Health Reform? Build on our History.
Stephen Kamelgarn, MD, Editor of The Bulletin of the Humboldt-Del Norte County Medical Society gives us his changing views of single payer healthcare in the February 2009 issue. His article is entitled, “Can We Get There from Here? Should we Listen to our History?”

Over the years I’ve written a number of diatribes expressing a need for the United States to adopt a “Single Payer” Health Care System. We’ve finally inaugurated a president who is, at least somewhat, amenable to listening to a variety of plans for health care reform. This would seem to be a time that we single payer advocates can push our agenda; or is it?

In the Jan 26, 2009, issue of The New Yorker Atul Gawande (one of the magazine’s medical correspondents) has written an intriguing article about health care reform. While he is in favor of single payer, he feels that we are in the grip of past precedents and history. He makes a very persuasive case for “listening to our history.” This holds true not only for health care reform, but for any transformative technology or practice in a society. He briefly traces the history of single payer in both France and Great Britain and shows why their plans have taken the form that they have.

In the article he states: “Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.” His point being that no matter what we Single Payer monomaniacs may want, we are going to have to build it upon what we already have. If we attempt to get “too radical” too quickly we will wind up with a gigantic failure on our hands.

I remember reading an interview with President Obama early in the past presidential campaign where he tried to defend his health care proposal. He stated that if he were to design a health care delivery system from the ground up, it would definitely be a single payer system. But he doesn’t have that luxury and must “patch” our current system.

Aside from the fact that we’re dealing with the most political of processes, with vast amounts of money at stake – money no insurance entity will willingly surrender – we also have to take into account all that’s gone before. Massive change “by fiat” will usually fail – witness the disaster of Part D Medicare.

The point being that we, as health care reformers, will have to adapt that which we already have, rather than coming up with something de novo. Besides the hundreds (if not thousands) of different health insurance plans we have in the US, we also have several government funded plans: Medicare, Medicaid and the VA to name but three.

Medicaid is so horribly underfunded that it doesn’t answer anybody’s needs except the very poor.

So, it becomes operant upon us to work to strengthen and expand Medicare. To me that seems to be the least traumatic, most equitable alternative. It also has the greatest chance of success, being an adaptive change to an already existing system, rather than something brand new.

Read Dr. Kamelgarn’s entire editorial at www.humboldt1.com/~medsoc/images/bulletins/.

Calling? Career? Job?
Philip R. Alper, MD, discusses whether physicians view their work as a Calling, a Career, or a Job and how it changes over our professional life in the March 2009 Issue of the Bulletin of the San Mateo County Medical Association. His article is, “Would You Choose Medicine Again?”

Back in 2001, Barry Sheppard polled the SMCMA membership on a set of questions dear to his heart: essentially, how do colleagues view their work as a physician? Is it a calling, a career or a job? Has the answer changed since graduation from medical school? And would you still become a doctor if you knew then what you know now?

Barry was impressed by the 28% response rate and intrigued by the number of doctors who modified the questions before they answered them. Most of all, he was impressed by the high level of positivity of the responses, something he said he would not have predicted.

On graduation, nearly half, 46% of the respondents to be exact, viewed medicine as a calling, while 52% considered it a career. Only 2% voted for “a job.” Once in practice, 30% still considered medicine a calling, while 56% now described it as a career. Job-minded physicians increased to 14%. In all, two thirds of physicians who responded did not change their mind with the passage of time. And a striking 70% said they would still become physicians all over again, even with the benefit of hindsight.

There was a hint that more recent graduates would be less inclined to choose medicine again than older doctors, but even they voted “yes” 59% of the time. Dr. Sheppard brightened at the end of his introspective analysis and spoke of “our strong and, for the most part, abiding love for our chosen profession.” Even though I myself have often grumbled about what could be much better in medical practice, I must admit that I too was pleased with the results.

I don’t know that at any time I’ve considered medicine a “calling.” For me at least, the idea is too pretentious, implying more things than I think I’ve given to medicine or my patients. But neither has it simply been a career for the 52 years since I graduated from medical school, much less a job.

I know I took – and take – the Hippocratic Oath seriously. Respect for patients, honesty and doing my best for them go without saying. Perhaps “a sacred trust” rather than “a calling” comes closest to the mark, though that too is rather pretentious. Were I to take Barry’s quiz now, I probably would have tried to change the questions because they are too hard to answer as given.

Would I choose medicine again?

That’s a more straightforward question. The answer is “yes,” but I’m not entirely sure why. I’ve been a doctor so long that the role seems to fit naturally. I’ve never been free to abstractly choose whether or not to become a physician again. What would I take myself for if I did something else?

There is a big problem with opinion polls like these. It’s not clear whether negatives represent healthy grousing like the attitude portrayed on TV in M.A.S.H., how deeply the sentiments are felt and whether they would lead to action…

One thing I miss is the number of people in health care who were willing to help me fulfill my role as a doctor. The pharmacist who dropped everything when I called years back has been replaced by the pharmacy technician who explains that the pharmacist is busy counseling a patient and that I will have to wait. Old-time nursing home directors like Mrs. Huntley in Magnolia Gardens, where often nurses made rounds with me and knew “our” patients intimately..

Diagnostic tests, surgical procedures and drugs are getting ever-better. But it is tougher for many of us personally. Still, the work seems to be getting done, patients are grateful and medicine endures. Yes, I would become a physician again, even if I’m not entirely sure why.

To read Dr. Alper’s entire editorial go to www.smcma.org/bulletin/issues/BULLETIN-09MarchR5.pdf.