Also, as the United States learned long ago, providers are not evenly distributed. Rural areas are a problem. Low-income urban neighborhoods are a problem. The massive growth in medical groups and salaried physicians — both of which I support — means that there are often fewer practitioners in disadvantaged settings, and it is much more difficult to find a physician who will accept a Medicaid patient.
The report on Taiwan found that one reason for a shortage of OB-GYNs is that the birth rate is so low that there is not as much demand as there once was. On the other hand, expect a boom in that specialty in China now that the one-child-only policy is toast.
The basic issue is that clinicians, like anyone else, want to have good quality of life, an acceptable income and a comfortable practice environment. The sometimes dreadful rural health centers in Cambodia are not going to float that boat.
There are all kinds of schemes being tested: Work in a rural area for a while and your medical school debt will be obviated; we’ll pay you more if you work here; or, in some situations, here’s where you are going to work, period.
But there is another issue here, which is that many health care professions have established certification and licensure and scope-of-practice requirements that are not necessary. Walgreens and CVS and Wal-Mart did not get into the primary care game by hiring physicians; they hire nurse practitioners. Pharmacists and techs give flu shots.
Many nonphysician clinicians can diagnose a cold. So can your mom. Most countries are reconfiguring their health care workforces to ease the burden on the physicians they do have.
There are things that only physicians can do — I don’t want a lab tech performing surgery on me. But the international trend is to broaden the scope of practice of health care workers and, in most cases, it works out fine.
And one of the most valuable tools at our disposal, in dealing with workforce issues, rural health care and quality improvement, is health care information technology.
Telehealth makes it possible for a physician in Bangladesh to seek a consultation with a physician from the Mayo Clinic. It also makes it possible for a patient with diabetes or heart disease to send A1C or blood pressure data electronically. The day of the prescription scrawled by a busy physician in indecipherable handwriting is ending, as e-prescribing becomes the norm. The integrated health record is becoming the preferred means of keeping patient information, especially in Singapore, which is so far ahead of the United States in this regard that I was almost embarrassed when I visited there.
Are there issues? Well, yeah. Providers in the United States are still protesting about having to adopt ICD-10 when many countries are preparing to adopt ICD-12. Some physicians are still relying on paper records, and I think it may take a nuclear weapon to get them to change.
And privacy of personal health information is an issue everywhere. I learned that in Singapore, despite total transparency and availability of health records to patients, people cannot gain access to their records at home over the Internet, because the system is wireless and therefore can be hacked. However, any patient can gain access through hospitals and clinics, many of which have do-it-yourself kiosks. A friend of mine told me, “Oh, only the old people actually use the keyboards on the kiosks. The young people just wave their cellphones at it.” Okey-dokey.
If a health care system does not discriminate against the sick — as ours still does, through insurer manipulation of formularies, provider practices and other subtleties — then perhaps privacy of personal health information is not so important. But for me, it’s my business, not yours. As health care attorney and ethicist Lori Andrews wrote years ago, “My body, my property.”
The Rise of Consumerism
I refuse to refer to patients as “consumers.” Most patient participation in health care is involuntary, and most of us would avoid it if we could. Few people look forward to a colonoscopy or pelvic examination. If they did, I would worry about them.
However, around the world, patients are demanding more of a say in how they are treated. Professor He told me about a phenomenon in China that has produced a new job description: “medical harassers.” For a fee, these folks will demonstrate outside hospitals in protest of poor care. Sometimes it is just an angry family. Sometimes it is a way to extract money from the facility. But given the tightly run Chinese society, this is akin to a revolution.
People expect more from their health care systems now. They want transparency. They want to know what they are buying. They want access to their records. They want to participate in their care and not have decisions made for them unilaterally.
Historically, at least in the United States, there were two main drivers of patient consumerism: the rights of female patients, and the rights of the terminally ill. As these movements spread around the globe, forgive me if I celebrate.
And that includes the tricky issue of end-of-life care. A scathing report was recently released about care for the terminally ill in Britain, and it wasn’t pretty. To quote an article about the report that appeared in The Times, “hundreds of thousands of people endure a painful, undignified or lonely death because of ‘appalling’ end-of-life care right across the health service.” That is hardly unique; some friends of mine reported that an Australian friend, hours away from death from multiple myeloma, was still being pursued by a physician who wanted him to participate in a clinical trial.
As most of my readers know, I oppose physician-assisted suicide because I don’t think anyone should have impunity when it comes to ending the lives of others. That doesn’t mean that I think allowing people to suffer when their time is coming is a good idea. We know how to provide palliative care. We know how to provide hospice care. Increasingly — it took us long enough — we know how to control pain, once we get over the ridiculous fear that someone who has a week to live is going to become addicted to narcotics. What if she does? So what?
On the other hand, in those cultures with aging populations and low birth rates, euthanasia — by which I mean causing the deaths of people simply because they are old and sick — troubles me deeply. As of October, human euthanasia was legal only in Belgium, Colombia, Luxembourg and the Netherlands. Physician-assisted suicide is legal in Albania, Germany, Japan, Switzerland, Germany and four U.S. states. It has been deemed illegal in Mexico, the Northern Territory of Australia and Thailand. And no, I don’t know why these countries made these decisions. I just work here.
I do think that better care at the end of life, consideration of the impact of euthanasia (which does not have a pleasant history, dating back to the Nazis and probably before) and monitoring of any death caused by a clinician are going to be global issues.
Violence Against Health Care Providers
I have written about this issue extensively [see the report, “Warning from a Mass Grave,” on my website, www.emilyfriedman.com, which is available at no cost], so I won’t dwell on it here. But perhaps the most disturbing international trend is attacks on hospitals and providers. I recently talked with a Pakistani health official who told me that polio inoculators — known charmingly as “lady health workers” — are being murdered on a regular basis by Taliban thugs.
Anyone who is not living in a cave knows that United States forces — for whatever reason — attacked a Doctors Without Borders hospital in Afghanistan and killed 30 patients and staff members; six ICU patients burned to death in their beds. The Syrian government seems bent on destroying its own health care system, despite the fact that its president is a Western-trained ophthalmologist. And the latest piece of gross hypocrisy is Vladimir Putin, the Russian president, condemning the attacks on civilians in Paris, despite the fact that a hospital administrator in the Crimea was kidnapped during the Russian takeover and hasn’t been seen since, and at least one patient was dragged out of a hospital, beaten and left to freeze to death, which he did.
Enough is enough.
We Are All Different, We Are All the Same
Our health care systems differ. Our societies differ. Our religions differ. But we are members of a very special community, a community of caring. And we need to stand with our health care brothers and sisters.
An attack on any hospital is an attack on all hospitals. An attack on any physician, nurse or other caregiver is an attack on all caregivers. An attack on any patient is an attack on all patients. We are an international community of healing, and an attack on any of us is an attack on all of us.
All of our health care systems face similar challenges, and we formulate different solutions for dealing with them. It is my hope that we can learn from each other, implement what works, and discard what doesn’t, but above all, stand together in trying to protect and improve the health of all people, wherever they are.
This column is based on a presentation by the author at WorldConnex2015, sponsored by Connexall, in Santa Rosa, Calif., Oct. 20, 2015.
Copyright © 2015 by Emily Friedman. All rights reserved.