SCOTUS, Aphasic Ladies, Pot, and a Car Crash

I was planning on posting pictures of our gummy candy bonanza, but then today happened.
There was a pretty significant SCOTUS decision made today, and I had a long an eventful work day. The gummies, news, and musings are all swirling around in my head and I thought I'd spew them out to share with any insomniac friends (or 2 AM nursers) who cared...


So I think by now we all know what SCOTUS concluded:  the healthcare mandate IS constitutional, and will become the law of the land.
Healthcare coverage is a truly wonderful thing. You don't know when you're going to be jumped on the street by a few guys with baseball bats. You can run weekly marathons and eat an organic paleo diet, and it's not going to prevent you from ending up in a coma with tubes that you breathe and eat through. Your habits MIGHT help you actually survive getting your skull bashed in to get to a rehab hospital, but doing the right things and having good genes aren't going to prevent you from needing healthcare.
And preventive medicine is a wise and wonderful thing. Spending a few hundred dollars teaching people to control their or their children's diabetes can save hundreds of thousands of dollars of medical care in the future. A few thousand dollars of prenatal care can prevent many more thousands of dollars of intervention if birth defects are prevented. It's just money wisely spent.


We have amazing healthcare in our country. And lots of it. You can find a healthcare provider on just about every corner in Boston. And lots of good ones. Yes, I know that not everyone in the U.S. has top-notch specialists on their street, but if you are willing to drive a bit, you can get to one. I take great comfort from the idea that, if needed, we could fly any family member to Boston to treat any rare malady that might occur. Healthcare is easy to get. Healthcare is of high quality. Healthcare for everyone!


According to a few randomly-googled sources (CNN, MSNBC and kaiserEDU.org,) healthcare spending is currently around 17 or 18% of GDP. That's almost 1 out of every 5 dollars spent in our nation. Wow. Don't get me wrong, I think spending money to birth healthy children and keep them healthy is a good use of my money. I think spending money to keep my family members' blood pressure in check to prevent debilitating strokes is a good use of my money. But here's a question:  is there such thing as spending TOO MUCH money on healthcare? Is there a percentage of GDP that we Americans could all agree is just spending too much on our health? Would we ever hit the "outrageous" mark? Or even agree that there is such a thing?


Please don't accuse me of supporting "Death Squads". I work in geriatrics, I think preserving the health of seniors is part of the Fourth Commandment. (That's "Honor your Father and Mother" for those who didn't attend Catechism class...) An extra healthy month at the end of a 95 year life IS valuable. BestestHusband wisely stated once, "I'm happy that we live in a country that values life." We were discussing DNR orders and related topics, and the fact that it's not easy to discontinue someone's feeding tube or breathing machines. Life is valuable. We need to err on the side of preserving it, even if much money is spent to do so. This is a noble concept.


But reality sets in at some point. Doctors and nurses must be paid. Enteral feeding supplies aren't cheap.  I've never worked in a medical facility that has its own money tree. Rationing already happens at various levels.


I do it regularly.


When I evaluate a patient, I must admit that I consider multiple variables in deciding "yes, she needs therapy" vs. "no, she's fine without us." Some of these variables are patient-specific:  medical history, pt motivation and participation level, family support and discharge plan, the baseline activity level of the patient. In other words, if a 40 yr old IT manager who just got married has very mild deficits but wants desperately to get back to being 100% of her baseline self so she can get back to work and start her married life with her husband, I'm picking her up for therapy. I'm going to max out my available time with her to help her meet her goals. Conversely, if a 75 yr old man with a history of medical non-compliance has mild deficits, but at baseline sat in a recliner watching TV all day and was taken care of by his wife, I might not pick him up. Especially if he didn't seem to try very hard on his eval. Do they have the same deficit level? Yes. Do they have the same ability to significantly benefit from the services I offer? No. Does the optimist in me say that "everyone deserves a chance" and "maybe I can help him despite himself"? Well, yes. But sometimes external factors make a difference.


The factors that I also take into consideration include:  what is our current caseload; who's available to help manage a large caseload; are many people up for discharge soon; how needy are the other patients on my caseload? These are factors that some might argue are unfair to consider when looking at a patient's allocation of therapy time. Maybe. But the factors and the limits they impose are REAL.


This allocation issue came up today at work. My optimism-killing patient is off caseload. He was sucking time from the patients who really WANTED to do therapy. The other therapists have to keep him a few days longer and are grumbling about it. He's sucking their energy, their spirits, and their time from more motivated patients. One of the therapists is pretty sure his family is bringing in pot that he sneaks out to smoke. Well, they sneak him out to smoke it. He's pretty dependent and can't really get himself too far... Let's compare this guy with a sweet aphasic lady I saw today. She's so impaired that she can't communicate basic requests for toiletting, food, or going to bed. But she's SO MOTIVATED to get better! I think I could easily spend 3 hours a day with her in speech therapy. Her husband would spend another few hours helping her out with homework activities. She would benefit from the therapy. My time invested in her would yield good dividends. It's a good resource allocation. Our pot-smoking, therapy-cancelling, drug-seeking, medically-noncompliant gentleman... well, I'm arguing that he's not a great allocation of our scarce resources. Who would you give an extra 30 minutes to? The eager aphasic lady? Or the "screw you" pot-sneaking guy?


Are we allowed to decide this on a grander scale? Who decides? I like to be an optimist and give people a chance. But this guy clearly blew his chances. Right? Or did he? If all Americans get healthcare that is subsidized by all other Americans, do we get to a point that we start setting limits on what people get?


What sets those limits? Age? Genetic factors? Lifestyle factors and behaviors? Financial resources? Realistically, we know that increased financial resources will always get you increased medical services. (The US has many well-respected hospitals with private-pay patients that fly in from all over the world.) Certainly at some point we as Americans need to calmly discuss that fact that our current habits of healthcare use just aren't sustainable for the long-term future. But will we? Can we get past the "I'm special, and I need all available resources.!" but still honor the Fourth Commandment and our nation's history of revering life?


So now to mention the car crash:  I was having a patient read from the newspaper to practice using clearer speech, and I noticed a picture of a strangely-familiar face to the side of the article he was reading. I eventually got the chance to look at the picture and recognized the face of a nurse I used to work with. Under the picture, it said "Tragic: Sarah E.*" She was one of those wonderful nurses who spent her career honing her calm demeanor and ability to create happiness and peace in the patients in her care. She worked with patients who had advanced dementia. She was a mother and grandmother. And she was killed in a car crash on Sunday by an illegal immigrant. Tragic. Life is sometimes just really unfair.


Can we create a "fair" healthcare system? Can we afford it?


Time to go into practice working with rich people who can afford to pay privately. Might be my best bet for job security...


*Sarah E's family could probably use some more prayers, if you're inclined to pray for strangers. God knows who you're referring to, I'm sure...