Health Care Foibles – A Personal Tale

An example of the stupid things even doctors do when it comes to health care. 

In March of 2013 I wrote Healing the Health Care Cost Conundrum. Four years later, in March of 2017, I have retired from the US Army and am practicing medicine in Memphis, TN. My practice is in the inner city, and our focus is serving the Medicaid population. Our patients are impoverished and often very sick, with chronic diseases frequently showing up 20 years earlier than in their more affluent counterparts. Many live in dangerous communities, have no reliable transportation, and have unhealthy food. Obesity is the norm, violence is taken for granted, and serious mental illness is widespread. It comes as no surprise that many patients abuse drugs, citing chronic pain that may or may not be real. Some come to the clinic for no other reason than to feed their drug habit, and try to get narcotics to generate a little extra income. It is the toughest medical environment I have encountered since my combat tour in Iraq.

Meanwhile at the policy level, Obamacare is proving too expensive to sustain, and just yesterday Republicans in the House of Representatives failed to pass a bill with their plan to reform health care. While the survival of Obamacare causes rejoicing in some and consternation in others, the simple truth is that neither the Patient Protection and Affordable Care Art (Obamacare) nor the American Health Care Act (Republican bill) are health care reform, they are health insurance reform. Both pieces of legislation regulate how health care is paid for, not how it is delivered. With all due respect to our legislative leaders, they cannot improve health care delivery. Only health care professionals can make health care all that it needs to be. This is what those in my practice are trying to do – build a system that can provide quality, affordable, medical care to the poorest Americans. If we can do that, in conjunction with others around the nation striving for the same goal, American health care will be transformed.

Revolutionizing medical care, rather than merely medical insurance, may be a noble goal, but achieving it is like walking from Cairo to New Delhi; long, arduous, and dangerous. One reason for this difficulty is that no matter the education, resources, or social support, humans will be humans.

My Personal Tale

This past week I developed an eyelid infection. I ignored it for a few days, and one evening after a long day at work I decided to do something. Since most medical facilities were closed, and we had no other antibiotics in the house, I took some long-expired antibiotics that had been prescribed for someone else. Taking expired medications can be dangerous, or at least ineffective, and expired antibiotics can increase resistance. I regularly tell patients not to use expired meds or those given to someone else. In this case, I opted for short term convenience, and hypocrisy.

After unsuccessfully trying home care, I went to the Emergency Department at a local hospital. This infection could have been treated more effectively, and far more cheaply, at a local primary care practice. But it was only 6:30 in the morning, too early to call for an appointment. Most practices that we found opened at 8 or even 9, while I had to be at work at 8, and I could not be guaranteed to be seen. So again, I violated my own standards and took a my eyelid infection to an emergency department, costing my insurance about $1,000 instead of about $50.

I tried to be a patient instead of a doctor in this setting, but my secret came out when the nurse asked my occupation. It would have leaked anyway, because medical people talk differently about medical conditions than lay people do. My description of my eyelid as red, swollen, and tender but not painful, was a dead give-away. When the physician’s assistant (PA) came in to examine me, he suggested that Vigamox eye drops would be the best to cure this infection. Even though I thought an oral antibiotic would be a better choice, I was still trying hard to be a patient and not a doctor, so I agreed.

My wife later called from the pharmacy. Vigamox, with a generic name of moxi-floxacin, cost $200 for three milliliters. I was more than a little annoyed; a similar ophthalmic solution of ciprofloxacin would cost $15. Why had the PA prescribed as his first choice something so ridiculously expensive? Word of mouth? Pharmaceutical company marketing? Ignorance of the cost? All of the above? How would this affect others such as the uninsured or the underinsured?

A day later, my eyelid got worse. The Vigamox was not controlling the infection, because it was more widespread than the PA realized. We made an appointment with optometry, and I worked from home. The optometrist prescribed oral Bactrim, which cost $2 at the pharmacy. The infection gradually improved.

The Lessons Learned

This tale of minor misjudgment, multiplied hundreds of thousands of times, is much of the story of health care in America, and around the world. Patients do things that they should not, even when they know better, and do not do things that they should. We opt for convenient care instead of cost-effective care. Had I been faced with the whole bill, I never would have gone to the ED instead of a clinic; I simply would have called in late to work.

Well-meaning but hurried providers make poor diagnoses and prescribe dauntingly overpriced treatments. Because of mistakes in primary care, specialists get involved unnecessarily. Drug companies tout their latest miracle cures, but make no mention of comparative pricing. In fact, no one knows the real price of anything in health care. The ED did not provide a clear statement of the total cost, nor did the optometrist. Further, the prices for me, someone with commercial health insurance, are different than the prices for a Medicare patient, a Medicaid patient, or an uninsured patient.

Quality is an issue. Was the ED that I visited a high-quality ED or not? How did they measure quality? How would I know what the scores were? The PA was a pleasant chap, but the quality of care that I received was lacking. In the absence of metrics, word of mouth rather than clinical outcomes becomes the main quality measure. I went to the optometrist that my mother had recommended because when she saw him, “he was nice”.

An eyelid infection is a relatively minor medical problem. Imagine how much mischief the same combination of human laziness, misjudgment, opacity, and inconvenience causes for more serious diagnoses. Imagine how much these factors contribute to unnecessary expense, and to human suffering.

Conclusion

When I told my daughter, a student in Public Health, my story, she was disgusted. She called it “a personal problem”, but unfortunately the effects are more than just personal. Rather than getting an inexpensive prescription at a primary care office, spending less than $100, I got ED care, an expensive prescription, and specialty care, likely costing well over $1,500. Rather than taking two days to get better, it took five, including time off work and lost productivity.

My foibles are obvious, but they are not unique. I have met few doctors who have never used higher priced care when a cheaper care would do. I have met even fewer doctors who have never taken someone else’ medicine or used expired medicines. Nurses and other health care professionals do the same, and we all know better. Little wonder that patients, who often don’t know better, follow our example.

How then do we revolutionize health care, my stated goal at the beginning of this article?

  1. By engineering hazards out, including mistakes, misjudgments, and misunderstandings.
  2. By transparency in quality and pricing.
  3. By better rewarding good behavior.
  4. By practicing evidence-based medicine.
  5. By intentionally using low cost medications and other interventions when the outcomes are similar.
  6. By making the patient more responsible for costs and outcomes, having “more skin in the game”.

Please also see Healing the Health Care Cost Conundrum for more ideas.

Republicans and Democrats at all levels, local, state, and federal, will continue to fiddle with American health care. Their work is important, but can only address a small part of the problem. We as health care professionals must figure out how to provide quality, affordable, and accessible care to everyone. Using lessons learned from stories like this, we can do it.

The Long Shadow – How to Follow a Superstar

A Tennessee democrat who was firmly committed to the Union, Andrew Johnson had a distinguished career as congressman, senator and governor of his state. Hoping to send a message of reconciliation to the rebellious South, Lincoln chose Johnson as his vice president in 1864. Johnson’s debut on the national stage went poorly, with a rambling and perhaps drunken speech when he assumed office in March 1865. Lincoln followed with a masterpiece, his Second Inaugural Address. Little did anyone know that in only six weeks, at one of the most crucial times in American history, the rambler would be President.

A Missouri democrat who came to national prominence investigating fraud, waste and abuse on the Committee of Military Affairs during the Second World War, Harry Truman had earlier served as farmer, haberdasher, judge and US senator. With President Franklin Roosevelt in declining health and many expecting that he would not survive his fourth term, the party looked for a vice president who could succeed in the top job. Eighty-two days after the Inauguration, Roosevelt lay dead, and Truman took the top job.

Johnson struggled during his presidency, continually battling Congress on civil rights and other issues, being impeached by the House, and retaining his job by only one vote in the Senate. Historians have judged him to be among the worst presidents. Truman could never compete with the wildly popular Roosevelt, and did not try. He stuck to his agenda and his style through the atomic bomb, economic upheaval, strikes, the war in Korea, and the start of the Cold War. Though his approval rating was 22%, the worst ever, in the final year of his presidency, Harry Truman is now ranked among the best US presidents.

Many have considered why Johnson failed and Truman succeeded in their quest to follow a superstar. Johnson had the disadvantage of following a relatively young and still healthy president who no one expected to die. He also had to rebuild the nation. Truman’s ascension to the presidency was expected, but he had to stabilize the world. This article attempts to help leaders know how to follow predecessors whom others consider to be superstars.

Publicly Acknowledge Reality

1. Your predecessor is loved; do not be perceived as diminishing that in any way. If you do, you, not he, will be diminished.

2. Charles de Gaulle is the most famous man credited with saying “The graveyards of the world are full of indispensable men.” While it is true that the world will not collapse with the loss of any individual, it is equally true that no one is replaceable. Each person’s combination of knowledge, skills, personality, and industry is unique. Don’t even try to replace a predecessor.

3. However, many people could do any given job competently. Your job is not to replace a superstar, but to use your unique attributes to move the team and the organization to the next level and face a new set of challenges.

4. No one, no matter how good, can or should stay in a job forever. New times call for new people. Lincoln had an excellent plan for bringing the United States back together after the Civil War, but Lincoln was one of the greatest leaders in human history. Judging from his performance at Yalta, it is not clear that Roosevelt grasped how the world would be after World War 2, and not clear that he had a sound plan.

5. There are some people in the organization who do not consider your predecessor a superstar. No one is loved by everyone. No matter how good you are, you are not loved by everyone either.

Transition

1. If your predecessor is a real superstar, he will be sad to leave the people he has worked with so well. However, he will not impair your transition.

2. Once she is gone, she will not interfere in the organization. She will stay gone unless asked to assist.

Your task

1. Maintain the advances of your predecessor. Andrew Johnson kept Lincoln’s rough outline for gently bringing the South back into the Union, although he struggled against a vindictive Republican congress. William Taft advanced, albeit imperfectly, Theodore Roosevelt’s progressive agenda. Neither tried to turn back the clock.

2. Move the organization ahead to meet new challenges. Moses led the Hebrews out of Egypt, but Joshua led them into the Promised Land. Moses’ task was great and his results were legendary. Joshua’s task was also great, and his results also stood the test of time.

3. Know and use your own style. You will fail if you try to mimic someone else. You have strengths and weaknesses just like she does.

4. Improve your strengths, improve your weaknesses, and use your staff to help compensate. Andrew Carnegie, the American steel magnate, famously opined that the key to success was to surround yourself with good people.

5. Leaders are beloved by their troops because they love their troops. You must care for your people more than you care for yourself. The Chinese military writer Sun Tzu wrote

“Regard your soldiers as your children, and they will follow you into the deepest valleys; look upon them as your own beloved sons, and they will stand by you even unto death. If, however, you are indulgent, but unable to make your authority felt; kind-hearted, but unable to enforce your commands; and incapable, moreover, of quelling disorder: then your soldiers must be likened to spoilt children; they are useless for any practical purpose.”

6. Leaders are respected because they know their job better than anyone else, and work hard.

7. Leaders are followed because they know where the organization should go and how to get there.

8. As you are accomplishing your mission, enjoy your job and your team. They will not enjoy you if you do not enjoy them.

Anticipate a Positive Future

1. Make sure that your team knows that while their beloved leader has moved on, the team’s future is bright. It is your job and theirs to make the future better.

2. If your predecessor is a real superstar, rather than someone who is interested primarily in himself and his legacy, he will want your tenure to be even better than his, because he wants the best for the organization. The group’s well-being is more important to him than his own.

Conclusion

Some may argue that Andrew Johnson had no chance to succeed following Lincoln, and that the best he could have done was to be a placeholder until the next president came in and the magic of Lincoln had faded from public memory. However, as the examples of Truman and Joshua prove, capable men can succeed in the long shadow of superstars.

You may be following a superstar, but no matter how good, his or her time is over, and yours has begun. You have been placed in this new role by your superiors, and by powers even higher. You must respect and appreciate the past, but you must shape the future. Now all that remains is to do it.