Perhaps the problem's just that time has passed me by. I hate to think it's done that. The laying on of hands was the greatest privilege I have ever known. I missed that the first day out, that strange and somber morning when I couldn't go to the coffee room at General and laugh with Paul Collins and Aubrey Cox and all the others. I'd tell anyone who'd listen, it was wonderful not to have the phone ring late at night. Truth be told, I missed that too.
I started this train of thought last night after coming home from the Texas Total Care party, a gathering of independent doctors celebrating the beginning of the Christmas season. Bill Dean, the cardiovascular surgeon who tinkered with my heart and gave me twenty more years than any man is my family ever had, told me that laughter was almost missing from the coffee room these days.
"It's not the way it used to be," was the way he started. I usually let a statement like that pass, believing for the most part that the more things change, the more they stay the same. But Bill had a look on his face that commanded inquiry. I asked him to explain, and he said the fun was gone from medicine. "Not completely gone," he added, "but going fast. There's too much emphasis on dollars and not enough on patients."
Knowing Bill has always cared more for patients than for dollars, I asked him to go on. The gist of what he said was that having to fight with insurance companies over every day a patient stays in the hospital has colored everything a doctor does. I understand the problem. The concept of the "patient advocate," a nurse somewhere in an insurance office in a tall building on the East Coast, was operant while I was still in practice. I had long distance arguments with several of that species. What a wonderful inversion of meaning, "patient advocate." The "patient advocate" is nothing more than an advocate for the insurance company. Their job is to see the insurance company gets the biggest bang for its buck. But doctors let that term slide. Somehow, lost in one reverie or another, we surrendered the proud term, "patient advocate" to someone off somewhere who never saw the patient and wouldn't know one if it up and bit her on the backside.
The argument over words reminds me of Alice in Wonderland talking to Humpty Dumpty.
I don't know what you mean by 'glory, Alice said.
Humpty Dumpty smiled contemptuously.
Of course you don't - till I tell you.
I meant 'there's a nice knock-down argument for you.
But 'glory' doesn't mean 'a nice knock-down argument, Alice objected.
when I use a word, Humpty Dumpty said,
it means just what I choose it to mean-neither more nor less.
the question is, said Alice, whether you can make words mean so many different things.
the question is, said Humpty Dumpty, which is to be master---that's all.
We've been sold a semantic bill of goods by insurance companies. "Managed Care" was never that. It was managed dollars all along. Yet that phrase was allowed into our vocabulary. Patients liked it. It even sounded good to doctors. Then we discovered that managed care was a cover for curtailing patient comfort and cutting back availability.
Look at what that misleading phrase did to medical care. Instead of doctors being the ones that patients could depend on, people were told insurance companies were the ones who had patient interest at heart. Patients were bombarded with statements that medical costs were out of control because doctors made too much. Never mind that the great increase in costs were for technology, not the doctor. In the search for a scapegoat, insurance companies settled on the individual practitioner. By the time that we discovered what insurance companies were doing, "patient advocate" and "managed care" were set in concrete in the public consciousness. And now we read of multi-million dollar platinum parachutes the CEO's of failing HMO's are taking with them. Money isn't being saved. It's being redistributed to the leaders of the "managed care" concerns.
No wonder the doctor frowns instead of smiles. Trust has been removed from the medical equation. Practice is not a happy arena. Doctors start the day now girding for battle. They have to fight to practice medicine: with insurance companies, with lawyers, and even with each other and sadly sometimes with the patient.
No wonder laughter isn't heard in the coffee room these days. I wouldn't laugh if I were there. I'd shake my head in puzzlement and wonder how and why we let it happen.
Dr. Miller has published a book entitled, "Pipe Tobacco and Wool". Copies may be ordered from Humphrey Press at 1602 Midwestern Parkway in Wichita Falls, TX 76302. The cost is $19.00 post paid.
editor@medmag.org