The Coming Red Tide in Healthcare
Pray it gets better and strengthen the feeble hands
I was walking behind a very tall young man in an airport recently. He had the appearance of an athlete. I looked at his right knee and with each step, it seemed to slide out to the side, then ‘clunk’ back in place as if there were some instability of a ligament. You watch the human body long enough and you learn things.
It’s both pleasant and terrifying to know what we know as physicians. Not terribly long ago I saw an old friend in public. I watched his gait and listened to his speech. I had a terrible sense of foreboding. He had passed away a few months later.
Infections can look this way; young men or women who inject illicit drugs will have angry, red areas on their body with streaks that show how the infection is moving. You can tell that without treatment they will die, or lose a limb. A young woman holding her abdomen, her heart racing, rings our internal alarm for an ectopic pregnancy.
On the street even the subtle remains of an old stroke, the step of the amputee, the scar of a major surgery, the purse-lipped, purposeful breathing of the emphysema patient, these are visible to the eye that has watched long enough, the ear that has listened to heart and lungs and stories and felt the disruptions of skin or bone with educated hands.
I think about the word prophecy. Sometimes we make small prophecies about our patients. They aren’t really mystical. They’re observational. Student physicians will ask, as we all did early in our careers, ‘how did you know that?’ They think we have some sort of medical super-powers or extreme intelligence. In fact, wee just learned to pay attention.
I’m paying attention these days. I’m paying attention to what’s happening in our hospitals, to the people that come into our emergency rooms as patients, to the resignation and exhaustion of the staff.
And my ‘prophecy’ is that we’re in a place of remarkable danger. At least, that’s what it looks like based on the 30+ years I’ve been practicing medicine. Despite our expensive care and remarkable research the reality is much darker.
The thing is, our hospitals are struggling and overwhelmed. We have too few beds and too few staff. We have shortages of medications and even blood. The smaller species of hospitals are closing from financial pressures and the larger ones are crushed with no beds. Only last year one of two trauma centers in the city of Atlanta, GA, closed its doors. (Driving the high-speed gauntlet through Atlanta on I-85 alone should suggest why one trauma center may be insufficient. Not to mention the issue of violent crime.)
Physicians and nurses, PAs and NPs and assorted techs and aids are the hands, feet and faces of hospitals, the humans who do the work that saves lives and make the money to keep the places afloat. And they’re exhausted. A huge number of nursing and medical students, up to 60%, don’t think that they will engage in patient care careers. About one fourth of current US medical students are considering dropping out of medical school. (Thanks Dr. Graham Walker for this information.)
Those who have money or insurance can rarely find a primary care physicians. In fact, it isn’t just an American problem. About 20% of Canadians, living under nationalized care, have no primary care provider. https://medicalxpress.com/news/2024-05-adults-canada-access-primary.html
People with no primary care doctor come to the ER. And while I was once bothered by that, thinking ‘this minor problem doesn’t belong in my ER,’ I get it now. It’s us or nobody. Many of them try to go elsewhere, knowing that the ER is busy and expensive. They just can’t be seen.
Those outside of cities who need specialists? Equally difficult. I work in a hospital in a small Appalachian city and our hospital has relatively a lot to offer. We have a cardiac cath lab. We have surgery. We have labor and delivery! (Increasingly rare as well.) And I routinely transfer patients to other centers for eye emergencies, facial trauma, neurological care, complicated cancers. This is especially true for pediatric specialties which only exist at all in small quantities in larger centers. Every week I discover a new entity that requires more than I can offer.
As our populations age, and our science grows, the sick linger but just get sicker. They live longer (and as I’ve said, this is good; we’re pushing the envelope). But they aren’t yet living that much better. The old and those disabled with chronic illnesses often exist in a cycle that goes from home, to ER, to admission, to rehab, sometimes to nursing home, then back to home. The cycle gets repeated month after month, year after year until finally their bodies have had enough.
It isn’t only the old who are afflicted and in need of more and more complex medical care. We have increasing numbers of unhealthy young people, either suffering with chronic diseases or with diseases induced by modern life. Starting at young ages they deal with obesity, diabetes, liver disease, de-conditioning, hypertension, heart disease, infertility and other woes.
They also live their lives diagnosed with a cornucopia of assorted psychiatric illnesses, some of which were properly applied, others improperly. As often, their treatments are mismanaged by those not properly trained to do the job (psychiatrists are precious hard to find as well, especially in rural America). Diagnoses and medications change with the seasons and the popular trends. But they can little afford the care they need, much less the medications recommended for them.
Their lists of psychiatric diagnoses are long and increasingly begin in childhood: depression, suicidal thoughts, anxiety, OCD, PTSD, ODD, ADD, ADHD, schizotypal, schizoaffective, schizophrenia. These are recited by patients and the parents of patients like some new, technical liturgy.
They also struggle with addiction: they are addicted to methamphetamine or fentanyl, to marijuana or sedatives. To nicotine and to pornography. And honestly, who among us is not addicted to caffeine?
For so many of them, the thing that caused the problem was abuse and fractured families. This is the thing we aren’t allowed to say since we can’t travel back in time to fix it. We can only hope that it gets better. But it doesn’t look as if it is.
Small armies of our citizens are homeless, predominantly from drugs or mental illness. I see them walking down the streets with backpacks, headed to no place in particular, sometimes in the cold of night or heat of day looking for all the world like characters from a zombie film.
Others are skating on the edge of homelessness. The economy, perhaps friendly to Wall Street, is positively cruel on Main Street; and crushing on the various side streets where the barely functional dwell, trying to care for themselves or their families as inflation rises.
Their illnesses keep them from work, or allow them to be convinced they cannot work. Their illnesses impoverish them; often uninsured or barely insured or state insured, their hospital visits ravage them with things we feel that they need ‘just to be safe’, and with admissions or transfers ‘in their best interest.’ Then our hospitals turn kind words about safety and safety nets into Shelob’s Webs of collections and they are attacked, finding themselves deeper and deeper in debt that they can never overcome.
It feels as if a great wave is rolling towards us. A wave of the very old and very sick, and also of the young and sick. I spoke with an administrator at a nursing home recently. She said that when she started her job years before, her residents were her mother’s age, older. Now they are younger and younger.
Economic indicators suggest to us that both young and old have precious little cash on hand or money for retirement. Barely enough for one financial catastrophe, much less one hospitalization. They had jobs that were not lucrative, or they were devastated by caring for their own illnesses or those of their families.
Many grandparents have used their savings to care for their sick adult children, or to raise the grandchildren of their own addicted, or just poor and unskilled, kids. Some seniors I know were robbed by caregivers who pretended to be angelic helpers but were no more than common thieves. No, given their victims’ helplessness they were worse than common thieves. And these will continue to prey as things deteriorate.
Many of the young seem too anxious for good jobs, or have too many diagnoses to hold good jobs. Or, in many cases, are now almost unable to maintain any but the simplest jobs due to poor health or addiction. And even the college educated have skill-sets not conducive to high compensation.
So what is healthcare facing? A tsunami of people with various illnesses, various addictions, unable to function due to age or illness. A tsunami of those whose crushing poverty will leave them with nowhere to live and little to eat. This in an age when homes and rentals are painfully expensive and concentrated ever more in the hands of large corporations. Having some understanding of history, and an intimate knowledge of what’s happening ‘on the ground,’ I predict a Great Depression level event before long.
This is coupled with a growing demographic disaster as young people have fewer children; fewer children to grow up, work and to pay taxes. Fewer people to grow food, to build roads and hospitals, fewer people to manufacture medical equipment and run power lines, fewer people to do research and become physicians.
This is what I see in the Palantir of my knowlege and experience.
This is what the house of medicine will have to endure. Having become the modern cathedral of sanctuary, having become one of the last places that the sick and broken can go day or night, I can say that we don’t have enough doctors or nurses, beds or waiting rooms, medicines or money for what’s about to hit us. I’m not exactly sure how it happened. But then, I’m only trying to give a warning, a prophecy, a Jeremiad.
Medicine continues to build beautiful hospitals and offer technically amazing specialized care. There are ribbon cutting ceremonies and parties for the latest, greatest thing. Administrators of healthcare companies and systems continue to do well. Their salaries in the millions, or the tens or hundreds of millions. Good for them, I suppose.
But this coming wave of sorrow is a red-tide of hopelessness and death. Nobody is talking about fixing even the simplest problems. In particular nobody is talking about the least dramatic problems, the things that don’t make the headlines. The provision of insulin. The availability of a counselor. Ready access to a primary care provider. The encouragement of families to stay together instead of splitting apart whenever possible and safe.
I’ve seen changes over the years. And I’ve seen troubles. In the same way that I can see sickness in a human and predict what’s about to happen, I’m starting to learn to see the sickness in the system and the complications (and suffering) that may now be unavoidable.
We need to brace ourselves for some rough times ahead.
I hope that those people about to leave medicine and nursing, or hoping for some kinder, gentler role away from the bedside, will reconsider. The sheer human need will explode in the next decade.
It may be that all of this looks more like mission work than business as the gap between rich and poor grows. I mean, unlike the old days of even bartering for care, the folks we will be seeing have nothing to barter. A farmer might have eggs. A homeless schizophrenic has what, a water bottle and a sleeping bag?
We will need our better angels to motivate us to do what needs to be done. And to do it without the temptation to offer assisted death to the masses. We will need transcendent love far more than the hope of compensation.
And those of us in medicine will need to reach deep down into our collective consciousness, and into the very DNA of our profession, and do the right thing simply because that’s what it is.
My communication specialty is finding common ground with the patients and their family members, not in expressing my concerns over our future. Dr. Leap, I am in South-Central Virginia, and see the same things you see. As an RN with 35 years' experience, the last 33 years in the Emergency Department, I am tired of seeing our system lose specialists, capabilities, and hard working and caring workers. The administration is rolling out state-of-the art Epic I-phones, but we have lost our labor and delivery services. We went from being a community hospital to a "Rural Healthcare Center." Our psychiatric patients may spend weeks in our ED, without psyciatric care because we hear on the phone, "They are not accepted at our facility because of their medical issues." I only have a primary care physician who talks to me because we worked together in our ED for years. I may be too close to the sub-strata of healthcare to see a solution. Thank you for your service and insights.
Dr. Leap this is SO profound!