Who Will Answer?

Today's morning paper is full of updates in the ongoing debate about health care reform, a misnomer, in my view, in that the bills on the table by and large are about access to and payment for services, rather than about the care that patients receive once they have that access and a means of payment (or not). Be that as it may, as another long week draws to a close I wonder about the question no one seems to be asking: When millions of uninsured and underinsured people suddenly have health care coverage, who is going to take care of them?

There is little doubt, and there are many data demonstrating, that people without adequate means to pay for their health care often defer needed services. Regardless of the specifics of whatever eventual "health care reform" package emerges, clearly a great many new patients suddenly will have viable options for securing health services that previously were beyond their reach. This is a good thing. We don't find it acceptable that our neighbors, family members, or we ourselves may have to live with relentless pain, growing tumors, untreated and uncontrolled chronic illnesses, acute diseases and injuries, poor vision, bad teeth, a wobbly gait, and more. Yet even now those who have insurance often are told that their doctors have no appointments available for weeks or months. Tests and consultations require still more waiting. Phone calls are not returned for hours, and some messages become lost entirely.

Providers are busy. A physician colleague remarked today that the primary care providers in his practice routinely work six long days every week, and have phone calls and paperwork to manage on the seventh. Another physician friend shared over dinner this week that while on call the night before she was awakened every two hours to deal with a problem, had to work the next day, and was on call again the day after that. My company often turns away referrals because there are no nurses or therapists available to see new patients. I know well the exhaustion of having too many patients crammed into a work day, with the attendant temptation to hurry, to cut corners, and to discourage questions and discussion; and I know the oversights and errors that can result. As a more senior clinician in a leadership position I sometimes make those difficult-to-staff or unscheduled emergency home visits myself, and more often than I like to think find evidence of shortcuts taken, skilled services withheld, and significant clinical data overlooked, no doubt because the nurse who preceded me was busy and tired.

The doctors and nurses with whom I speak are not happy in their work these days, and many are leaving their professions. Last year a doctor described seeing a new patient in his clinic, doing a complete evaluation, and then providing a treatment. After all the associated paperwork had been completed and submitted the patient's insurance company paid the doctor $12.00. Twelve dollars. This doctor is no longer practicing medicine, except for occasional appointments after his new, non-medical job is over for the day. I know of many other physicians who have closed their practices and left medicine in recent years. Two weeks ago I sat in a conference of medical superspecialists and listened to concerns about the paucity of "new blood" entering the field, as young doctors choose specialties with easier hours and fewer demands. Primary care doctors are closing their practices; new doctors are not choosing primary care or many specialties, opting instead for careers in fields with steady incomes, regular hours, and no "on call." So as scientific knowledge burgeons, the number of those who would put it to use in patient care dwindles.

The "nursing shortage" has been in the news for years. Actually there are plenty of nurses out there; they just no longer practice nursing. After a few years of long hours, physically and mentally taxing work, toxic organizational cultures, rigid rules, and lackluster compensation and benefits, many nurses move on to other lines of work. No longer confined to traditional roles, many women do not choose nursing, and those who do are aware that there are many other options available to them. The knowledge, skills, discipline, and insight that make people good nurses also make them good business people, lawyers, administrators, politicians, clergy, and more.

With the national economy in the sewer and thousands of jobs lost, there has been an influx of students into nursing and allied health programs, particularly at community colleges. While it is good to see people from a wide range of backgrounds coming into and enriching the health care professions, one must wonder if he or she truly wants to be in the care of a nurse, therapist, or other provider who went into that line of work only because his or her real estate, dot com, banking, or manufacturing business failed, and entered the profession with the minimum credential for licensure. The shortage of qualified faculty to teach these students is real as well.

The posturing and politicking going on in Washington as "health care reform" is discussed give me a headache. But what gives me a heartache is that few seem to be remembering that when we say someone has a right to receive something, such as health care, we implicitly say as well that someone else has a duty to supply it. Clearly it is not acceptable for injured workers to go untreated, for isolated elders to need to choose between food and medicine, for children to be denied preventive care, and more. But when "health care reform" passes, in whatever form it may take, and millions of the previously uninsured and underinsured persons join the rest of us in the quest for health care services, when we call for doctor appointments, ring for the nurse, or otherwise ask for help,

Who Will Answer?

This question needs to be on the table alongside those of access and payment, for without a coherent plan for all three, all will fail.