Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Coming Cost of Medical Care (2) Substituting Frills for Life-Threatening Disease.

Right now, what I am about to say has no urgency to it, because right now no new diseases have suddenly been cured. But nevertheless, the financial benefits of curing some diseases could be lost by substituting make-work for real work. That's a major flaw in predicting the cure of disease will cut costs. In the first place, there is a delay in transmitting the news that the disease can be sure-enough cured. These cures typically take place in urban medical centers, and often make their way to the remote practice areas when a doctor graduated from a medical center and takes new practices with him. If it's just a new pill, the manufacturer sends a salesman to inform the practicing doctors, who then have to discuss it with their colleagues, try it out, and circulate the news it really works. The average doctor only has time to attend one or two national conferences a year and read one or two journals a week. He depends on his colleagues to keep him current. Sometimes there is jealousy, and they don't. It may take a year for the news to settle in. You could speed this up, but if you do something else must make room for it, and costs would go up in a different way. Sometimes the cure isn't as wonderful as early reports of it, and you can be very glad the inertia of the system has reduced the damage. After all, most conditions a practicing doctor sees aren't new, aren't novel, and don't require a few months hurry-up by a young hotshot from out of town.

For one thing, a busy fee for service doctor is highly allergic to adding new overhead. It may be a thrilling experience to have five or six assistants to relieve you of tedious details, but they add overhead that continues when you are gone--it's hard to take a vacation, for example. Or to put it another way, it's fairly easy to quit, but it's very hard to slow down. Consequently, the Affordable Care Act introduced the electronic medical record without understanding that the practicing physician hoped it would reduce overhead, but it actually increases overhead, by adding three or four hours a week to an already overloaded schedule for the same number of patients. It has a few advantages which have been exaggerated, but they are mostly advantages to the management or the system, not to the doctor or the patient. It does not help that it might have been otherwise if the programmers had spent more time with the doctors. A salaried position tends to create an instant forty-hour week anyway, so adding more workload is no attraction. And automatically reminding him that his ten minutes with this patient have expired, merely infuriates him. Only a system which doctors have personally had a lot to do with designing will compensate him for interfering with what he has been doing for years. Most of the doctors I know who have quit have done so because of the electronic record.

Finally, with every advance of science, it takes time to adjust to the idea they are really cured. President John Kennedy had Addison's Disease, a rare and usually fatal condition. How often should you see this patient with Addison's disease, now that there is a useful treatment? Every week? Every year? President Kennedy took matters into his own hands and behaved the way we now know he behaved. He died of gunshot wounds, so it was all for naught. It takes a long time to adjust to people with fatal diseases when the rules of the game change. But they do change, and although I can remember making ward rounds on forty people, two or three of which died every day, I now observe ads in the paper for doctors who will adjust your diet and exercise for you. They don't feel they are doing anything dishonorable, but they and their patients are sustaining the cost of care.

Originally published: Thursday, March 31, 2016; most-recently modified: Wednesday, May 15, 2019