The Death of Clinical Thinking

Luckily, feminists have been writing about, thinking about and advocating for universal health care system for a very long time. Without a universal health care system; health outcomes are significantly worse for the poor, women and people of color. For too long, people have languished in sickness, unable to receive care due to the inability to pay for a doctors visit. I feel so lucky to live in a state that has been on the front line for fighting for health care with dignity and feel excited to continue the crucial struggle for access to health care for all. https://www.workerscenter.org/healthcare

But there is more to the tragedy that is health care for profit that few have talked about: the reduction of medicine to factory production. Anyone who works in health care knows that insurance companies have come to dictate clinical practice. Clinical thinking has been reduced to routinized, non-personalized care and clinicians have been reduced to technicians. Due to high overhead costs, intense insurance bureaucracy and lack of autonomy, "Doctors are leaving private practice in droves." http://www.healthcarefinancenews.com/news/doctors-leave-private-practice-droves
Despite evidence that physicians have the best clinical outcomes, the overwhelmingly majority of hospitals in the country are run by CEOs with an MBA. http://well.blogs.nytimes.com/2011/07/07/should-hospitals-be-run-by-doctors/?_r=0
Meaning we literally have people who have never interacted with a patient dictating hospitals policies and protocols!

So how does this impact clinical thinking? Let me give you an example from a patient I have head recently:

I have a 22 year old patient who has started trying to conceive a baby with AB- blood type. Nearly two years ago, she had an ectopic pregnancy, which was undiagnosed for six hours in the emergency room leading to an laproscopic tubal ligation when one of her fallopian tubes burst. She received no RhoGam post-op (the standard of care for an Rh- woman with the potential maternal-fetal blood mixing during the surgery). Now that she is trying to conceive, she is trying to find a provider who is willing to test her for antibody screen to insure that there has been no blood mixing.

The standard of care is: to run an antibody screen during the second trimester, administer RhoGam at 28 weeks and if the patient goes past her due date to administer a second injection of RhoGam at 40 weeks. If a second injection is no administered during the pregnancy, then a second injection should be administered within 72 hours postpartum. These protocols insure the protection of Rh-women with Rh+ babies in subsequent pregnancies from bad outcomes. If there are antibodies to the babies blood during a pregnancy, the baby is at risk for very serious conditions including fetal hydrops.

So here's the dilemma, protocols dictate that all Rh- women MUST receive an antibody screen during the second trimester. What these protocols do not say that a woman COULD NOT receive a blood screen earlier. So now back to our case, My patient has a simple request: to know whether or not she will have a low risk pregnancy. If she has antibodies present to reduce her risks as much as possible to protect her future baby. So her desires are life and death matters. And the only risk to the screen is a blood draw that she desire.So why is she having such a hard time getting an antibody screen from her doctor? Because clinicians no longer consider personal circumstances when determining her plan for care. Because we, as clinicians, are now spending longer talking to insurance companies than to our patients. Because we, as clinicians have learnt to read protocols rather than take patient histories when we have questions about how to proceed. Because we have allowed insurance companies and the profit motive to take over our practice. So lets fight for a universal health care system not only so all people have access to health care but so that we can be clinicians again.