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Clinton's Mis-Managed Care : Doctors Claim They Are Already Sinking Under a Sea of Red Tape. Some Insist It Will Get Even Worse Under The Proposed Health-Care Plans.

February 06, 1994|Dr. Jane M. Orient | Jane M. Orient is an internist in Tucson, Ariz. Her book "Your Doctor Is Not In" will be published in May by Crown

In clamoring for "health-care reform now," the American public reminds me of the patient who comes to my office demanding to know "What's the matter, Doc?" and "What are you going to do to cure me?" before I even have a chance to say hello.

"Just a minute!" I have to say. Mere human beings like myself (doctors are not God, you know) have to start by taking a history and doing a physical exam. Only after making a diagnosis--which they hope is the right diagnosis--should doctors reach for the prescription pad.

Sometimes doctors have to tell patients that yes, there is a medicine that will make their heart stop "skipping beats" (suppress "PVCs" or premature ventricular contractions). The only problem is, the medicine that regulates the heartbeat might also stop it altogether. The majority of patients--there's no room to explain the exceptions here--would be better off to tolerate the aberrant beats.

In some patients with a complex history of seemingly unrelated symptoms, the most useful part of the examination might not be listening to the patient's chest but looking in the shopping bag filled with the patient's medicines. The first one might have been prescribed for the wrong diagnosis, the second for the side effects of the first, the third to counteract the interaction of the first two, and so on. And there might be some medicines that are causing idiosyncratic side effects.

Sometimes, one can become a real medical hero very simply: Just stop all the medicines. ( Sometimes.)

This is not the same thing as stopping all treatment and abandoning the patient. Call it a diagnostic test to determine whether the treatment is worse than the disease, or whether it really is the disease.

Many of our politicians hope to become heroes and get reelected by giving the American people a "Health Security Card." They remind me of myself when I was an internal medicine intern at Parkland Memorial Hospital in Dallas. I saw a man who had come to the Minor Medicine section of the emergency room because he had a cold. On listening to his heart, I detected bigeminy (every other beat was a PVC). The next thing he knew, the man was on a stretcher being whisked to Major Medicine to have an electrocardiogram.

I don't know what happened to him after that. At the time, I thought I had made a dramatic save. But 20 years later, I am sure that that patient should have stayed home. There was nothing I could do to prevent his cold from turning into "double pneumonia," and there still isn't. But our heart medicines could have given him something worse.

Our treatment was given with the best of intentions and the most expert advice.

The Clinton Administration tells us that its proposed Health Security Act was devised in consultation with prominent experts in the health-care field. But unlike the doctors at Parkland or any other hospital, these experts didn't have to put their signatures on the progress notes or the prescription. In fact, the Association of American Physicians and Surgeons and others had to sue the White House to find out the names of task force members, and, a year later, the White House is still trying to prevent the public from finding out who paid how much to whom to do what. Was the plan drafted by special-interest groups (such as big insurers, nonprofit foundations, vendors of information technology, bureaucrats) who stand to profit from it?

The secrecy of the Clinton Administration's Health Care War Room is one issue. The actual prescription is now out there for everyone to see--all 1,300-plus pages of it. It has a lot in common with most of the other "health care reform" prescriptions before the U.S. Congress. It creates cartels, empowers bureaucrats and disenfranchises both patients and doctors.

These nostrums do not even consider the possibility that the patient--the health-care system--is the victim of the legal equivalent of polypharmacy (too many drugs): too much regulation, too much management, too many subsidies and too much of the wrong kind of insurance.

What if the chief symptom--the outrageous cost of medical care--is caused by laws that we already have? In that case, the answer is not to pass 1,300 pages of new laws, but to repeal some of the old ones. It would be like stopping highly toxic drugs that are prescribed to "regulate" conditions that are best left alone.

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