With the roll out of the Affordable Care Act and perhaps more significantly the approach of the 2012 elections, public discussions of healthcare reform has been drowning in an alphabet soup of ACOs (not to be confused with the above ACA), CMS, SCHIP, and RUVs, just to name a few. The challenge is twofold. Most of these plans/systems/agencies deal with how to better pay for a seriously flawed system. But just as significantly, this crazy swirl of acronyms can make the whole topic of health care seem too complicated and inaccessible for most of us. Somebody call a doctor.
Doctors and other health care providers are carrying around a powerful tool in their little black bags: stories. We call them anecdotes. Most people consider doctors to be wise, trustworthy storytellers, and our simple, unsensational narratives can get to the heart of even the most complicated topic. Sure we may have to disguise the characters, and maybe leave out the part about the purulent drainage or the philandering husband, but our everyday stories brim with simple truths about human suffering, and about the obstacles we face everyday in relieving that suffering. They can provide something that the nation badly needs right now – the chance to drown out the politicians and pundits so we that we can focus on the essential questions. Doctors’ stories matter, and we should find ways to share them in a way that can shape the narrative of health care reform.
One simple story that comes to mind for me involves the worrisome role I had in the evaluation and treatment of serious mood disorders. The story of how I was placed in that role is an echo of many of the crucial yet neglected questions in our national healthcare debate, and my unassuming patient, Marissa, can help focus our attention.
Fifteen-year-old Marissa was brought unwillingly to the office by her mother, who was concerned that Marissa was depressed. Mildly overweight, sullen expression, stringy hair falling in her eyes, she sat slumped against the wall.
“I don’t know why I’m here. Go ask my mother. She’s the one who made me come.” Her tone is more petulant than defiant.
“I think it would be better if you could tell me what’s been going on.”
My preliminary fact finding revealed how stupid mom was, how lame step-dad was, what a waste of time school was, what jerks all the rest of the kids were. Marissa grew slightly more animated as we talked, shrugging or waving her hand dismissively now and then. I slowly teased out more details – who’s fighting at home, who’s drinking, what substances Marissa herself uses, her sexual experiences, just who her friends are, what she likes to do in her free time. We slowly achieved mutual eye contact, exchanged facial expressions. I tried really hard not to look at my watch. This was the kind of work that primary care physicians do well, but it can take time, and conversation between doctor and patient is the most undervalued commodity in our health insurance system. After the first fifteen or twenty minutes of the visit, it was my dime. But the crushing economics of primary care practice would have to be ignored for the moment.
“Do you ever feel sad?”
Marissa looked down at the floor with great concentration and grew completely still, almost frozen, trying to will herself not to cry. Silent streams of tears rolling down her cheeks finally betrayed her. I handed her a box of tissues and she pulled one out, waving it like the flag of surrender that it was.
“I just don’t know what to do,” she whispered.
She wasn’t the only one.
I spent four weeks out of my three-year specialty pediatric training working in child psychiatry, and this involved mostly talk therapy. (Compare this to the 6 months of round-the- clock training I spent in the newborn intensive care unit.) Yet the number of patients that pediatricians are called upon to evaluate and treat for serious mental and behavioral problems has been growing steadily, as insurance coverage has greatly limited the availability of outpatient psychiatrists and psychologists to young patients, and turns any encounter other than a pill prescription into financial loss for the physician. Here, as in so many areas of health care, health insurers’ payment strategies and a lack of informed public policy, not specialty training or best clinical practice, determine what a physician is expected to do.
Marissa needed help; that much I knew. But how much help? How urgently? We called Mom in to join us, and I explained that we needed to set Marissa up with a therapist. I knew Mom’s next question before she asked it.
“Will insurance cover that?”
I advised her to check with her insurance company and see which therapists it would cover and for how many visits. Unfortunately, none of the ones I personally knew and had confidence in accepted private insurance; the reimbursement was too spotty and too small. A psychiatrist referral was out of the question - more healthcare economics. A child has to be engaged in pretty destructive behavior, before her insurance will cover that. So Marissa and her parents would have to weigh everything in the balance and go with what they could afford out of pocket. I hoped they wouldn’t just give up and try their luck with herbal teas.
The therapist that Marissa’s family chose, a non-physician, wrote a letter to me three weeks later, recommending a trial of antidepressants and continued therapy, which her family could not afford.
This poses a serious dilemma for many physicians, and we need to draw patients’ attention to this. A 2004 survey of primary care doctors revealed that only a tiny percentage, 16%, felt comfortable in prescribing antidepressants, but a whopping 72% actually did. There is little evidence that this disparity has lessened. Meanwhile, over 16 million US children are currently on antidepressants or are other antipsychotics as the robust pharmaceutical industry spends hundreds of millions of dollars annually marketing these classes of drugs and health insurers continue to reward only quick fixes. I wrote the prescription, full of worry and resentment, feeling like I was flying by the seat of my pants. I scheduled Marissa for close follow-up.
This is not the stuff of TV dramas or medical bestsellers. But if there is one thing that doctors are extraordinarily good at, it is taking complicated issues and framing them in simple, clear ways those patients can understand and relate to, even when they are worried or frightened. We do it everyday. Lets take that skill beyond the exam room and into the arena of health care reform. Lets help focus the attention on questions about what a smart health care system would deliver, and to whom. Lets get everyone thinking about how much they want health insurers to shape clinical practice, or to what extent drug therapies should be driven by profit. I would stack up one good doctor story against a 1000 pages of legislation any day of the week. Its time.