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Just as you suspected: The doctor at the government hospital is Dr. Bureaucrat

By Daniel M. Ryan
web posted October 10, 2005

As a result of an overly enthusiastic bout of branch-cutting in the wake of a tree-damaging windstorm which visited the city of Toronto a week-and-a-half ago, I have gotten a six-day first-hand glimpse of the public heath-care system in the province of Ontario at the emergency level. This is not a story about being on a 180+-day waiting list for an operation, as the nature of my recent injury was such that I would have had a crooked limb had I not gotten an operation for it within three weeks, maximum.

I write this now with a still-broken left forearm; it broke near my wrist and at/in my elbow as a result of me falling six feet off a ladder while sawing at some branches whose height above the ground was such that I needed to use a small folding ladder. The branches in question were from part of a neighbor's tree which had fallen onto our side of the yard; what got me cutting them was a concern that some of the trees on our side were, or would be, damaged by that fallen limb, which had comprised about a quarter of that large tree. It wasn't just neighborliness which had motivated me; I have to admit to a kind of zeal inspired by sympathy for the victims of Hurricanes Rita and Katrina. However inconvenient the work I planned to do with the saw and the leaf-bags was, it seemed small by comparison to the clean-up responsibilities of the suffering residents of Louisiana, Mississippi and Texas this past month.

My zeal could be the attributed cause for my recklessness while up there, or my clumsiness in "landing wrong" could be blamed for the fracture, or the cause could simply be the embrittling of the bones of a nearly middle-aged man. This was the first bone fracture I have had in my life.

Before I get into the more immediately relevant experiences I have had when in the hospital and the conclusions which I have drawn from them, I should note one experience which has a relevance to the continuing legal troubles endured by Rush Limbaugh over his alleged abuse of the painkiller OxyContin, a story whose latest installment appeared in the news about two weeks ago. I tend to be a "tough guy" when enduring physical pain, but the pain which resulted from the fracture made me howl like a wounded animal, not only right after the fall, as well as after repeated attempts on my part to get out of bed so as to get myself to the emergency ward of the hospital after successfully "crawling back to my lair," but also at the emergency room itself when my arm was examined. I had to use a stiff upper lip when waiting to be admitted and while going through the admittance procedure, but this was only possible because my left arm did not need to be touched. Once it did, after my admission, the pain resulting from the grating of the bone pieces against my interior forearm muscles, and the nerves in there also, was simply too excruciating for me to do anything other than – howl like a wounded animal. The emergency room staff had to administer a double dose of morphine in order to make me fit at all for the necessary X-ray procedure, and I was damned glad of the dulling of the pain that this drug brought.

Experiencing this kind of excruciating muscle pain – a level of pain which is hard to even believe in the possibility of unless you've gone through it - makes Mr. Limbaugh's subsequent trials take on a wholly different meaning. Instead of snickering over his "secret drug habit," you begin to wish quite fervently that you don't wind up with a similar dependency yourself because you suddenly feel how necessary narcotics are to even tone down such pain. I can say as a result of recent experience that there are orthopedic injuries which carry with them a level of pain which requires a level of narcotics which both make you "dopey" and only endullen the pain of such an injury. It should be of little surprise that the orthopedic trauma unit has always been the part of the hospital where morphine has been "dished out like candy;" principled refusal becomes little more than fools' folly after only a few hours.

The pain drugs also made me somewhat chatty and perhaps even charming, but it is hard to say whether or not this is a direct result of the pain medication or an indirect consequence of the "blessedness of relief" from the pain.

A health-care cynic could point out that the ready, though limited, availability of pain medication serves also as an anodyne against the discomforts of waiting for treatment. It doesn't; nor does the assurance that the cost of the entire procedure will be picked up by the government offer any assuagance. In fact, an argument can be made that the "free" element of a government heath-care system has been put into place to assuage the qualms of the <I>staff</I>, not of the patients. A system where the government pays the patients' bills means that a patient who wants, or needs, treatment ASAP has far less rationalistic grounds to press for this, and is far easier to cast as merely self-seeking and/or querulous by hospital administrators. As a result, the incentive to look for time efficiencies in the delivery of health-care solutions evaporates under a "free" system.

This replaces one kind of cost with another. The financial cost which has to be assumed by the patient is gone, but this cost has been replaced by a cost of the patient's time; because any incentive to improve the time-quality of health-care services delivery has been obliterated, the time-cost of such a system rises once the transference from private to government health care has been effected, as later improvements of procedures, as well as new procedures, developed after nationalization lack the earlier time optimization of the ones developed under the earlier private system.

"Free" heath care imposes additional <I>psychological</I> costs upon the patients in it. I should add that such new costs do provide a large corresponding incentive for someone to avoid becoming a patient in the first place. This hidden set of non-monetary costs does consequently reduce demand for government-owned health care services once word of them spreads, which does explain the apparent paradox of the findings that a government-owned heath care service is cheaper to run than a hybrid system like the U.S.'s. Trivialization of patients' complaints, except for the ones which can be alleviated by a "technical fix," has not entered into the American health care system to the extent to which it has in a fully government-owned system.

Another source of psychological cost is not inherent in a government- owned health-care system, but is inherent in one which is centralized for reasons of operational efficiency. It seems a real honor for the local hospital to win a designation as the best place for a certain kind of treatment, but this engenderment of pride does carry with it a huge letdown later: if your local hospital has a deserved reputation for the best care of your injury for the entire county, region or province, then everyone from that same county, region or province is going to be demanding to be sent to the same ward where you will be too. This implies longer lineups.

I found myself in the triage category which bears the brunt of the cost of such provincial "magnet hospitals:" my injury was too serious for me to walk away with a cast, as the broken bone in my elbow would have fused in such a way as to leave my left arm crooked for the rest of my life, but it was not serious enough to be life-threatening. This meant that anyone <I>within reach of the hospital through means of an ambulance helicopter</I> who had an injury deemed "life- threatening" would get ushered into the operation room ahead of me – and that my preparative fasting for an operation would prove to be an exercise in frustration.

This happened to me for most of the days I stayed there. A day spent with no food or water from 12 AM would end between 6 and 8 PM with the word that the operation I had been abstaining from liquids and food for was not available for me that day because of yet another new patient being ushered directly in to the operating room as a result of his or her injury rating a most-serious designation.

Theoretically, this should not impose that much of a psychological burden upon those in the second tier, but when the behavior of another patient does not match up to their top-need triage designation, it does awaken a kind of spitefulness. "That guy you say is sicker than me don't act as if he's that sick. Is he pulling strings or something?"

This impression can definitely be misleading in a ward where pain medicine is dispensed on a regular basis; such "lording it over" on the basis of triage category may only be the result of compensatory bravado on the part of a much sicker and more drugged-up person than oneself is. I would go so far as to note that this is the most probable explanation for such apparent unfairness. But a systemic weak point such as this, where the most logical response to any complaint is to automatically treat it as merely symptomatic of mean- mindedness, does put a penny in the fuse box which will muffle any emergent signs of real string-pulling in the future.

The hidden vulnerability of the ostensibly efficient centralized health- care system to this kind of string-pulling is aggravated by the overall tradeoff criteria of the triage system which is part of it: minimization of legal liability and minimization of political liability, especially through the avoidance of damaging media stories. This implies that the next breed of hospital fixer under such a system is going to be the person with connections to the media. "Press pull" will be more efficacious than political pull.

These conclusions are the result of my own experiences as a patient of a health-care system which is organized and does function as a results-driven bureaucracy, as opposed to a rule-enforcement bureaucracy. It's only the latter which is prone to "bureaucratic laziness"; the former isn't, because results are what is watched for, and are also explicitly tracked. The professionals in a results-based bureaucracy tend to be unconscious Veblenites as opposed to unconscious Weberites; the consequent Veblenite contempt for the private sector as a breeding-ground of waste and inefficiency, as a result of the presumed inherently obstructionist nature of the price system, makes this kind of bureaucrat both officious and very hard- working. Because of this kind of motivational spur, any attempt to reform the government-owned health-care system through privatization measures will be one of the hardest privatization sells possible, because the present government-owned system both looks and acts much more efficient than the old country-doctor and charity- hospital setup. Add to this the fact that the true added costs of "free" health care are psychological, and therefore are obscured, and the privatization advocate does face the dilemma of advocating a system where the benefits are immeasurable but whose corresponding drawbacks are immediately evident to the average person with an average amount of common sense.

I should reiterate, as emphasis, that the reintroduction of a patient- paid system would detrivialize complaints based upon wait times and reveal that the slipstream efficiency of the government-owned hospital has come at the expense of letting other efficiencies fade away because of their supposed irrelevancy. What doctor would like to be shown up by a now-needed time-and motion consultant?

Given this mighty set of obstacles, there's only one piece of patient- to-patient advice I can give for those who wind up in the same boat. Roll with the triage system in this way: unless you are sure you can qualify for a top-of-the-line spot, go to the least distinguished hospital you can get to. Incentives for advancement of treatments are directed by the same triage system which governs who gets into the operating room first; as a result, the care you would receive at a smaller, more out-of-the-way hospital would be of the same quality as you would get in the famous "magnet hospital," even if appearances do not suggest so, unless you qualify for the top-priority list. The difference in the level of care is concentrated at the life-threatening end.

So, if you have an injury which does not qualify you for the helicopter- ambulance-to-the-big-city treatment level, I suggest that you check into a smaller hospital which either has a small, disused helicopter pad or none at all. The staff there will probably be more easygoing, but, because they are pegged as mid-range anyway, are much less likely to receive a patient who will be whisked into the operating room ahead of you despite you being checked in first. The sense of time- certainty which this will grant is, I would argue, well worth the possibility of a slightly longer stay there.

Especially if the sight of hard-working and officious people inside a hospital where you've been benched makes you even more stir-crazy!

Daniel Ryan can be reached at danielmacryan@yahoo.com. (c) 2005 Daniel Ryan

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