American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, July 21, 2016

Freedom versus control in a private vs. public health care system

This is my 12th year as a physician in the United States. I was born in London, grew up in Berkshire, and decided to become a doctor when I was a teenager. I remember being asked what I thought about the National Health Service (or NHS, the UK's government-run health system) during my medical school interview. That question is almost a rite of passage for anyone applying to medical school in the UK. My answer was an idealistic one, probably identical to what most people in England—if not Europe—would say. Health care is a birthright.

The NHS is a wonderful concept and immensely fair and just. Nobody should ever have to pay for medical care in their hour of need, right? I speak too as someone of Indian heritage, who has seen up close and personal how unexpected illnesses in relatives can completely bankrupt families, causing untold anxiety and stress. Surely nothing could be worse than that free-market extreme with no public system backup?

During medical school, I also worked for a couple of months in Adelaide, Australia, primarily in Accident & Emergency/Trauma in a major tertiary care center. I also did a stint with the Royal Flying Doctor Service going on airborne missions to the outback, mainly rescuing very sick indigenous (Aboriginal) people and bringing them back to the city. The system Down Under is an interesting mix of both public and private health care, but still with a solid government-run backbone for people who really can't afford insurance. However, at that time, even the thought of having to pay for health care at all still seemed very foreign to me as I began my career as a physician.

Before I came to the U.S. back in 2005 to start my medical residency, these were my views on the funding of health care. Fast forward to 2016, and my opinions have shifted rather dramatically in terms of what a health care system should look like and whether people should contribute more themselves. Looking back to when I first moved here, one of the things that first struck me about U.S. medical care was the sheer speed and freedom of it all. Patients appeared free to choose their physicians, were in more control over their care, and didn't have to wait so long to get things done. My jaw dropped when one of my first patients was admitted from the ER, and had already had most of their tests and scans done, including an MRI. They would then be seen by all of the doctors they needed to, including any necessary specialists, within a very short period of their hospitalization. These attending physicians would follow-up with them daily (unlike in the UK, where the vast bulk of the work is left to more junior doctors).

We can get into a debate about fee-for-service and incentives, but it's human nature that people and organizations work harder when they are incentivized to do so. Documentation was also much more thorough than the couple of lines that I was used to seeing scribbled in a patient's chart (True, a lot of this was for billing purposes, but it's still always good to be thorough). Since my very first week working as a medical resident, I've said, and continue to say, that a homeless person presenting with an acute illness such as sepsis or a myocardial infarction in America, will get better and more outstanding care than a rich person almost anywhere else in the world. There's a very common misconception overseas that patients in America are left dying on roads outside the hospital if they cannot afford care! This simply isn't true, and I learned it very fast. Clinical care in the United States is top-notch (albeit at a high cost). As are the central issues of patient dignity, patient rights, and accountability of any hospital or clinic to seriously address any complaints.

Physicians too in America, appeared to have a much better deal than in the system I'd just come from. They were more in control of where and how they worked, weren't restricted in terms of their career progression by the government, and were also compensated a great much more for their hard work (granted however, they also had a much higher debt burden). Despite the problems and changes in U.S. health care over the last decade, it remains the case that doctors here have an unprecedented amount of freedom in how and on what terms they work, compared to almost any other country.

Having all these different experiences over the years, if you were to ask me today, I don't believe such a centrally controlled system like the NHS is an ideal system to aspire to. It restricts patients and physicians alike. It is too much at the whim of transient politicians, with no medical knowledge, who can enforce a universal country-wide policy change almost overnight (such as a change in patient rights, physician scheduling, or even banning all doctors from wearing white coats and ties, which is what happened in the UK). Neither does a centralized system foster the best environment for innovation or individualized care. Go to any patient floor in a socialized system, and it often has a Soviet-style aura about it, with rows of patients lined up, little personal space, monolithic designs, and staff wearing the same uniform. The collective American psyche is very different from Europeans, and the consumer-driven mentality here probably wouldn't endear itself to an NHS-type system anyway.

With regards to funding, I don't think it's necessarily a bad thing for patients to contribute themselves for doctor visits and hospital stays, as long it is capped at a very manageable level for the individual, with absolutely no “surprise bills”. There's an argument to be made that if people in England are so willing to spend £30 ($50) for regular restaurant visits, haircuts and other entertainment—why not a small co-pay for a doctor visit? Anything that's completely free can easily foster an increasing culture of entitlement, reduced self-responsibility, and sadly sometimes abuse of the system.

At the other end of the spectrum, is the idea of caring for peoples' health from cradle to grave a noble one? Yes, it is. Should anyone be refused coverage because of a pre-existing condition or go bankrupt and lose sleep because of unforeseen medical bills? No, they shouldn't in any civilized country. Do many of the socialized healthcare systems produce better outcomes than us? Yes, they do. Is the high-cost system we currently have sustainable over the long term? No, it isn't.

Perhaps something in-between the two extremes would be best, like Australia, which gives tax breaks for people who take out private insurance, but still offers a public system as backup to anyone who needs it?

For this debate at least, I'm stuck between a rock and a you-know-what.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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