Dr. Garfield's Dilemma

This story is purely hypothetical. Any resemblance to characters, real or fictional, is purely coincidental. Wonks Anonymous is not a doctor and any errors in medical fact or interpretation are his and his alone.

Dr Sydney Garfield practices medicine in Richmond California, a working class suburb of San Francisco. He is worried about one of his patients. George H. has come into to see Dr. Garfield after spending an entire day in bed with severe dizziness and nausea. George, who has a history of migraines, now has no symptoms other than exhaustion and appears to have no weakness, lack of coordination slurring of speech or other symptoms that would indicate a stroke or other neurological damage. 

George is not very active. He is a security guard and spends most of his day at a desk. He is overweight, although not clinically obese, and he takes a diuretic to control mildly elevated blood pressure. George has just had a baby and he is suffering from sleep deprivation. In their conversation Dr. Garfield also discovers that George's employer has just converted the company health plan to a new value driven product with an $8,000 family deductible. George has not met the deductible and he is worried about the cost of the doctor's office visit.

Although George does not appear to be in immediate danger, Dr. Garfield would like to order an MRI scan to make sure that the blood vessels in George's brain are normal. Dr. Garfield knows that George will have to pay over $1,000 for the MRI and that this payment will be difficult, if not impossible. What should Dr. Garfield do?

Clearly the best choice here would be to find a way for George to get the MRI free or for a reduced rate. If Dr. Garfield were rich or knew of a community organization that helped with such cases he could arrange this. But what if Dr. Garfield is still in debt for his medical education and his practice is not that lucrative? Suppose all of the community agencies are already using their resources to help those who have no insurance?

Should Dr. Garfield rely on his hunch that George is just suffering from sleep deprivation and skip the MRI? The additional strain of paying for the test will only exacerbate George's stress and this might cause more harm than waiting and praying.

Wonks Anonymous is an economist, not a doctor and he does not know the answer to this one. He does know that the question would not even have come up if George H. had old style, comprehensive health insurance or if George H. had a high paying job.

Is where we want to go: To a world where there are two standards for medical care, one for the well off and one for the rest of us?


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  • 5/16/2008 3:42 AM R Garth Kirkwood MD wrote:
    This hypothetical situation describes the following reality. Instead of unobstructed doctor---patient relationships, we have doctor---$$$---patient relationships, where interference from the dollar bill determines the direction of health care. This interference can occur at many different levels. As long as health insurance companies are involved, this dollar obstruction will remain to enhance insurance company profit. Even after health insurance companies descend into oblivion in favor of a single payer, there will still be the dollar obstruction, if billing for medical services and product remains open-ended, i.e., the free market. (Bill as much as you can to support the highest profit margin humanly possible) This is why the legislation, HR 676, from Representatives Conyers and Kucinich will create the same problems as the single payer systems in Canada and Great Britain. It leaves the dollar bill in the driver's seat by making the occurrence of health care dependent upon a budget. When the budget becomes subordinate to the occurrence of health care, a single payer system can function properly. When a single payer sets prices paid for services and product in advance and when doctors are free of financial conflict of interest, everyone living in America will have clear and equal access to sound, ongoing, unobstructed, unconflicted doctor---patient relationships. Then, it will be the job of the doctors and patients themselves to see that this relationship functions properly. Local peer review and quality assurance review from the single payer apply.

    R. Garth Kirkwood MD
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