Surviving the Health Care System Introduction The Basic Problem The Health Care System - Explained at Last!      1) the rationing imperative      2) the Health Care Myth      3) Clintonians v. Gekkonians      4) portrait of a modern HMO      5) the Clintonians strike back      6) where this leaves patients and doctors Becoming an Effective Patient

Where this leaves patients and doctors Whenever you bring up the subject of health care today, either to doctors or to patients, you are immediately rewarded with a litany of complaints.  You’ll hear about the greedy, heartless HMOs; the growing difficulty in getting health insurance (whether you’re employed or not); the distracted, money-grubbing doctors; and the overly demanding and increasingly litigious patients.  Yet, despite this symphony of grievances, you will find it strangely difficult to put your finger on what, exactly, the real problem is.  For underlying these more concrete complaints you will perceive something else – the stirrings, expressed in vaguely wistful tones, of a more fundamental problem.  And if you listen carefully, what you’ll hear is the expression of a deep, if poorly defined, sense of loss. The sense of loss is genuine.  Because something is being lost, and it's something important, something vital, something necessary to the integrity of this or any health care system.  It's far more than just a patient's freedom to choose his own doctor, or to see a specialist when he wants to.  And it's far more than just a patient's freedom to practice medicine as she sees fit.  What we're losing, we doctors and patients, is the sanctity of our relationship with one another.

This is a very special relationship. It's not one based on feelings of affection, like those between friends or lovers.  It's a relationship more like that between allies fighting a war.  It's a relationship based on mutual dependence and trust - on mutual survival, in fact.  We, doctors and patients, allow this relationship to weaken only at our own peril.

As we have seen, however, the doctor-patient relationship is completely incompatible with covert rationing.  Covert rationing requires that decisions made at the bedside be made with society’s priorities in mind, and not the patient’s.  Indeed, covert rationing demands that the doctor forego her primary duty to her patient, in favor of “the greater good.”  The demand is non-negotiable.  If doctors are reluctant to give up their traditional role as their patients’ advocates, they must be coerced into doing so, and the ones who still refuse need to be weeded out. 

Covert rationing thus has as its central mechanism the destruction of the doctor-patient relationship.  We have seen how both the major factions in the health care wars - the Gekkonians and the Clintonians - have adopted, as their primary operating principle the need to control the behavior of physicians.  And that means making physicians beholden to them (the managed care organizations on one hand, the government on the other) above all others.  While many doctors fight the coercion, it is a losing battle.  It is the systematic undermining of their profession, their professional standards, and their moral underpinnings that is disaffecting and frustrating doctors today.  Their profession is being destroyed, and they know it.

Well, that's too bad for the doctors.  But doctors can always change professions, or retire, or just look the other way.

The patients, on the other hand, are stuck.  When you're sick, you're sick.  And you need medical help whether that medical help is really concerned about you as an individual or not. Destruction of the doctor-patient relationship may be destructive of the doctor's livelihood, but it's potentially destructive of the patient's life.

Some day perhaps our society will face up to its imperative to ration health care, and devise a way to ration openly and fairly.  Acknowledging and accepting the need to ration will liberate us.  It will finally give us the impetus we need to reform policies that distort the demand for unreasonable or unnecessary health care on one hand, and generate growing millions of uninsured citizens on the other.  Appropriate policy changes will allow us to take many of the necessary rationing decisions out of the hands of bureaucrats (and of doctors acting as their reluctant agents), and give them back to the patients whose lives will be affected by those decisions (with proper incentives, of course, and aided by doctors now restored to their rightful role as patient’s advocate). 

Such “voluntary” rationing will eliminate at least some of the pain.  Then, to deal with the remaining rationing decisions that must be made, let society – led by economists, the policy-makers, the government, and health care experts – establish clear policies and guidelines for rationing health care, through open and public debate.  Finally, let doctors and patients, in the full bloom of their fiduciary relationship, operate within the constraints of those policies and guidelines (like lawyers and clients working within the confines of the law), to assure that all patients have advocates who are able guard their rights and welfare to the fullest possible extent. 

Maybe that will really happen one day.  Until then, what are patients supposed to do?

Given the fact that patients are, more and more, left to fend for themselves, how can they optimize their chances of getting what they need from an increasingly complex and hostile health care system?  The next section deals with this question.  

Next - Becoming an effective patient

Surviving the Health Care System is adapted with permission from YourDoctorintheFamily.com

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