I saw this cartoon posted recently on Facebook, and am sorry
that I can find neither the cartoonist nor the original site of publication. It
is, as is the case with most good humor, both funny and sad, in that it cuts
close to the reality of the lives of people seeking health care. This particular
cartoon emphasizes the technology obstacles to receiving care, which represent another
layer of obstruction beyond insurance, distance, availability of providers,
and, generally, a system that favors the corporations involved in health
care over the people (also known as ‘patients’) seeking it, or the clinicians
who provide it. One of the biggest complaints and stressors (and reasons for
physician burn-out) is the Electronic Medical (or Health) Record which consumes
enormous amounts of clinician time inputting data (many clinicians report at
least a 1:1 ratio of charting on-line to seeing people).
It take so much time and is so onerous in large part because
it involves, in addition to charting the note recording what the person was
complaining of (“Subjective”), what was found on exam, lab, imaging (“Objective”),
what was diagnosed (Assessment) and what was done (Plan), many click boxes have
to be filled out to record specific data digitally. While this includes things
that are sensible because they enhance easy retrieval (e.g., a flu shot), and things
that are otherwise ostensibly documenting preventive care for certain issues
(e.g., alcohol or tobacco use), they also include many things that ensure
compliance with specific government regulations or insurance companies rules,
and extensive and complex documentation and clicking to ensure that maximum
reimbursement is received by the employer.
There are benefits to having data stored in a searchable and
easily retrievable digital format. However, on balance, patients find their
access to medical care, already strained by financial, time, and distance constraints, further limited by technologic
obstacles, and doctors find them terribly burdensome and of less utility, but yet they proliferate. Patients do not
usually want to blame their doctors or other clinicians, most of whom
they value and trust, but cannot understand why those obstacles have been put
in place.
Let us go back to “maximum reimbursement is received by the
employer”. Most doctors and other clinicians are no longer in solo or small-group
practices, but rather are employed by corporations (both for-profit and ostensibly
not-for-profit) or by large groups that, even when physician owned or managed,
have the same incentive to maximize reimbursement, even at the cost of
efficient use of the clinician’s (not to mention the patient’s!) time and
effort. Of course, for the corporation, the most efficient use of a physician’s
time is that which generates the greatest reimbursement, which is not
necessarily the same as that which generates the greatest marginal health
benefit for the patient. This is an issue I have written about many times
before, but it bears repeating. People who are willing to vote against an
administration because gasoline prices are high, even though that is a result
of corporate greed and is most supported by the administration’s opponents, are
not always ready to think deeply. Indeed, physicians and other clinicians retain
a great deal of respect and admiration despite the violence done to people in
their name (usually not, of course mainly physical violence, although making it
difficult or impossible for folks to access health care can certainly result in
physical damage!)
People often want to take credit for what is seen as good,
and to deflect blame onto others for what is seen as bad. This is a
particularly common trait in those called “leaders”, although they are often
just bosses, not leaders. It is so common in this group, in fact, that we are
often shocked when a person in a position of real authority takes
responsibility for their – and their subordinates’ – mistakes, and gives credit
to others for accomplishments; this is why Harry Truman’s sign “The Buck Stops
Here” became so famous. In the case of health care, such duplicity by the “leaders”
often takes the form of the corporation wrapping itself in the mantle of “caring
for and about your health”, while actually creating obstacles (including those
technological ones) to accessing care, particularly if you are not a
high-profit-margin patient, and even blaming those doctors, nurses, and others
who actually do provide care for the problem.
In a different context, this theme has been replicated in
Mexico, by the government rather than the corporation. Doctors (and their
patients) in rural areas are being kidnapped, killed, and otherwise abused by
drug gangs,
as reported in the NY Times. In a cynical political move to seem to
address this problem, the government is talking about bringing in 500 Cuban
doctors. ‘“They [that is, the rural physicians] forget about a
patient’s primary right, which is to be cared for wherever they are, and it’s
because of this that we needed to resort to contracting foreigners,” Dr. Jorge
Alcocer Varela, Mexico’s secretary of health, told reporters at a recent news
conference.’ Safe in his cabinet office in Mexico City. This generated an appropriate
response: ‘The announcement about the Cuban doctors provoked outrage among
many Mexican doctors, who said the problem was not a lack of physicians or an
unwillingness to work in rural communities, but the life-threatening conditions
they must work under.’
The lower your own risk, the easier (but more ignoble) it to criticize those who are at risk. The less value you (as, say, a CEO) bring to the actual provision of health care, the more you can feel free to blame those who do, or who criticize the way that you have organized systems to maximize your profit, not to improve people’s health. Such CEOs love to brag about their great programs that bring highly-reimbursed care to well-insured people, but are rarely willing to spend much on high-value (as opposed to high-profit) care for the most needy.
Healthcare is scarcely unique in having been seemingly overtaken by systems that have the goal of limiting human-to-human interaction and replacing it with often difficult-to-navigate (especially for the older or less computer-savvy person) human-to-machine systems. “They” want you to download their app (after upgrading your operating system), go to their website, and do anything that does not require them to pay a person who can actually help you. Almost no actual people prefer that, but we’re usually stuck. When they can’t force you off the phone and on to the computer, they can sure make you wait – at your doctor’s, at the pharmacy, at the airport – and maybe you’ll give up. It does not just happen in health care, but when stakes are your life and health, it seems particularly bad.
Just remember who and what is at fault; usually not the doctors and other clinicians, who actually want to help you, but corporate capitalism, motivated by greed.
