The Troubled Road to Universal Health Care

The Troubled Road to Universal Health Care

TWENTY-FIFTH A N N I V E R S A R Y The Troubled Road to Universal Health Care From the Departraent of Emergency Medicine, Bellevue Hospital Center, N...

164KB Sizes 3 Downloads 105 Views

TWENTY-FIFTH A N N I V E R S A R Y

The Troubled Road to Universal Health Care From the Departraent of Emergency Medicine, Bellevue Hospital Center, New York, NY.

Lewis R Goldfrank, MD

Copyright © by the American College of Emergency Physicians.

In our country the increasing commercialization of medicine is taking control of our medical school faculties, hospitals, and education. There is an overemphasis on health care efficiency, with a dramatic decrease in the commitment to research, an increase in the cost of medical education and resultant staggering student debt, an increasing number of medically uninsured, and an everwidening gap between the best that American medicine can offer and that which the indigent receive. [Goldfrank LR: The troubled road to universal health care. Ann EmergMedDecember 1997;30:737-738.]

At the beginning of this century, the Carnegie Foundation, in its Flexner report, spoke for the need to keep medical training free from commerce. As the century concludes medicine and medical education are becoming increasingly commercialized. There is an overemphasis on health care efficiency with a dramatic decrease in the commitment to research. There is an underemphasis on the devastating effects of the transformation of our profession into a profitable commercial enterprise. Medical and news journals focus on the finances of health care and the need to limit expenditures for physicians, nurses, hospitals, and medical education. Few focus on the plight of the increasing number of medically uninsured and the eve>widening gap between the best that American medicine can offer and that which the indigent receive. Although approximately 20% of the US population has no health insurance, voters, legislators, health care prm~ders, and our own professional organizations remain silent on a commitment to a universal national health care plan. Most of our coworkers did not become physicians and nurses to render bills to patients. Most came with an idealized view and an ethical foundation to render care to all who need it. We must maintain this ethical commitment to universal care even as ma W trainees are now being educated in universities and hospitals that have gone from public to private and nonprofit to for-profit status.

DECEMBER 1997

30:6

ANNALS OF EMERGENCY MEDICINE

73 7

TROUBLED ROAD

Goldfrank

I fear that medical students will not learn to be caring physicians if they are educated in medical schools ruri as businesses, by teaching physicians preoccupied with the bottom line, and in hospitals that are more oriented to commerce than care. They will learn that resources are finite. They will understand how managed care organizations work, how their populations are developed, and how care may be limited by cost. Where will they learn about the millions of Americans with no health insurance? How will these providers learn to care for the medically untouchable if they become invisible in most educational sites? Students might meet these patients in the ED, but not all students train in EDs. As emergency physicians, we too have become commercialized as we try to expedite the care of the uninsured. If hospitals become efficient components of health care and managed care organizations, they may provide a good education in business administration and an ideal environment in which to train insurance agents and accountants. But they will not provide an environment conducive to the training of physicians and nurses whose priority is patient care. How will health care providers develop the skills necessary to construct an honorable safety net for America~ uninsured and indigent? Will Americans' rejection of a universal health policy be accepted passively by students and staff? Will they be corrupted by the for-profit environment? Should we be satisfied with supporting universal access to the ED and not demand universal care? We and the system we believe in cannot be maintained as federal and state governments redirect health care funds and demonstrate the lack of a systematic approach to uncompensated care. The need for universal health coverage is obvious to most of us. We must convince our peers and our leaders that managed care can meet society's needs, create an acceptable educational environment, and be ethically sound only if the medically untouchable--those with chronic mental illness, the homeless, and those suffering from substance abuse and poverty--are included in a single organized and compassionate plan. Let us not continue to pretend that we can truly meet society's needs without a system that serves the large number of disproportionately needy among us--the rural and inner-city poor, those between jobs, those who have jobs but cannot afford health insurance, those who have been too ill for too long, new immigrants, tourists, and those who have succumbed to a disaster. They have been our patients and our problems, and within a patchwork health care system we have attracted the best and most committed to serve them. I fear, however, that the educational environment is changing so drastically that the current and next generation of health care providers may lose the humanism they brought

738

to medical and nursing schools during their commercial education in the hospital. I fear that our students will be deprived of the opportunity to spend time at a needy patient's bedside. I fear that our most gifted and most needy students will be deprived of the unique educational and research opportunities offered by their faculty and mentors. The loss of our rich research and educational environments, where our future potential for creativity is nurtured, and our lack of a universal health care plan will deprive society of our system's strengths and amplify its weaknesses. The longer we wait to act as leaders in health care reform, the greater will be the need for our patients and the greater the loss of hospitals serving needy communities and people. The more we develop our commercial skills, the less time we will devote to the ethical and humanistic education of our students and the care of those who have nothing material except that which is our responsibility, desperate medical needs. I have no doubt that our high ethical standards and humanism, the foundation of our professional standards, will allow us to lead our nation to a responsible health care policy. I am optimistic that the ethical and economic transgressions of this era of managed care will move us to a higher standard. I believe that we can show that universal health care is not only possible but essential. I know that we are wasting too much time and energy working with the business of managed care and doing too much to corrupt ourselves, our staff, and our students. I fear that we will lose the faith of our patients, who have trusted us during these societal experiments. We know what should be done. We practice universal access. We must not temporize: We must rise to the occasion as leaders in American medicine. Reprint no. 471]86527 Reprints not available from the author.

ANNALS OF EMERGENCY MEDICINE

30:6

DECEMBER 1997