run obscenely, and I think you need at least some business acumen to run a private practice.
Steve,
You touched on one of the biggest issues I have working in the business environment when you mentioned the word “economics” being used the way it is. And, the article that you’ve linked to where Carl Elliott called what he sees a facade. Exactly.
It is all the lies.
I briefly mentioned integrated care being “all about the lie”. And that is what is so troubling to me. I found myself abhorring something that for all appearances should benefit patients greatly. Nothing new to me, I told Dr. Moffitt almost a year ago that I was 100% behind his vision for integrated care (it included being seen by a psychiatrist, btw). Yet, even then I used the word “vision” specifically.
I have no doubt that in Dr. Steingard’s world, integrated care works well. Yet, I think it is the individuals there who created it and make it work. If it was the system itself that caused it to happen, I would be surprised, yet still I wouldn’t think it was the system that managed card and the APA have in mind. I think theirs is for an entirely different purpose and they cover it with lies. You can tell by the spin.
I listen to the talk from psychiatrists about taking themselves off of insurance panels because of managed care, which has not exactly been managed (outside of behavioral health) for about 15 years. I get why they want to do this for themselves. I sort of get why they might think paying for therapy makes it more valuable.
But here’s the rub: the really psychotic people don’t have money. Frequently, their lives are in shambles. The guy whose depression barely responded to maintenance ECT who can’t work because of a broken back and whose wife left him is now on disability.
Maybe he ought to pay some sort of co-pay, but he can’t pay full freight. Volunteer and charity clinics aren’t enough. All of these people should be seen by a psychiatrist, but somebody has to pay. If it’s insurance (whether public or private) there will be cost controls–either arbitrary rules or capitated payments.
What’s your preferred solution? I’m genuinely curious, and I hope that I don’t come off as overbearing when I’m asking.