Rationing medical care: in the absence of an infinite budget, it only makes sense.


Out here where they’re grazing the sheep,

They know MRIs don’t come cheap

      The skin takes a beating

   Though winter is fleeting

And the snow never gets very deep.

    

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and working the last half of a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

This part of New Zealand lies as far south of the Equator as Sioux City lies north, but has a much gentler climate.

The trees shed more leaves every day, most have bare branches.  I found frost on the windshield one morning last week.

Still patients come in wearing shorts, albeit with three or four layers up top.  With the first day of winter only twenty-eight days away, and a dusting of snow most mornings on the Southern Alp peaks, I wear my jacket in the car. 

We haven’t seen central heating in New Zealand.  Our apartment has two space heaters and good sunshine during the day; we haven’t needed more so far, and I wear my jacket inside.  My medical consultation room has a switch marked HEAT, I turn it on and the room warms up but I can’t tell where the heat comes from.

I see lots of firewood piles; smoke rose from chimneys in Waikari on my way home.

Of course my clinic load reflects the change in climate.  Cold air dries when heated, and in turn dries out skin and medical problems follow.

Thus dermatology constitutes a disproportionate part of my case mix.  I saw patients today with scabies, eczema, ringworm, psoriasis, viral rashes, and impetigo; all received straightforward treatment. 

One pediatric patient came in with fatigue, poor appetite and fever.  The physical exam gave no diagnostic clues.  My dialogue with the parent (who gave permission to use this much information) boiled to two choices: do nothing and see what happens, or draw blood work and get x-rays.

In fact, in the US, I would order CAT scans of the chest and abdomen, because fear of lawyers drives the system.  The parent laughed at the idea.  In New Zealand, generalists like me can order CAT scans and MRIs only if the patient wants to pay for those studies out-of-pocket. 

I don’t find the idea insulting, in fact I rather like it.  In Iowa I relied far too much on CYA documentation and not enough on common sense. 

In Alaska, the nearest CAT scan machine resided at a distance of eight hundred air miles, and the over-worked specialists I talked to did their best to keep my patients away.

Here, the referral hospital in Christchurch maintains a website with excellent clinical information for the front line doctor, so that calls to registrars (the equivalent of US residents) go smoothly and efficiently.

The twenty-one District Health Boards effectively ration medical care when they decide what services are subsidized.  After all, with a finite budget, they have to set priorities. 

Demented octogenarians with sputtering neurologic symptoms, for example, don’t get a full neurologic workup.  Not only wouldn’t the government pay for it, but the families wouldn’t stand for it. 

When I made my weekly rounds at the Waikari Country Hospital, five of my seven patients (not the oldest one) struggle with dementia to one degree or another, but further neurologic work-up remains out of the question.  And no one expects it.

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