Instead of “Yes we can,” many Democrats have adopted a new slogan this election year: “We shouldn’t even try.”
We shouldn’t try for single-payer system, they say. We’ll be lucky if we prevent Republicans from repealing Obamacare.
We shouldn’t try for a $15 an hour minimum wage. The best we can do is $12 an hour.
We shouldn’t try to restore the Glass-Steagall Act that used to separate investment and commercial banking, or bust up the biggest banks. We’ll be lucky to stop Republicans from repealing Dodd-Frank.
We shouldn’t try for free public higher education. As it is, Republicans are out to cut all federal education spending.
We shouldn’t try to tax carbon or speculative trades on Wall Street, or raise taxes on the wealthy. We’ll be fortunate to just maintain the taxes already in place.
Most of all, we shouldn’t even try to get big money out of politics. We’ll be lucky to round up enough wealthy people to back Democratic candidates.
“We-shouldn’t-even-try” Democrats think it’s foolish to aim for fundamental change – pie-in-the-sky, impractical, silly, naïve, quixotic. Not in the cards. No way we can.
I understand their defeatism. After eight years of Republican intransigence and six years of congressional gridlock, many Democrats are desperate just to hold on to what we have.
And ever since the Supreme Court’s “Citizens United” decision opened the political floodgates to big corporations, Wall Street, and right-wing billionaires, many Democrats have concluded that bold ideas are unachievable.
In addition, some establishment Democrats – Washington lobbyists, editorial writers, inside-the-beltway operatives, party leaders, and big contributors – have grown comfortable with the way things are. They’d rather not rock the boat they’re safely in.
I get it, but here’s the problem. There’s no way to reform the system without rocking the boat. There’s no way to get to where America should be without aiming high.
Progressive change has never happened without bold ideas championed by bold idealists.
The flip-flop behind the flawed attacks on Sanders’s single-payer plan
The Jan. 29 editorial “The real problem with Mr. Sanders” alleged that Sen. Bernie Sanders’s (I-Vt.) health-care plan “rests on unbelievable assumptions about how much he could slash health-care costs.” That dismissive claim was based on a deeply flawed analysis by Kenneth Thorpe, an Emory University professor and former Clinton administration official who, like Democratic presidential candidate Hillary Clinton, has done a recent flip-flop on the facts about single-payer.
So what has changed? In 2003, Thorpe calculated that single-payer would achieve huge administrative savings — more than 10 percent of total health spending, equivalent to $350 billion this year alone. Now he has cut that estimate by more than half, even though the costs of bureaucracy in the United States have continually climbed, while they’ve remained low in single-payer nations.
Thorpe previously predicted that single-payer would cause a modest uptick in the utilization of care. Now — despite the fact that fewer are uninsured — he has decided there would be a huge increase.
Finally, Thorpe says nothing about savings on drug prices, despite the fact that every nation with a national health-insurance program gets discounts of about 50 percent.
The old Kenneth Thorpe — like the old Hillary Clinton — acknowledged the facts about single-payer. The new one ignores them. The editorial board should know better.
David U. Himmelstein and Steffie Woolhandler, New York
The writers are professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School.
Led by presidential candidate Bernie Sanders, one-time supporters of ‘single-payer’ health reform are rekindling their romance with a health reform idea that was, is, and will remain a dream. Single-payer health reform is a dream because, as the old joke goes, ‘you can’t get there from here.
Let’s be clear: opposing a proposal only because one believes it cannot be passed is usually a dodge.One should judge the merits. Strong leaders prove their skill by persuading people to embrace their visions. But single-payer is different. It is radical in a way that no legislation has ever been in the United States.
Not so, you may be thinking. Remember such transformative laws as the Social Security Act, Medicare, the Homestead Act, and the Interstate Highway Act. And, yes, remember the Affordable Care Act. Those and many other inspired legislative acts seemed revolutionary enough at the time. But none really was. None overturned entrenched and valued contractual and legislative arrangements. None reshuffled trillions—or in less inflated days, billions—of dollars devoted to the same general purpose as the new legislation. All either extended services previously available to only a few, or created wholly new arrangements.
To understand the difference between those past achievements and the idea of replacing current health insurance arrangements with a single-payer system, compare the Affordable Care Act with Sanders’ single-payer proposal.
Criticized by some for alleged radicalism, the ACA is actually stunningly incremental. Most of the ACA’s expanded coverage comes through extension of Medicaid, an existing public program that serves more than 60 million people. The rest comes through purchase of private insurance in “exchanges,” which embody the conservative ideal of a market that promotes competition among private venders, or through regulations that extended the ability of adult offspring to remain covered under parental plans. The ACA minimally altered insurance coverage for the 170 million people covered through employment-based health insurance. The ACA added a few small benefits to Medicare but left it otherwise untouched. It left unaltered the tax breaks that support group insurance coverage for most working age Americans and their families. It also left alone the military health programs serving 14 million people. Private nonprofit and for-profit hospitals, other vendors, and privately employed professionals continue to deliver most care.
In contrast, Senator Sanders’ plan, like the earlier proposal sponsored by Representative John Conyers (D-Michigan) which Sanders co-sponsored, would scrap all of those arrangements. Instead, people would simply go to the medical care provider of their choice and bills would be paid from a national trust fund. That sounds simple and attractive, but it raises vexatious questions.
What’s wrong with Sanders’ single payer plan and health care politics?
Like 2008, health care is now an important issue in the Democratic nomination fight. Back then Clinton and Obama both wanted Affordable Care Act-like policies, although they differed on whether there should be an individual mandate.
This year, Senator Bernie Sanders is promoting a single payer plan and his campaign is criticizing Hillary Clinton for purportedly abandoning a commitment to universal coverage.
The Sanders plan has gotten a lot of criticism from liberal writers because it lacks critical details and the numbers don’t seem to add up. There are no cost-control mechanisms. A health policy wonk I know said the plan shows a lack of seriousness about the issue and so may undermine the future of single payer as a real option.
Even more, there’s a big policy error in how single payer is being characterized and this mischaracterization has political implications. What’s wrong comes down to presenting universal coverage and single payer as equivalent.
Single payer and universal coverage are not the same thing.
It’s very common to see people write as if they are. This mix-up is pervasive. But it’s not true in the least.
Universal coverage comes in many flavors. Single payer is one of them, and it’s not even very common.
There are few truly single-payer systems in the developed world. Canada has one, as does Taiwan. Most countries rely on many, many insurers. Germany, for instance, has more than 150 “sickness funds.” The Swiss and Dutch health systems look a lot like Obamacare’s health-insurance exchanges. In France, about 90 percent of citizens have supplementary health insurance. Sweden has moved from a single-payer system to one with private insurers.
T.R. Reid, author of the wonderful book The Healing of America, puts universal health care systems in three main categories, with some countries having a mixture of them. These three can be described as single payer, a national health service and a social insurance system. (See them in comparison to an “out of pocket” system by clicking here.)
At the bottom of this post you can click over to a page showing how a number of different capitalist democracies deliver universal coverage.
The U.S. has a mixture of health care systems. Medicare and Medicaid are single payer. The VA is a national health service model. The ACA is a social insurance model. And then we have lots of private insurance that’s regulated under the ACA but its financing is from employers or individuals or both. Some people pay out of pocket themselves.
In mixing up single payer and universal coverage, Sanders and his supporters are making a misleading political argument.
The politics matters because the chance of Congress passing single payer anytime soon is effectively zero and because it is part of today’s nomination debates.
Democrats strongly support expanding health coverage but many likely believe what the Sanders campaign incorrectly suggests.
In reality, Clinton has not attacked universal coverage and she hasn’t changed from supporting single payer before. She never proposed single payer, not in the 1990s and not in 2008.
Now, the Clinton campaign was wrong in having Chelsea Clinton talk about single payer as taking away people’s coverage, with what looked like an implication that they’d lose insurance. In fact, single payer would replace other sorts of insurance. And Hillary Clinton should go beyond the bare bones health plan she’s proposed this election cycle and present more detail herself.
However, Chelsea Clinton was right that the particular sorts of insurance people now have would disappear. In fact, that’s a key feature of a single payer system.
How many people would prefer single payer over what they have now? It’s hard to say for sure. But there’s no doubt there would be disruption as people who have private insurance move to what single payer insurance would provide.
A robust health policy debate is good.
Moreover, I don’t think anyone thinks the ACA doesn’t need some improvements.
It’s wrong, however, to act as if single payer and universal coverage are equivalent when they are not.
Today’s discussion should be based on a more accurate understanding of health policy options. And that means avoiding myths about single payer and discussing the range of ways universal coverage is achieved around the world and could be in the United States.
In our "read my lips/over my dead body" political culture, the threat of tax increases usually shuts down proposals for single-payer national health insurance. Lately, conservative pundits - and even liberals like Hillary Clinton - have been repeating the mantra that single-payer insurance would break the bank.
Never mind that Canadians, Australians, and Western Europeans spend about half what we do on health care, enjoy universal coverage, and are healthier. Their health-care taxes are higher.
Or are they? According to our study in the current issue of the American Journal of Public Health, American taxpayers picked up 65 percent of the total health-care tab last year - a figure that will soon rise to 67 percent.
We paid $2.1 trillion in taxes to fund health care - $6,560 per person. That's more per capita than Canadians or people in any other nation pay. Indeed, our tax-financed health-care bill is higher than total health spending (private as well as public) in any other nation except Switzerland.
Official accounts from agencies like the Department of Health and Human Services peg taxpayers' share of U.S. health spending at about 45 percent, a figure that includes Medicare, Medicaid, the Centers for Disease Control and Prevention, and Veterans Affairs. However, this kind of tally omits two important items.
First, it leaves out government spending to buy private health coverage for public employees like teachers, firefighters, and members of Congress. Indeed, government employers account for 28 percent of all employer health spending.
Second, it excludes tax subsidies for private employer-paid plans and other privately paid care - $326 billion last year - that mainly benefit affluent families.
Omitting these government expenditures from the official health-spending tabulations obscures the fact that our health-care system is already about two-thirds publicly funded. In contrast, the Office of Management and Budget, not to mention most health-policy experts, considers tax subsidies for private insurance to be tax expenditures.
Even many uninsured families pay thousands of dollars in taxes for the health care of others.
More than one-third of these tax dollars meander through private insurers on the way to the bedside. These private insurers siphon off 12 percent for their overhead and profits (vs. 2 percent in the Medicare program) and also inflict huge paperwork costs on doctors and hospitals. A shift to single-payer national health insurance would save at least $400 billion annually on paperwork alone, enough to cover all of the uninsured and eliminate co-payments and deductibles for the rest of us.
That means a national single-payer plan wouldn't cost Americans any more than we're currently spending. Moreover, the taxes to pay for it would be fully offset by the savings from eliminating private insurance premiums.
Moving from our current level of tax financing, 65 percent, to Canada's 70.7 percent would mean a tax increase of about $185 billion per year. But Americans would save at least that much on premiums. The vast majority of American households would come out ahead financially, and everyone would be covered.
Drug and insurance firms that would lose billions under single-payer health coverage generously fund its detractors (including Clinton, who has gotten more health-industry dollars than any other presidential candidate). These naysayers suggest that a single-payer plan (or "Medicare for all," as Bernie Sanders likes to call it) would downgrade Americans' coverage, and they also raise the specter of big tax increases.
But a national single-payer plan would give all Americans the first-dollar coverage enjoyed by Canadians and Brits, and guarantee them a free choice of doctors and hospitals - a choice that private insurers currently deny to many of us.
Surprisingly, American taxpayers already pay enough to fund national health insurance. We just don't get it.
In Fact, Argue Experts, Sanders' Medicare-for-All Numbers "Do Add Up"
"It's indisputable that single-payer systems in other countries cover everyone for virtually everything, and at much lower cost than our health care system," PNHP co-founder says
During Thursday night's Democratic presidential debate, Hillary Clinton criticized Bernie Sanders' proposal for a "Medicare for All" healthcare program, stating, "the numbers just don't add up."
"A respected health economist said that these plans would cost a trillion dollars more a year," Clinton said, likely referring to a recent analysis by Emory University professor Kenneth Thorpe, who helped craft a single-payer healthcare system in Sanders' home state of Vermont, which said Sanders' proposal was off by an extra $1.1 trillion annually.
"So if you're having Medicare for all, single-payer, you need to level with people about what they will have at the end of the process you are proposing," Clinton said. "And based on every analysis that I can find by people who are sympathetic to the goal, the numbers don't add up, and many people will actually be worse off than they are right now."
But according to other healthcare experts, both Clinton and Thorpe are working with false calculations.
Dr. Steffie Woolhandler, a professor in public health at City University of New York at Hunter College and co-founder of the advocacy group Physicians for a National Health Program, said Friday that the "numbers on single-payer do, in fact, add up."
"It's indisputable that single-payer systems in other countries cover everyone for virtually everything, and at much lower cost than our health care system," Woolhandler said. "Experience in countries with single-payer systems, such as Canada, Scotland, and Taiwan, proves that we can have more, better and cheaper care."
For example, "if the U.S. moved to a single-payer system as efficient as Canada's, we'd save $430 billion on useless paperwork and insurance companies' outrageous profits, more than enough to cover the 31 million Americans who remain uninsured, and to eliminate co-payments and deductibles for everyone," she said.
In January, Woolhandler and her colleague Dr. David Himmelstein authored a response to Thorpe's analysis that found it to be based on "several incorrect, and occasionally outlandish, assumptions," including "administrative savings of only 4.7 percent of expenditures" and "huge increases in the utilization of care, increases far beyond those that were seen when national health insurance was implemented in Canada, and much larger than is possible given the supply of doctors and hospital beds."
"Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform," the professors wrote.
Woolhandler said Friday, "A single-payer system could save even more money by bargaining with drug companies for discounts on drugs. Other countries get discounts of about 50 percent, and as the biggest customer we could have the bargaining power to get similar savings...Finally, single-payer systems have been better at controlling costs over the long-haul."
"Our medical arms race—with hospitals competing to offer expensive high tech care, even when they don't do enough to be good at it—has driven up costs and compromised the quality of care. In contrast, single-payer nations have used thoughtful health planning, to invest in expensive high tech care where it's needed, not just where it's redundant but profitable," she said.
During Thursday's debate, Sanders rejected the argument that his plan was "unachievable."
"Every major country on earth, whether it’s the UK, whether it’s France, whether it’s Canada, has managed to provide healthcare to all people as a right and they are spending significantly less per capita on healthcare than we are," he said. "So I do not accept the belief that the United States of America can’t do that."
"Please do not tell me that in this country, if—and here's the if—we have the courage to take on the drug companies, and have the courage to take on the insurance companies, and the medical equipment suppliers, if we do that, yes, we can guarantee health care to all people in a much more cost effective way," he said.
The charge that the numbers for a sweeping healthcare reform plan "don't add up" is one that Clinton herself has been hit with in the past, regarding the Health Security Act—dubbed 'Hillarycare'—introduced in 1993 under President Bill Clinton's administration.
InHealth customers mad about late notice dropping OhioHealth
by Ben Southerly
Some central Ohio consumers say a Westerville-based health insurer intended to keep quiet about its plan to drop OhioHealth hospitals and doctors from its provider network until it was too late for many of its enrollees to change their health plan.
As of Tuesday, 45 people had filed complaints with the Ohio Department of Insurance, and The Dispatch obtained about half of the complaints through a public-records request.
Many consumers said they were not notified of InHealth’s plan to narrow its provider network until last week, though some received robocalls on Jan. 30, the day before the deadline to sign up for health insurance through the federally run health-insurance marketplace.
Richard “Rich” Schooley, himself an insurance agent, said he carefully vetted InHealth’s coverage before he purchased coverage through the marketplace, only to receive a letter last Wednesday telling him that OhioHealth would be dropped from the network on March 1.
“It’s terribly wrong, and it really screwed the consumer,” said Schooley, 53, of Canal Winchester. “We’re stuck; they can do anything they want to do. That’s not fair; that’s not right.”& amp; amp; amp; amp; amp; lt; /p>
InHealth officials declined to be interviewed for this article, but in a statement, the company reiterated that it is a nonprofit mutual insurance company that is “doing all we can to work in the best interests of our members.”
In an interview last week, an InHealth official acknowledged that efforts to get OhioHealth to agree to lower reimbursement rates had broken down by late December.
During the first half of January, InHealth’s leaders decided to drop OhioHealth from the provider network. An official with the Ohio Department of Insurance said that InHealth contacted the department late on Jan. 15, triggering a required 15-day review period during which department officials review documents to ensure that insurance companies clearly explain provider-network changes to consumers.
However, an official with the Ohio Department of Insurance said nothing stops insurers from starting the notification process during the 15-day review period. The Department of Insurance did not encourage InHealth to begin the notification process earlier.
“We consider this decision to be a business decision of the company,” the official said.
The official said the department sometimes gets notices from insurance companies about their plans for a “market disruption” that ultimately doesn’t happen. “This is, from our perspective, not a done deal until it’s a done deal.”
But some Ohioans said they are furious that InHealth is putting coverage with OhioHealth on the line.
Obamacare is putting the agricultural industry in a tizzy.
Many contractors who provide farm labor and must now offer workers health insurance are complaining loudly about the cost in their already low-margin business.
Some are also concerned that the forms they must file with the federal government under the Affordable Care Act will bring immigration problems to the fore. About half of the farm labor workforce in the U.S. is undocumented.
“There’s definitely going to be some repercussions to it,” said Jesse Sandoval, a farm labor contractor based in Stockton, California. “I think there’s going to be some things that cannot be ignored.”
Sandoval came to an educational conference for farm labor contractors — essentially staffing agencies for field workers — held at the San Joaquin County Agricultural Center in Stockton in the fall. Men with broad shoulders, wearing denim jackets and cowboy hats, sat in the audience, listening to lectures on a litany of laws and rules regulating their industry, including Obamacare’s employer mandate.
Last year, employers with 100 or more full-time employees had to offer health insurance to their workers or pay a stiff penalty. This year, employers with 50 to 99 full-time employees must comply.
Sandoval has about 100 workers on his payroll. When farmers need a crew to pick cherries, pumpkins or asparagus, they call him to send the workers. He has to offer them insurance this year, and he’s smarting over the price tag. At $300 a month per employee, he’s looking at a $30,000 monthly bill.
Sandoval said he can’t absorb the hit. “The numbers aren’t there,” he said. “My margin is 10 percent, and I have to increase expenses 10 percent? Well, that doesn’t work.”
So, like a lot of contractors, he’s passing the bill on to the farmers, who in turn are passing the bill on to the farm workers. Under the Affordable Care Act, employees can be asked to contribute 9.5 percent of their income toward health premiums.
But for farm workers who pick oranges or peaches for $10 an hour, that’s still too much. Agostin Garcia of Fresno, California, said the two contractors he works for near Fresno offered him insurance directly. But when he saw the price tag, he turned them both down.
“For me, I’m the only one in my house who works,” he said. “There’s five of us in the family. It just wouldn’t work. Either I pay for health insurance, or I pay the rent and utilities.”
Garcia said only a fraction of his co-workers have signed up for coverage. He said when farm labor contractors hand out packets explaining the coverage, the page where workers reject it is right on top.
“I think they do it intentionally,” Garcia said. “They comply with the laws by saying, ‘I offered.’ But they know that nobody’s going to accept it, they know that nobody’s going to pay those amounts.”
The cost isn’t the only thing about Obamacare stressing people out in the ag industry. Some are worried about immigration problems. Employers have to file new health care forms with the IRS for all their workers, whether or not they accept the insurance.
Attorney Kaya Bromley said this will make it harder for some contractors to turn a blind eye when workers give them fraudulent documents. “Now that there’s more transparency because of all of the reporting, I think we’re going to have a lot more data on how many illegal or undocumented workers we have,” she said.
Just as the tobacco and fossil-fuel industries sponsored “experts” to perpetuate the idea that their industries were harmless, the for-profit American heath care industry is now engaging in misinformation claiming Bernie Sander’s single-payer system would “break the bank.”
The truth is that an “Improved Medicare For All” single-payer system would cut costs drastically and provide coverage for everybody. Virtually every other developed country has an affordable universal system that proves the point.
At issue is that single-payer threatens the multi-million-dollar paychecks of insurance companies and their CEOs, and the outrageous profits of drug and medical device companies and medical entrepreneurs. Under single-payer, private health insurance companies are gone and the system can negotiate for lower drug and medical device costs.
People are waking up to see that corporate greed is hurting Americans. We have a broken for-profit health care system. Quality is mediocre, and more than 25 million Americans are still uninsured. Medicare, Medicaid and hospitals are under threat of new cuts. Meanwhile the nation’s for-profit health industry nets billions in profits, and CEOs take home tens of millions in pay.
A single-payer “Improved Medicare For All” would cut costs dramatically by streamlining health care paperwork and making health care affordable. Savings would be enough to provide coverage for everyone, without ANY additional spending! The concept is popular with the American people and enjoys the support of most doctors.
Consult Physicians for a National Health Plan (pnhp.org) and learn how you can help bring about a real universal health care system. Add your voice to the growing chorus, and tell our leaders to stand up for the health of the American people rather than the wealth of our richest firms.
More and more hospital guards across the country carry weapons, sparking a fierce debate whether that improves safety or endangers patients.
Founded for the Poor, Mass General Looks to the Wealthy
By JOHN HANC
FEBRUARY 12, 2016
Can a hospital founded more than 200 years ago to treat the poor also adopt a form of medicine some criticize as health care for the rich?
The answer may come in August, when Massachusetts General Hospital, the third-oldest general hospital in the nation, plans to open a concierge medicine practice.
Based in Boston, the hospital, whose $800 million annual research budget is among the nation’s biggest, is affiliated with Harvard Medical School and is perennially ranked No. 1 in many categories of U.S. News & World Report’s listings of the country’s best hospitals.
Despite its reputation, Mass General — as it is known — was established in 1811 to care for the city’s poor and indigent. Patients in concierge medicine are likely to be anything but that.
For $6,000 a year (and whatever their insurance pays), patients in its new Concierge Medicine Practice will get round-the-clock access to their doctors (initially, there will be three in the practice), as well as personalized nutritional, exercise and wellness counseling.
The idea of wealthy people paying doctors a retainer for exclusive service is not new. With concierge medicine, which was introduced in the 1990s, patients pay physicians a monthly or annual retainer and expect more personalized care and greater access. “A concierge patient who signs up for a practice is not only looking for quality care, they are looking for unfettered access to their provider,” said Dr. Michael R. Jaff, the medical director of Mass General’s Center for Specialized Services and a professor at Harvard Medical School.
There are pros and cons to concierge medicine — or direct primary care, a similar model — which, according to the industry trade magazine Concierge Medicine Today, is embraced by about 6,000 doctors across the country. (Another 6,000, the magazine estimates, are in practices that offer some form of retainer or concierge service.)
“The upside is that it gives more time for patient-physician interaction, and the data shows that generally the more time a patient has with a physician, the better the outcome,” said Dr. Wanda D. Filer, president of the American Academy of Family Physicians. “The downside is that it can be very exclusive and difficult for middle- and low-income patients to afford. So there’s a concern that you’ll have a two-tier system.”
In recent years, concierge medicine and similar types of programs have spread from private practices to hospitals. Mass General’s embrace of it may prove influential.
“It’s a significant development, simply because of the name and the prestige,” said J. Catherine Sykes, publisher of Concierge Medicine Today. “To have an organization that has the core values Mass General holds enter this arena adds momentum to the movement.”
To critics of concierge medicine, Mass General’s foray into the field is no cause for celebration. “It’s worrisome, unless you’re rich,” said Pauline Rosenau, professor of public health at the University of Texas Health Science Center in Houston. As for the hospital’s historical mission, she added, “I’d say it’s in jeopardy.”
For almost 40 years, I practiced general internal medicine and geriatrics in my own office. I had tens of thousands of face-to-face interactions with a group of folks who, with time, grew to trust me. I respected them as well; many I came to love — a term that I hesitate to use in this hypersensitive age. Given how geographically dispersed families are today, for many of my older patients I functioned as a surrogate son.
There is no doubt that the kind of medicine I was fortunate to practice is disappearing. Most doctors are employed by large group practices, hospitals or insurance companies. Many want to have personal connections with their patients but have too little time. Young primary-care doctors are relegated to assembly-line clinics; their patients pass through as widgets, not as individuals with complex inner lives, wrought family structures, varied spiritual and cultural beliefs — not to mention their individual capacities to understand and deal with their medical symptoms, diagnoses and multiple medications, as well as their own hopes and fears.
Physicians are now insulated from knowing too much about their patients. It is all about the technology, the testing, the imaging, the electronic health record, the data — once collected by the doctor, but now so regulated and overwhelming that paramedical professionals have been enlisted to record the so-called minutiae, the often rote information in which may lie important clues. Some of these may remain forever buried, the patient not wanting to share sensitive details with just anyone, especially someone who no longer makes eye contact, whose face remains buried behind a computer screen, who seems uninterested or just unskilled in reading body language — that downward glance, that shift in the chair, that half-swallowed response.
I teach medical students now. All they have to do is look at me to know that I am — in the vernacular of the day — a “dinosaur.” Many are already jaded by their fourth and final medical school year. They know little to nothing about how medicine was once practiced. They have experienced the system only as it currently exists. Students nowadays — and, of course, there are exceptions — are looking to choose a field that will allow them the lifestyle and personal time they want, along with the compensation they feel they deserve for the hard work they will endure, for the debt they have accumulated. Most won’t consider a career in family medicine, general internal medicine or geriatrics.
Many new career opportunities have opened up as the role of the old primary-care attending physician has been crushed and splintered in this postmodern medical age. The shards sparkle with possibility: hospitalists care for sick inpatients and are charged with rapid throughput by their administrative overlords; nocturnists do this job as well — but at night; intensivists take over when work in a critical care unit is required; transitionalists step in when the patient is ready to be moved on to rehabilitation (physiatrists) or into a skilled nursing facility (SNFists). Almost at the end of the line are the post-acutists in their long-term care facilities and the palliativists — tasked with keeping the patient home and comfortable — while ending the costly cycle of transfers back and forth to the hospital. Finally, as the physician-aid-in-dying movement continues to gain support, there will be suicidalists adept at handling the paperwork, negotiating the legal shoals and mixing the necessary ingredients when the time comes.
And to think that not so very long ago I did all these tasks myself — except for the last one — and practiced across all these varied settings. I was there whenever and wherever my patients needed me.
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