Rocking Your Fragile World-View

Let us again consider Albania, a tiny country tucked into a little corner of Europe which is only now emerging out of the communist Dark Ages in which it had stagnated while the rest of Europe moved on. This very poor country sits on the Northern border of Greece for whom it serves as a sort of Balkan Mexico, sending a steady stream of poor illegal immigrants into Greece looking for a better life and overwhelming the Greek welfare state. The average life expectancy (a statistic that sleek United Nations bureaucrats and the People Who Love Them use as a surrogate indicator for the quality of a nation’s health care system) of an Albanian is close to 78 years. A typical Frenchman, since France is held to be some sort of medical Shangri La by many Americans, can expect to enjoy pointless cinema, runny cheese, and l’ennui francaise for around 79 years. The typical American might live a few months less than a Frenchman or other comparable European but he can reasonably expect to live as long as an Albanian as will the typical Greek. The United States spends the most per capita on medical care followed by the French, the Greeks, and lagging way, way behind, the hardy Albanians who, despite spending less per capita on medical care than many Americans spend on frothy coffee drinks, still manage to hang on for a long life that is only a matter of months shorter than that enjoyed by a Frenchman, a Greek, an American, or just about anybody in the the rest of the developed world.

Indeed, those thrifty Albanians manage to spend less than 400 bucks apiece per year on medical care, have almost none of the advanced treatments available in the United States or the European Union, very sketchy access to doctors, and still manage to live long, healthy lives eating their Tavi Kosi and smoking their harsh Red Star Tractor Brand unfiltered cigarettes. By comparrisson, we spend close to 6000 bucks per head per year, the Greeks spend about 2500, and the effete French spend around four thousand. If you look at the rest of the developed world, there appears to be a similar discordance between health care exenditure and longevity. Past around six hundred bucks, typical of most of the Balkans and other emerging European nations that have reasonable sewage and other public health measures, there doesn’t seem to be much of correlation between spending and longevity. Maybe a two or three year difference between the top and the bottom which shouldn’t be anything to get excited about. I can easily think of a couple of cultural factors that might account for a bit of this slight difference. In the United States, for example, every Tupac harvested early to the Lord in a pointless rap war, besides being a mighty blow to the music world, drives down the average life expectancy.

I have also never seen, in all of my extensive travels in Europe, anything remotely similar to the four or five-hundred pound behemouths that roam the American landscape in vast herds, making the buffet lines tremble from the thunder of their comfortable shoes and darkening the parking lots of all-you-can eat waffle joints across the fruited plains. I mean, I’m treating obese kids with with type II diabetes, most of whom have free health insurance via medicaid and of which their parents avail themselves with the same gusto they otherwise reserve for nacho cheese biscuits. Lack of health care is not the problem here, nor is access.

In earlier articles I have suggested that we waste a lot of money in the medical industry. How much, exactly, I am unsure. There is a large gray area between what I would consider the completely appropriate use of medical resources and what I know to be the equivalent of flushing burning hundred-dollar bills down the toilet. But I think that most of my learned colleagues on the medical internet will agree that wasted money accounts for a horrifically large percentage of our total two-trillion-dollar yearly spending binge.

Oh my loyal and long-suffering readers, you who I delight in entertaining with detailed prose as I attempt to wrap the truth of the world, or at least how I see it, in a little bit of humor, a little bit of sarcasm, and a little bit of shameless pandering to the understandable instinct to despise the French; I confess from the depths of my black, misanthropic heart that I am not much of a writer. I try hard, of course, and I can occasionly tame an idea or two in my brain long enough to lead it to paper but since I am having a hard time thinking of a clever way to illustrate exactly how much money we waste in this country on medical care, I’m just going to say it plainly with no art or interesting literary devices. Just Keep in mind two things. First, I’m going to tie it all in to the Albanians and second, every patient I’m going to describe costs the system money even if they are what is optimistically called self-pay (a cheerful euphemsism for “There is No Way in Hell I Would Pay a Dime for my Medical Care”). The temptation is to say, “Well, since they can’t pay there is no money changing hands and therefore no real cost to the health care system.” This, however, is a stunning example of wrong-headed thinking. Every patient costs money to somebody if only because the infrastructure to deal with them has to be maintained. Of all the individuals and organizations involved in delivering medical care, the only ones who will work for nothing are doctors. Try getting a nurse or a radiology tech, for example, to work a few extra hours or fill in some holes in the hospital’s schedule for free. They’d laugh, as would the janitors, clerks, and even the nice ladies slinging the chili mac down in the cafeteria. Medical care is a huge team effort involving expensive infrastructure and many highly skilled and not-so-skilled people, none of whom would even consider volunteering their time except, as I mentioned, physicians who are not only regularly asked but expected to work for nothing as the need arises (a typical Emergency Physician working on a production basis and not as hospital employee, for example, gives away a hundred thousand bucks of his time every year).

So let me just state that In the United States, we are terrifically over-doctored. Much of what we spend is to overtreat either self-limiting things or to throw marginally effective therapy, at least in regard to decreased mortality, at chronic medical problems, most of which are lifestyle related. Either that or we burn through money like drunken sailors on futile end-of-life care for people who have absolutely no quality of life unless we are now measuring quality by how long you can lay motionless in your own urine before a minimum-wage nursing home caregiver decides to roll you around a little. Let me give you a few examples of typical patients to illustrate the many ways in which your money is squandered.

“There, you see? She blinked! I love you Grandma!”

I see this patient or some variation at least once on most shifts. An incredibly frail, some might say cadaverous, woman, somewhere in the neighborhood of ninety who has been in a nursing home for a decade and was doing all right with her end-stage renal disease, advanced senile dementia, and congestive heart failure until about a year ago when something broke loose during dialysis and she suffered a stroke, turning her from a demented elderly lady who had broken her hip twice to a demented, aphasic, ancient lady; completely immobile except when indifferently turned by the staff of the warehouse in which she is stored. Because she can no longer swallow the surgeons obliged her family with a PEG tube (to pour liquid food directly into her stomach) and to protect her airway she breathes humidified oxygen through a tracheostomy (a hole in her neck, with another tube sticking out of it). On a philosophical level we can debate the nature of quality of life but I’m going to go out on a limb here and suggest that laying in your own feces on eroded bed sores is not much of a quality of life. In other words, we’re not talking about a hale and hearty nonagenarian who will live to be a hundred provided she can avoid being admitted to the hospital. This is a patient who is living on borrowed time, one who will not last another six months despite our best efforts and yet, in those last six months we will spend large sums of money on her, probably more than the total spent in her whole pre-stroke life, in an inexplicable quest to stave off death, spending money at an increasing rate the closer she gets to actual “reaper” death and not the living death to which she is condemned.

It is also both amusing and edifying to peruse a list of her medications which, after a decade or two of failing health, has grown into a two-page manifesto, a declaration or our faith in evidence-based chemistry. For starters she is on three-hundred dollars a month of Namenda, a new drug that is only marginally effective in improving the memory of patients with early Alzheimer’s but, if you think about it, is kind of ridiculous to use in a patient who is so far gone that even before her stroke she couldn’t even remember how to feed herself. Because of her cardiac history, she is on the obligatory statin and beta-blocker although against what looming cardiac event we are protecting her is not clear. Because of her atrial fibrillation, for which she recieved an implanted defibrillator two years ago, she is on coumadin. Now that she has no risk of ever getting up to fall it has been cranked up, giving her the occasional gastrointestinal bleed as her doctor disinterestedly tries to control her wildy fluctuating levels. As a little bit of seasoning she is on the digoxin to keep her heart beating as well as the usual four or five narcotics which are poured carefully into her feeding tube at regular intervals with the rest of her medications.

We pour expensive medical care into her in equal measure. The PEG and tracheostomy are only the latest procedures. If the squad of specialsts following her play their cards right, she’s good for at least a few bronchoscopies, an echocardioram, and maybe even a battery change on her defibrillator before they’re through

And she’s a full code. The family wants “everything done,” no matter what, up to and including artificial ventilation, defibrillation, and even more tubes. You see, “She knows we’re in the room, doc. Can’t you see how she perks up when we speak?” Against this kind of faith there is no argument possible, not in our totally out-of-control health care system where, since somebody else is always paying, money is no object. I have no doubt that the last six months of her life is going to cost a couple of hundred thousand dollars. A day in the intensive care unit by itself costs a cool four grand. She will probably burn through a couple of weeks of these before the final, terminal admission where at last, somebody has the common sense to say “no mas” and, after one final orgy of spending (for old time’s sake), we finally let her go.

Where’s the Fire?

Every now and then our already busy Emergency Department is innundated with a surge of patients. The waiting room is packed and the over-flow are seated in folding chairs in the hallway. The chart rack spills over, five rows deep instead of the usual two and you’d think a plane had crashed or the Four Horsemen were abroad. A quick survey of the new charts, however, shows the usual minor complaints, things that eventually turn out to be colds or vague abdominal pain. The panic begins, tempers get short, and, already working at a dangeorus speed, we are expected to double our efforts and move patients. God forbid we get a critical patient at a time like this because that will gum up the waiting room to an unacceptable degree. Why, and please try to choke down your horror, people with minor complaints might even get tired of waiting and leave the department without being seen. Which is sort of the problem. While it is no doubt true that hidden among the irritated patients spilling into the hallway is a real, honest-to-God heart attack or a smouldering acute appendicitis about to become dangerous, the majority of the deluge are patients with complaints that turn out to be minor, self-limiting things or even no problem at all except the siren call of the only representative of the all-giving and all-powerful Man that is open at 2 AM.

Now, I’m not saying that patients don’t need to be seen. Many have no other access to medical care and some are really quite sick. Although I would hate for the Emergency Department to become a primary care clinic for the indigent (a direction towards which we are lurching as hospital bureaucrats think up even more ways to jack up Press-Ganey scores), there is a need for medical care that somebody has to fill. On the other hand many of the complaints are so minor that they don’t need to be seen at all, even if the patient has premium insurance and is followed by the best internist in town. A request for a pregancy test, for example, should never make it past triage. Likewise what is obviously a cold in an otherwise healthy young adult. It is true that both of these complaints might be more than they seem, the pregancy may be an ectopic and the cold may be a Wegener’s friggin’ Granulomatosis but that doesn’t mean that they need to be worked up, a difficult concept for people to understand.

Or, to put it another way, if we work up every minor complaint under the sun looking for a big, bad, macho, internal-medicine-type thrill kill we won’t miss it when it pops up but we are going to have a horrifically expensive health care system with money being spent where it will do the least good. I’m not implying that every cold gets the million dollar workup. We still have a little common sense left. But these patients are dutifully triaged and seen, leading to crowding in the department, already more than a little constipated with “Emergency Department Admissions” (patients with orders for admission but no available beds or nurses in the hospital). There is no “Triage to Home” which is what we really need (and not just in the Emergency Department but in the whole medical profession), that is, a designation for a patient who has been quickly assessed by a skilled nurse, a PA, or even the Emergency Physician making waiting room rounds to not be sick enough for a full work-up and diagnosis. Because somebody pays, you know. Every chronic back pain, every cold, every vague psychosomatic disorder costs money somewhere. The tab is either picked up by Medicaid (and Medicaid patients are ravenous consumers of free healthcare), Medicare, private insurance, or even on rare blue moons when lightning strikes, by the patient himself…but it is all part of the two-trillion dollars we spend every year. Even if the care is unreimbursed the cost to maintain the needed capacity is very real and paid for by everybody.

The idea that some socialized, quasi-socailized, it-ain’t-socialized-much-cause-it’s-single-payer, or any other scheme to give everyone free medical care is going to alleviate the problem is laughable. While there is currently some restraint in the system against using medical resources for minor complaints, it really only effects those who make co-pays for their medical care. If you pay nothing, there is no incentive not to crowd the doctor’s office or the Emergency Department for your free pregnancy test or your motrin. All you have to spend is your time and while our department sometimes slows to a crawl with ten hours waits, you can usually be seen in three or four hours. A long time but I have waited an hour or two to see my doctor for my annual physical (itself largely a waste of money for an otherwise healthy guy) when he is running behind. What’s another couple of hours if it’s free?

What We Have Here is a Failure to Communicate

How many cardiac workups does one person need in a year? Or how many CT scans? Because I work in the Emergency Departments of two rival hospitals I am in the unique position of getting a patient admitted for vaguely cardiac-sounding chest pain and then, as if nothing happened, seeing him at the other department often only a few days later with the same complaint and, unless he remembers me which he may not, no mention in his past medical history of his completely negative nuclear stress test and exhaustive workup. The story is the same for all manner of patients. Some, like drug seekers, attempt to game the system and make the circuit of local Emergency Rooms, shamelessly spinning a tale of woe four or five times a week. Others just don’t know any better and, despite having various deadly conditions definitively ruled-out on multiple occasions at other hospitals, are perpetually looking for the definitve second opinion, or attention, or someone to take care of them for a few days…who knows. Some people just feel bad all the time and have developed a co-dependent relationship with the hospital. They suck down many, many scarce medical dollars in redundant tests, consultations, and brief hospital stays where, in reading the discharge summary, you can sense the dictating physician trying to express his frustration without out-and-out accusing the patient of malingering. For our part, they are what we call “weak admissions,” embarrassingly weak, the kind that make you cringe to discuss with the admitting service.

Some patients, let’s say someone with a volvulous, are incredibly strong admissions. All you have to say is, “The patient definitely has a surgical abdomen, is distended, tender, guarding, and vomitting,” and the admitting surgeon will say, “Okay, I’ll be right in.” Some admissions are decent, like a 65-year-old smoker with pneumonia. You will rarely get an argument or the telephone equivalent of rolled eyes. Some admissions are weak but so routine that the admitting service will demur with little complaint. Some are so weak, so worthless, and such a waste of money that I cringe to hear the voice on the other end of the line, rippling with sarcasm, saying, “You know we admitted him for that last week and found nothing, don’t you?”

Or worse yet, “Oh, we had to discharge him from our practice for violating his pain contract and trying to get narcotics from almost every hospital in the state.”

And you’re left holding the bag, playing a game of legal chicken. The patients may cry wolf but there is going to be a real wolf someday and, like a game of hot potato, nobody wants to be holding the spud when the music stops. I have a patient like this, a serial abuser of Emergency Services whose hospital tab must run in the millions, who came in one day in her usual excruciating pain but which this time was not relieved by her customary dose of narcotics and who turned out to have a perforated colon.

There are two salient points here. The first is that the medical profession does a poor job of coordinating information. It almost makes one wish for a standard, nation-wide electronic medical record accessible by every physician and made mandatory for everyone. In this manner, every prescription, test, study, and discharge summary could be pulled up and viewed by any doctor. The second point is that what we need isn’t a Good Samaritan clause (protecting physicians who offer free care) but a “Wolf Clause” to set an upper limit on the amount of work-ups and Emergency Department visits allowed for one patient. I have a 22-year-old patient, an otherwise healthy young woman, who has been to our department thirty times in the last year, been hospitalized a few times, been worked-up redundantly at both of our big hospitals, and there is nothing physically wrong with her. But she is a spud, and since I’d rather spend your money than risk my livelyhood, we take her seriously every time we see her. We may joke about it and roll our eyes but we don’t dare put our money where our mouths are.

What’s Albania Got to Do With It?

Nothing, really. Except that the Albanians don’t have anywhere near the access to high-tech health care that our citizens enjoy. Like the Greeks and many other Europeans, even their sickest patients are not typically on a long list of medications. There is nothing like our buzzing Emergency Medical hives in Albania where every Albanian who is not feeling well can get relatively instant access to almost every labratory test, imaging study, and specialist known to the medical profession. In Albania, much of what we consider the standard of care is unheard of and reserved for those who can pay for it up front. You certainly will not have your terminal illness interupted by too many of the heroic measures which are routine in our country, even for the poor. People grow old, get sick, and die almost as they have been doing since my ancestors regularly invaded and enslaved theirs.

Ah, Albania! Tarnished Jewel of the Balkans! Despite no medical care to speak of you live as long as we do and even give the perfidious French a run for their money. What does that say about how we spend money? I am pefectly willing to concede that there are quality of life issues at play. Certainly I’m glad that I may one day get an artificial knee if mine should ever wear out. And I also concede willingly that if I were critically ill, I’d be immensely glad to be in Pocatello, Idaho and not Tirana. But I’d like to humbly put forth the notion that most of the money spent on medical care in the United States and Europe is spent on the margins, which is not to say that people don’t want it and don’t demand it, but only that it is spent in large amounts with very little to show for it. Maybe past a couple of thousand a year we’re just pissing in the wind. And maybe what we need to do is to start doing less for most patients, most of time, reserving our big guns for worthy targets and not for killing gnats.