#note/sharing Lon Setnik, MD, FACEP, MHPE Dec 15, 2024 Anyone who starts the conversation with the statement, "If they would only ..." doesn't understand the complexity of the problem. In February 2020, my wife had influenza and couldn't stop vomiting. She's one of the strongest people I've ever met, and needed emergency help from the healthcare system. At Concord Hospital, where both of us work as physicians, the wait to be seen was over six hours on that particular Monday. The Concord Hospital ER is the only place to receive emergency care in our community, and lately a six hour wait has become as good as you can expect on many days. Her experience reflects the larger crisis in our healthcare system: even in well-run hospitals, systemic misalignments lead to delays, frustration, and burnout. I know this because, up until now, I have spent most of my career as an Emergency Physician working in Concord. I've had to say "I'm sorry for your wait" tens of thousands of times. I won't be working here anymore. I share your anger. I hope to convince you, though, that your anger should be directed at the right issues. My goal is to leave you with a perspective on what is ailing our system, some balance to the current narratives, and some personal steps you can take. Along the way, I'll try to give you a nuanced view based on my experiences. The data is clear, however. The wait in our community is not from the unhoused, minor problems, or the uninsured. Those patients are quicker and easier for us to care for. The challenge is the backed up system, with dozens of admitted patients staying for days at a time in our bursting ER. We often start the day with a full ER of admitted patients, and that's before the 130 of you that need help show up. "Show me the incentive, and I'll show you the outcome," says Charles Munger. Concord Hospital is one of the best run organizations around, as measured by success in our healthcare environment. When the government comes to measure the quality, they typically give great marks. Concord Hospital is financially stable in a world of huge financial losses in healthcare. How is it possible that, despite overflowing hallways, rampant burnout, delayed care, and a primary care exodus, healthcare systems still receive high marks for quality? Why then, is our healthcare not getting the outcomes we want? We fail on the quadruple aims of healthcare: access, low cost, great outcomes, and fulfilled workers. The answer is partially in the set of incentives that have been created to define success. The answer is held somewhat in the dysfunction of our government. One of the government's main jobs is to define and regulate markets. This regulatory system has created a complex web of incentives driven by public and private organizations and put in place by the government, insurers, universities, drug companies, special interest groups, medical societies, medical journals, and health system leaders, among others. They are both internal and external to each healthcare organization. You may want to solve this with a different form of governmental support for healthcare, single payer, free market, public/private. In my current role as a consultant for international health systems and healthcare education organizations, I see that many of the same challenges are being felt in countries with totally different healthcare delivery models and governments. As previous president of the medical staff, board member, medical director of simulation and education, and various other leadership positions, I can tell you the people in charge are doing what they think are the best things to run an organization for the community. Canada, with its province-based single-payer system, is seeing massive closures of rural hospitals and ERs, just like the US. Australia, with its public/private system, has nursing shortages, long waits, and burnout, just like the US. Healthcare has become a scapegoat for what is really a sick society. We need to address the core issues, wealth disparity, nutrition, safety, hopelessness, loneliness, etc. These are not fixed by healthcare. Just as schools couldn’t fix broken households under ‘No Child Left Behind,’ healthcare alone cannot resolve issues like inequality and societal fragmentation. This will take experimentation, time, failure and incremental improvement. It won't be fixed with catch phrases like "free market" or "single payer." There is no easy answer. How do we do better? A part of the solution is gratefulness. We actually have made many incredible advances, they are often lost in the conversation. Since starting as an EMT in 1993, I have seen the development of robust trauma systems, minimally invasive heart surgery, magical chemotherapy agents and blood thinners that come in daily pills without need for monitoring and fewer side effects. We have ready access to CT scanners, MRI's, and robots assisting in our operating rooms. I have also seen the destigmatization of people living with homelessness, substance use disorder, mental health conditions. When you come to your local ER, be kind to the people still there. When you go to the polls and listen to politicians, don't fall for easy answers that feel good. Let's push them on the values we strive for, not on sweeping solutions. And, take a moment to be grateful for what we do have. For my own wellbeing, I'm moving my practice to a critical access hospital with a different set of incentives and outcomes. I still love caring for patients, I hope to say "Thank you for waiting" a lot less, while being able to treat people humanely. Meanwhile, if we can focus on what truly matters—care that is patient-centered, humane, and sustainable—we can rebuild trust in our healthcare system and create a future where no one has to wait hours for help. Keep demanding the outcomes we deserve while thanking those doing their best to help. %% #note/sharing | #on/politics | #on/healthcare