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The Left Atrium
Contents
• Costs and cautions in health care • Psychiatry divided • Chalcedonies • One thousand words Costs and cautions in health care
The economic evolution of American health care
Despite the largesse of our country's investment in health care, there is universal dissatisfaction with our health care system. Some 42 million people who are uninsured or underinsured get either no care or spotty care. Even patients who are insured under government programs can find themselves flung from one insurance company to another and from a long-trusted doctor to a stranger. Physicians are constantly grumbling about managed care bureaucracies, their need to see more and more patients in shorter time frames, and the loss of their professional autonomy. Academic medical centres that are strapped for cash because of cutbacks in income from the federal government and insurance companies are dropping valuable community programs that are not profitable; some medical centres have gone bankrupt. Vertical integration and mergers of major academic medical centres, expected in the past to help those centres survive, have often not done so, and many of these arrangements have fallen apart. Many not-for-profit health maintenance organizations have faltered, even to the extent that some have been forced into receivership. Shortened hospital stays and pre-admission workups have reduced the quality of in-hospital medical education, and no adequate substitute has been identified as yet. Needless to say, many of these problems can be traced to the failure of the market to deal adequately with health care.
David Dranove, a professor at Northwestern University's Kellogg Graduate School of Management, has been actively studying health care markets, organization, regulation, quality, financing, competition and managed care for two decades. In this book he documents succinctly and accurately the economic and political forces that have shaped our current system. He does so with a minimum of jargon, thus making his book accessible to physicians and even the public. He starts with a look at our traditional health care system and shows how accelerating costs led to governmental intervention, and how frustrations with the lack of success of these programs ultimately led to the managed care revolution. He painstakingly elaborates on the kinds of health insurance systems that have evolved and the benefits and drawbacks of each. He tackles important issues. His analysis of the status of measuring the quality of care is scholarly and dispassionate.
Dranove's reference to Alain Enthoven as an early mentor is no small clue to his considerable initial enthusiasm for markets and managed care as a solution to the organization of our health care system. Nonetheless, he admits openly that this strong bias has subsequently wavered. As managed care has moved from theory to practice, and as the negative public and professional reaction to it has grown, Dranove has added a coating of realistic scepticism to his view of the future of managed care.
Advocates of managed care underestimated the public's persistent desire to remain with a doctor of their choice and their profoundly negative reaction to highly visible instances of denial of care. Moreover, proponents overestimated physicians' willingness to use structured algorithms and guidelines for patient care, their willingness to manage care, and their ability to restrain the use of resources. Politicians, encouraged by the remarkable reduction of health care inflation (generally attributed to managed care), assumed that they had finally found a mechanism to avoid continuous inflation in health care far out of proportion to general inflation. By the end of the century, however, there were already signs that the savings resulting from managed care practices accepted by physicians had run out. Physicians and their organizations were crying out for more money, academic medical centres were running deficits on operations and imploring the federal government to restore cutbacks, and health maintenance organizations were again raising their rates to fund the march of technology, the expense of caring for more and more elderly people, and the cost of pharmaceuticals. In short, managed care had failed in its current incarnation to achieve its promise.
The lesson for other countries is hardly inchoate. Market forces do work effectively for consumer products and services, but unconstrained market forces do not produce an ideal health care system. Many countries have looked toward the drastic changes in the US as a possible model for dealing with problems and defects in their own system, especially health care cost inflation. Any country interested in embarking on changes in their health care system that include elements of our recent experiment would do well to read Dranove's authoritative text. They should then proceed cautiously. Very cautiously.
Jerome P. Kassirer Contents
• Costs and cautions in health care • Psychiatry divided • Chalcedonies • One thousand words Psychiatry divided
Of two minds: the growing disorder in American psychiatry
Having spent 30 years of my life as a psychiatrist, I find it interesting to see my profession as others do. Tanya Luhrmann, a psychological anthropologist at the University of California, is well suited to the task of holding the mirror up to psychiatry. In preparing Of Two Minds: the Growing Disorder in American Psychiatry, she spent several years researching the training of psychiatrists in the United States. She studied various residency training programs and teaching hospitals, interviewing psychiatrists, psychiatric residents, hospital administrators and other mental health staff at both inpatient and outpatient facilities. She attended lectures for psychiatry residents and was present for all of the usual activities in the training program, including admission work-ups, case conferences, community meetings, group therapy sessions and supervision interviews. She was even given the opportunity, with supervision by a senior psychiatrist, to admit and treat patients. To immerse herself in the total experience of psychiatric training, she went twice a week for three years to a psychiatrist for psychodynamic psychotherapy. "I did this," she writes, "following the advice that to understand therapy, one must do therapy and be in therapy."
The initial premise of Luhrmann's research was that some feature in the experience of residency would orient the resident toward either biomedical or psychodynamic psychiatry. However, during the course of her research her focus changed, partly as a result of the shift in the American health care system toward "managed care."
Reading her book was like having my life reviewed before my eyes. Although I took my psychiatry training in Canada and New Zealand, Luhrmann's account of the American training experience was very familiar; I have faced many of the trials and issues she describes.
Much of the book focuses on psychoanalytic versus biologic approaches toward mental illness and its treatment. The author provides a thorough and readable history of psychiatry, including the changes that occurred with the development in the 1950s of pharmaceuticals to treat depression, anxiety and psychosis. She describes how the theories of Freud and other analysts ruled psychiatric treatment and training until the 1970s. There was great resistance to the idea that mental illness arose from an organic disorder of the brain and should be treated medically. For a while it seemed that there were two camps. One interpreted all psychiatric disturbance as the result of a clash between the patient's personality and a pathological environment (especially in the family). This could be treated by providing years of psychoanalysis in a safe, nurturing setting. The second camp considered that mental illness was caused by genetic and unknown external factors leading to altered brain chemistry, which could be treated by altering the balance of certain neurotransmitters. Initially, there was little cooperation between the two camps.
In the psychiatric training programs that Luhrmann studied, residents were exposed to both concepts and were often expected to integrate the two, while their mentors wanted them to choose one path or the other. She describes the completely different atmospheres on wards where the patients were treated in accordance with one approach or the other. This confused not only the psychiatrists in training, but also the patients in their care. In the psychoanalytic model, patients were considered responsible for their actions and treatment. In the biologic model, patients were the victims of their illness, and medication was the primary route to recovery. Moreover, if a patient responded to psychiatric medication, it seemed to follow that the illness had an organic cause.
Some of Luhrmann's conclusions mirror my own experience and probably that of most psychiatrists in North America. She presents evidence that, for some mental illnesses, pharmacotherapy is the most effective approach, while for others a psychodynamic approach is more appropriate. "Psychodynamic" and "psychoanalytic" approaches are not the same, although both are based on common principles; Luhrmann does not seem to advocate the latter, as it is expensive, time-consuming and of questionable efficacy. She concludes that combining pharmacotherapy with psychodynamic treatment is the most effective. For example, patients with schizophrenia or bipolar disorder benefit from but are not cured by medication. They still benefit from counselling in managing their lives with mental illness. Other interventions such as education about medication and supportive living and working arrangements can greatly improve quality of life.
At the end of the book Luhrmann discusses the truly frightening crisis of managed care. In the US the economics of medical insurance has compromised patient care, especially for those with mental illness. An insistence on shorter hospital stays has essentially eliminated psychodynamic approaches in favour of pharmaceutical "stabilization." Institutions have been forced to cope by reducing staff (especially costly psychiatrists), increasing the workload of those who remain, and increasing admissions while decreasing length of stay. Patients are often discharged before they are considered to present no risk to themselves or others. Thus, Luhrmann is compelled to conclude with a chapter on "madness and moral responsibility," in which she makes an impassioned plea for society to make moral choices rather than economic ones in caring for the mentally ill.
I recommend this book to anyone interested in the treatment of mental illness, especially psychiatric residents and their mentors. It is easy to read, and the issues addressed are vitally important to all of us.
Peter Uhlmann Contents
• Costs and cautions in health care • Psychiatry divided • Chalcedonies • One thousand words Room for a view Chalcedonies
In some cultures, chalcedonies endow the wearer with wisdom and courage. In others, they grant healing powers.
Chalcedonies occur in many rock formations: stalactite, stalagmite, geode, but also in chronic care beds, outpatient clinics, emergency rooms. These chalcedonies may have neurogenic disease, cancer, diabetes. We are all chalcedonies to some degree, but none so much as those whose acute minds are entwined in burdening bodies.
The septic patient lay gurney-bound, clinical fellow pronouncing MS-bedsore succumb. Immobile blackened skin, beyond my skill, beyond any physician's skill, was glimpsed like guilt through a white drape. We murmured apologies for our inability, in the muted doctors' tones she had heard so many times before.
Perhaps it was her eloquent tranquility that spoke to me through dishevelled hair and down-drawn drinking-straw lips. Perhaps it was her eyes, imbued with dignity through this objective observation of private wounds, or the brow-crease of understanding that her lips were too weak to convey. Perhaps it was the chart's chime of her age, mine exactly, less a day, that compelled me. Perhaps it was that I was unaccustomed to inability, much less to her silent acceptance of inability. Whatever it was, I prescribed my human presence to distract her from an evening of loneliness or pain. This was not altruism; I knew I would receive more than I could return.
The next evening I visited the patient, for a patient Janice still was to me, IV-inserted, hospital-gowned, hospital-bedded. She was already asleep, the translucent skin of her forehead screening the colours of the television suspended above her bed. By my return the next evening, antibiotics had resolved the sepsis, presenting the person inside the patient: the exceptional mind so eager, still expanding, though confined in a diminishing body. She did not remember me. How could she? I had been just another sepsis-seen chess piece she could not move.
I asked her permission to visit, not as a physician, but as a person: a person who would like to know her as a person, who would learn from her, who would gratefully reciprocate whatever she chose to share. I knew that the doctor–patient differential defies dissolution, but I also sensed that Janice, for she was now Janice, possessed the strength to order my dissolve.
Janice exhaled her acuity in soft segments: her before-and-after life, her holistic view of medicine, of religion, of people, of poetry; her two-year-and-still-counting wait for the district health council to turn her wheelchair's chin-operated joystick into the magic wand that would bestow her the world by unlocking the Internet; her multiple sclerosis diagnosed at age 19; its revocation of her marriage, of her painting and sculpting and copper enamelling. She laughed at her reluctance to give up her copper kiln, but when she described the wonders worked by melting enamels, their beauty was renewed in her eyes.
She described her arrival in the emergency room: very septic, barely conscious, too ill to participate in the five-doctor debate about death now with dignity or admission to the hospital's long-life-support system. Without power to speak, she tried to amplify her heart's harangue: "I want to live! I want to live!" But the doctors could not hear, could not know there was so much to live for, so much left.
As I said goodbye, Janice asked me to come back the next night. But I couldn't; I was facilitating a compassion-conserving program for medical students dissolving in memory work and call schedules. Janice said she would like to come, and then asked me to position her television headset. As I covered her ears with its stethoscope, I wondered how many hours a day Janice listened to the world instead of having the world hear her. I pondered how she and so many others were forced to accept what access the health care system allowed, instead of promulgating their potential through software so easily obtained.
The next night, before she was surrounded by a hundred students, I asked Janice's permission to introduce her as my friend, rather than as the patient she portrayed, immersed in a wheelchair with a half-filled catheter bag. I wanted to insist that they saw Janice as a person, not a patient; a friend, not a phenomenon. She agreed. And then she asked my opinion of her slippers, the bear-paws one sees padding patients through halls. Before I could reply, she continued, "I've had these for years." I couldn't tell whether she was trying to throw me off (slippers never wear out when their owner is wheelchair-bound); or trying to double-take me in a smile, or genuinely applauding the endurance of those slippers, not being lost, spilled on, or accidentally angst into the trash basket. I'm still not sure, but the slippers' possibilities wore welts on my voice as I introduced her to the class.
When the lights were dimmed for my film, I walked to the back of the lecture hall to watch the head-language that tells me what moves modern medical students. On this particular evening, my eyes kept returning to the head tilted above the back of a wheelchair. I knew Janice couldn't comment with her head or hands or voice like the others in the room, but that night it mattered to me only what she thought. She came to ten of my programs in the year before an antibiotic-resistant sepsis defeated her.
I teach compassion, but the first time I saw Janice I did not see her as a person, but only as a patient with an MS-engraved bedsore. If I hadn't visited her, with the sepsis resolved, I would never have known the person, Janice. I would be less; my students would be less. Janice referred to her illness as a gift. But she was a gift, a gift who taught me to be more compassionate, to try harder to catalyse compassion in others. She taught me that a society that allows a working mind to stare at a television instead of exploring with a computer is not the society I want my children to inherit. I hope she will continue to teach me, to teach us all, to be my friend, to be a friend to you. For it is easy for caregivers to overlook the chalcedony that is Janice, and that is so many others, by seeing only suffering, documenting only disease, analyzing symptoms and signs of a sickness-roughened surface, and not to peel the patient layers to the person beckoning within.
Jeffrey A. Nisker Contents
• Costs and cautions in health care • Psychiatry divided • Chalcedonies • One thousand words One thousand words
Copyright 2001 Canadian Medical Association or its licensors |
Notwithstanding all the negative publicity in recent months about deaths in the United States from medical errors, our poor record on infant mortality rates, and our failure to rise to the top of all nations in the longevity of our population, few Americans, including physicians, choose to get their health care anywhere else. Our physicians are highly trained and skilled, the technology we apply to medical care is the envy of physicians outside the country, and the resources we expend on care exceed those of other countries by an embarrassingly wide margin. This vision of accomplishment, along with the recent success at holding down the inflation of health care costs, has led many countries, including Canada, to look to the US for lessons to apply to their own health care system. Many governments are actively considering market-based solutions to health care inflation. My message to them is simple: before you try to emulate much of what we have done, read David Dranove's sobering book.
Chalcedonies are lustreless rocks whose scabrous surface opens
to chrysoprase or agate or onyx. We know them as jewellery, amulets, paperweights, bookends. Poured in melted laminations or explosions of petrified stars or seas of clouds, each chalcedony's crypt is charged with unique, alloyed amazement.
