Checkup

Vital Signs: Who's going to pay? Part I

Dr. George Bartley

Dear Reader:

I had the opportunity recently to leave administrative duties behind for a few hours to speak at one of our nation's top medical schools about my subspecialty of oculoplastic and orbital surgery. A standard feature of such sessions is questions from the audience about unusual, difficult cases. This puts the visiting physicians on the spot. Not only do they have to describe how they would examine the patient, formulate a diagnosis, and devise a treatment plan, but their solution is expected to be brilliant, the kind that leads to spectacularly successful results every time. (It's even more educational — and entertaining — when the visiting professor fails to recognize that he or she has just been shown the world's second case of a syndrome that was first reported the previous week in the Tibetan Medical Journal. Students love to stump their teachers!)

Anyway, one of the more challenging cases at our symposium was a child who had been born with severe abnormalities in the eye region. The other speakers and I offered our opinions about how we would approach the reconstruction, which would require several complex operations over a number of years, involving a team of ophthalmic surgeons, neurosurgeons, anesthesiologists, radiologists, pediatricians, nurses, surgical technicians, and other specialists. After much debate and discussion, we came to consensus that with a lot of work — and luck — the patient just might be able to go out in public without wearing a black patch. Optimism prevailed. A life could be improved, even transformed. The decision to go to medical school had been a good one.

It was with some hesitation, then, that I slowly raised my hand to ask a few more questions. Where did the patient live? Could the family travel to the medical center for regular visits? What kind of support system was available to help with postoperative care? And the most uncomfortable query: who is going to pay the bills?

Unfortunately, the answers were discouraging. It turned out that the child was a citizen of a distant developing nation in which the local medical system and social services were bare-bones, and the family was of limited means. Although the American hospital and its medical staff could and would perform their work for free — most academic medical centers, including Mayo Clinic, do charity care — the surgical procedures would have been relatively straightforward compared with the logistical complexity of coordinating the patient's care. In the end, the group came to the frustrating conclusion that it would not be in the patient's best interest to start an aggressive course of therapy that had little realistic chance of success. Our initial enthusiasm replaced by disappointment, we moved on to slides of the next case.

People go into medicine because of a desire to heal the sick. Many years are spent obtaining the skills and experience to achieve that end. Miracles occur every day, in hospitals and clinics all over the world. Unfortunately, medical care is expensive, and increasing costs threaten even basic health care for many patients, let alone esoteric therapy such as would have been needed in the case just described. In this election year, Americans should encourage an honest debate about who will pay for health care in our country, a theme I'll address in more detail in the next issue of Checkup.

Sincerely,

George B. Bartley, M.D.
Chair, Board of Governors