I have been an academic surgeon in a large medical center in New York City for the past 20 years. The current climate of scrutiny to systemic racism and bias (including prejudice against all “different” populations) coupled with our own struggles with growth and equitable distribution of resources has highlighted a disturbing trend.
It is and has been customary for as long as I’ve been practicing medicine to relegate patients with “poor insurances” (such as Medicaid products) to less-experienced doctors. Patients with “poor insurance” are likely economically disadvantaged themselves. (In our catchment area, this also often correlates with non-white race.) In the world of surgical practice, the less-experienced doctors, for the most part, scramble for OR time and position, often starting cases late in the day, which means the patients with “poor insurances” are left to languish anxiously and NPO for hours. Once they get into the OR, they may have an assortment of nursing and anesthesia hand-offs, as well as a frustrated and inexperienced surgeon operating in the late hours of the day with no support. In contrast, “VIP” patients, i.e., patients that are approachable for philanthropic gain, are shepherded with kid gloves through the system, enjoying early starts in the OR, with fresh surgeons, anesthesiologists, and staff virtually guaranteed.
Another common scenario is for patients with “poor insurance” to be shifted to an attending-“supervised” but resident-run service. Here the attendings have little “ownership” of patients, handing them off to each other not infrequently on a daily basis. Important trends in vital signs, laboratory data, and physical examination, often too subtle for less-experienced trainees, are left unnoticed, with consequences. For operative cases, it is not uncommon for two or more residents to work with each other, with only perfunctory “supervision” by an attending. This is in contrast to “private” patients where one attending takes full and daily responsibility of their patients and ensures continuity of care.
To phrase it another way, it is common for more senior doctors to release themselves from “inferior” insurance products so they can: 1. Earn more money for themselves, and 2. Give the junior doctors a cache of patients that seemingly have no choice in the matter. To many, earning more money seemingly (and often falsely) proves that you are a superior doctor. But, for the patients under this system, the truth is simple: Poor people get poor doctors, poor positions on the OR schedule, and poor continuity of care.
Health care for all is a lofty, worthy goal. But what health care leaders really want is more complex than that. They want to display that all should have some kind of health care; what they do not want to reveal is that the ability to pay premiums and copays (and make philanthropic donations) greatly influences the quality of health care available.
Although this tale may be familiar to many, I believe we should reconsider this and discard it along with many of the “old-boy” behaviors we have become comfortable with in the past many years. Practicing medicine is a privilege, not a means for financial comfort and ego-enhancement.
Beth A. Schrope is a surgeon.
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