It's Elementary, Watson

DO YOU KNOW The Great Camping Adventure of Sherlock Holmes?

He and his straight man, Dr. Watson, went camping, pitching their tent under the stars. During the night, Holmes called to Watson, "Watson, Watson, look up. What do you see?"

"Stars," the groggy Watson muttered.

"And what do you deduce from that?"

"If just a few of the millions of stars I see have planets it is quite likely some of those planets are like Earth, and if a few of the planets out there are like Earth, then there might also be life out there," replied the always game Dr. Watson.

"Watson, you idiot," scolded Holmes, "somebody stole our tent."

There is a time for imagination and a time for reality; a season for conjecture and a moment for conclusion.

Our problem is the missing tent, not the abundant stars. Was the missing tent stolen or given away? We must answer that to get the tent back and to prevent a recurrence of the loss.

Our best tent has always been our alliance with our patients. That has required us to put patients' interests before our personal interests and before the interests of our employers or our patients' employers. Despite our secondary responsibilities to health care insurers and society, our primary responsibility is to offer our patients the best of the least disruptive, least costly, most effective diagnostic and treatment options, and to discuss the pros and cons of those options with our patients, fully and candidly, uncensored by third-party payers and unmotivated by personal or corporate gain.

Medical management organizations, whatever their acronyms, are payment systems that we change over time, but that we hope will treat enrollees and providers justly, but they are the stars that invite speculation. To secure our tent, we must be able to fulfill our professional responsibilities.

Where and when did Dr. Watson last see that tent? When he served a patient as fully and honestly as he thought necessary, no corners cut to save time or money, no fluff added to increase income, mysticism or power. When he put the needs of his patient before conflicting personal or organizational needs. When he encouraged a patient to check the statement from the third-party payer to compare the doctor's charges with what was paid and ask whether the physician was overcharging or the payer was underpaying.

When Dr. Watson first agreed to accept payment from a third party, he loosened the tent. When he offered a harmless intervention that offered no benefit other than remuneration, Dr. Watson loosened the tent. When he inflated charges to compensate for underpayment, he loosened the tent. When he offered a patient limited options due to benefit limits, when he let commercial considerations squeeze the medical alliance aside, he loosened the tent. When Dr. Watson ceded his professionalism to the marketplace, he let commerce steal his tent.

Instead of cursing the past, let us learn from it. Our "burn out" comes not from underpayment or overwork, but from our inability to do what we believe we should do for our patients. Whether we are self-employed or work for a private medical organization, non-profit or for-profit, or for government, when we serve our patients as we believe we should, we will not "burn out." When our humanitarianism replaces our materialism, we will have our tent back.

That's elementary, my dear Watson.

Ed_Rudin@macnexus.org

The January/February issue of Sierra Sacramento Valley Medicine carried an article by David Gibson, MD, describing a member of his family's experience with emergency department care and associated costs. The care given hastened the individual's recovery, and the family appreciated the medical outcome.

The article raised important questions about the current state pf healthcare financing, emergency services and primary care access. Unfortunately, the system that now exists too frequently defaults patients to expensive emergency departments rather than less expensive, more appropriate or traditional alternatives. This default has resulted in routine diversion of ambulances, crowded emergency departments, overburdened on-call physicians and a host of other serious problems.

Unfortunately, some of the author's comments angered many emergency medicine physicians and others who find themselves at the end of the default line. For these comments, which angered our friends, supporters, readers and colleagues, we apologize.

We must now direct our combined energies toward finding solutions for our patients.

— Ed Rudin