Which oath? Hippocratic, hippocritic or hypochondriac?

This blog has been years in the making–possibly long before I had ever heard the term ‘blog.’ Spurred on by the recent series of blogs by Henry which have at least indirectly addressed the medical profession and the sensitive and often incompatible relationships between doctors and patients, here I am ready to throw in my own two cents worth. Well, with inflation, make it a dime– or ten pence, or whatever your currency may be.

What gives me the right and immunity from moral turpitude to open my mouth (or computer) and discuss these issues? I do have a few reasons:

First, I have declared openly in previous blogs of my own hypochondriac tendencies. I don’t intend to elaborate in this forum, except to say that my recent novel “Welcome Home, Sir” (or on Kindle) deals with a scientist suffering from hypochondria and hiding it from his colleagues. For those interested in so-called mental illnesses and their potential impact on people, and scientists no-less, this is your opportunity. But I shall say no more on this particular matter now. The point is that hypochondriacs have a unique vantage point concerning doctor-patient interactions.

Second, I have lived almost equal periods of time in 3 countries, each with its own and very different system of medical care and insurance. This I feel qualifies me as a semi-expert in making comparisons, at least from these 3 systems.

Third, I work as a scientist at a major medical center, which provides me with a lot of peripheral insight into the way things work at a research and teaching hospital.

Finally, my own father is an pediatrician in Canada, and through frequent discussions I have gained a lot of knowledge of how things work–or rather how they don’t–on the northern side of the border.

So let’s start with the two radical opposites, situated so close together, yet so far apart in their respective medical systems. Here in the US, I feel that the medical care available (compared to Canada or Israel) is vastly superior. Of course, that depends on whether one has insurance and can afford that care. But if we remove cost from the equation–with money not an object as they say–I think there is little doubt that the system here offers the highest level of medical care. Specialists of all types available (this also has to do with the size of the country), and a plethora of high end medical tests routinely done.

Just a few years ago I was telling my father about an episode of cluster headaches I had been plagued with, and how my GP sent me for an MRI that they were able to schedule for the very next day. Why not, with dozens of MRI machines available at the various hospitals and clinics here in Omaha. Not an issue. Taken for granted. Yet my father had explained to me that on his side of the border in Winnipeg, a city roughly the size of Omaha (750,000), there were only 4 MRI machines in the entire city with a waiting time of 6-8 months for any test that wasn’t deemed a life threatening emergency. As a pediatrician, he had been sending families who could afford it to do private MRIs across the border in Grand Forks, North Dakota (population ~50,000), which had at least a dozen MRIs available.

So what is wrong with Canada’s socialist medical system? Nothing–except that it’s gone bankrupt. And people begin to take medical care for granted. So for example, if new vaccines (ie., chickenpox) are not covered by Canada’s medical system, the vast majority of patients will not vaccinate their children. Pay for vaccines? They must not be necessary if they are not covered. They are “frills” and frivolous.

Now I fully realize that these are all anecdotal comments and observations, and quite possibly regional differences within Canada make things better (or worse?) in other areas of the country. But as I am not writing a peer-reviewed paper now, but rather just passing along my impressions, I have no qualms about making these observations.

I won’t say much about the system in Israel (because it generally falls in between the US and Canadian systems), except to note that I often encountered a weird situation in Israel. While doctors here in the US will do a battery of tests to ensure that the patient is healthy and that they are not missing any hidden ‘signs’ about the patient’s health, in Israel I’ve noticed that many doctors seem to do the opposite. They try to show the patient that he/she is healthy. So coming to an orthopedic surgeon without a torn ligament, but just moderate pain in the patella region (that’s hard to quantify), someone such as myself always had the uncomfortable feeling that the doctor thought I was trying to “cheat”–perhaps to get a doctors note to avoid military reserve duty? Or work?

My hypothesis is that since most doctors served for some time in the military and did encounter hordes of sick and not-so-sick soldiers, some of whom were indeed trying to evade one type of duty or another, this has caused generations of physicians to become overly suspicious of patients’ complaints and colored their vision of the medical profession even in civilian duty for years to come. It’s certainly no fun seeing a physician who doesn’t really believe you when you profess your symptoms. All the more so for any issues dealing with mental health…

Back to Canada, (or at least Winnipeg) there seems to be an acute lack of certain specialists–children in Winnipeg in need of pediatric nephrologists need to fly to Toronto or Vancouver. And this is only one example.

Having children, I have visited pediatricians here in the US many times. The doctors seem to have a lot of time for each patient, to answer parental questions and do full physicals. Nurses and assistants give the vaccinations and do the weighing and measuring. Sources tell me that pediatricians typically see 20 or so children a day in a US clinic. In Canada 50-60 is more typical; doctors are paid much less and also do not usually employ nurses and assistants for vaccinations and measuring/weighing. Where would you expect care to be better?

But as I alluded to earlier, better care depends on the ability of patients in the US to handle their medical costs, or be covered by insurance. Those unable to pay and up to their eyeballs in debt can burn out their retinas with no help on the way. For many, getting sick just isn’t an option; the only possibility is emergency room visits–often when it’s too late. Stories abound of chronic illness causing families to sell their homes and undergo painful bankruptcy. A merciless system, and one that some democrats in the US have been dreaming of improving for years. Time will tell how much Obama’s health care plans and reorganization of the medical insurance system will improve matters.

 

 

About Steve Caplan

I am a Professor of Biochemistry and Molecular Biology at the University of Nebraska Medical Center in Omaha, Nebraska where I mentor a group of about 10 students, postdoctoral fellows and researchers working on endocytic protein trafficking. My first lablit novel, "Matter Over Mind," is about a biomedical researcher seeking tenure and struggling to overcome the consequences of growing up with a parent suffering from bipolar disorder. Lablit novel #2, "Welcome Home, Sir," published by Anaphora Literary Press, deals with a hypochondriac principal investigator whose service in the army and post-traumatic stress disorder actually prepare him well for academic, but not personal success. Novel #3, "A Degree of Betrayal," is an academic murder mystery that is now in press! All views expressed are my own, of course--after all, I hate advertising. http://www.stevecaplan.net
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5 Responses to Which oath? Hippocratic, hippocritic or hypochondriac?

  1. Interesting observations, Steve.

    In Ontario, I believe that something like half of the provincial budget goes to health care. That’s a staggering amount of money, especially considering the caveats you point out (some tests aren’t listed for reimbursement, access to facilities and specialists may be limited). In some areas, even major (sub)urban ones, it can even be challenging to find a family doctor. That’s a situation that frightens me a bit (although walk-in clinics abound).

    The access to advanced machinery such as MRI is a bit of a boondoggle though. Every time a visiting athlete (Canadian, American or otherwise) sustains an injury, they magically seem to be whisked off to hospital for an MRI with little to no wait time. And there are many anecdotal stories of people (even some I’ve met) who’ve seemingly jumped the queue, or been slotted in to a mythical “cancellation”, and had imaging done very rapidly. I suspect that the purported lack of access and long wait times are more of an administrative hurdle than a real lack of capacity. Honestly, four MRI machines running full bore ought to be more than enough for a city the size of Winnipeg, if used efficiently.

    Final point – your assertion that doctors “do not usually employ nurses and assistants for vaccinations and measuring/weighing” sounds false to me. Doctors in this country don’t waste their time weighing patients, or vaccinating them. They are far too busy moving from one patient to the next so as to jam as many into the day as possible – a direct result of the lower per-patient reimbursement that our healthcare system provides.

  2. Steve Caplan says:

    Richard,

    You are right about the issue of finding a regular family doctor or GP. It seems that walk-in clinics with non-specialized doctors are the only growing group of MD in Canada. The reason for this, my experts tell me, is that the government has totally cut funding and slots for specialists, including pediatricians because the government has to pay more to these specialists for every doctor’s visit. Their solution is to ensure that there are fewer specialists, and thus the cost of healthcare goes down. At the expense of poor medical care. Walk-in clinics are sub-optimal care, because there is generally little follow-up and this is not the way medicine should be practiced. According to my father, though, spoiled and unappreciative patients would prefer to be seen immediately rather than have to wait for an appointment even a couple hours later, and end up taking their children to these walk-in clinics rather than getting continuing treatment from a knowledgeable pediatrician who has all the history charted.

    As for not using nurses/assistants–that is anecdotal, but my father does all his own vaccinations and weighing etc. Yes, their is an office assistant to prepare the examination room, clean it and change the paper towels, etc. But everything else he does and has always done. I can’t give you any stats, but according to him it’s pretty typical in Manitoba for pediatricians.

    • Hm, of course, I suppose there could be regional differences (Manitoba being among the so-called “have-not” provinces). My view is of course slanted by being in the largest conurbation in the country, and in a “have” province (although you might not think that’s the case, some days).

      It’s definitely true that some of the more esoteric specialists (e.g., rheumatologists) are hard to find, even in relatively well-serviced small cities in Ontario.

  3. Cath@VWXYNot? says:

    It’s often said that socialised healthcare systems work better the sicker you are. So for serious emergencies and diseases like cancer (where BC has the best outcomes in North America – I work at the BC Cancer Agency and hear that statistic a LOT), there’s actually not a huge difference between developed countries. In contrast, for the management of less serious / chronic illnesses and injuries, yes, you’re probably better off in the US IF you have good insurance.

    I’ve never had a problem finding a doctor or seeing a specialist in Vancouver, and my friends and family members have had excellent care when needed. And we all said when my MIL was having brain surgery following her aneurysm last year what a relief it was not to have to even think about money, and how glad we were not to be in the States for that reason – you hear so many horror stories about people going bankrupt, even if they have insurance. However, the situation outside the city is definitely much worse – my MIL was initially taken to a hospital in a small town a short flight or ferry ride away, where it took them hours to figure out what was wrong with her (they thought she had a norovirus!) and then by the time they realised she needed a CT scan, it was too late in the day – they have a scanner but not the staff to run it in the evenings and overnight. There were then some delays arranging a helicopter transfer to Vancouver the next day. I also work with a surgeon who serves the rural/remote/Aboriginal populations in the North of BC, and some of her stories about the challenges her patients face even to get to an appointment would turn your hair white.

  4. Steve Caplan says:

    I see only the Canucks responding! Bloody favoritism…

    Anyway, I don’t doubt that Toronto, Vancouver, Ottawa and Montreal are big enough metropolitan areas that specialists are not lacking. At the same time, I’m certain that far north in Canada rural medicine is not highly developed, and I suppose that’s to be expected. But mid-sized cities like Wpg, Regina, Saskatoon, London, and probably even Edmonton and Calgary (not to mention Nova Scotia, Newfoundland, New Brunswick, etc.) are probably less fortunate to maintain high level specialists.

    I am not pronouncing either system as optimal–the US is crazy, and a friend of mine wisely noted: “If car insurance is mandatory, then why not health insurance?” There is a tremendous paranoia here about the government controlling people’s lives–so much so that not just gun issues, but helmets for motorcyclists etc. have become issues. One sometimes wonders how mandatory seat belt laws were passed…

    At the same time, I think it’s clear that with no patient accountability, the system is not optimal either. There needs to be a middle road.

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