Wednesday, January 17, 2007

A Pretty Hollow Complaint, Doctor

The AMA and their current president can lament until the cows come home, but they haven’t done a damned thing to provide medical care to the poor before it becomes a matter of emergency rooms. By then, the acute has become chronic. I doubt that anyone even vaguely connected with the self-righteous AMA has ever sat up with a seriously sick child and had no place to go.


Minuteclinic Ranit Mishori, (himself a family-medicine resident at Georgetown University/Providence Hospital) writes in the Washington Post about an intriguing, new, and (in the eyes of some physicians) controversial medical treatment philosophy;

Some of the newest players in health care are rubbing doctors the wrong way.

You may know them: those small clinics at your neighborhood Wal-Mart, Target or CVS that promise quick attention for routine visits -- sore throats, minor aches and pains, flu shots -- with no appointments needed. The clinics, which go by such names as MinuteClinic, RediClinic, QuickClinic, Medpoint Express, Curaquick and MediMin, offer convenience and low price -- scarce commodities in today's medical marketplace. But while consumers are taking to the concept, physician resistance is building.

I’m not an unbiased observer in this controversy, because I have long advocated just such centers, across the nation and operated on the McDonald’s model of low cost and universal sameness. It fascinates me that private capital has wedged itself into a market where public access has increasingly failed.

  • Emergency rooms have become the source of primary medicine for the poor.
  • Children, particularly inner-city and poor children, are not sufficiently served by public medicine.
  • The cost of this ignorance toward the poor and the uninsured is short-term individual health crises that turn into long-term disabilities.

The market speaks for itself—these facilities are a public success. But the familiar whine of the AMA and various doctors can be heard in the background like chainsaws in the north woods. From Mishori’s article;

"The quickest, most convenient medical care is not always the best," says Caroline Van Vleck, a Washington pediatrician. Particularly, she and a growing chorus of primary care physicians contend, when it comes to children.

Emergencyroom Van Vleck is hard to argue against, as far as she goes. Problem is, the best is not even an option to huge portions of the population. Their option is none at all, until the relatively simple case of a sore throat or chronic cough gets to the point where a frantic mom takes her child to an emergency room in the middle of the night. Guess how much chance that poor and uninsured mom has of getting her child admitted. Yeah, that’s right. None.

There is the world as we would have it—the well scrubbed and best-care world of Dr. Van Vleck--and then there is the real world. In that grubby, dangerous, unsanitary real world of the poor and uninsured, MinuteClinic, RediClinic, QuickClinic, Medpoint Express, Curaquick (or any such available option) is a life-saver. These clinics exist because private physicians and public medicine have failed those who need it most.

"Convenience is not enough," the AMA lamented in a recent editorial. Comparing the mini-clinic phenomenon to kudzu -- the tree-strangling vine rampant in the South -- the AMA complained these new services are spreading too far, too fast. In a policy statement issued this fall, the AAP "opposes retail-based clinics as an appropriate source of medical care for infants, children, and adolescents and strongly discourages their use."

Plestedamapresident The AMA and their current president can lament until the cows come home, but they haven’t done a damned thing to provide medical care to the poor before it becomes a matter of emergency rooms. By then, the acute has become chronic. I doubt that anyone even vaguely connected with the self-righteous AMA has ever sat up with a seriously sick child and had no place to go. Kudzu is a plant of opportunity and so is the failure of national health. Each of them thrive where no one cares.

Interestingly, on the AMA web site Advocacy Page, their first three goals are listed in this order:

  • Medical liability reform: To preserve patients' access to care, the AMA will continue to lead an aggressive, multi-year campaign to reduce medical liability premiums.
  • Medicare physician payment reform and regulatory relief: As the leading force in Washington for Medicare reform, the AMA will be relentless in the battle to replace the flawed Medicare physician payment formula.
  • Expanding coverage for the uninsured and increasing access to care: The AMA is committed to leading the response of America's physicians to solve the health coverage crisis for all uninsured patients.

So, after all those predominantly white and predominantly rich and predominantly insured members of the AMA get their liability eased and their payment schedules improved, then they might get around to expanding coverage for the uninsured. Meanwhile, they’ll continue to oppose and strongly discourage.

The poor and uninsured certainly ought to rally around that flag.

Drrobertcorwin In more blather from the American Academy of Pediatrics, Robert Corwin, who recently served as a director, worries about a child's receiving medical care at different places by different providers -- most retail clinics are staffed by nurse practitioners and physician assistants, not doctors -- who may not communicate with one another.

Children, he argues, need a "medical home" -- a place offering comprehensive, family-centered, coordinated, continuous care, in which a doctor knows the patient over time.

"Parents may say, 'It's just a sore throat,' " explains Corwin, a practicing pediatrician in Rochester, N.Y. But those sore throat visits, he says, are a pediatrician's "vehicle to continue developing the relationship with the family."

Childpatient Planet Earth, calling Dr. Bob—these clinics are a life-saver to children who hardly have any home at all, much less a ‘medical home.’ The current vehicle that fails medicine is most often a Mercedes or Jaguar and before developing relationships with poor kids’ families, a whole lot of self-serving and profitable layering of interventions to the practice and delivery of medicine are going to have to be torn apart.

In the meantime, the market will have to serve where doctors fear to go.
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