Hello, Craig Brooks,

You always share interesting articles and news on the PDA-IOT listserv (and PDA is the primary way that I have been affiliated with the single-payer movement for the last 8 or 9 years).

But I felt compelled to compliment you “in person” (so to speak), for your link today on the STAT article on “moral injury.”

Believe it or not, my own PCP started having problems functioning (and thus treating me) with regard to my own medical problems about 4 months ago – concerning a 5-month-long bout of a constellation of sever pains in my legs that are probably caused by some irritated or pinched nerve in my spine. 

And after having to conclude (because he had been an excellent primary doctor for me for the last 4 years) that my doctor was going through something that was causing him (and his office) to, in essence, drop me off his/their radar screen, I had to spend several months trying to navigate the medical system myself (which, even with the Internet, turned out to be very difficult to do effectively.

So, this month (after trying many different alternative pathways to getting care), I finally found a way to consult with an “in network” (my CareFirst BC/BS network for a Maryland State Health Exchange alleged “Gold” Plan) internal medicine doctor. And I had to explain that I needed to be evaluated as if I had never been treated for this condition – in other words, I had to ask to have a thorough physical examination and also have this new doctor order any tests (especially an MRI) that she might need to make a truly “productive” diagnosis. That is to say, a diagnosis that could lead to an effective treatment plan. 

Several months back, as I was trying to get over the “shock” that the PCP I had highly respected was going through some kind of strange type of dysfunction or burn-out, I started reaching out to people in other cities whom I knew as friends and who had become doctors (two in particular). A female high school friend, who was always quite academically talented in the sciences, had become a primary care physician in a New England/Northeast state.

And when I called her to ask for advice about what to do (I knew she had retired from her practice two years ago), she told me for the first time that she had felt compelled to close her practice (which was a combination of primary care and treating, in particular, older patients). She explained that she simply could not keep up her role as a PCP – due to the excessive paperwork overall, and the specific, frustrating demands of various health-insurance companies. She had come to believe that the PCP model of medical care was never an adequate “system,” and that it was bound to collapse once the insurance companies accelerated the pressure they putting on the system for less treatment and more quantitative accounting from doctors.

My friend’s candid account of her own need to close her practice made me realize how dysfunctional the entire PCP “system” had become. And although I have still not been able to find out why my own PCP’s behavior has become – at least towards my current medical problems – so erratic and//or “under-performing,” I have made sure not to hurt his public reputation or humiliate him in any way. Because I now understand, even more than before, that whatever my (formerly greatly admired) PCP is going through, he has probably also become a victim of our truly distorted, profit-centered, insurance-dominated “system

The great British researcher of medical care and collective welfare systems, Richard Titmuss (author of the classic book, The Gift Relationship, that explored the vast differences in the 1960s between British and American policies for blood donations) explicated this quite well in a speech he gave in 1966 (contained in a book of his essays and speeches about the immense benefits of social welfare systems) that I recently found in a used book store:  Commitment to Welfare.

Although Professor Titmuss could quite plainly explain in 1966 why healthcare services would never “work” if treated as a “market” commodity, American society (more than 40 years later) still doesn’t seem to get the undeniable reality that a society cannot treat healthcare like a somewhat predictable and fungible product. In this particular l966 speech, Professor Titmuss gave about a dozen different, economically and sociologically logical  reasons (as well as some references to supporting economic scholarship going back to 1963) why the “market” would never be an adequate or even remotely fair method for providing healthcare.

He used the purchase of cars, a typical example used by many “free market” economists,  to demonstrate the great differences in purchasing something even without “perfect information.” He discussed why, ultimately, although a car market could still continue to work “adequately” with all of the uncertainties of information existing especially in 1966 (before personal computers or the Internet), that healthcare could never be treated as a market commodity – for about a dozen obvious reasons that he spelled out quite plainly in that one speech.

This is all to say that this STAT article is perhaps the first article I myself have seen (I don’t presume or pretend to be able to read every single important article) that focuses specifically on how, e.g., primary-care doctors are being not only burdened, but, in fact, demoralized and psychologically injured, as doctors and as human beings, by our current medical-care model (despite the ACA’s beneficial enhancements to Medicaid in those states that are not entirely living in the 18^th century!).

So thank you for this article. Because it has not only given me more intellectual (especially sociological) ammunition for why our current system is more broken than many people are willing to admit or realize), it has also given me a better theory for understanding better why my own PCP has been, in actuality, “unavailable” (as a doctor and healer) to help me with my relatively serious medical problems for the entire past 5 months. (And I’m sorry to report that, at least in my own experience, the staff people who work in doctor’s offices or clinics also are too easily convinced or fooled that the current system works. Even with my very new doctor, who works at a medical center that is part of the Johns Hopkins Medical System, the staff were clueless about the constraints and limitations of my health plan’s network. And so, for example, they set me up for an MRI within the same Hopkins facility that, in fact, is **not** in my network – even though there are Hopkins MRI facilities in other parts of the region (although certainly less convenient to travel to) that **are** in my network. The same problem arose with my doctor’s order for some bloodwork. I could not use the lab facility in the same Hopkins building as my doctor’s office. I had to find an independent lab, in another part of my region (the Baltimore City/County) region to find an “in network” facility where I could get my blood drawn and tested. 

Above all, I don’t understand why Hopkins, which is a “big” institutional player in the Baltimore/Maryland medical sector, seems to have only relatively weak influence in terms of its own facilities and keeping every part of one of the medical centers in a certain network (like mine). It’s seems crazy to have some parts of one facility be “in network” and yet other parts, even two floors away, are not part of the same “network.” It is truly illogical, as well as undoubtedly frustrating for everyone involved (and certainly to me as a patient who has had serious trouble with mobility in the last 5 months).

I myself think this aspect of the “system,” (which perceptive and experienced researchers of collective government benefits like Professor Titmuss, or even William Beveridge, in England understood 40 to 60 years ago) has still not been discussed as much as it should be here in the U.S (Or else, like many other political issues, the discussion has been squelched and distorted by ideologues who are determined to thwart progress in medical care.).

As I noted above, my first “empirical” confirmation of this one (of many) destructive aspect of the current healthcare “model” was when I found out precisely why my very smart and compassionate friend from high school felt compelled to close her own primary-care practice (in a very small city) two years ago. Because the fact is that she personally wanted to keep practicing. But she was, in a sense, defeated or broken by a system that never going to be sustainable – despite all of the false and misleading information and assertions from the health-insurance industry (and their political “agents” in both federal and state legislatures).

Best regards,

Richard Mandelbaum

Resident of Baltimore, MD for the last 5 years; and

PDA Healthcare Issues Team “Supporter” since 2010.