3 of the most frightening things in healthcare today

Halloween will come and go, but three problems in healthcare today will likely persist for longer than anyone in their right mind would like.

1. Ebola.  Ebola is harrowing at its most basic pathological level, with severe symptoms, a high mortality rate and no vaccine. But the Ebola epidemic has proven deeply alarming in many ways beyond its science. There were more than 10,141 confirmed, probable or suspected cases reported as of last weekend, according to the World Health Organization. While Ebola cases in West Africa continued to climb, national attention turned inward as American public health officials and politicians sparred over how to appropriately stop the virus' spread. The debate unfolded as the number of diagnosed Ebola cases on American soil dropped to one Tuesday, when nurse Amber Vinson was discharged from Emory Hospital in Atlanta, Ebola-free.   

The American healthcare system has performed remarkably well in past moments of national distress. Remember how it functioned in the sobering aftermath of 9/11, and more recently, the Boston Marathon. Emergency workers, physicians, nurses and hospitals worked as a united front, delivering much-needed medical care that rose above tough media scrutiny and the fray of politics or opinion.

But the Ebola epidemic has proven more damaging to our domestic healthcare system and global health thinking. It has brought on a sense of self-interested panic that is feeding divisions over national security, whether between the White House, governors, media outlets, healthcare professionals, CDC, mission workers, Texans, New York City residents — the list goes on. The number of lives Ebola has affected or taken in West Africa is devastating and the United States' poor response is disappointing. If anything, the confusion, schisms and shifting of blame have only exacerbated the crisis, taking attention away from the intervention desperately needed in West Africa.

2. The depersonalization of medicine. Transitioning from Ebola is uncomfortable, since the weight of other problems seems to shrink in the shadows of a  global emergency. The depersonalization of medicine is not nearly as visible or grave. Rather, concerns about the weakening physician-patient bond have gradually intensified throughout the healthcare system and are likely to persist for some time. With no easy solution, if one at all, this dilemma is often placed on the backburner to make room for the dozens of other pressing healthcare concerns du jour.

In many cases, the term "burnout" is too mild to describe the disenchantment many physicians feel about their work. "I don't know about other physicians but I am tired — tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine," orthopedic surgeon Daniel Craviotto, MD, wrote in a Wall Street Journal op-ed this spring. Dr. Craviotto is just one of many physicians to take his thoughts to pen and paper. In a piece for The Atlantic, essayist Meghan O'Rourke drew attention to how many physicians are writing books about their professional problems. (The titles often share a common tone, such as "The Doctor Crisis" or "Doctored: The Disillusionment of an American Physician.")

"What's going on is more dysfunctional than I imagined in my worst moments," wrote Ms. O'Rourke. "Although we're all aware of pervasive healthcare problems and the coming shortage of general practitioners, few of us have a clear idea of how truly disillusioned many doctors are with a system that has shifted profoundly over the past four decades."

Physicians feel they are failing patients or resentful of them. Many feel as if they are working like cogs in a wheel. Survey and study findings shed light on what is causing many of these sentiments. On average, physicians today spend about a third of their time with patients looking at a computer screen and about nine hours per week on administrative tasks, such as billing and insurance approval processes. A study from Johns Hopkins Medicine in Baltimore found first-year residents in internal medicine spent just eight minutes interacting with each patient. Numerous surveys have found only half of physicians would choose medicine as a career if they had to do it all over again.

Demoralization is scary thing, largely because it is messy and emotional — a problem not easily solved by healthcare policy or hospital administration. How can we focus less on sentimentality for the golden days of medicine — the pleasant collective memory of "Marcus Welby, MD" — and focus more on what we can actually fix? (For instance, Johns Hopkins Hospital turned all of its EMRs in exam rooms to face patients, increasing the opportunity for eye contact and interaction.) Many things are at play when a physician feels demoralized, such as her sense of occupational prestige and collegiality, and many things are also at stake, such as patient safety. It will be interesting to see if the healthcare system can alleviate such a deep-dwelling emotional problem with operational changes.  

3. Healthcare access. The amount of time patients must wait for care is a big blemish on our healthcare system. It's embarrassing, frustrating, and in some instances, disturbing.

The problem is especially acute in America's safety-net hospitals. If you haven't seen it yet, check out the documentary "Code Black," which is set inside the emergency room of the public Los Angeles County Hospital. In the film, patients wait up to 18 hours to receive treatment because they have nowhere else to go. This wait-time problem was not alleviated by the healthcare reform law's insurance reform. Even though more people may have health insurance coverage today, it's not always premium, says Ryan McGarry, MD, director of the film. "And we're already in a system where a lot of specialists won't take a sub-premium insurance card, because you're not seen as profitable enough," he told NPR. "So many people end up coming to public hospital emergency departments, just to see an orthopedist, or an endocrinologist or someone who won't take their probably decent insurance, but it's not good enough."

Beyond safety-net hospitals, the American healthcare system lags far behind its international peers for how quickly and conveniently it interacts with patients. Last year, the Commonwealth Fund found the U.S. came in dead-last out of the 11 Western democracies surveyed for after-hours primary care: Only 35 percent of adults' primary care physician practices have arrangements for patients to see physicians or nurses after hours. (In the Netherlands and the United Kingdom, this figure is 95 percent.) The U.S. came in third-to-last when it came to physicians' response time to patients who call with a question — 73 percent of U.S. adults said they "always or often hear back on the same day," while 90 percent said the same in Germany.

For some patients, a wait time is a secondary concern. They can't even get an appointment. The number of physicians who opted out of Medicare in 2012 was still a small proportion — about 9,540 compared to the 685,000 participating — but it was nearly three-times as many from three years prior. Even fewer physicians reported they were taking new Medicaid patients.

The moral implications of the country's access problem are evident, especially when there is a relationship between patient access and profitability. It is disturbing to see the intentions of healthcare reform — greater insurance coverage and improved access to care — get loopholed for financial reasons, reinforcing so much ugly cynicism about the healthcare industry.  

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