Editorial
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Trickle Trickle: All Fall Down
Gilbert I. Martin, MD
Trickle economics is a familiar term to most Americans. Allan Greenspan, Chairman of the Federal Reserve, and his Board lower and raise
interest rates depending on the state of the economy. If inflation is a
possibility, interest rates are increased, which will have an effect on all
sectors and filter down to large corporations and finally the consumer,
who will purchase less and therefore slow down an over expanding
economy. “Laissez-Faire”, Economics 101 . . . it all seems simple
enough.
However, this “trickle economic” approach has now pervaded
medicine and has changed the way physicians think and practice. I
am tired this morning. I wish this malaise was due to the “happy
exhaustion” physicians feel after a night on call where our “presence” made a difference or we learned something new and found
intellectual stimulation.
No, I am tired because I am beginning to believe that in this state
of “health economics,” physicians and hospitals are fighting a losing
battle. Follow along with this if you will.
Academic departments, receiving less grant funding and decreased remuneration, are asking the “bench research faculty” to take
clinical calls and care for patients. The financial reasons are clear,
but the following has occurred. First, with less time to spend in the
laboratory, less research occurs, basic advances, which we have seen
over the previous decades, are starting to decline. Second, the individuals now caring for patients opted for research as their primary interest (not clinical medicine); therefore, they may be unsuited for this
new responsibility. Patient care will suffer. Last, the number of original nonclinical research articles submitted to peer-reviewed medical
journals has decreased because of this “trickle down” approach.
There is simply not enough money to allow for the usual and customary natural order.
There have been commentaries in several renowned journals that
discuss the fact that many clinical studies appearing in journals have
in fact been funded by the “drug companies,” as a result, there are
biased results. Most likely the research group would prefer not to receive these funds from the Drug Company. However, if there are no
other sources available and if “disclaimers” are offered, isn’t it better
to be able to do the research than to abandon the project because of
lack of funds?
This trickle down approach has affected pediatrics and neonatology with dangerous implications. Residency programs have decreased
the amount of time spent in the neonatal intensive care unit over a
3-year program, to 3 or 4 months. Therefore, the residents and neona-
tal fellows are less experienced and the clinical obligations of the
attending physicians are increased. Many pediatric residents complete
their training programs with very little hands-on experience in resuscitation and critical care and do everything they can postresidency to
avoid both the hospital in general and the neonatal intensive care
unit in particular. Does this approach offer the best care to our patients?
I read in national newspapers daily about cuts in health care
costs and different organizations suing health care organizations
alleging breach of contracts, deceptive business practices, and other
mundane complaints. It is true, that the “practice” of medicine today
has become the “business” of medicine. Is it ever going to stop?
There may be an answer. There may be a new approach. Pediatric intensive care specialists and neonatologists in California have
organized and become proactive. Realizing that California has a very
high percentage of managed care, a very low remuneration scale, and
rapidly depleting physician and nursing resources, they organized
into a California Coalition of Pediatric SubSpecialists. A lobbying and
public relations firm was hired and a political agenda was outlined.
Letters and telephone calls were made to key members of the Senate
and Assembly Health Budget Committees. A proposal to increase pediatric subspeciality remuneration to 100% of Medicare levels was requested. Both Houses unanimously approved this request, although it
was scaled down in the revise of the Governor’s budget. The group is
now actively lobbying the Governor to preserve this budget increase,
citing less access to care, difficulty in retaining physicians in the state,
and problems in recruitment. If we are successful in this approach,
this process may serve as a catalyst for pediatric subspecialists in other
states to organize.
As physicians, we have never stood together as a group, for there
were always others who would “work for less.” The line between quality of care and cost containment became fuzzy. The American Academy of Pediatrics has recognized this dilemma and has formed a
“Reimbursement Committee” to assess the problem. We have always
felt that socialized medicine should be avoided at all costs, but maybe
both health professionals and patients would be better off. The Health
Care Financing Administration and the American Medical Association
have in fact made things more difficult for physicians, and a new
cottage industry of “coding and documentation” has flourished.
I no longer see younger colleagues with the same futuristic goals.
Where will the leaders come from? Hospitals are failing, physician
groups are going bankrupt, there are further cuts in health care financing . . . who would feel optimistic?
Like “ring around the rosy,” we are falling down. This “trickle”
Journal of Perinatology 2000; 5:283–284
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Martin
Editorial
needs to stop. Sooner or later it will affect all of us who are practicing
neonatology. Budget cuts and more onerous requirements will mean
longer hours, less remuneration, and dissatisfaction with our lives.
Neonatalogists sat on a wall,
Neonatalogists had a great fall
All the King’s horses,
And all the King’s men,
Couldn’t put our profession together again
Be Thoughtful
If there is one idea to confirm that students learn,
It is to be thoughtful.
With yourself,
With your family,
With your patients,
It is most important to individualize . . .
Hey! That is a second important thought . . .
Did that come out of nowhere?
When you have a student “on the bubble,”
Be thoughtful, individualize, and give him the benefit of the doubt . . .
Oh no! another important thought . . .
How could this be?
This is thought number 3!
Wait, you just put three thoughts together in a single sentence . . .
This poem was supposed to be about one thought!
Well, sometimes, being a little unconventional can help . . . (don’t tell anyone, that is thought
number 4!)
I have trouble with rambling, not gambling!
In general, better to be thoughtful, to individualize, give him the benefit of the doubt, and be
compact . . . This is getting ridiculous!
Well, my dear old dad used to say . . . if you have a good idea, go with it until somebody credible
and/or your boss says, don’t.
Thought number 6.
For those of you who don’t understand, be patient with yourselves . . . oops number 7 . . .
Oh well, 1 has somehow become 7 thoughts . . .
Are they unrelated?
If you are not sure, be thoughtful, reread the poem, individualize, and don’t forget to give
this humble poet the benefit of the doubt because he is a bit unconventional . . .
Please make your analysis compact and to the point . . . no rambling.
If it’s a good idea, go for it . . . if at first you don’t get through, be patient.
So . . . it’s hard to believe that one important thought has become seven . . .
If it is still not clear, remember the title of this poem . . .
“Be Thoughtful.”
Exactly!
Joseph R. Hageman, MD, FAAP
Neonatology Editor
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Journal of Perinatology 2000; 5:283–284