Society’s health should not be doctors’ responsibilities


I thoroughly enjoy my 65-year-old male with his horrendous diabetic foot ulcer.  But there’s not enough insulin in the state of Tennessee to cover the two bacon, egg, and cheese biscuits he eats every morning.

And I adore my 57-year-old female with COPD.  But the inhalers won’t work until she stops smoking two packs of cigarettes per day.  I laugh every time I see that hilarious 32-year-old with hypertension.  But the ACE, calcium channel blocker, and diuretic won’t overcome the cocaine he does every day.  And the 42-year-old female that already has cirrhosis?  Her smile lights up the exam room.  But her liver won’t improve until she slows down on the 12-packs.

Fast food companies can make it seem so fun to eat an extra meal, but it’s my job to deal with the obesity.  Cigarette companies can make smoking seem so sophisticated, but it’s my job to salvage the lungs.  Beer brands can make it seem so glorious to drink.  But I have to deal with the devastation that ensues.

Modern health care feels that it’s my job, as a physician, to fix society’s health problems.  It’s really not.  My job, or at least what I’ve come to see, is to help guide people through their own health issues.  In the minuscule amount of time I get to interact with a patient (maybe 15 to 30 minutes every month), it’s impossible for me to overcome the habits/decisions they make all day, every day.  Especially considering how often they’re bombarded with the advertisements of the things that harm them the most.

Think about it.  Society’s health is my responsibility?  Nope, it’s really not.  Society’s health is society’s responsibility.  Physicians are a very small portion of society.  My health is my responsibility.  My patients’ health is their responsibility, despite the fact that I lose sleep over them constantly.  Despite the fact that I’m woken up at all hours to help take care of them.  But in the future, I’ll probably be “graded” by how many of my patients’ A1cs are at goal.  I may even be paid by how many of my patients’ blood pressures are better than 140/90.  I’ll be paid for my performance according to certain business metrics.

So that 65 year old with the diabetic foot ulcer?  Probably going to lower the grade.  He’s told me how much he loves his breakfast sandwiches.  And the 57 patient with COPD?  Still my patient, and I’ll counsel her every office visit, but she’s told me she’ll die with a cigarette in her hand.  The 32 year old?  I’m going to give it my best despite probably getting paid less.  And the 42 year old who drinks?  Yep — I’ll see her as often as I can, and do whatever I can, but she’s not going to make my health outcomes look any better.

It won’t take long for physicians to figure out health care “grade inflation.”  Most physicians mastered grade inflation long before high school.  Health care grade inflation is rather simple: Just cut out the unhealthy portion of society.  Cherry pick the patients that take responsibility for their own health.  It’s so much easier to control a patient’s diabetes if that patient follows their recommended diet.  Lungs clear when the cigarette assault stops.  Livers regenerate after successful rehab.

The obvious problem is that nobody will want to take care of society’s sickest.  The smokers, the alcoholics, the fast food addicts, the drug addicts — those are going to be the ones that suffer — the ones that require the most but yield the least results.  The ones that honestly need physicians.  And the physicians that truly care about them are going to have the lowest grades.

They’re patients.  They’re people.  They’re human.  They’re the reason why I got into medicine.

And they are not business metrics.

Justin Reno is a family physician.

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