Doctor’s Watch Dog

It took some doing, and S.Q. Lapius had to introduce himself as a former classmate of Charles C. Edwards, assistant secretary for health of the Department of Health, Education and Welfare, but finally the call was put through, Lapius motioned to me to pick up the extension.

“Hello, Charlie.  S.Q. Lapius here.”

“Who?”

“You may not remember me--.”

“Of course I do, S.Q.  It’s just that I get so many calls.  What can I do for you?”

“I’m just curious why you are pushing so hard for these Professional Standard Review Organizations, Charlie.  After all, you are really putting a watchdog on the doctors.  I am not sure they deserve that.  But in addition, it may hamper their care of patients.  It’s hard to make independent decisions if you have some government agency looking over your shoulder all the time.”

“That’s the wrong way to look at it, S.Q.  Actually, I believe that the PSRO’s can provide the medical profession with a vehicle for change whereby the best and most effective of care becomes the standard care.  We can establish norms that all physicians can adhere to.  For instance, if a patient with a heart attack could do just as well with two weeks of hospitalization, instead of three, then the PSRO should be able to shift the pattern of care.  No one will be looking over your shoulder.”

“You will be looking over my shoulder.  Why should a doctor be concerned about what your governmental organization decides should be the national norm.  Every case must be decided on its merits.”

“But you know as well as I that three weeks of care for a heart attack is too long.”

“No, Charlie.  I don’t know that.  It depends on the case.  Sometimes five weeks is too short.”

“But look at all the hospital beds we would free for other cases, Lapius.”

“If you are short of hospital beds, Charlie, build more.  The practice of medicine has a right to change slowly.  Doctors have to adjust to new norms at measured pace, not be pushed into new value judgments by a government agency.”

“You know, Dr. Lapius,” Edwards was becoming acerbic, “We must consider society as a whole, not just the patient.”

“No so, Charlie.  We must consider the patient only.  He doesn’t come to us to have us consider him in light of other social pressures.  He wants to survive that heart attack, and he wants to be in the safest environment possible until he recovers.  Sure we may be extravagant with time and hospital beds, but that is what the sick person expects and needs.”

“But we can’t take care of all our citizens on that extravagant a basis, doctor.  It is not reasonable to expect that.”

“Why not?  We took care of Europe after the war to the tune of countless billions.  We are still sending aid to Vietnam and India and a number of African countries.  It would seem to me that the list of priorities should have our citizens on top.”

“That’s a political question.  We can’t get involved in that.  Incidentally, not to change the subject, but we are coming out with a new national health insurance plan, which will afford every American the opportunity to obtain health insurance, and we are offering a broader benefit package than we had previously considered.”

“I see,” commented Lapius, “And you won’t build more hospitals, but will insure beds for this increased population of patients by mandating shorter hospital stays, bringing pressure on the doctors to send their patients home earlier.  You know, Edwards, not every patient who leaves a hospital goes to a posh home, with proper heating and facilities, or a loving family waiting to render proper nursing care, or the wealth to buy it.  Some go home to cold water flats, poorly heated, no insulation, no family.  Are these patients going to be discharged early from hospitals?”

“But Lapius, the nation has to be careful.  As we extend health care to everybody, the cost becomes stupendous.  We will have to raise new revenues.  We will have to manage the system with great restraint.  Otherwise we would have intolerable cost escalation.  It is the responsibility of the doctor to monitor costs.”

“The hell it is.  It is the responsibility of the doctor to take care of his patient.  That is all.”

“That is where we disagree, Lapius.  The fact is that we can’t construct a system that is inherently perfect, not so long as patient care is a matter of judgment.  Incidentally, Lapius, I don’t remember you exactly.  Were we in the same class?”

“No.”

“But I thought you told my secretary we were classmates.”        

“Well, thanks for your time, Dr. Edwards.  It was nice talking to you.”

Lapius hung up.  “There you have it, Harry.  You heard him.  He is going to take the judgment out of medicine.  Next they will remove the compassion, and all the elements that make it a humane profession.”

“But you admit there is a problem.  To extend medical benefits we will have to expect to pay a big bill.”

“Well, that’s preferable to lowering the quality of care.  Medicine won’t be improved by the imposition of a medical Czar who will tell each of us what to do and when.”  

“You never were in the same class as Edwards, were you Simon?”

“I would put it another way, Harry. He never was in the same class with me.”

(The source for this article was written by Dr. Edwards for Medical Tribune, December 5, 1973)