I asked my old doctor about his thoughts a while ago and he said something along the lines of "it could be a great thing, but I have no confidence that patients will get what they're hoping for and doctors certainly won't get what they deserve." And then he obviously stopped himself from going into an extended rant, which is odd, because he never seemed to shy away from ranting before.

And the reason he's my old doctor is because my insurance company was feuding with the the hospital group he's part of, which eventually ended in both parties terminating their relationship. So now we can't use the hospital that is less than two miles away.

You might find this interesting.

My dad's old doctor used to be my old doctor, part of an HMO that split and moved and restructured so that the doctors we had long ago disappeared and we were left with this guy, who was by all measures an excellent physician. He did a nice job diagnosing me with pneumonia once. My mom, with a different set of medical needs, went to a different general practitioner. I switched doctors because I moved and healthcare became unaffordable.

My dad has suffered from heart disease, so he has more frequent checkups and takes statin drugs to lower his cholesterol. It took a few tries to get his prescription right, but they did. Not long after that was all sorted out and his numbers settled well, the new doctor started pushing newer and more expensive drugs on him; drugs of which the doc had plenty of free manufacturer samples. When my dad would demur, or ask if they'd really work better than what he was taking now, or if there were generic versions available at lower cost, the doctor would get increasingly angry, and say things like, "I'm putting this on the record that you won't take your doctor's advice; your insurance company will hear about it." The final straw came when, after my dad questioned another hard sell, the doctor said, "Hey, are you trying to keep me from closing on my lake house? Are you trying to ruin my kids' vacation?"

So my dad switched to my mom's doctor, who is an old man, probably not long for his practice. But he's an old man with a lot of patients, a stack of files on his desk, a "booming business" as it were (though I don't know how seemly it is for doctors to talk about their "businesses" anymore); I wonder if my dad will be able to find an honest doctor when his current one retires.

I know this is tangential, but it goes to illustrate some of why I would say don't listen to a word your doctor says about anything other than your personal health, and even then, listen very closely for the sound of money. If you think greed is motivating your doctor, run to the hills.

And before all the honest doctors come in here fists swinging, pleading honesty; it's in the honest doctors' power to change the way the AMA and other organizations do business. There are models that encourage fairness and seek what's best for the patient, and some can be found here in the States. Seriously, greedy doctors need to knock that shit off, and honest doctors need to speak up against the greedy ones. It will take a nasty fight and the demolition of some seriously entrenched industry, but we're talking about healthcare, about which nothing positive can be said until doctors' greed is no longer killing people.

My doctor has never mentioned anything. But then again, the particular practice I go to isn't exactly full of chatty Cathy's. It's pretty much in, discuss medical things, do testing, write prescriptions, out.

(Which works for me. I hate that stupid small-time chitchat crap.)

it's in the honest doctors' power to change the way the AMA and other organizations do business.

Bear in mind, the greedy doctors have more money, and therefore more influence, than the honest doctors.

My husband is a pathologist and two of my closest friends are a medical oncologist and an ER doctor (used to be an attending at Harlem ER - oh the stories he could tell) and they all agree that major healthcare reform, preferably to get it more in line with every other freakin' healthcare system in the developed world, is necessary.

Maybe they have that opinion because they are all only in their late 30s and haven't long finished paying off their student loans so thus haven't really got used to the money. Who knows.

There was a good article in last weeks (?) Economist about US healthcare.

And nope, I haven't heard anything from my physicians about restructuring healthcare. That sucks, Thorzdad.

My doctor works for the state, and doesn't have time to give lectures about healthcare reform. He does examine me properly and prescribe the appropriate stuff, though.

When I saw a private surgeon last year, he had plenty of time to talk about all kinds of things, but as he was employed by the NHS as well as by the private hospital, he wasn't about to criticise one of the hands that feeds him.

My doctor doesn't really talk about that stuff, mostly he wants to hear about my neighborhood. I think he wants to move here. Last time I saw him he was asking me about the school system while listening to my lungs.

Wow. People actually have doctors. What's that like? I haven't had a doctor who knew my name since I was a child.

I haven't had a regular physical or check-up in about a year, save the "emergency" ER trips I take because I know I have high-blood pressure, I know what my other health issues are, and I'm just... not financially ready to take care of myself.

And to get on a wee bit of a rant, I have a Canadian friend who has horrible health issues who is livid at hearing that the myth that Canadians are streaming across the border for U.S. health services is still perpetuated. This dude always gets his needs looked after, and I am very glad that he does because without those services, he wouldn't still be around.

My previous regular doctor is running for a SC seat in Congress in 2010. He has a big poster in the waiting room and he personally walks you to the check-out desk with a minute-long speech on the need for healthcare reform and then he gives you a bumper sticker.

BOP, I have a doctor in so far as I am registered to him in the practice I go to. I have met him once (I previously could only get appointments with his partner, whom I don't like much so now hold out for him if I can) and I'm pretty sure he only knew my name because it was on the screen in front of him :)

I haven't had a regular physical or check-up in about a year, save the "emergency" ER trips I take because I know I have high-blood pressure, I know what my other health issues are, and I'm just... not financially ready to take care of myself.

Yep, and the fact that you need to take "emergency" ER trips, which use up so many expensive resources instead of being able to use affordable regular healthcare is one of the things that is fundamentally wrong about the current system.

In the UK, people don't really go for check-ups unless there's something wrong. Those who have private healthcare are encouraged to do so, but it's not customary to go to your NHS doctor unless you're experiencing symptoms of some kind.

I don't count things like cervical (PAP) smears, and mammograms for those of the relevant age, and immunizations. Everyone registering at my practice sees the nurse once, just for a general check and chat, but this isn't repeated.

Hell, I have insurance and I still don't get a regular physical. Insurance doesn't cover it. The cost applies to the deductible, but I can't afford the up-front out-of-pocket cost.

Wow. When I hear Germans bitching about their doctors and health care system and then I read threads like these and other stories about the US healthcare system, I want to tell the Germans to shut the fuck up.

But then again, Germans love to complain about everything. The national pastime in America is baseball. In Germany it's complaining.

In germany, if I remember correctly, at age 35+ you get one free checkup per year.

The health care situation is the number 2 reason why I will probably never move back to America. The number 1 reason is, of course, my Schnukipoohasebär.

"I have insurance and I still don't get a regular physical. Insurance doesn't cover it."

The doctor I had specifically would not do physicals for that exact reason. If any procedure needed anything more than a copay, he sent patients to a specialist.

It's hard to ignore the tragic fact that about 1 out of 6 people have no health care program at all, not even MediCare or school health services. I understand the professional and personal anxiety that things are going to change, but for those people who have not had the benefit of benefits for years at a time, it's hard to make a case that a public option is going to destroy health care. For them - and if we are not among them we certainly know them - it can only improve it.

"For them - and if we are not among them we certainly know them - it can only improve it."

I think that is a dangerous assumption to make. It may look obvious that that is the inevitable conclusion, but it is a tremendous leap in logic.

Recall the old joke, Q: "What do you call the guy who graduated last from med school?" A: "Doctor." The question becomes, "Which is better? No healthcare, or treatment by the bumblers and the fumblers who get shuffled down into working the public clinics yet must be carried on the payroll just to fill the vast number of slots that will be opened?"

I don't know, Ardiril. I see your argument, and yet I've personally seen and understood too much totally unnecessary suffering due to the absence of routine care to take that point so lightly.

It's also a leap to assume all care, even preventative, is going to be in the hands of "bumblers and fumblers."

And even then, a dental cleaning is a dental cleaning. Treating strep throat is better than letting it become a systemic infection. Treating pinworms is better than letting them run out of control. Talking to someone about pre-diabetes is better than never giving them message. Etc.

Contrary to our imagining, most medical care, especially of the preventive variety, really is quite routine. It's only in serious illnesses and outlier cases that we are so sensitive to performance. And even then, performance is only good for those who can afford it - which will not change with the advent of a public often. The wealthy will always have access to the best of care.

But for those who are totally without access, there really isn't a good case that no care is better than some care.

(the other issue, of course, is costs. Currently, if a person is uninsured and hit with a major medical episode requiring surgery, hospitalization, etc - that can completely destroy their family's financial health. Costs are rising and will continue to. Letting ordinary citizens run the risk of tremendous, unpayable debt - which, when unpaid, is passed on to private insurers and then to employers like mine and finally, back to me in the form of my pay-in - is not a fair plan or a smart use of existing resources.)

My Canadian doctor is always surprised when something comes up in conversation about my lack of medical care until I got a regular job at 17 (and don't get him started on HMOs). We simply couldn't afford to go to a doctor or hospital except for major injuries. Mum was poor but, most times, made too much for welfare/medicare. I'm quite sure there were medical bills she just didn't pay for lack of funds.

We already have clinics being closed and investigated for a variety of unsanitary procedures. To fill all the extra positions created to treat this many more people means lowering standards even further in both skills and ethics as well as accept less recourse to malpractice suits. In the interim, we wait for the DeVry and Phoenix Universities to crank up their MD and PA assembly lines because almost any system is going to eat doctors by the hundreds, if not thousands, once you enter the burnout factor. Virtually every community college will need a full RN program. The good news is that over time, this will put a LOT of people back to work.

As a side note: the one person who had a feasible healthcare plan including implementation and maintenance got kicked upstairs to Secretary of State. As things stand now, I think we will be lucky if over the next four years we only manage to get Medicare and Medicaid fixed. Admittedly, Congress and Obama have managed to apply some temporary patches, but Bush let the whole system deteriorate possibly to a point of no return.

To fill all the extra positions created to treat this many more people means lowering standards even further in both skills and ethics as well as accept less recourse to malpractice suits.

Are there any studies you can cite to support this claim, reports of the kind one can find here? What you're asserting one of those statements that seems logical, yet it contains a lot of embedded assumptions that I don't think are necessarily true. One is that the standard of care will inevitably drop. I don't see why this should be true. Within the last twenty years we've seen a massive expansion in the field of information systems. Has the standard of performance dropped? No - on the contrary, the marketplace created certificate programs, higher-education programs, scholarly support, and ongoing training, meaning that more people have been attracted to this field and it has been adequately meeting the public demand.

Also, not all services delivered in health care need to be delivered by the highest qualified staff. Presently we have a lot of waste in the system because we stipulate that only doctors, or only RNs, etc., can do certain procedures - when in fact, with reorganization and proper oversight, nurse-practitioners, LPNs, midwives and technicians will be able to do many more of those services.

The mystification and glamorization of doctors' abilities are partly behind the anxieties about drops in the quality of care. As I noted above, the vast majority of what most doctors do is not rocket science. It's routine medicine in every sense of the word. Yes, it's important that doctors be skilled and properly trained, but doctors aren't magicians, and there's no reason to presume that by creating more doctors, they won't be as good. Most medicine is quite mundane. Most of the healthcare need in this country is for regular and preventive care, which is quite mundane and doesn't require highly specialized or skilled medicine. Some of the doctors we have now who charge the most and make the most are actually thoroughly crappy. There's nothing in our present system protecting you from bad care, and much that puts you at risk. Outcomes already vary hospital to hospital, as do costs, with little respect to the education or performance level of the MD staff.

The thing is, even if you presumed a drop in quality of care - which I definitely don't take as a given, especially as there are few things in our present system to ensure a better quality of care - any care that follows protocol is better than no care at all. And many people presently have no care at all. Those who can afford it will always be able to see a more expensive doctor or specialist on the private market. It's those with no access to any kind of insurance at all that most need the assistance of a public program, and will definitely benefit from having care available to them which is unavailable from any source right now.

There have, actually, been a number of studies showing a great deal of attrition in family practice medicine (with the exception of pediatrics); the ones I've read about have pretty much blamed cost-cutting measures and controls that more or less render PCPs ineffective (smaller reimbursements for shorter appointments, requiring doctors to have more and more appointments every day to cover their overhead and yet taking actual medical care out of each individual appointment, leading to burnout).

The article I'm thinking of that talked about this was in a recent issue of JAMA and does not seem to be online yet.

Those who can afford it will always be able to see a more expensive doctor or specialist on the private market.

Some of that, though, depends on whether or not those specialists can afford to keep their doors open, and whether it's worth the hassle. Related essay in the NYT.

My patients ask my opinions about these things all the time. If they really seem interested, they get an earful.

The current payment system is so badly broken that it's not even funny.

Then again, I am a specialist, and what I do is glamorous and mysterious. I know it is mysterious, because every hour of the day and night I am beseiged by other doctors - themselves well-educated, hard-working, and highly trained, and they need my help knowing how to figure out and manage their cases.

My patient's aren't Miko's "routine" cases, though. They are severely ill from terrifying, debilitating illnesses. Many of them got that way because "routine" docs followed the mandate that "protocol-based," flowsheet care delivered in 5-minute visits is going to be how we do healthcare now.

As Miko points out, there is a substitute for caring, compassionate doctors who sacrificed the best years of their lives to acquire a great deal of non-common-sense understanding of the mechanisms of disease. I have seen that substitute up close and in action in the rural community where I practice now. The result: horrific human suffering and death that could have been easily prevented.