Saturday, August 14, 2010

ICU's, interesting cases, and Primary Care

Atul Gawande is a genius writer in my book, or rather in his books and articles. But, even though I think his mother was a pediatrician (in Ohio), he is still a Boston-based high powered endocrinologic surgical specialist. So, in his latest New Yorker article on the depredations of high powered specialities ICU care and end of life expense and torture, I think he steps on his lede.

In the article Gawande writes very approvingly about hospice care, and recounts the torture inadvertently administered by the ICU doctors to dying patients. At the very end of the article - every article he writes is more than worthwhile reading - he mentions a case where the primary care doc had kept in touch with the patient and with the prospect of ICU care the primary doc gets the patient turned off, then quietly exits stage left.

Hey, Atul! That's the whole ffing point!! It's primary care, man! It was also the point in your South Texas article of the best little medical money machine in Texas. Stop stepping on your lede.

He and the other New Yorker doctor-writer, Jerry Groopman, also generally quite well worth reading, especially on EMR's in the NEJM, come from the background of intellectual (I'm not using that word in a good sense here) pompous (also not in a good sense) Boston specialist doctors (also not in a good sense) on rounds saying, "Hmmm. A very interesting case indeed!" And then they trot off the the next. Some decades later, Groopman says, in the face of caring for his own medical needs - hey! There are people in there with these "interesting" diseases!

No s... Dick Tracy! There are others of us, who I can only think very often wound up in primary care, who from the very first said, "What are these guys doing?" Don't they realize they are dealing with people? Is this part of the God complex? So removed? Then they come back to see, post-seduction, what the game is really about.

For a great comment from a pediatrician turned health policy guy, and classmate and friend of my step-daughter Sara, see

While I'm on this rant, might as well take on the academic liberal primary care establishment who take the position that those who look nostalgically to the family doctor of the 50's are doomed to disappointment. They say, we can't do that in this day and age. We need to cut costs and be efficient! We need to have Nurse Practitioners, and they should be independent! We need clinics with teams for all our patients! And, btw, doctors are people, too, so they need a very definite work week so they can be with their family and have enjoyable lives - so that means they can't be tied down to patients, rounds, call, etc.! (Okay, that last one is unfair, but I'm leaving it in anyway.)

Well, as my old roommate from Caribou, Maine used to say, bulldiggy. With all the money going to the money pit of hospitals and anesthesiologists (starting at $600K around here) and cardiologists and ortho and imaging (many with millions each year), what we want to economize on is primary care? You've got to be out of your mind!! We're great, we are what's needed, and the system needs to be based on us! We are the biggest bargains in the medical care arena, and you want to cut us??? We love our PNP's - they are great - but they ain't doctors, buddy. We're going to direct all the doctors to be these same specialists who are causing all the ICU problems, those emotionally dead souls, or at least confused? Give me a break!

OK, I know, I shouldn't be on the fence so much, you should know where I stand. OK. Next post I'll take a stand.

Budd Shenkin

1 comment:

  1. How do you really feel about it, Budd? Not sure there is anything left to say. The structure of how we delivery health care services must change and now there are competing models. I just hope the incentives are such that we get a good solution. Not sure we are heading there yet.