Doctoring Health Care Reform

Healthcare reform — A colicky and disruptive child

Before I start, let’s do a disclaimer: I, myself, John Mandrola, having practiced for nearly 16 years, and having saved and lived frugally, am going to be okay. In the game of medical practice, I am in the sixth or seventh inning. I’m almost done. I write such healthcare essays then, not so much because I expect or hope for improved working conditions for me, but rather, that the public know what is happening to the players. For without expert players, the game is diminished. It’s enigmatic, but indeed commonplace of the time, that one feels the need to start non-praiseworthy words with such disclaimer. (At work, one often starts by saying…”I’m not angry; you are a good person who does good work–that I value, but….might you consider…”

Enough already. This post comes after the 323rd time I came home and told my wife, “I need a new job.” Usually these proclamations are uttered after Friday office days–almost never after procedure days, and so far, I have always recovered by Monday. Here goes.

Healthcare reform and its implementation remind me of pregnancy and child rearing.

Humor me for a few paragraphs, please.

At the moment a family learns mom is pregnant, it’s hard to imagine the new life. One knows things will be different, but the distance in the future and the unknown-ness don’t change much in the present. Sure, one worries and nominally prepares, but nothing too significant happens until the new child comes. It’s after the child is born that parents and current family members discover the chaos. There was no pre-ride; it’s just buckle up and go.

Well, the healthcare reform baby is here. And man is he colicky, sickly and disruptive to the family.

Blissful life for real-world doctors is over. The days of running on time in the office—gone. The days of having enough time to chat and get to know patients—gone. The days of doing one thing at a time—gone. This one hits yours truly the hardest: The days of crafting a narrative to a primary care doctor on a patient—gone. Now it’s a sterile environmentally abusive multi-page list of bullet points included as protection against medical fraud. These are just a few of the new rules. The suffering of course is that many doctors were attached to these self-evidents of good doctoring. Attachment always causes suffering.

Life is changed. The new child has rocked a once happy family.

You have heard this from me before:

These are not complaints; these are the facts.

Back to the new child: We are happy for the new life. We welcome the birth. Bringing healthcare to all citizens is a must. So is doing away with pre-existing conditions. These changes, in their infancy now, will surely make us proud in the future. Some day, perhaps many years forward, there will also be a system that emphasizes healthcare, not sick care. (All parents dream big.)

The problem now is that this baby is unmanageable. The parents and child aren’t getting along well. They are both suffering. The neighbors don’t seem to notice the turmoil.

Take this past Friday: Over-scheduled in the office, patients were frazzled by long wait times and the sight of a rushed doctor—an especially bad thing for arrhythmia patients who do best to avoid anything frazzled.

Why is this? Perhaps it’s the untested unproven EMR system. The time spent in front of that white screen eliminates face time with the patient. But you remember our president’s promise: something along the lines that the efficiency of digitizing records will make all this possible. (Grin.)

Perhaps it’s because no employer of ‘providers’ can afford to hire help. Just like an understaffed restaurant, the healthcare delivery system is trying to get by with fewer helpers. (You have seen how well that works.) The doctor used to be just the doctor. Now, along with duties as educator, practitioner and healer, she must also be a data-entry clerk and life coach and protector of health.

More truth: I don’t know a doctor that has increased the number of patients they see. All docs that I know say they are seeing fewer patients.

You know why that is? It’s because many good doctors, like good parents, fight to do the basics well. We simply can’t abandon our current patients. We try to spend time with them; we try to do the right thing; we shun paternalistic decrees. We must share medical decisions. No one needs a risky procedure or pill. There are options to talk about and then click about. Therefore the suffering continues. Damn attachments.

And then there are these telling iMessages: (Factually received by the author–except with name changes.)

  • From the EP lab: With two patients yet to see in the office, one with newly diagnosed severe disease: “Your patient is prepped and draped, where are you?”
  • From a medical assistant: “Mr. Jones—my next patient–has another appointment, when will you be seeing him? He’s mad.”
  • From the practice manager: “Dr. NewGuy decided he wasn’t coming for a second interview. Too much night call, not enough procedures and the salary was too low. Also, he said family was a priority.”
  • From the front office: “I’m working on your schedule: Did you know you were booked solid for months?”

A new child is born. For those already in the family, it’s tough times. There will be adjustments. I can offer this nugget of advice to current family members: learn to be more independent. Learn to demand less of your parents.

In other words, try not to get sick.

There’s a plan for that. I think I have mentioned heart disease prevention strategies once or twice.

Seriously, I am not mad.


7 replies on “Healthcare reform — A colicky and disruptive child”

Your comments, in general, mirror a recent conversation with a cardiologist friend of mine – a slightly different take on some points, but pretty much the same overall summary.

John – I understand completely. I experienced it all when I was in the top of my 9th inning. I feel fortunate that no extra innings were needed. I do what I can to help the current players … I think it is rather sad. I also think your writing is very helpful to many!

Well put Dr. John. I think an Rx for more cycling might help. The massive bureaucracy dulls our senses and undermines quality of care to the extent that we better all understand the need to prevent.

I hope you’re right about this baby. Babies grow up to be productive citizens, usually. Let’s hope this one doesn’t buy a lifetime of therapy with a) over-controlling parents, b) addiction to drugs, c) brain damage from suffocating regulation, or d) too much screen time.

I work as an LPN in a GP’s office and can agree with much of what you say, but I wonder about the statement that the employers of ‘providers’ can’t afford to hire more help. The CEO of the company that owns our practice makes 20 million in salary and side benefits yearly. Small beans, perhaps, for a CEO, but add in all the productivity bonuses that the multiple layers of administrative types get for pushing productivity of the line staff (docs, nurses, MA’s and clerks) in the hospitals and clinics around the country that the company owns, and to many of us lowly workers, it seems that profit trumps patient care every time. Providers are just caught in the middle of the mess. I’ve been doing this work since the ’80’s, and when I started off, most of the hospitals were non profit, and mostly just concerned with making enough money to cover expenses and improve conditions. When the change to for-profit medicine came along, I saw, and still see patients and providers suffering. Somehow it seems the ACA just doesn’t address the real problem.

Dr. Mandrola,

I see a deep contradiction and a misplaced hope in what you have posted, I quote you, edited for space.

Bringing healthcare to all citizens is a must, and doing away with pre-existing conditions. These changes will surely make us proud in the future.

Patients are frazzled by long waits for over-scheduled doctors. The docs I know are seeing fewer patients. Perhaps it’s the untested, unproven EMR system. Along with duties as educator, practitioner, and healer, she must also be a data-entry clerk, life coach, and protector of health.

– –
A hope doesn’t offset or excuse the bad results of a bad plan. For example, why do you struggle with an untested, unproven EMR system? I say, because arrogant people who don’t really know have rushed through a top-down solution to an ill-defined problem of record keeping, while hoping to create a utopian future.

Your analogy to a newborn is misplaced. The demands of a child are well known along with the results. The PPACA is an abomination of confused law, the micromanagement of people’s lives, and givign unknown ultimate results. The current effects are a disaster. Why so hopeful?

The PPACA completes the socialization of healthcare. Doctors, hospitals, and insurers all maintain their supposedly private roles and responsibilities, while subject to prosecution and fines for not following detailed instructions and practice guidelines from the government.

Good policy does not produce a flood of burdens and confusions. Good policy provides immediate benefits and clarity, along with some adjustments to doing things differently. The PPACA is not good policy. Utopia is proclaimed while all of the costs and details have been delayed into the future, leaving greater burdens and confusion in the present.

The Medicare Tomato Market

This is an explanation of current Medicare economics by analogy. Say that tomatoes were declared vital to life and made available free through the Medicare National Tomato Bank. This translates the story of health care to the availability and price of tomatoes.

Healthcare is expensive and scarce because it is being distributed as a free good. Whatever people pay for it, insured or not, payment is by estimate and is first. Then, people demand services at their discretion, and have no incentive to lessen their demands. They can’t get a refund. A benefit administered this way is always rationed by detailed rules. Those rules will not be better for the patient. Worse, the rules slow any changes in the way care is provided, slowing the process of finding more efficient less expensive ways of delivering the truly needed services.

John et al…I am in the top of the 10th by choice. This is a ministry practiced on my terms, with my own staff, my own (broadly expanded medical principles and approach including a lot of molecular biology and functional medicine). I left hospital based IM practice at the age of 50 in 2000 and established a cash based consulting medical. We have grown after 13 years, have the most sophisticated EHR on the market (with menus written by me and not 3rd parties or CMS), do many virtual consults (~40% now of our practice), and deliver all of those meaningful items: patients are seen on time, focus is on one case at a time, and we do establish an ongoing narrative for all the specialists who almost never have to see our patients. It’s doable…one simply needs to step off the grid and become a physician.

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