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The New England Journal of Medicine, arguably the world's premier internal medicine journal, is well know for the series, “Case Records of the Massachusetts General Hospital.” Every week a complex medical problem is examined by a group of brilliant physicians who dissect the case. Using the patient's history, physical examination, and every conceivable laboratory test and invasive procedure, they invariably solve the case and prescribe the proper treatment. No expense is spared in their quest to provide optimal and timely care for the patient.
The editorial page of the Journal is a different story. In years past editorials focused on medical issues such as new drugs and tests, medical ethics, and critiques of antiquated methods which were no longer appropriate for patient care. Several years ago the editorial page expanded dramatically, and the subject matter took on a new flavor – the flavor of politics. Not a week goes by without another essay touting the benefits of national health care, criticizing the influence of physician specialists, and advocating complex government regulated programs on cost containment and reimbursement.
The State of Massachusetts offers universal health care. A greater percentage of its citizens are covered than any other state, but there are serious cost overruns which leave the system unsustainable in its present condition. The Journal strongly supported the adaption of universal health coverage in Massachusetts, and despite the financial difficulties of the state plan, the Journal advocates a similar national program.
Now that the euphoria of establishing the nation's first state universal health care system has subsided, editorial comment has focused on convoluted ways to pay for a program that is experiencing huge cost deficits. The proposed solutions follow these general categories:
- Higher taxes on businesses, employers, and individuals “most able” to pay
- Establishment of boards of experts to allocate revenue fairly among providers
- Independent agencies prioritizing health care options – a euphemism for rationing
- Enactment of comprehensive and meaningful tort reform
- Measures to ensure patients assume some individual responsibility for their health
- Programs which allow patients to possess financial leverage when seeking health care
Recent proposals discussed in the Journal question the rational of the fee for service medical model and favor large salaried multi specialty groups. Another recently promoted view is that it is immoral for United States citizens to automatically receive the H1N1 flu vaccination before people in the third world. The expression “we should stand in line with everyone else” was used. Still another stance from this influential magazine openly criticized the number of specialists as opposed to primary care physicians and listed mechanisms to reverse the trend by diverting revenue from specialists to primary care. Similar efforts by the Clinton Administration to change this ratio by training fewer specialists caused severe shortages in specialty care for over a decade. For these philosophies to become policy, extensive government control is required – solutions which seemingly rest comfortably with the editorial staff of the New England Journal of Medicine.
Case # xxxx - 2020 “A 45 year-old Woman with Rheumatoid Arthritis and Diminished Level of Consciousness” The patient presented with a heart murmur, renal failure, and diminished level of consciousness. She had no urine output for two days.
Physician #1 (Visiting Professor): This case involves a critically ill patient with multiple system failure. In addition to routine laboratory I would order an echocardiogram and an MRI of the head. Due to the complexity of the case it will be necessary to notify the appropriate specialists.
Physcian #2 (Staff): I'm sorry, doctor. There are few specialists in Massachusetts. Also, the Medical Resource Board does not allow physicians to order specialized tests without their approval. This condition is waived, of course, if the patient is a politician. A complete blood count, urinalysis, EKG, and chest X-ray should provide adequate information to solve the case.
Physician #1 (Visiting Professor): How are you going to obtain a urinalysis if the patient has not urinated for 48 hours?
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