Here’s The Thing About You Patients

Posted on August 6, 2009
Filed Under General Rationing Issues |

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Since leaving the practice of medicine ten years ago, DrRich’s only real encounters with the healthcare system have been as a patient, or as the loved one (or in-law, which is not necessarily the same thing) of a patient. And after a former physician such as DrRich has lived awhile in this situation, it becomes easy to begin viewing oneself more as a patient than as a doctor - especially when considering the impact of impending healthcare reforms on one’s life.

So DrRich thanks his good friend and colleague at About.com, Trisha Torrey, for setting him straight on this matter. Once a doctor, he’s now reluctantly concluded, always a doctor. And when he’s called before the Congressional Subcommittee on Un-American Medical Activities, and is asked in stentorian tones, “Sir, are you now, or have you ever been, a physician?” sadly, DrRich knows how he must reply.

So this being the case, DrRich understands that he must make the best of it. Accordingly, he now finds it entirely suitable for him to revert to form, to do what doctors down through the generations have always done, and to tell all you patients out there the way it is.

So listen up.

Most of you patients have been taken in by the soothing blandishments of the healthcare reformers when they tell you that what’s broken about our healthcare system, and what they aim to fix, is: Too many greedy doctors using too much expensive technology.

DrRich, until only recently an ersatz patient himself, understands how comforting this sounds. Everyone knows that somebody is going to have to be punished for the mess our healthcare system has become - and thank God it’s only the greedy doctors and the evil biomedical companies.

Best of all, they tell you, once they take care of the evildoers, you, the patient (the Sun around which your advocates in the new government healthcare bureaucracy will revolve in dedicated servitude) will be left with full, efficient, timely, and effective healthcare.

DrRich (again, being darned near a patient himself) knows that you understand how bogus this promise is. He knows you’ve dealt with government officials enough to realize that what you can really expect from government-run healthcare is the clarity of the IRS, the competence of Cash for Clunkers, and the compassion of the Department of Motor Vehicles. He understands that the only reason you’re thinking about giving a pass to government-run healthcare, as bad as it promises to be, is that it couldn’t be much worse than what we have today.

And besides (you’re thinking) the ones who are really going to have it stuck to them are the doctors and the companies. While patients will no doubt suffer to some extent, their suffering will largely be due to mere collateral damage, and will be entirely unintended.

And this, my former colleagues, is where you are wrong.

If you believe that you patients are not, in fact, the primary target of the healthcare reformers, you have not been paying attention. If you would like to get a preview of how you are going to be treated under the new healthcare regime, consider the growing plight of one relatively small subset of your number - the obese.

Obesity, as a health risk factor now marked for particular excoriation, has the decided advantage of being easy to see. Unlike, say, hypertension, obesity immediately sets fat people apart from everyone else. And indeed, we don’t like what we see. The obese can be unpleasant to look at; they move slowly and obstruct grocery aisles; they tend to be more odoriferous than others on hot, humid days; sitting next to them in a packed movie theater or an overbooked airplane can be an objectionable experience. It can be argued (as long as you are willing to overlook the strong genetic predisposition that underlies most true obesity) that they have become this way because of their obnoxious lifestyle choices, namely, their habitual sloth and gluttony. Their protests that they “can’t help it,” and that they remain overweight despite dedicating themselves to sundry diets, attempts to exercise, hypnotism, and legitimate and illegitimate weight-loss drugs, can be readily dismissed as proof of weak character. They have become fat because of their own personal choices, and their utter disregard for their own health is costing the rest of us our hard-earned dollars.

Being obese has already become such an unforgivable sin that, when the president nominates an African-American woman as Surgeon General, it has become entirely acceptable to attack the nominee because she’s overweight. Even in an era of Affirmative Action, being overweight now trumps being black and being a woman.

Accordingly, it has become legitimate to seek ways to establish discriminatory taxes against the obese. At the moment we are talking about taxing soft drinks and fat content in food. But it won’t be long before we are taxing the fat content of obese people themselves. And adding an “obesity surcharge” to health insurance premiums seems a sure thing. It is not difficult to imagine actually withholding healthcare services from people like the obese, who, thanks to their sloth and gluttony, threaten to use more than their rightful share of our communal healthcare resources.

We have largely agreed, as a society, that the obese are fair game.  And what this means is that we are already well along the path where we can demonize anyone in whom we can impute unwise behavior which, we think, may result in their consuming a disproportionate share of healthcare.

Now (and DrRich hopes you will take this observation in the helpful spirit in which it is intended, from one who still would cherish at least an honorary membership in your club),  here’s the thing about you patients: All of you are fair game.

There are, of course, some obvious categories of individuals among you whose behaviors, like those of the obese, predispose them to certain health problems, and whose demonization would seem, therefore, to be an obvious next step. Some of these would be smokers (unless, of course, they are elected to a high enough political office to exempt themselves from any criticism whatsoever, much less arbitrary limits to their healthcare); those whose sexual predilections tend to be decidedly non-vaginal in nature; those who engage in various high-risk recreational activities, such as rock climbing, bicycle racing, hang gliding, motorcycle riding*, etc.; those who choose to live in areas where certain illnesses are endemic (such as Lyme disease in the northeast, histoplasmosis along the Ohio River valley, and gunshot wounds in various inner city neighborhoods); and those who have made unhealthy career choices, such as policemen, firemen, military, miners, and construction workers. Patients who fall into any of these categories are obviously fair game; that is, their access to the healthcare they require because of their unwise lifestyle choices can be safely restricted without violating the bounds of equity and fair play.

But one must listen closely to the healthcare reformers themselves to see the real potential for cost savings when it comes to holding patients fully accountable for their unwise lifestyle choices.  No less an authority than President Obama himself has said (ostensibly to demonstrate how his reforms will save us lots and lots of money through preventive care) that a great number of common diseases are ultimately preventable, and can be greatly reduced or even nearly eliminated with the proper application of preventive medicine policies, and that chief among these are heart disease, stroke, diabetes, and cancer. And while DrRich bets that most of you patients out there think the President was talking about getting doctors to behave appropriately, and concentrate more on preventing disease instead of waiting until it develops and then treating it, what he was really saying was that it’s your lifestyle choices that are causing these diseases, and your lifestyle choices that are wasting all those healthcare dollars.

Our new healthcare system will undoubtedly be quite successful in browbeating physicians into telling you (yet again) all the stuff about your lifestyles that you damned well know already. But when, in spite of this really good advice, you go ahead anyway and acquire heart disease, stroke, diabetes or cancer, well, who’s at fault then? Plainly, the mere fact that you’ve developed these eminently preventable, lifestyle-mediated conditions will serve as prima facie evidence that you must have made some very unwise lifestyle choices, despite all the good advice the new healthcare system has provided you, and that as a result of your lack of self-control you threaten to consume far more than your rightful share of healthcare resources. The bad choices you made, of course, might not be as readily visible to everyone as, say, gross obesity, but the undeniable fact of your illness is itself sufficient to prove that you indeed made them.

Now, obviously there are illnesses that are not particularly preventable with wise lifestyle choices, and many of these are associated with genetic predispositions. And clearly, our new healthcare system will find it outside the bounds of equity and fair play to withhold medical services for such genetically-mediated conditions. After all, you didn’t ask to be born with substandard DNA. So if you are one of these patients who gets such illnesses, you can probably count on receiving therapy without any particular financial or medical punishment. (This supposition will not always be the case however, as illustrated by example of obesity, which indeed is usually genetically mediated.)

Of course, once you have become aware that your particular collection of genetic material predisposes you to certain illnesses that will require the consumption of valuable collective healthcare resources, then choosing to pass that genetic material on to future generations does constitute an unfortunate lifestyle choice. In other words, once you choose to have children, then you will have imposed the results of that lifestyle choice on the availability of healthcare resources for your fellow citizens. And at that moment, in the name of fairness and equity, you can be held accountable for that choice. DrRich will leave it to you to imagine what such accountability might look like.

DrRich is trying not to be bitter about having been excluded from your ranks. Since being a “patient” implies “illness,” who really wants it anyway?  But here’s the thing. You patients need to understand that it’s not just the doctors who are going to be punished for their sins under our new healthcare system, but you also (or rather, you especially).

The only salvation for both patients and doctors would be to forgive and forget, and to forge a new contract with one another - one that excludes third parties like the government - that reestablishes the traditional, fiduciary doctor-patient relationship. DrRich has talked until he’s blue in the face trying to convince doctors of this. This is an attempt to convince you, the party with whom DrRich’s (scorned) heart now lies. If you don’t do this, you and the doctors are both well and truly screwed.

Note from DrRich: Sandy Szwarc has been posting a series of well-documented articles at Junkfood Science on this general topic. DrRich highly recommends it. Here’s one of Sandy’s eye-opening examples of where we may be headed.

*There may be an exeption, of course, for motorcycle riding, but only if you ride without a helmet. Motorcycles that are ridden by unhelmeted riders are referred to in transplant centers as “donorcycles,” and it is unlikely that the transplant lobby will want to actively discourage this activity.

Comments

21 Responses to “Here’s The Thing About You Patients”

  1. Ren R on August 6th, 2009 10:20 am

    Dr Rich: the fact that you continue to use big words that are hard for us patient types to understand is clear evidence that you are still a doctor!

  2. DrRich on August 6th, 2009 1:56 pm

    Ren,

    But I didn’t know any of those words until I stopped being a doctor! (I learned them from all the lawyers I’ve gotten mixed up with since then.)

    Rich

  3. Lisa Emrich on August 6th, 2009 3:29 pm

    Oh boy, it always comes down to ‘you patients’ - the troublemakers. If not for patients, then there would be no need for reform. BTW, I’ve never heard a patient, in real life, complain about “all those greedy doctors.”

    And when, exactly, did ‘health care’ gobble up ‘medical care’? Medical care is what I seek when I take time to visit a doctor’s office.

    Just sayin’

  4. DrRich on August 6th, 2009 7:48 pm

    Lisa,

    Except in my case, of course, where “you patients” (a group of which I long to be a part, but from which I have been heartlessly rejected) is a term of endearment.

    Besides, here and elsewhere I have urged patients to be troublemakers whenever they can. Being a “nice” patient and a “compliant” patient in a system that is geared toward covertly rationing healthcare against them is simply not wise. Patients should do their own research and question everything, every time.

    And while I also have not heard many patients throw around the words, “greedy doctors,” the fact remains that “greedy doctors using too much expensive technology” was Hillary’s explanation of what’s wrong with American healthcare (and what she aimed to fix) in 1993. And if good Democrats like the Clintons don’t speak for the people (which still includes patients, I believe), then who does?

    Rich

  5. DrPoor on August 7th, 2009 7:04 am

    Don’t underestimate the accountability to which we primary care doctors will be held (or worse, liability to which we will be susceptible) when a patient develops a so called “preventable” illness. It will only add insult to injury and drive the remaining few of us out to the pastures.

  6. DrRich on August 7th, 2009 7:18 am

    DrPoor,

    There are already some congressmen talking about holding doctors accountable for their obese patients who fail to lose weight, and their smoking patients who fail to quit. This kind of thinking, of course, merely reflects a world view in which, once the right processes are established, all people will display ideal behavior.

    Rich

  7. Kim on August 8th, 2009 11:48 am

    I absolutely, unequivocally love the way you write; it’s everything I want to say but don’t possess the articulateness to do so.

    Now, while all the above is 100% true, I do hope it increases my chances of getting into GR this week…

    : D

  8. Rose on August 8th, 2009 1:35 pm

    I loved every thing what u wrote. One thing i like to mentionn is that the blogs are not supposed to be that long long.

  9. DrRich on August 8th, 2009 1:39 pm

    Kim,

    Fear not. This compliment gets you in.

    Rich

  10. DrRich on August 8th, 2009 1:41 pm

    Rose,

    Thanks for the compliment, and especially for the advice. I have never been good at following the rules, which is what makes me so endearing. Also, knowing that most people will stop reading after a paragraph or two, I always hide my secret messages at the end.

    Rich

  11. Dr. Wes on August 8th, 2009 4:02 pm

    Another instant “Dr. Rich Classic.” Well done.

  12. MacGhil on August 10th, 2009 3:40 pm

    Dr. Rich,

    Is your evaluation of what the bill constitutes as “acceptable coverage” the same as this blogger’s?:

    EVALUATION OF THE PASSAGES:

    1. The bill defines “acceptable coverage” and leaves no room for choice in this regard.
    2. By setting a minimum 70% actuarial value of benefits, the bill makes health plans in which individuals pay for routine services, but carry insurance only for catastrophic events, (such as Health Savings Accounts) illegal.

    http://theobjectivestandard.com/blog/2009/08/health-care-bill-what-hr-3200-americas.asp

    It essentially outlaws concierge care/retainer medicine, does it not?

  13. DrRich on August 10th, 2009 4:51 pm

    MacGhil,

    The bill is very difficult to read (almost to the point where I can forgive the dim bulbs in congress for not reading it - they have no prayer of understanding it anyway), and intentionally ambiguous. It is a pile of language that will be shipped off to the nameless regulators and bureaucrats to interpret as they see fit.

    I strongly believe that HSAs and self-pay medical practices are being targeted for elimination; I agree that the passages cited here are consistent with doing so; and I expect that once these passages are translated into actual regulations (by regulators) it will become so.

    But they are ambiguous enough that at the moment, while we are being “sold” on this, our elected officials (who, as I say, have no clue) can assert in all honesty that as far as they’re concerned the bill does no such thing. We are seeing, in my opinion, deception turned into a high art.

    Rich

  14. Jupe on August 10th, 2009 7:48 pm

    Why would they want to outlaw retainer practices?

  15. frank on August 11th, 2009 1:20 pm

    I don’t think most advocates of healthcare reform believe the main problem with our system is greedy doctors. Most think the docs are the “good guys” who are unfortunately caught up in a market-driven, for-profit practice that inefficiently distributes resources. Add in the outsized influence of insurance and pharmaceutical companies whose purposes are at odds with the true calling of the physician and we’ve got the inefficient behemoth we call a healthcare “system.” Yes, government insurance can improve healthcare - as the efficiencies in both Medicare and the VA system demonstrate. Is the status quo the best we can do?

  16. Laurie Avocado on August 12th, 2009 4:48 pm

    But wait a minute….do you think fat people are getting medical care under the current system? They have to be either rich enough to get medical care directly, or they have to have entered a plan before they were fat. Fat people are routinely denied coverage by all the currently existing health plans, unless they can sneak into the system through an employer who doesn’t discriminate against them.

  17. DrRich on August 12th, 2009 4:57 pm

    Laurie,

    Of course I don’t think that. Obesity, being a preexisting condition, is treated by insurance companies as any other preexisting condition. Insurance companies are paid to be evil, so that’s what they do.

    What I’m going off about is actually bigger than that. It’s the general, societal demonization of the obese I’m worried about. If we can convince each other that the fat are somehow subhuman, or otherwise are unworthy of our love, respect, concern, or healthcare, because (by our high standards) they are slothful and lazy, then it’s a relatively small step to do the same to others whose “behavior” can be painted as imposing on us.

    Rich

  18. Laurie Avocado on August 13th, 2009 3:06 pm

    Plenty of people already believe the fat are unworthy, because it’s their own fault they are fat. Doctors tell fat people to lose weight. Various methods of weight loss are prescribed. Sometimes those methods of weight loss actually work, but then the fat people turn around and gain even more weight later. They are labeled “non-compliant.” Some people are blaming the fat for global warming, too! My personal opinion is that health-care reform is not likely to make it any worse than it already is.

  19. Laurie Avocado on August 14th, 2009 2:54 pm

    Furthermore, I don’t think it would be such a bad idea for race car drivers, mountain climbers, sky-divers, etc. to purchase insurance policies specifically for injuries incurred while pursuing those activities, in the same way that a homeowner can purchase a special policy to cover specific valuables such as an art collection. In addition, it would be more fair for fat people to be able to buy insurance for treatment of non-weight-related illness and injury, such as infectious disease or a broken leg. However, someone out there will probably discover that fat people break their legs more often than thin ones.

  20. Heather Rogers on August 26th, 2009 5:38 pm

    I have discovered this website today and have been vastly impressed, not only by the irony but also by the erudition displayed here. Being one of the “vast uninsured masses”, otherwise known as “patients” who are unable to pay and/or otherwise receive the benificence of our current “healthcare system”, allow me to hopefully dispel a few myths about it (which I am sure that Dr. Rich is well-aware of.) Due to the fact that I work all too often as a contractor in the Information Technology world, all too often, we are offered inadequate, expensive and nearly insulting levels of insurance by contracting companies. Since the pay of this area of IT is insultingly low, thanks to the massive export overseas of professional level jobs to places like South East Asia and India (which, I’d like to point out, have universal healthcare….), the “offered insurance” which the company picks up NONE of the tab for can account for more than 15 percent of pay. It is not uncommon for said healthcare to run at a rate of more than $400 dollars per month and on the average salary of 18 - 24.00 per hour… well that’s a big bite out of your salary. And that’s when it’s “offered” at all. Should you foolishly try to self-insure, then the costs and the risks are even worse. I was just turned down for self-insurance through Kaiser because I am “obese” by their definition. It’s funny because I was insured by an employer just last November but like so many, I was laid off, couldn’t afford my insurance and so it lapsed. The insurer I was insured by? Kaiser! My medical records with Kaiser go back nearly 15 years and despite my offensive weight, my blood pressure, cholesterol and every other indicator of heart disease do not exist because I live a healthy life-style by exercising and eating low-fat, high fiber foods. My last health exam with Kaiser was Sept 08 (showing these same results) and I was turned down last week after applying so… where do we go from here? Well, one only hopes that some form of reform goes through because folks, it scares me to be a part of the rationed masses…. Even though I AM very healthy… I am 46 and nothing gets better from here really…

  21. marilyn on August 28th, 2009 11:54 am

    Reminds me of the old poem by Friedrich Gustav Martin Niemöller:

    When the Nazis came for the communists,
    I remained silent;
    I was not a communist.
    When they locked up the social democrats,
    I remained silent;
    I was not a social democrat.
    When they came for the trade unionists,
    I did not speak out;
    I was not a trade unionist.
    When they came for the Jews,
    I did not speak out;
    I was not a Jew.
    When they came for me, there was no one left to speak out.

    If they can divide us up by our health problems, they can conquer (or ration) all of us eventually.

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