The AMA – Trust At Your Own Risk

Adapted from an Op-Ed in today’s NYTimes by Nicolas Kristof

Some fun facts about the AMA (American Medical Association):

  • supported segregation
  • opposed President Harry Truman’s plans for national health insurance
  • backed tobacco
  • denounced Medicare
  • opposed President Bill Clinton’s health reform plan
  • probably represent less than 25% of practicing physicians, most of which are specialists who dearly want to protect incomes from $250,000/year to over a million per year

Here is their current position on a National Insurance system:

“The introduction of a new public plan threatens to restrict patient choice by driving out private insurers.”

They might have been right about opposing Clinton’s freakish health care plan.  They should have shaped the medicare debate instead of obtusely opposing it, and you can be the judge on the whole segregation and tobacco thing.

I think for-profit medical insurance is morally wrong.  Insurers should not make more money than patients, and not doctors, either.  If you want to be available to help someone in a time of weakness and need…you shouldn’t make 20% returns on them until that time arises.

*Disclaimer:  The AMA is a putrid organization from the inside out (and hopefully will be obsolete in 10 years)…but they do have it right on tort reform.

Specialist

I can’t tell if the problem was the doctor, the system or my own perceptions and biases. Whatever the source, I found myself feeling judgmental and annoyed as I followed a pediatric specialist on her morning rounds recently. Sweeping into one patient’s room – at the hospital because of abdominal pain – the endocrine specialist proceeded to rapid-fire questions about diabetes. After a few minutes, the specialist concluded with: “I’ll be honest with you, I don’t think you’re taking your diabetes seriously.”

The patient looked at her disconsolately, as if to say, “Sure. Fine. You’re right. Diabetes sucks when you’re a kid and I DON’T care about it. And by the way, I’m here for my stomach pain.”

The specialist went on, offering her one of two insulin regimens. “You can do this one, which doesn’t offer very good glycemic control but suits unmotivated patients like you better,” She drew an illegible graph of glucose curves on the back of the patient’s food menu. Or, you could do this one, which requires blood glucose testing around 6 times a day but gives you much better control.”

The patient, of course, chose the “easy” plan, which still required 3-5 finger-pokes a day to check blood sugar and insulin injections as well.

Somewhere in the middle of this – I think when the patient chose her arduous “control” plan – she started to cry. The specialist waited impatiently, softening her voice imperceptibly, “Now, you don’t have to start that. We’ll take good care of you. Sometimes you need to hear the hard words.”

I stood there wondering what must be going through the mind of this obese teenager who already needed both oral and injected diabetes medications. She only recently arrived in this part of the country, doubtless because of some unstable situation where she lived in Atlanta. I wondered how many friends she had, if she liked the Pacific Northwest, what she was most afraid of at this time in her life. I surmised that kidney and eye disease – however dire – were not on the top of her list of current fears. I wondered if this was how the specialist treated all her patients. As we left the room, I got my answer. With a terse laugh, she said, “I make a lot of my patients cry.” Not hard to believe.

Sure, I was then and continue to feel imperious and rather self-important. I’m disapproving of this doctor’s bedside manner, and in watching her, I’m inclined to feel critical of specialist medicine in general. But I have to remember that as we stood in that room, my mind was filled with family medicine questions. We pride ourselves on our communication abilities; our ability to relate to patients and our genuine interest in people’s lives. But what do we have to show for it? Would a family doc have better motivated this recalcitrant teen to care about her diabetes? Do FP’s have better diabetes management outcomes than specialists? I doubt it. Maybe this specialist’s approach was a good as any other…since nothing NO approach has been successful so far in conteracting the allure of food and sedentary living.

Bottom line, healthy living is a less-appealing alternative to sitting around all day eating high-calorie foods. Most of us eat more calories that we need for breakfast. But, since so far neither approach seems to be working, I vote fro the one that is at least pleasant for the patient. The one that allows the doctor and the patient to work together and understand each other. When I end up sick, I’m pretty sure this is the kind of doctor I’ll choose if I’m given – unlike this patient – any choice in the matter.