A Tale of Two Systems…

I am close with this doctor who works in the government health care system.  She is a palliative care/hospice doctor.  We live together and as such discuss clinical cases frequently.  This evening’s discussion sheds much light on the many differences in the systems in which we practice medicine.

A vignette…

But first a disclaimer:  The opinions expressed herein are solely my own.

Staci has a hospitalized patient under her care, who, by virtue of multiple medical problems developed a major electrolyte problem.   The patient is on dialysis and so has a nephrologist (kidney specialist) seeing him daily.  A call comes to inform Staci of a really abnormal lab value.  She considers calling in some orders but this entails high level specialty doctoring in nephrology, which she is unaccustomed and appropriately decides to call the specialist.  The kidney specialist calls back and is rude, short and unhelpful.  OK, there is no help from the specialist, but the patient still needs some intervention.  Major electrolyte imbalances are not our field; we think back to training, pull up google and read.  Stay tuned.

Here is how the same situation would proceed at my hospital, Baptist East, a private hospital in a fee for service system with multiple competing specialty groups.  I would get a call about the markedly abnormal lab value.  Ooh, I would think and immediately call the nurse of the patient and ask her/he to notify the kidney specialist, whom I previously chose, to deal with this issue.  That is it.  I would be confident that the nurse would call, the kidney specialist would answer and then proceed to fix the problem.  If I happened to call the specialist myself, then there would be respect and helpfulness.

As it happened tonight, after we read about how to treat a problem neither of us are comfortable with, I decided to “phone a friend.”  My friendly kidney specialist answered despite being on vacation and proceeded to give us instructions on how to help this patient. 

Take home messages…

Fee for service and competition is often good for patient care.  Although I would like to think that I would provide the same service in a government salaried system,  I cannot say for sure.  It is certain, however, that in my present situation of practicing electrophysiology in a highly competitive market place, there is no option other than being helpful, skillful and available to patients and referring doctors.

In a government run health care system specialty doctors are without competition and are salaried.  There was no other specialist to turn to and worse yet, Staci will have no choice in the future but to use this same specialist.

This budding master of the obvious does not have all the answers, but it is clear that removing competition and incentive will not improve patient care.

This idea builds on my worry about an impending shortage of talented doctors.  Think shortages are not real? Hope this neurosurgery shortage doesn’t affect you in the event of head trauma. 

Now for what I am not saying…

Not all doctors caring for our veterans fall into this category, and likewise not all private practice consultants are great.

During my residency and fellowship I formed very fond memories while working at the Indianapolis VA.  I met many dedicated, graceful and tireless caregivers.  Special people that I respect highly.

I am not no so naive to think that the present day fee for service model, which disproportionally rewards procedures or more simply, the doing of more, is without fault or abuse.

JMM

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