The conventional wisdom is that the American health care system is broken. This is the party line parroted by the various media organs of the dependocracy in their attempt to stampede an excitable public towards socialized medicine. Like a lot of the conventional wisdom, the idea of a broken health care system gets repeated so often that it has become a cliche, something that people spout in a self-righteous reflex. It is certainly a pleasant metaphor and an easy one for the people to get a handle on without having to think about the real complexities of delivering zero-defect medical care to a largely non-compliant public, most of whom care more about their cable television and their personal watercraft than they do about their health.
In other words, while you can poll the public and health care makes it to the top of the list of concerns, most people, at least the ones sucking up a disproportionate number of somebody else’s health care dollars, spend considerably more on cigarettes than they would ever dream of spending on medical care which shows you its true importance to most people.
Putting aside the fact that there is no health care system, just a collection of independent hospitals, clinics, and private practice physicians, the system is not so much broken as it is a tool being used for a job for which it was not intended and for which it is ill-suited, namely being completely responsible for all aspects of the health of a feckless and helpless public for whom the thought that they are responsible for their own health is completely inconceivable. We pay lip service to the idea of patient-centered health care of course, and including the patient as an equal partner in medical decisions is the New Religion. In our society however, where a physician can get sued for not having written on the discharge instructions for a dead crack dealer, “Return to Emergency Department if chest pain returns,” well, there just isn’t as much equal partnering as you’d like to believe.
In fact, there’s none to speak of where it counts. Not an artery hardens or liver fails without a physician somewhere, somehow being blamed. Personal responsibilty having long ago been abandoned in every other part of society has finally been driven from medicine which is the one place above all others where it is critical. The medical schools, for their part, have moved completely away from the notion of expecting patients to care. To even breathe the words “personal responsibility” is to invite criticism from your instructors who despite their professed love for their patients view them as contemptible creatures who are incapable of making rational decisions and little more than slaves to their conditioning. As a result there is a natural tendency to try to become deeply involved in the lives of the patients in the hopes that some combination of cajoling and psychobabble will save them from themselves.
This creeping paternalism is the new medical paradigm and, as it will serve to dissipate finite medical resources instead of concentrating them where they may do the most good, it could not have arrived at a worse time. The level of involvement required to change bad habits is simply more than we will be able to fund. Every patient cannot have a dietician, a therapist, a substance abuse counselor, and a life coach. It’s too expensive. They’ll be lucky to get a physician and he’s not going to have the time to arrange their personal lives, especially when everybody is entitled to all the free health care they can suck down.
Almost every social pathology you can think of has it’s origin in a lack of personal responsibility. As much as we continue to move away from encouraging it we will be continuously chasing the tiger and wondering why he keeps getting bigger and meaner. The solution is a simple one but hard for those deeply invested in paternalism to stomach.
Is it Worth It Redux
Look, if you like medicine and your specialty it is “worth it” (whatever that means to you). I say this after receiving a lot of angry emails from people chastising me for having the unmitigated gall to imply that income potential is a legitimate factor in the decision to pursue medicine. Who am I, yer’ friggin’ mother? Make your own decisions. If medicine is that fantastic a career than I am just a lone crackpot and the desire to smack me down is therefore inexplicable.
What can I say? I assure you that if the potential salary was not substantially more than what I made as an engineer I would never have made the switch. I like Emergency Medicine just fine and am glad to be in it but if all that was waiting for me salary-wise at the end of the dark tunnel of medical training (the light at the end of which I can now see) was the same income or less than I made before I decided to throw it all away, well, I’d be pretty disappointed. And my lovely and long-suffering wife would be devastated. Marriage is a partnership and, while my wife is happy that I am in a rewarding and useful career, the usefulness and intangible rewards of it don’t put vittles on the table and logs on the fire. There’s got to be some bacon to bring home for her to fry up in a pan or it’s just a selfish personal hobby of mine for which she gave up security, stability, family, and financial solvency.
In fact, my wife cried when I didn’t match into Emergency Medicine the first time around and scrambled into Family Practice instead. She knew instinctively that on the balance sheet, the whole adventure had now become a rather bad investment and one in which we might never recover financially. For what Family Medicine physicians make I may as well have stayed in engineering where devoting the time I did to medical training would have paid better sooner. And without the call, the abuse, the humiliation, and the constant feeling that my gonads are not my own.
Why this is hard to understand is beyond me. And if you think I’m unique in my point-of-view then stand by to be surprised and disappointed in your colleagues.