At a recent meeting of the American College of Chest Physicians it was of interest to note the large number of presentations with titles such as: Ethical issues… in medicine… In the ICU… In death and dying…. In withdrawing life support… In health care delivery… Most were rather thin on any ethical discussion and should probably have just been given a cost emphasis title. The honest topics simply said: Economics: cost-effectiveness and resource utilization; or Impact of Managed Care on Physicians; or Taming the Beast: Managing Cost and Quality of Critical Care. This was a small meeting of only 3500 for the Moscone Center in San Francisco which can comfortably handle 15,000 and even seat 7500 at a banquet. But with a dozen or so countries represented, it did allow for interesting discussions at breaks, lunches, and in the latrines.
A Korean physician reported that he was now seeing 150 patients in a 10-hour day which gave him about four minutes to obtain a medical history, physical examination, and review lab work and other data; give his instructions to a physician assistant as to what further tests he should order; what Rx he should write; and the final disposition of the patient before walking to the next room and patient. He stated that even the wealthy could not buy better care because it was illegal. They had to go to Japan or the USA for private care… If we eliminate private care in this country, we can essentially consign the world to mediocre medicine.
A VA doctor from Long Beach stated that the new patient appointment has been reduced to 20 minutes and follow up visits to 10 minutes.
A Canadian Thoracic Surgeon stated that he feels medical practice and medical care is deteriorating rapidly in his country. He said that it is difficult to obtain approval for any surgical procedure in less than 6 weeks, generally it takes three months. Doctors are hesitant about doing emergency procedures. The penalties are severe if, in retrospect, some reviewer thinks it really was not an emergency.
A Chinese doctor explained that it was comforting to be in San Francisco Chinatown. All those dragons drive the evil spirits away. All those bells attract good spirits. Therefore, you are in really good hands.
A Canadian Pulmonologist stated that things are so rigid in his country that you can not do any private practice. If you get caught, it’s a felony and you go to jail… He wasn’t sure if you would be put in the same cell with your patient (who is also guilty).
A San Francisco native boasted that his city has the best politicians that money can buy.
One discussant claimed that the only reason we have managed care is that doctors refused to be concerned about cost containment. He pointed out that many doctors still are not concerned about cost. He felt some still view a clinical indication, that may have been valid in the past, as adequate reason to proceed with a procedure or test regardless of costs or other variables. He assured us that they would be deselected… soon.
Are things ever going to get better? One presenter quoted Yogi Berra: “Predictions are very difficult, especially about future events.”
A presentation from Germany was on the quality of life (QOL) in their health care system. From the perplexed looks on the faces of the audience, this seemed like comparing apples and grapes. Transcultural comparisons, although important, are difficult at best.
A Minneapolis consultant, who stated that the Twin Cities, Los Angeles, San Diego and Worcester have the highest managed care penetration in the country, mentioned he had received a phone call from a Sacramento double-boarded surgeon who was deselected and now makes one-fourth of his previous income scrounging for surgical assisting jobs. (Sacramento was in the second tier along with Salt Lake City.)
Question: Can physicians survive the managed care environment? With difficulty. The bigger question is: Can patients survive the managed care environment? From all that was presented, the answer was quite clear. Only with a decreased QOL.
Epitaph on Tombstone: Here lies Billy Osler, Jr, MD, a medical felon, who spent his last years in prison when his only crime was trying to give a higher level of medical care.