Dermatology Online Journal

Parable: The broken reed
Mauricio Goihman-Yahr MD PhD
Dermatology Online Journal 15 (1): 12

Professor (E) of Dermatology and Immunology, Vargas School of Medicine, Central University of Venezuela, Caracas, Venezuela. mgoihmanyahr@yahoo.com

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Disclaimer: The contents of this paper represent the writer's own opinion but do not and do not intend to represent those of the Central University of Venezuela.

King Hezekiah was warned by the King of Assyria not to rely on "This broken reed".

The "Broken reed" metaphor has been used so much, that the reader may miss its tremendous strength and the clear image that it conveys. A reed makes a very poor support. It does bend under weight. A broken reed is even worse. It may wound the hand that holds it in hope of succor.

The provision of health care and related subjects have been major problems for governments, providers, and potential recipients. This is the case, partially because of the true complexities and importance of the matter, and partially because of the emotional and political overtones that enhance its value for all involved.

The basic needs of human beings are food, drink, shelter, clothing, and personal safety. Health care comes only after these other basic needs. One can live for a long time without professional health care, but not without these other basic requirements. Yet, physicians, politicians, and the people of many countries do feel that health care ranks above some other basic needs as a right. Physicians also have a complex relationship with the subject. Our job is not simply to have the knowledge and technical capacities to perform a task following certain ethical rules and under the law. Our job is not merely to earn fees for work done under the specifications that the laws of contemporary societies allow. Our job is to promote the maintenance and preservation of the health of body and mind of our patients and our populations; the complexity of this surpasses current knowledge. In addition, we must somehow integrate and harmonize our lofty ideals with down-to-earth cost to benefit analyses. To add to the difficulty physicians carry the same complement of human weaknesses – graft, greed, pride, and fear – as everybody else.

We may look nostalgically at the Hippocratic training of the past that involved a few chosen students and a single master. We may miss the one-on-one direct patient/physician relationship based on mutual trust. But in those simpler days, there were only simple medications and crude hand-held instruments. We do want to maintain the best of that heritage; today, however, conditions are very different. The needs of large populations are overwhelming. Government involvement and extensive resources are a must for public health, training, technology, and research. The practice of modern medicine needs an enormous source of money and has to be organized under a certain structure. Physicians (and patients) have to give up some of their independence and freedom of choice to permit the flow of resources and organization.

Socialist countries developed structures that involved central planning, financing, and controlling of most aspects of health care. This was coherent because other facets of society were similarly organized. The Soviet version of socialism failed, but this does not necessarily mean that all types of socialist nations and their health care structures have failed or will fail. Indeed, Scandinavian countries are examples of the contrary.

The United States and many other countries have opted for taking health care as an industry with certain regulations and needs, but basically as a for-profit enterprise. This enterprise needs doctors and patients (now called providers and clients). To recruit doctors and hospitals this industry has promised income and delivered improved organization. To prevent the problems brought about by organized labor, doctors and other personnel have avoided becoming employees; but are effectively lessees. Physicians have grasped at these companies of pre-paid health care as a support. They have found a broken reed. The way in which they are organized has produced the progressive destruction of the patient-physician relationship and of medical ethics. The latter has been replaced by lawfulness, which is not the same. The patients have progressively lost their freedom to choose their physicians. Slowly but surely treatment has become more a matter of economics than of patient need. I have experienced the previously uncommon occurrence of having patients travel from the United States to my office in Venezuela to be seen by me (as well as by other physicians that they trust). Soon, assistants will perform medical procedures, not because they do them better, but because they cost less. Supermarket chains may be the current model to deliver goods of fair quality to a great number of people. Supermarkets should not be a model for health care delivery. In addition, under the American health system, care is not available to a sizable proportion of the population unable to pay required insurance fees. How should this be improved?

There should be an organization (under governmental aegis) that would take care of public health (water, physical infrastructure, air, immunizations, epidemics, and catastrophes) plus a public autonomous insurance that would strive for financial stability, but not necessarily for profit. Beneficiaries would pay a fee; the government would subsidize those that cannot pay it. Beneficiaries would be able to choose their own physicians who would be paid directly by the patient. The latter would then be reimbursed by the insurance. Patients would pay a deductible out of their own pocket to prevent overuse. Physicians might charge whatever fees they wish, but the insurance would reimburse only the prescribed fee. Patients would also be able to choose physicians who would charge only what the insurance allows. Physicians would then have their own patients, who would choose them under flexible fees. There would not be infamous capitations or "gate keepers." No person would remain without basic medical care. Needless to say, I am not original in this suggestion. The French have carried this out. Their insurance is valid worldwide. I have seen patients from France in my office and it takes me five minutes to fill out the required forms by hand. Patients perform the rest of the paper work, which is not difficult. The above does seem better than a broken reed.

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