Bear Traps and Health Care Reform

The current healthcare reform debates are redefining roles for all involved. Politicians think they are historians, civilians fancy themselves as a legislative body, and media personas suddenly see themselves as newsmakers rather than reporters. I recently joined this trend. By all accounts, I'm an academic, but in the dogged-days of summer, I became a patient. It was an unintended change in perspective, but the experience was a valuable one. As an exasperated patient, I began asking new questions about rationing in the American healthcare system.

While vacationing in the White Mountains of New Hampshire this summer, I stepped in a makeshift bear trap, set along a rural river a few miles from where we were staying. The barbed wire of the trap shut around the back of my ankle and pulled a chunk of skin with it as I wrestled free of the contraption. Bleeding but feeling no pain, I hiked up from the river and sought the nearest emergency room to get a tetanus shot and stitches, so the scar would not be too bad.

The hospital was impressive. Its brochure described their balanced scorecard approach to measuring performance, their 100 percent compliance with clinical guidelines, and an 89 percent quality rating on The hospital CEO was a Fellow of the American College of Healthcare Executives and her picture caption said, "We care about you." I felt in good hands and hoped they had a tetanus shot.

At triage, the nurse told me I would have an x-ray and someone would look at the wound. I explained that I had hiked up from the river without any real pain and proudly showed her the mobility of my ankle, saying I did not want an x-ray; she brought me to the treatment room. There, the nurse practitioner repeated that the x-ray was important to be sure I had not broken anything and that there was no metal inside. I flaunted my athletic ankle again, saying there is no swelling or pain, and I did not want the x-ray. She mumbled, "Well, it would make me [herself] feel better." A male nurse then arrived to take me to x-ray. Having just read the CEOs words that it is all about the patient, I mustered up my courage and said that it was my body and he needed my consent to give me an x-ray, which I did not want. After consulting with nurse practitioner, they relented and over the next hour proceeded to clean and sew up the nasty cut and give me a tetanus shot.

By all accounts, I was very lucky. The gash missed my Achilles tendon; my skin flap was sewn back into place with 10 stitches, and the scar, if there is one, will look like a cool tattoo on my lower ankle. But as I left the hospital, I wondered why we are not talking more about the use and abuse of technology in our health care system. This is not about whether my insurance is a co-op based or a public plan, and it is not about the exotic application of new technologies to rare conditions. It is about the routine day-in and day-out care in community hospitals across the country.

Somehow, "rationing" has become something of a dirty word in US healthcare politics. Although rationing is very much a part of our American system, many have convinced themselves that rationing is a feature found only on the 'socialized' British model of healthcare. The difference between the two is that while the Brits have explicitly accepted the effects of rationing, we here in the United States have long ignored its implicit effects. My experience as a patient is just one testament to these implicit effects. By giving me more care, haven't we denied someone else somewhere down the line? The answer is "yes," but that person is far away and unidentified. We ration health care in every decision we make - not just in denying coverage or care to some but also in providing coverage and care to others almost without limits.

If we are to move forward, Americans desperately need to reach a new level of maturity in the discussions, where politicians and policy-makers can say the "R" word -- rationing -- without fear. Only then can we have the needed debate about tradeoffs, which may result in new ways to solve old problems. Rationing, in relation to both cost and quality, needs to become a permanent and oft-used word in Americans' health care vocabulary.

-written with Lauren Taylor, MPH