Saturday, 26 May 2012


So I may not have been the best blogger and neglected to post last weekend.  Oops.  I find that I just keep running out of time.  I'm so tired during the weeks, I usually just eat, read for the next day's surgeries and then fall asleep and the weekend is the only time I have for sight seeing so I'm trying to cram everything in to what is essentially a very short space of time. But I'm here now. This is my third week in Boston now.  I've settled in, I know most of the team and I think I'd adapted so much I've probably forgotten how we do things at home now.  But I had a minor epiphany this week.  I've been really trying to get my head around how things work here and the main differences compared to home and then I realised.  I suppose it came after a discussion with my attending on how many of the orthopaedic consultants were paid by lots of the companies that produce orthopaedic medical devices such as implants, screws and plates and such in order to use their stuff.  And not just a little bonus.  We're talking about a lot of money here.  For some attendings, it runs into millions.  This is in addition to their normal salary paid by the hospital(s) they work for.  Which is just crazy.  That's not being impartial when you recccommend a particular company's product.  They're PAYING you to do so.  I just don't understand it.  This is not something that could ever happen at home, drug reps aren't even allowed to take GPs out to lunch any more in case this is enough to persuade them to use the brand drug rather than the generic so what happens here takes it to a whole new level. Anyway, the companies were forced to make all this knowledge public as the CEOs of the companies were threatened with being taken to court if they didn't.
So after hearing about all this, I suppose I was taking it all in and I suddenly realised that essentially, healthcare in America is seen as just another consumer business.  It's not about providing a fundamental human right. it's something that money can be made from.  As the Government doesn't provide insurance if you earn over a certain amount, you're forced to obtain health insurance from the private market.  Most people can't afford to just buy it, like you'd buy house insurance so they get it through their employer who provides it at a subsidised cost, as all the employees get their insurance through the same company... lots of people putting money into the same cost lowers the cost to them individually.  But if you lose your job or the insurance offered isn't quite what you want, you're on your own.  The thing that bugs me the most about this system is that the companies sees this as purely a way to make profits.  They don't think of all the lives they ruin by chasing people for each last penny that they owe.  This isn't just a bad loan, this is someone's health.  The criteria they apply for paying out don't always go with the way that rehab or treatment goes.  At my hospital, patients are seen in clinic at dates when their management could change.  So for an ankle fracture, they get seen at 6 weeks as their weight bearing status may change then (from non to partial) they get seen at 3 months to see if the fracture has fully healed and no time in between.  There's no need for it, the doctor doesn't learn anything new and the patient has to traipse to the hospital, sit there for a number of hours, see the doc for 10 mins then go home.  Not worth it when your mobility is limited due to your broken leg.  BUt we had one patient who came in before her scheduled appointment otherwise her insurance were not going to pay for the rest of her treatment.  We also had another patient who was asking for her weight bearing status to be changed otherwise her company was going to stop paying for her rehab.... Sometimes the first questions out of a patient's mouth after they've been admitted is "Will my insurance pay for this?"  I despair at this.  That shouldn't be a worry; the likelihood is that they've, through whatever reason, just had an accident and they need to be taken care of, fixed and set on the road to recovery.  They shouldn't be panicking about the cost of their medical fees and where it's going to come from.  That shouldn't be what healthcare is about.
Coming from England, where all medical schools are public and we get loans from the Government to cover our tution fees, people primarily go into medicine aiming to make people better in some way.  There's definitely an altruistic component.  Here, it seems like that's missing.  Or maybe it gets eroded away over those four years of study.  Maybe, before you've even begun your medical studies you've already got four years of debt hanging over you and you're looking at higher tuition feees, maybe all you can think about is the money and paying all of that off rather than helping all those patients in their time of need.  I know this seems very jaded but there definitely doesn't seem to be as much of a caring culture here.  I miss that.  Patients are described by what's wrong with them, rather than who they are.  A few of the expat doctors on the surface closer to my ends have also echoed this sentiment.  The patients in England are incredibly grateful for what you do.  There's still a few that remember what it was like before the NHS existed and when you needed a doctor but couldn't afford one, so they went without.  And people died.  So to have everything you might ever need, without having to worry about where the money will come from to pay for it is like a miracle to some people.  There's a sense of quiet pride about working in the NHS.  True to form, we complain but when it's under threat, like it is now, we rally round and do what we think is right to protect and save it.  And this stretches nationwide.  I think the fact that doctors in the UK can move around a lot more unlike the doctors here (residency for 5 years in one place vs 2 year of Foundation training, reapplication for Core Training followed by reapplication for Specialty training and then consultant jobs) means that people often work in a number of different hospitals, large teaching ones, smaller DGHs and we get exposed to these different working environnments, their strength and their struggles.  I'm immensely proud to be from a country that back in the Fifties came up with this, it was that forward thinking and I feel incredibly fortunate to be British and entitled to that sort of care.

The patient expectation here is huge.  Bordering on unbelievable.  Unfortunately the internet has made everyone a doctor in disguise and they all think they know better than you do.  So prepare for your next consultation to be an exercise in fending off questions: "I'm on this drug but I read that it causes you cancer so do I really need it?" "I've seen this plate on the tv and I want you to put this one in my leg, not the one that you normally use".  "I've got an important work do in two weeks, now I know I've broken my leg and can't walk but do you think I can leave this until after then or fix me so I'll be like new in time for it?"  "I know I had an absolutely awful break but I thought I'd be running by now (two months later) so what's the hold up?"  Patients want it all and they want it now.  They want to be back to normal or if they have some sort of arthritis, they want to be better than normal and super fast too.  They don't understand the nature of an operation:  erm, we just made a huge hole in your leg, moved all your muscles out of the way, hacked into your bone, for Goodness sake fixed everything and then patched you up.  Yes, it's going to hurt.  A lot.  But don't worry we'll pump you full of super strong narcotics for the first week so you don't feel a thing.  And then they wear off, you'll start to understand what pain really feels like and instead of learning to push through and realising it's not forever, you'll come to the ED, convince everyone there's something seriously wrong and get another refill...  Not all patients are thankful for what you do for them, they expect it as a service, maybe because they pay for it and because the hospital I'm at is ranked very highly unlike at home where care should be universally good (unfortunately not the case) so it's not quite so nice to look after them, not to say they don't deserve it but it's those things that factor into job satisfaction.

I guess this is what happens when you try to turn healthcare into a commodity.  And it should not be treated as such.  Unfortunately, when the insurance companies are making such huge profits from it, I doubt there'll be much call for change.

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