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March 12, 2013

The Social Glue of Healthcare

A friend of mine from Europe told me that everybody likes socialized medicine until they get sick. Security is comforting, but that doesn’t mean you will be comfortable when the security you think you have becomes necessary. Humans find their greatest security in the things that bind them, one to another, like glue.

I like my insurance guy, but, having never filed a claim, I have no idea if he is worth a damn. Just as you learn the true character of your insurance man when you have a claim, a patient learns the true character of his surgeon when he has a complication. The patients to whom I am closest are not those who came and went, but the ones who unexpectedly stuck around. I have never been sued as a practicing physician, and I have long suspected that many suits arise from the perception of indifference to suffering and emotional abandonment. No less important is for a patient to be secure in his knowledge that his surgeon will be available in the event of suffering.

As I am writing this, I received a call from a young surgeon seeking advice about a case. Perhaps I helped him and his patient, and perhaps I did not. Ultimately, what was important is that I was there for him in much the same way we physicians are there for our patients. That is the unseen glue of the healthcare system that we have so miserably failed to explain. It is a human, social bond that cannot be legislated or imposed by bureaucratic fiat and which, once lost, is irreplaceable.

As a surgeon, I fix things. I’ve been dismantling and fixing things since I was a little kid. I cared for every kind of pet you can imagine as a child, and my mother knew I was going to be a surgeon before I finished elementary school. There is no medical discipline more different from mine than neurology, but the most meaningful words spoken to me in medical school were spoken by a neurologist. After seeing a patient together, he pulled me aside and said to me with an alarming seriousness: “I can’t help that man. I can’t do anything for most of my patients. But what I can do is be there for him.” I call that pure human, social glue.

I do a lot of minor surgery. Not uncommonly, I meet patients in clinic, do an operation, see them one more time, and never see them again. Most of these patients probably don’t know a lot about me, perhaps less that they know about their auto mechanic. They rely on the “system” that makes sure there are no quacks out there cutting on people. Of course, a few bad apples slip through the cracks, but they are quickly exposed and drummed out. What should make the news is the astonishing number of good apples. There are a lot of things that go on behind the scenes that people take for granted, particularly the credentialing of physicians to meet and maintain standards. This vetting process is currently performed voluntarily by other physicians, during medical school, training, board certification and maintenance of certification, hospital credentialing and review, and peer review. Our patients are oblivious to this professionalism. This glue that binds us is taken for granted.

I suspect that in countries with socialized medicine the vetting of physicians is not done by other physicians, but by professional bureaucrats who check boxes and shuffle papers. (If it is done by physicians, how much are they paid and have the reformers factored in those costs?) A bureaucrat can verify that a physician has done such and such number of a particular type of operation and should be credentialed to continue do such cases, but he will never understand the sudden, deadly clarity that comes from standing over a wound and wondering what it is that should be done, or the tossing, sleepless nights wondering if what was done should have been done. These questions are not answered in lectures or textbooks or “guidelines.” The truth may come in quiet reflection at the OR table, or in the form of a phone call to someone with more gray hairs bought dearly through his own tossing, sleepless nights. Will those phone calls be answered in the future, or will shifts end and beepers be turned off? Who will consider the subtleties, stand for that young surgeon, and say before his peers: “He agonized over that patient, and we should give him the benefit of the doubt?” That is the glue of the healthcare system.

For the first time in my professional career, after treating thousands of patients, I received a letter from an irate patient. She accused me of rushing straight to surgery with her child to look for his missing testicle instead of doing an ultrasound first. It matters little that if an ultrasound had identified an undescended testicle that her child would need an operation, or that if an ultrasound had failed to find a testicle that her child would need an operation. What matters is that I apparently failed to make her understand that her child needed an operation and to gain her trust. We have lost our standing as physicians because we have lost our patients’ trust, which is why they don’t trust us now when we speak. We can debate the cause of that loss of trust, but I think it springs from the perception of greed. I believe the third party payment scheme was a Faustian deal, a solvent on the glue, and the source of our collective insolvency.

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