The Problems I Can't Fix

(Or, why current Democratic proposals for health care kind of suck, but are still probably a good idea.)

It's been an interesting and stimulating two weeks since last post. I got my very own medical student, and on Friday I had my first night of overnight call. Both are experiences I'll write more about, but after I've got a few more data points.

For now, let's talk about the (many) things doctors can't fix, by way of an example patient I saw this week. He came in to our inpatient unit this week, brought in by the police after being found trying to jump off one of our more lethal bridges. As you might imagine, he's depressed. VERY depressed. The problem is the chain of events that led up to his current level of depression:

1. He's got a strong family history of depression, including multiple relatives who died of suicide.
   
2. He happened to only find out about those suicides recently, when researching his family in order to find some inspiration to get him through a tough economic patch.
   
3. Because of the tough economic patch, he's been using his illicit substance of choice a bit more heavily than usual.
   
4. Poor income, combined with spending more on substances, has dug him into some pretty deep debt and left him about to lose his apartment, if not both his apartment and his job.
   
5. The just-about-to-be-a-toddler baby doesn't help with the financial issues or the life frustration.
   
6. His wife is not from this country, and thus has limited options as far as work goes.
   
7. His wife's parents, living far away, do not particularly approve of him as far as we can tell.
   
8. Because those in-laws have decided to bail him out of financial trouble, they're extracting a price: they want the marriage divorced and the wife and child returned to the country of origin.
   
9. His wife decided to inform him of the divorce, and of everything she's doing to pack up their apartment and get out of his life, as soon as he was hospitalized.
   
10. You want me to tell you about his what? His health insurance? See above list. Ain't none and ain't likely to be none anytime soon.
    

As you might imagine, "seething cauldron of emotions" doesn't even begin to describe this man. Read that list again and think about how good a shape you'd be in if it all happened to you over the space of a few months. There's depression, but there's also a ton of anger: at his extended family, at his wife, and most of all, directed (probably not fairly) at himself. At any given moment, he's barely able to decide whether he wants to laugh, cry, hurt someone, try to put it all back together, or run away from it all right over the railing of that bridge.

My job, by general consensus, is to make him "stable and safe". My tools are a chest full of drugs and one experienced social worker. The drugs can handle #1 and #2 on that list and combat his brain's natural tendency towards depression. That may or may not help #3. Plus, they'll only cost him $5-$10 a month. We can't get him a home or a job, but social work can at least plug him into services for the homeless (and he's been homeless before, not coincidentally during his last major depression), which at least mitigates #4. #5-9 inclusive is where we start to get to problems. Obviously, I can't fix his marriage or his social environment. Nobody can. However, that environment alone isn't what's going to kill him. Lots of people survive family strife and divorce. What's going to kill him is that he's got almost nobody to lean on during one of the most ego-crushing experiences imaginable.

We do, in fact, have a cure for that as well. We call it "psychotherapy", or "counseling" if you prefer. Get him plugged in to a good therapist in the community, plus someone who can keep his med prescriptions current, and he's got a solid chance of making it through this, given that he did it once before. Only problem: therapist and doctor visits cost money. The people who benefit from them most tend to be those with serious psycho-socio-economic stressors, i.e. people who don't have any money. "But wait!" you say. "Medicaid solves this problem!" Sure. When you can get it, i.e. once you can get the application, fill it out, get on the waiting list, make it through the waiting list (which gets longer during budget cuts and recessions, even here in the "blue states"), get the card, and then find a doctor who'll accept new public-insurance patients. While I don't know the system 100%, I'd estimate minimum three months to get that set up.

In short, we have little chance of bolstering against #5 through #9 because of #10. If we want to keep this man alive and allow him to return to his former status as a contributing and functional member of society, not to mention thousands of others like him, we need a better answer to health insurance. Leaving the Republicans out of the picture for now, the Senate, House, and President all have different ideas on that better picture, with a lot of mumbling about a government-run national public health plan. Do I really like any of these bills? No. They all involve higher taxes for me, and I'm already feeling a bit of sticker-shock in terms of how much gets taken out of each paycheck (being, for the first time in my life, subject to both income tax AND Medicare/Social Security tax). As a physician, I can say that they don't adequately fix a number of problems, including really crappy Medicare reimbursement policies, liability issues, the balance between specialties, and what the heck "we pay only for quality health care" means anyway. You can see the level of imperfection by the fact that the conservative medical societies are fighting the AMA over it, i.e. the closest thing we have to a unified medical voice is seriously conflicted on the matter. That said, we can continue to bicker about imperfection, ideology, and Not My Taxes, or we can actually try to do something and save some lives. Will it work first time around? Unlikely. But until we take some steps down the road, we haven't a chance of building a health system that will actually get my patient the things he needs.

There's a lot of rhetoric about waiting times for MRIs and heart surgery and other high-visibility interventions. Nobody notices the deaths that are racking up simply due to our own inaction. None of the proposals likely to see a vote this year are excellent; all of them are just-barely-adequate enough to be better than what we have now. That's politics. We can either accept imperfection, or we can just let people like my patient fall through the cracks and, ultimately, off of bridges. I promised I'd do whatever I reasonably could to take care of the patients who come to my door. As far as I'm concerned, that makes the right answer pretty obvious.