The death of medical care
Published 9:55 am Saturday, July 12, 2008
in North Carolina
It has become apparent that medical care in North Carolina is dying. What is causing this demise, and why is it happening to us? We all are dependent on medical care, especially the younger and older populations. We have had the finest medical care in the world and we are blessed with four medical schools in North Carolina. Many of our residents have studied numerous years and moved back to their home towns to serve the public. Others have continued their medical education up to 15 years after medical school in order to provide the latest surgical techniques. In the field of medicine, many have studied up to five years after medical school to increase their diagnostic and treatment skills. All of these physicians have continued their medical education through post-graduate courses while practicing in their communities. Their duties have included serving on committees on the hospital staff to insure proper management of medical and surgical care. All have taken night call at the hospital to insure service to their patients 24 hours per day.
In 1956, when I started medical school, the competition for training was intense. Only the highest ranked students were eligible. These students have studied long hours. Following medical school, internship was even more intense. Many of us worked 36 hours and were off 12 hours in two days. We were paid $210 per month. We had to pay our own moving expenses and care for our wives and children. Many of us had our residency training interrupted by medical service, and some went to Vietnam and others served during the Berlin and Cuban crises.
In 1966, I returned to my hometown where eight generations of my family had lived, and there I served over 10,000 families for 31 years through the practice of internal medicine before I retired 11 years ago. My great-grandfather, Dr. William A. Blount, served Washington from 1860 to 1911, and my grandfather, Dr. John Gray Blount, served Washington from 1832 until 1919. He was on the North Carolina Board of Medical examiners and had trained under Sir William Osler. The Dr. Dave Tayloe family has served Washington for over five generations. With this historical and personal perspective, I make some observations about medical care.
During the 1950s and 1960s, medical care experienced growth and modernization. At the new Beaufort County Hospital, our physician staff grew from eight physicians to 22 physicians, and new subspecialties and services were added. The climate for care did not change and was good. The practice of medicine was more of an art than a science. The physician saw the patient and made his best diagnosis of the problem. Then followed a treatment plan in which the physician decided which was the best available treatment, always aware that all medicines might do harm. The physician was not God and was not held to a standard of infallibility of judgment or decision. The patients realized that all die eventually. The doctor did everything he knew to promote healing, to relieve suffering and to postpone death. When the patient died, it was not considered the doctor’s fault. He had done the best he could, and it was better than the patient or his family could have done.
Malpractice was unheard of and claims against the physician were usually unsuccessful. When awards were made, they were modest and covered by insurance. Physicians were loved and respected for providing the best care they knew. This was the standard of care. Dr. John Cotton Tayloe was charged with malpractice. The case was laughed out of court. He had delivered the judge, most of the jury, and over 8,000 others in the area. Dr. L.H. Swindell graduated in 1912, long before antibiotics were discovered, and when bleeding was a treatment method. But he was beloved, and no one would have imagined suing him for an unsuccessful result.
People were glad to have obstetricians and surgeons available for deliveries in case of complications. These physicians were not blamed if the mother had no prenatal care; the baby died, or was born with congenital defects. Malpractice insurance now costs an obstetrician in excess of $100,000 per year paid in advance even before one baby is born.
Malpractice awards are murdering medical care. The attitude of the public has changed in relation to the physician. He is held to an unattainable standard and is blamed for events beyond his control. Suing a physician is similar to “winning the lottery.” Many patients have developed a mentality of entitlement to cure rather than appreciation for care.
All medicines are dangerous, even though they may be extremely beneficial. Every time a physician prescribes a medication, he has to use his best judgment in consultation with the patient. This judgment is based on his training and experience which the patient does not have. Patients now respect friends’ recommendations, television ads and Internet testimony as more valuable than the physicians’ experience. Serious diseases often result in death, regardless of the attempts of the concerned physician. Who will want the job as physician if he must be infallible and blamed for death?
People are saying, “Those bad physicians should be punished and the insurance companies have plenty of money.” Guess where the money comes from for the insurance companies? Yep, from all of us patients, through higher fees we pay to doctors so they can pay the premiums. When giant awards are given, this exceeds the insurance coverage of the physician and he has no option except bankruptcy. Many physicians face bankruptcy before any malpractice suits, because the insurance premiums may exceed the possible income of the physician. I know of physicians who are borrowing money to meet their expenses. Many obstetricians have stopped deliveries, because the insurance costs and the excess malpractice risks exceed the value of the practice. Our great-grandchildren may be born without medical care.
Lawyers advertise opportunity for large awards, putting the idea of malpractice suits in people’s minds. Their clients pay no costs in return for sharing in the windfall. Thus, lawyers have contributed to the mentality that every patient should benefit financially from every event they considered substandard care. Many medical professors have tried to define “the standard of care,” which usually means what they would do in hindsight. Many of them have not practiced, and they have limited experience or judgment. They are often happy to testify against the practicing physician by signing charges drafted by the lawyer paying them to testify.
Often the only option left to the prudent physician and his insurer is to settle even ridiculous claims. This feeds the sharks to bring more frivolous suits and to get higher settlements which increase their fees. There are no caps on punitive damages. Thus, the juries can and do award millions. Many people think that this is the right thing to do and that doctors accused of substandard care should all be punished and their licenses be revoked. This is all fine and good, except that nearly all physicians are now being sued.
I know physicians here in Washington who have retired early in order to get out of the frying pan. I know them to be highly competent and have trusted my own family to their care. These physicians are not being replaced. Very few medical students are entering the specialty of internal medicine. The medical schools are teaching cookbook medicine based on very expensive CAT scans and MRIs. These tests are now the “standard of care,” despite the unnecessary high costs and the dangers of excessive radiation.
The shortage of physicians has lead to an infusion of foreign trained physicians. Many people are not even being diagnosed and treated by physicians at all. They are being treated by physician assistants and nurses.
Government intervention has led to bureaucratic running of medical practices. In many of these HMOs the physician is paid whether he sees the patient or not. My brother’s HMO physician asks my brother what he wants and tells him that he does not have time to examine him. These physicians often are not available or reachable in emergencies.
The payment from the government for Medicare patients does not cover a physician’s expenses, and the payment for treating Medicaid patients hardly covers the administrative cost of sending the bill. Most of our elderly in Beaufort County are either on Medicare or Medicaid. Many of our younger people have lost their industrial jobs and thus their medical coverage with private insurance companies. Most of these companies do not cover outpatient care, and hospital stays have been regulated by nonmedical people to less time than often is needed by the patient for safe recovery. The patient is discharged before the physician thinks prudent and then the physician is penalized by Medicare if the patient has to return to the hospital.
What is the solution to the myriad problems listed above? I do not know. I do know that we are headed for third-world medical care if these problems are not resolved. We are destroying physicians who have dedicated their whole lives to the service of others, and we are repelling others who would take their place. We will all suffer the consequences.