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Winter 2008 - Vol.3, No.4 MEDICINE IS A SERVICE PROFESSION BUT WE CANNOT IGNORE ECONOMICS   Lawrence I. Bonchek, M.D., F.A.C.S., F.A.C.C. Editor-in-Chief

Since the first issue of the Journal in April 2006 I have written a column entitled “From the Editor’s Desk” to tell you what we are doing, planning, or thinking in the editorial office, and to focus your attention on the articles in each issue. In that first issue I promised to “not only report on progress at the Journal, but in subsequent issues… to stimulate your thinking on a variety of medical issues.” In that spirit, the last issue contained my articles about frustration with inaccurate medical acronyms,¹ and an interpretation of the medical events that presaged World War I.²

Because our publishing schedule obliges me to write my columns more than a month in advance, I generally eschew consideration of current events, lest circumstances change enough to embarrass me. But now I take that risk, because this is no ordinary time.³ There are currently forces pressing down on our nation that may override even the weighty but individual concerns that characterize our medical practices. America’s finances continue to be drained by two longstanding wars, and we are in the grip of the most serious global credit crisis since the Great Depression. (Our budget deficit is far greater than is commonly realized or reported, because the multitrillion dollar cost of the Iraq war has been sequestered in “emergency supplementary appropriations,” which – in the particular sleight-of-hand known as Congressional budget writing, means that it is almost entirely off budget! ⁴) Perhaps by the time you read this, the global financial situation will have somewhat stabilized, but at the moment that seems an optimistic view.

These monumental developments cannot help but affect health care. An economy in recession will not support generous action to help the 50 million Americans who lack health insurance coverage. Before the election, more than 80% of Americans thought we were “on the wrong track.” Our new President thus carries our fervent – even desperate – hopes that he can redirect America’s course. He and the new Congress will certainly make changes in the way health care is paid for and delivered. Despite the Democratic control of Congress, the realities of the legislative process make it likely that any final plan will contain elements of compromise. During the election campaign, the New England Journal of Medicine carried a series of articles about the various policy recommendations, including how costs would vary under alternative systems. These related articles have all now been brought together on one page of the NEJM website, accessible with a single URL.⁵ (This seems handier than giving you a series of references that requires sifting through multiple issues of the NEJM.)

In an editorial on October 26, 2008 about paying for health care, the New York Times said:

“The economic crisis is exposing further weaknesses in this country's healthcare system. With family finances strained, many Americans are skimping on medications, physician visits, and preventive screening, in order to pay other household bills.” The Times argued that this “could be dangerous to their health and costly for the economy if more Americans lose work time or end up in the hospital.” Moreover, “some evidence suggests that many people are cutting back on drugs . . . they will not feel the effects now but could be in for severe illness later.”

If unemployment rises, health coverage will erode. More than 60% of workers get health insurance through their employers.⁶ Inevitably, demand for health services will drop as the unemployed defer needed care they cannot afford. Since health care is such a large sector of our service economy, the expected decline in expenditures for health care will add another ingredient to the downward recessionary spiral that slows economic activity and the circulation of money. Demand for health care workers (including technicians, dietitians, cafeteria workers, office staff, etc.) could well decline, and their unemployment would remove from the economy additional consumers with discretionary money to spend. The cycle continues when these consequences spur additional unemployment.

We get so wrapped up in the intricacies and complexities that typify the practice of medicine in the 21st century that we sometimes forget we became doctors in the first place to help people. We are fortunate members of a noble and helping profession. And now our hurting patients need us all the more. With that in mind, I offer for your consideration an item brought to my attention by Dr. Henry Wentz when I interviewed him for the CD that accompanies this issue.⁷ It is part of an obituary that appeared in the Lancaster newspaper in 1914 upon the death of Richard Vaux Raub, MD, who had been a “country doctor” in Quarryville.

“His funeral and the manifestations of heartfelt grief and personal loss by the hundreds in attendance, strikingly illustrated the simple life of the country doctor and the affectionate relations that exist in the rural district between the man who ministers to their physical wants and the people to whom he ministers. The life of a country doctor is sacrifice. His fees are small and his hours are long. No night is too dark, nor no storm too tempestuous for him to brave. He catches sleep as he climbs the steepest hills, and his faithful horse neighs at the stable door to tell him he’s at home. He knows no luxury of office hours, nor specializes on any one disease. He reduces the fractured limb and oft-times soothes the broken heart.

He responds to the call of the poor and never takes advantage of the well-to-do. In his laborious work, he is seldom seen in a house of worship but in the love of his profession and the nobility of his practice he seems to walk with God. If St. Peter honors a pass, it is when the weary country doctor knocks for admission and begs for rest.”

Our nation’s current economic problems may well intensify before they begin to improve. We can only hope that the enormous creativity, resolve, and energy of the American people, coupled with noble and intelligent leadership, will abbreviate the period of suffering that seems likely to befall so many in ill health. Physicians in particular, members of a caring and helping profession, will be called upon to help patients who cannot afford the care they need. We have always done so to a greater or lesser extent, but the need for that kind of service will doubtless be greater in the near future than any of us have ever seen personally. We should be prepared to respond.

REFERENCES

1. Bonchek LI. What’s in a Name? A Critique of Procrustean Acronyms. J Lanc Gen Hosp 2008;3:82-83.

2. Bonchek LI. How Cancer Caused World War I. J Lanc Gen Hosp 2008;3:108-111

3. Kearns Goodwin D. No Ordinary Time: Franklin and Eleanor Roosevelt; The Home Front in World War II. Simon and Schuster, 1994.

4. http://www.commondreams.org/views06/0719-24.htm

5. http://content.nejm.org/misc/election2008.shtml?ssource=e08home

6. http://www.workforce.com/section/00/article/25/82/27.php

7. Wentz, HS. Patients are a Virtue. Masthof Press. 1997