by Esther Buddenhagen, MSW

I write as a lay person concerned about the gap between what many people should receive and what they actually receive. The question of good medical care for ordinary people is being buried not only by insurance issues but by failure to come to terms with what primary care should be about.

Even Atul Gawande, who is particularly good at making distinctions between good and necessary care versus profit-driven care, doesn’t appear to completely understand the question. In an interview with Ezra Klein last June, he talks about the current science underlying medicine mentioning that we have “13,000 diagnoses….more than 6000 drugs and 4000 types of operations and procedures.” He goes on to say, “I think the extreme complexity of medicine has become more than an individual clinician can handle.” He holds up the Mayo Clinic’s team approach as something we might consider.

I wish he and others involved in this debate would actually put themselves on the ground, so to speak, experience an ordinary neighborhood as both patient and doctor. The Mayo Clinic is not the right model. People go to the Mayo Clinic they need complex care.

Most people who go to the doctor don’t need the latest medical technology. They need a doctor who knows them and understands how they interact with their medical problems; who first offers the least intrusive care: who provides the special compassionate support a physician can provide to regular patients and which builds up trust; who knows when to make referrals and who is able to coordinate care with specialists. As coordinator, she should maintain a list of all medications a patient is taking, all specialists he’s seeing, etc. to not only enhance the patient’s treatment but to offer support and answers to patient questions about their care.

Perhaps, too, there should be layers of specialization. Thus, a healthy woman may need a pap smear, but not all the procedures that accompany it today in a fancy practice. The fancy procedures should be saved for the next level. And perhaps only at the next level should all the machines be available.

In a similar vein, there have been articles saying that preventive medicine costs more than defensive medicine. Again, it strikes me that a primary care physician with a good relationship with his patients might be able to deal with preventive care on the most basic level with simple efforts and to good effect.

I live in Mexico, in an area which is not rich. Here middle class people get good to excellent care. The national medical service which all people who work in the formal economy are covered by has clinics in many locations. A patient is assigned her own physician in one of these convenient places. Doctors spend more time with patients than any I’ve been to in recent years in the US. There is a hierarchy of up-to-date specialist care. Friends have had bypass surgery and cancer surgery and are doing well.

I mention the Mexican system because I think many people in the US don’t get anywhere near the care middle class Mexicans get. It seems unlikely that US physicians would consider looking at the Mexican model, but it seems to me that our health care argument should be starting at the first level of care, not the highest, and one should look hard at the virtues of non-profit systems.

Esther Buddenhagen is a retired clinical social worker.

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