Do you think there should be stricter allocation of medical resources?

One of the doctors that I have a weekly preceptor session with is a bitter, bitter man. I seriously don't know why he's in the field of medicine because he bitches and complains about everything. However, the other day he brought up a point that I hadn't really considered before.

To a certain extent in medicine, there is allocation of scarce resources. For example, with an alcoholic vs someone with primary biliary cirrhosis who both need a liver transplant (the former self-induced) it is much more likely that the person who didn't cause their liver failure will get it. Well, at least that's my understanding as I don't regularly deal (as in observe) with such matters.

Now it's an accepted fact that many people use the emergency room as their doctor's office. From what I've seen in my time in the hospital, many of these same people are repeat visitors. They come in, sometimes in bad enough condition to be admitted, get "tuned up" and given instructions to follow up, take their medications, etc. (often these people are of lower SES but there are many generics that are available for $4/month at Target, Walmart, etc.) and then discharged. Then they come in again for the same thing and we learn that they didn't bother to take their meds or go to the clinic for follow up or just plain aren't taking care of themselves.

Sadly, we live in a society where the idea of personal responsibility has less and less meaning every day (in the US anyway), but said doctor that I originally mentioned made the suggestion that at some point it should be okay to refuse to treat these people and put the money, time and manpower towards those who actually seem to take an interest in themselves. Of course, I'm talking about "repeat offenders"

I know there's all kinds of wrong with this thinking and I don't ever really see something like that ever taking place but I have to admit that the idea does appeal to me somewhat.

Of course it's appealing, and it's effectively impossible to implement correctly because it relies on the judgment of doctors and hospital staff--which is fine when it comes to medical diagnosis and treatment, but is extremely not fine when it comes to abitrary decisions about who receives what could eventually end up being life-saving care. Even with a good system in place (whatever system would be developed, I am sure, would be very much not good) someone would eventually fit certain criteria who shouldn't have, and will be denied treatment. There's a reason we say it's better to release 10 guilty men than jail one innocent, and it's applicable to this.

Originally Posted by eidolon

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Of course it's appealing, and it's effectively impossible to implement correctly because it relies on the judgment of doctors and hospital staff
Mostly, yes. But, for the sake of argument, if you repeatedly tell a visitor to the E.R. with congestive heart failure to take their diuretics, etc. and each time they come in you learn that they aren't taking it there is some objective criteria to base a decision on.

--which is fine when it comes to medical diagnosis and treatment, but is extremely not fine when it comes to abitrary decisions about who receives what could eventually end up being life-saving care.

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I agree. But I'm not talking about someone who overdosed on cocaine, for example, where they'd say "well, he's a drug addict so let's forget about him and treat this upstanding businessman instead." I'm thinking more along the lines of repeated non-compliance e.g. "you're still smoking even though you have COPD and are on oxygen. How about you get to the back of the line..."

Even with a good system in place (whatever system would be developed, I am sure, would be very much not good) someone would eventually fit certain criteria who shouldn't have, and will be denied treatment. There's a reason we say it's better to release 10 guilty men than jail one innocent, and it's applicable to this.

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I agree.

Originally Posted by Jumbie

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Mostly, yes. But, for the sake of argument, if you repeatedly tell a visitor to the E.R. with congestive heart failure to take their diuretics, etc. and each time they come in you learn that they aren't taking it there is some objective criteria to base a decision on.
Of course there is objective criteria, I'm sure plenty of hospitals would do better if they could ban the obvious, repeat offenders.

But, and be honest, how many bad doctors do you know? I'm guessing a lot, and if I asked you to name names, that number would fall to 0. The white wall of silence is an issue if something goes wrong here, and there are too many people to efficiently regulate (assuming this could ever be regulated even sans efficiency). While a doctor != a pharmacist, there are plenty of pharmacists that think not only that they can refuse to issue birth control (which they can, normally), but that they can take the prescription and refuse to return it (which they cannot, legally). There are plenty of bad doctors, like there are plenty of bad anything else. One bad doctor making this decision, or a group of bad doctors, or a hospital that's trying to save money pushing good staff to make bad decisions will result in some people being dead that should not be. That's enough reason to never give anyone the power, at any time, for any reason, to refuse to give someone basic treatment.

I agree. But I'm not talking about someone who overdosed on cocaine, for example, where they'd say "well, he's a drug addict so let's forget about him and treat this upstanding businessman instead." I'm thinking more along the lines of repeated non-compliance e.g. "you're still smoking even though you have COPD and are on oxygen. How about you get to the back of the line..."

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And that's fine, and that's what should happen if we assumed every person on this Earth was capable and reasonable. But the existence of that person in the first place disproves the idea of infallibility, and fallibility has only slightly less potential to plague someone with years of medical school under their belt than it does the COPD patient on oxygen who refuses to quit smoking.

Most hospitals, social-workers (which would inevitably have to have a role in something like this) and anything related to insurance are bureaucratic nightmares. There's no doubt that innocent people have died being at the end of a long line because of assholes that shouldn't be in the ER in the first place. There's also no doubt that if doctors and hospitals had the choice, no matter how restricted, to not give certan people basic care based on certain criteria, even more people would die, and only a slightly greater percentage of them would probably be the aformentioned assholes.

Originally Posted by eidolon

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Of course there is objective criteria, I'm sure plenty of hospitals would do better if they could ban the obvious, repeat offenders.

Probably. To be clear, I'm not wishing for this.

But, and be honest, how many bad doctors do you know? I'm guessing a lot,

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Yes.

and if I asked you to name names, that number would fall to 0. The white wall of silence is an issue if something goes wrong here, and there are too many people to efficiently regulate (assuming this could ever be regulated even sans efficiency).

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You are correct. In the end, everyone's looking out for themselves.

While a doctor != a pharmacist, there are plenty of pharmacists that think not only that they can refuse to issue birth control (which they can, normally), but that they can take the prescription and refuse to return it (which they cannot, legally).

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Really? I didn't know that.

I did see that first hand from a doc though when I was in family practice. Myself and some of the other students were quite shocked at her treatment of a teenaged girl who came in concerned about an STD and wanting OCPs.

We did kind of bring it up to one of the other docs but nothing came of it.

On the flip side, despite being in a Catholic hospital which is against birth control, I've seen docs in the Ob/Gyn clinic give it out for "other reasons".

There are plenty of bad doctors, like there are plenty of bad anything else. One bad doctor making this decision, or a group of bad doctors, or a hospital that's trying to save money pushing good staff to make bad decisions will result in some people being dead that should not be. That's enough reason to never give anyone the power, at any time, for any reason, to refuse to give someone basic treatment.

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I agree with you. Like I said in my OP, the idea has some appeal but there's plenty wrong with it.

Most hospitals, social-workers (which would inevitably have to have a role in something like this) and anything related to insurance are bureaucratic nightmares.

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They sure are. It's freaking marsupialed how things get done; or not done.

There's no doubt that innocent people have died being at the end of a long line because of assholes that shouldn't be in the ER in the first place. There's also no doubt that if doctors and hospitals had the choice, no matter how restricted, to not give certan people basic care based on certain criteria, even more people would die, and only a slightly greater percentage of them would probably be the aformentioned assholes.

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Once again, I agree with you.

Originally Posted by Jumbie

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said doctor that I originally mentioned made the suggestion that at some point it should be okay to refuse to treat these people and put the money, time and manpower towards those who actually seem to take an interest in themselves.

Absolutely, and in my work I do just that.

I'm a year away from finishing my PhD and work part-time at a local community mental health clinic. The general show rate is about 55% (mine is around 75%). All patients are self-referred so no one is forcing them to come to therapy. From my perspective, my time is extremely valuable, particularly because I have the most education among the other 20 or so masters-level therapists who work there. My position is fee-for-service so if someone doesnt show, I dont get paid. The discharge policy of the clinic is absurd. They insist that someone has to no-show 3 times and then be sent 2 letters giving them 2 more appointments before a final letter including 3 referrals is sent. Most of the patients are of a lower SES; many of them on disability because of their mental illness.

I certainly look at non-compliance as a treatment issue, but the majority just dont give a **** and have no problem with wasting your time and the free service. When I get a new patient with a history of 10 no shows in 15 scheduled sessions they better have a damn good reason why they are motivated for treatment or I refer them out. With the clinics waiting list of 300 patients, some of whom may be very impaired due to their mental illness and possibly willing to engage in treatment, I have no problem referring people out who I believe will waste my time in the future.

My personal policy is that if someone doesnt show for the initial assessment, they are rescheduled but double booked with someone who is consistent. No show again, and they are out, back at the end of the 300 patient waiting list. That being said, I am aware that many people have issues with transportation and child care but the least they can do is call which may don't. My personal policy can sometimes cause conflict with my superiors, but I refuse to deny services to potentially motivated patients because I am waiting on people who have been given chance after chance.

dl

Originally Posted by dl20

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Absolutely, and in my work I do just that.
While I appreciate your opinion, and while I have respect for your field (my mother has a masters in psychology and practiced for a time), the impact you have is not nearly as direct as not doing X = person dies. It's not even as direct an impact as a psychiatrist, and the possible results of, say, a paranoid schizophrenic not receiving their medication.

A refusal of treatment from you in an unlikely scenario results in someone maybe not having any other options, and at the end of a long and winding path assuming a few very specific things happen that person might eventually somehow end their life, but it's not the same as someone in distress who needs direct care. You, in private practice, are a choice for your patients. They can choose someone else. You can also refuse them. Doctors in an ER are not a choice for the patient, and they cannot and should not be able to refuse anyone.

In my neighborhood, we have two hospitals nearby, one for the surrounding cities which house people of lower SES and one that caters specifically to our city which is a gated community. I don't know how they manage to do it but at this point it is illegal (in our part of town) to visit the E.R. in the better hospital without proof of residence. Of course, it is relegated to EMS personnels in case of emergency to enforce this policy but it is a headache for them as in some cases the patients are not even conscious to ask for legal residence. Perhaps, apartheid is the temporary solution to the current health care crisis.

It is important to state that the United States is one of two countries, the other used to be South Africa, who have traditionally viewed health care, esp. in the form of access, as a commodity rather than a right. Looking at the U.S. health care system through this lens of consideration, it makes it easier to argue and justify, through congressional implementations, the allocation of health care resources to those citizens who can pay and limit access to those who, by economics, cannot or those, who by choice, will not. Of course, the advent of Social Security programs in the sixties changed the underlying assumption in this system somewhat, as access to health care is now considered a right if you're poor (Medicaid), old (Medicare), part of a minority (Indian Health Service and Vet. Affairs), etc. Even in this progressive shift of viewpoint, access to general health care, as a finite resource, cannot be offered to everyone if the burden of the cost is borne by a small group of individuals. At least in the U.S., the government has implemented the "cap" system in terms of how much physicians can charge (Medicare) for a given procedure. This slow shift means that if we are to move to a nationalized system of health care delivery, it is mostly physicians who will bear the brute of the change. This happened to Canadian physicians in the sixties, but theirs is not a true nationalized health care system as the government pays physicians through indirect fiscal intermediaries. The economics of health care delivery stipulates that access, quality, and cost make up the vertices of a triangle, and one can only balance this imaginary triangle at a fixed, and specific point. That is, it is impossible to increase access without compromise quality and perhaps cost. If we are to move forward and make access to heath care even stricter, then the current crisis of people going to E.R. s as the only source of entry to health services will be even worse. The sensible step right now is to lower "quality", esp. in the amount of specializations that occur in the medical field, and produce more general practitioners. Much have been written on this subject, and if IIRC, Oregon has implemented a similar plan a few years ago by increasing access of primary care to more of its citizens while capping the more specialized services to steady cost. The majority of the people who visit the E.R. are there for minor problems that can easily be resolved with a GP, and those that come in for more serious conditions, would be reduced by size in offering screening for their conditions at earlier stages. I think most physicians feel that this is the way to go in terms of "reforming" the system, but the American people have to make tangible sacrifices along with them for this process to truly work. The climate of change favored this shift in the 60s but it was physicians themselves (AMA) who adamantly opposed to it and they are a powerful lobbying group. I find it funny when Obama-ites scream "change" but I've never heard "change, we can bare!" Just my ramblings.

Originally Posted by Jumbie

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To a certain extent in medicine, there is allocation of scarce resources. For example, with an alcoholic vs someone with primary biliary cirrhosis who both need a liver transplant (the former self-induced) it is much more likely that the person who didn't cause their liver failure will get it. Well, at least that's my understanding as I don't regularly deal (as in observe) with such matters.


At least technically, this is NOT true. If you look at all the official guidelines by organ procurement agencies and transplant centers, it's the NEED that determines who gets the transplant. As long as the alcoholic has passed the basic screening criterias, and IF he has a higher need than the guy with the PBC, your alcoholic who casued his own liver failure will get the liver.

Now remember I said technically. There will always be exceptions/shady instances of celebrities getting organs first (governor of PA, Mickey Mantle)

Originally Posted by G18C

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The sensible step right now is to lower "quality", esp. in the amount of specializations that occur in the medical field, and produce more general practitioners. Much have been written on this subject, and if IIRC, Oregon has implemented a similar plan a few years ago by increasing access of primary care to more of its citizens while capping the more specialized services to steady cost. The majority of the people who visit the E.R. are there for minor problems that can easily be resolved with a GP, and those that come in for more serious conditions, would be reduced by size in offering screening for their conditions at earlier stages. I think most physicians feel that this is the way to go in terms of "reforming" the system, but the American people have to make tangible sacrifices along with them for this process to truly work.

You are vastly overestimating the abilities of the general practioner. About 15 years ago there was a general push by practically all the medical schools to produce general practioners. I'll just say that such a push no longer exist. Additionally, it's a fact that GP's are the least paid of all doctors. If you truly think that all people go to medical school for altruistic reasons you would be quite delusional. Specialty offers the luxury of specialized set of knowledge and better pay.

In any case, the field of medicine is advancing so rapidly that the traditional role of a medical school graduate as a general practioner should probably be retooled. There is no reason why the simple checkup that you mention (fine tune blood pressur, diabetes, cholesterol meds, council patient to quit smoking, increase exercise...etc) cannot be done by a mid-level health care practioner, like a nurse practioner.

Isn't this more or less covered by the Hippocratic oath.

Also,

Originally Posted by lee_44106

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You are vastly overestimating the abilities of the general practioner. About 15 years ago there was a general push by practically all the medical schools to produce general practioners. I'll just say that such a push no longer exist.

I'd actually say, based on my limited experience, that there is some resurgence in the field of general medicine. The 2008 match (for residency positions) showed in increase in the number of US grads going into this field compared with IMGs and FMGs.

Additionally, it's a fact that GP's are the least paid of all doctors. If you truly think that all people go to medical school for altruistic reasons you would be quite delusional. Specialty offers the luxury of specialized set of knowledge and better pay.

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Yup, this is the case.

The amount of "resistance" I receive when I tell the docs that I want to go into primary care is astounding.

Part of it is supply and demand but I honestly feel that a GP is much tougher in some cases in that the required range of knowledge (as in anything can walk through the door) than a specialist where they pretty much know what they're getting. However, everyone wants to do procedures because that's where the $$$ is although there is a lot of capping on that in recent years.

The lifestyle of a specialist can also be significantly better. No calls in the middle of the night for dermatology, ER leaves their work behind when they go home, radiologists can work from home in some instances (high speed internet to send images to them for reading), etc.

In any case, the field of medicine is advancing so rapidly that the traditional role of a medical school graduate as a general practioner should probably be retooled.

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I'm not so sure about this.

There is no reason why the simple checkup that you mention (fine tune blood pressur, diabetes, cholesterol meds, council patient to quit smoking, increase exercise...etc) cannot be done by a mid-level health care practioner, like a nurse practioner.

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For routine care, I see the possibility but there will always be the need for doctors. Yes, even the GPs who manage blood pressure. The knowledge base just isn't there with the NPs IMO.

Originally Posted by eidolon

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And that's fine, and that's what should happen if we assumed every person on this Earth was capable and reasonable. But the existence of that person in the first place disproves the idea of infallibility, and fallibility has only slightly less potential to plague someone with years of medical school under their belt than it does the COPD patient on oxygen who refuses to quit smoking.

I agree with much of what you are saying, but this is just a terrible argument. The idea that a capable and reasonable person is infallible is preposterous, and the idea that the fallibility of man proves it unreasonable and incapable is also wrong. The only proof of the ability to reason is that people are able to get from having a goal to accomplishing a goal, the worthiness of the goal is not the issue. In other words, if a drug addict decided that heroin was more important to him than food, what would be reasonable would be that he were to buy heroin with his last dollar, what would be unreasonable would be if he were to buy food.

Originally Posted by Augusto86

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Isn't this more or less covered by the Hippocratic oath.

To which I respond with the fact that it is a fallacy that this is an actual requirement to be a doctor. It's more of a tradition than anything else at this point but many medical schools don't even use it any more. Mine did, but see:

http://www.nlm.nih.gov/hmd/greek/greek_oath.html

Over the centuries, it has been rewritten often in order to suit the values of different cultures influenced by Greek medicine. Contrary to popular belief, the Hippocratic Oath is not required by most modern medical schools.

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Please note that the above site is the National Library of Health from the National Institute of Medicine. It's not John Smith's webpage opinion.

Originally Posted by iammatt

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I agree with much of what you are saying, but this is just a terrible argument. The idea that a capable and reasonable person is infallible is preposterous, and the idea that the fallibility of man proves it unreasonable and incapable is also wrong. The only proof of the ability to reason is that people are able to get from having a goal to accomplishing a goal, the worthiness of the goal is not the issue. In other words, if a drug addict decided that heroin was more important to him than food, what would be reasonable would be that he were to buy heroin with his last dollar, what would be unreasonable would be if he were to buy food.

It was a weak transition and the logic is questionable at best, but I made it because it was easy and I'm a big believer in taking the path of least resistance.

Interesting. So is the Oath legally non-binding? I seem to recall it being deployed in Kevorkian's case, but I could be dead wrong. (NPI)

In any case, I'm wondering what exactly it is that you propose. I do understand the allocation of scarce resources argument, but the implementation is troublesome. I mean, there are arguably a huge number of conditions which are the fault of the patient - that is, he bears the sole responsibility based on his choices.

Take a man coming in with a case of syphilis or gonhorrea. That's his fault, or that of his partner. Ought you refuse to treat him because his own irresponsibility resulted in the infection? What about Type 2 Diabetics, who have eaten their way into the condition? People who injured themselves screwing about with firearms, or in a car? Motorcyclists?

Of course, there are degrees of responsibility. But where do you draw the line? How many times does a biker have to come in with a broken leg before you say - we won't treat you until you stop doing that?

Abuse of the medical system's loopholes is a problem, but granting the power to simply deny certain people care for their mistakes is, IMO, even more dangerous. It could also quickly fall prey to the profit motive and result in extortionate practices...

Fundamentally, I believe healthcare is a right, and not a commodity, and I think treating it as the latter has created many of the problems we face, although government short-sightedness and periodic stupidity and insurance company greed has created a vicious cycle.