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After the Match

After the Match

No Good Deed Goes Unpunished

Cook, Thomas MD

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doi: 10.1097/01.EEM.0000475579.86352.4a

    History is ironic. What originally is hailed as a major achievement often creates a new set of problems that no one anticipated, especially when the problems occur a century later. This is the story of a 19th century German chancellor who created a system for his own political gain, and how it grew into the 800-pound gorilla that is 21st century U.S. medicine.

    Once upon a time, back in the 1870s, a man named Otto von Bismarck consolidated the German empire through his shrewd political skills. One of his many actions was to create the first social security system for the elderly. Can you guess the age he chose to receive this entitlement? It was 65. Of course, almost no one actually lived to that age. The average lifespan of Americans in 1900, in fact, was only 47. But this was perfect for a politician who wanted to give the elderly something without really having to pay for it.

    Several American presidents would try to create a similar system, including Teddy Roosevelt during his final campaign in 1912. (He lost.) It was not until the Great Depression that President Franklin Roosevelt, a fifth cousin of Teddy, was able to enact social security. Again, even though the average American lived 62 years, the age chosen to receive benefits was 65.

    Harry Truman and John Kennedy also tried to put together a program to pay for medical care of the elderly. But it was not until 1965 that Medicare was born during President Lyndon Johnson's plan for the Great Society. What was the age to get this entitlement? Yes, 65. How did you know? At that time, the average lifespan in America was right around 70 years. You would receive five years of benefits on average if you made it to 65.

    The benefits, however, did not include prescription medication (that would come under George W. Bush), and chances are you would die within a year if you had a heart attack, stroke, or even broke your hip. This government benefit was still relatively cheap by today's standards, but few at that time saw the building tsunami created by the intersection of politics and the advancements in health care.

    A Vicious Cycle

    When I started residency in 1990, we were ambulating hip fractures within a few days of surgery and experimenting with new drugs that dissolved clots in coronary arteries. Strokes were still pretty lethal, but today we keep most of these patients alive and occasionally completely reverse the effects. Even sepsis, considered by many physicians to be the old person's best friend, is aggressively treated when it hits the doors of the ED.

    Patients get older and older because we can do more to keep them around. But this creates huge stress on the health care and financial systems. Too many old patients chew up more health care resources that then need more doctors, nurses, beds, imaging studies, medicines, and EMS providers. Meanwhile, the government picks up most of the cost, and this creates a practice environment in which the price tag is the last thing we consider. Honestly, it's nearly impossible to figure out the cost to the individual because the price tag fluctuates wildly based on the health care insurance or government entitlement program.

    It is a vicious cycle with no end in sight. Economists can be ruthless in their pragmatism, but they often long for the good old days when folks would work into their 60s and then die. But physicians have become too good at too many things, and there is no way to turn back the clock.

    Older physicians often suggest that the best days of being a doctor are behind us. Many advise their kids to avoid going into the family business. But another old saying is important to remember: “The time to buy is when there's blood in the streets.” Every dilemma provides an opportunity, and this is no different. This is a huge opening for emergency medicine and especially our specialty's young residents. I will address this next month in a cheerful little column called, “Were All Going to Hell.”

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