Is good healthcare even possible?

A quiet sea day. Lovely temperature. A bit windy and of course a bit too much sun for me. Over the past few days I have been had 2 different health situations in members of extended family that I have been providing support from afar. Even as I pose the question, is good healthcare even possible, I realize the question is absurd. Our entire system is set up to make as much money as possible out of diagnosing and treating diseases.

When I was training in the 70’s and 80’s there was concern that we were educating too many doctors so the number of residency positions in some specialties was cut back. It was very important to protect the income potential of those in practice and being trained. I guess the decision makers were not considering the fact that people were going to be living longer as the greatest generation and boomers reached maturity and aging. Now we do not have enough doctors to take care of a growing number of persons that are reaching older age with a lot of chronic conditions that require a lot of care. Very few individuals are able to die peacefully anymore. Hospital beds are often occupied with chronically ill people that are waiting for beds in skilled nursing facilities to the point that very sick people are waiting days in the emergency room for a bed to become available in the hospital. This had started before Covid, but is worse now with staffing shortages.

The latest story starts with a 92 year old woman living in a nursing home who developed blood in her urine a week ago. It was diagnosed as a urinary tract infection and treated with antibiotics. The antibiotics seemed to be working but then the urine got really bloody with clots last Friday. She was taken to the university emergency room – not the closest hospital but the one that had all of her medical records from her many illness over the past 20 years. A CAT scan was done and she was found to have a large blood clot in her bladder. Her lab values were all fine. She did not have a fever and she sent home with instruction to call urology on Monday for an appointment. She was able to manage herself and was taken back to her nursing home bed. The bleeding continued and by Sunday she was too weak to walk and was taken via ambulance back to the emergency room. Another CAT scan was done and she had back up of urine to her kidneys and was in early renal failure. She got a urology consult., a catheter was placed, the clots irrigated and she was eventually admitted to the hospital. She was started on intravenous antibiotics and with bladder drainage, the bleeding stopped and her kidney function improved. Over the course of 4 days she has become so weak that she can barely support herself and will need to go to a skilled nursing facility for a few weeks before she can go back to her nursing home bed.

She is now getting a 3rd CAT scan and an ultrasound to see if the changes in her kidneys are improving. Neither was likely truly necessary in this 92 y/o woman as she is clearly better.

“In my day” urology would have been consulted on her first ER visit and the clot would have been evacuated and that likely would have prevented the deterioration in her kidney function. She would have been admitted to the hospital and she wouldn’t have needed a second ER visit and 2 more CAT scans and an ultrasound and without the continued bleeding and renal failure she may well have not decompensated to the point she needed admission to a skilled nursing facility.

Our disease care system is falling apart at the seams and while we spend more money on disease care than any other country we are not receiving good care. There are too many entities making huge profits from the system as it exists for any meaningful change to occur.

I think being blissfully ignorant of the crisis in “healthcare” is perhaps a good thing. It is believable that with all the money that we spend, we are getting the best care in the world. It simply isn’t true.

I left the practice of medicine 20 years ago when it because crystal clear that the incentives were all in the wrong direction. I have tremendous respect for everyone on the front line of disease care delivery – doing their best against tremendous institutional and socioeconomic obstacles to do the best they can to help people.