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 staff, 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 psychological 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 within reach of
the hospital through means of an ambulance helicopter 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 [http://www.danielmryan.com] can be reached at
danielmacryan@yahoo.com. (c) 2005 Daniel Ryan
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