Tuesday, February 6, 2018

6 February 2018: We demand Vicodin; the Germans accept Ibuprofen

Great article sent to me:


We demand Vicodin; the Germans accept Ibuprofen

Whenever someone touts the much less expensive healthcare systems outside the US, and suggests that we adopt a single payer system, I remember the experience we had with our son James in Florence Italy at the best children's hospital in the country. He was hospitalized for a condition that, fortunately, was not life-threatening, but we followed the advice of the doctors to keep him there overnight.
I was with him, and we were in a bare-bones semi-private room, not a private room, and we had very little nursing support during the night, in comparison with an American hospital. He received excellent care, but there were no amenities of the kind we are used to having in a US hospital. We noticed a similar pattern in Switzerland, when one of our executives broke his leg on the ski slopes and was airlifted to the hospital for emergency surgery. The surgery was done flawlessly, but he was kept in the hospital for two weeks, and had almost no amenities.
With that in mind, I was most interested in the first-person narrative of an author named Firoozeh Dumas in the Sunday, January 27, 2018, issue of the New York Times, entitled "After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea." The author described a major surgery she had in Munich, more specifically, the very different practices of German surgeons relative to pain management, after surgery. In contrast to what she had come to expect in the US, the German surgeon initially told her she would not get a prescription pain killer, but would get Ibuprofen.
More revealing was his comment, which the author paraphrased and translated; "Pain is a part of life. The pain will guide you....If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you....And please be careful with Ibuprofen. It's not good for your kidneys. Only take it if you must. Your body will heal itself with rest."
Imagine an American hospital confronted with the same kind of request from a patient. Our doctors do more, and are far more accommodating to patients. They are also graded by Medicare on patient satisfaction with their attentiveness to patient complaints of pain. The scenario this author describes probably would be very unlikely in an American surgical setting. Similarly, she asked for stool softeners, but the surgeon directed her to sip coffee slowly and have the coffee serve as a laxative.
The reason this story is worth retelling is that anyone who believes that we can replicate the lower costs of healthcare by importing a single-payer model from another country is failing to take into account some of the attributes of our healthcare delivery system that we take for granted, but that are not standard practice outside the United States. As a general rule, we are far more impatient and intolerant of pain or of delays in getting care for medical conditions that give us discomfort. In fact, many Medicare patients end up going to the emergency department for a non-urgent and relatively minor problem if they wake up with it, because they do not want to wait for the doctor's office or the urgent care clinic to open at 9 am.
Our impatience is deeply imbedded in our culture in large and small ways. I spent 10 days in Ottawa with my son James at a chess tournament and went to the one coffee shop open at 7 am every day, the Tim Horton's. At the Starbucks where I live, there are two cashiers and almost no one waits more than two minutes to have an order taken by a barista. At the Tim Horton's, we were 18th in line and there was one cash register being used. Everyone patiently waited 20-30 minutes to get served.
This "quick fix" mentality is more prevalent in America than anywhere else, with the possible exception of China. The lower-cost, higher-quality developed country healthcare systems in countries like Germany, Italy, the UK, Switzerland, Canada, and the Netherlands work, in large part, because these countries focus on delivering necessary care through primary care physicians, not elaborately gold-plated care that dazzles patients, but is over and above what a patient needs.
In fact, I would argue that the German surgeon may have a better case for his point of view than the American physician who quickly gives the patient a prescription for a medication that masks pain. I visited with a great podiatrist named David Armstrong from Arizona who referred to the devastating effect of diabetes in depriving patients of "the gift of pain."
There is no right answer, but there are very clear cultural differences that make the adoption of a single-payer system less likely to achieve the results it achieves elsewhere if used in the United States.

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