The U.S. Healthcare System – “It turns out it isn’t all bad”

Several months ago one of my longstanding patients gave me a fascinating book entitled “The Healing of America – A Global Quest for Better, Cheaper, and Fairer Health Care” by T.R. Reid. Taking some time this summer, I have finally had a chance to read this very well written book. Mr. Reid’s writing style is quite enjoyable and his method of exploring various health care systems around the world through the use of a personal ailment is both unique and relevant. I highly recommend this book for any American who wants to learn more about our healthcare system as it compares to those in other countries. Furthermore, I think this book ought to be required reading for any lawmaker who endeavors to discuss healthcare at either the state or national level, particularly if they feel strong support for or revulsion toward the Affordable Care Act – a.k.a. Obamacare.

This summer, Our Family Doctor had the pleasure of hosting two young Scottish medical students from the University of Glasgow for three weeks. Patrick and Euan came to our practice with the hopes of learning a bit more about the American Healthcare system as part of an international rotation during their final year of study in the U.K. While this international elective provided the students with many learning hours during their stay, their visit also created a fascinating learning opportunity for the doctors at Our Family Doctor as well. In this blog post I’d like to share some of the observations made by these students after having been embedded within our (very different) healthcare system for three weeks. My hope is that the take away message will be that while the American healthcare system has many flaws and shortcomings to be sure, from the perspective of these fresh foreign eyes, our system isn’t all bad.

Euan and Patrick are learning and practicing medicine in Scotland (a nation within the United Kingdom) and therefore participate in the National Health Service or “NHS” as it is affectionately called. In this system, health care is provided and financed by the government through tax payments. There are no medical bills as medical treatment is considered a public service. Not surprisingly, in this system many hospitals and clinics are owned by the government, though some doctors and clinics are private. Other countries that use this model of healthcare include Spain, Italy and most Scandinavian countries. Some Americans refer to the NHS as “socialized medicine”. But as T.R. Reid explains in his book, the NHS is not a pure form of “socialized medicine”. Perhaps the purist example of socialized medicine (ironically) is the U.S. Dept. of Veteran Affairs that we find right here in America which provides complete medical care (free of charge) to our active military personnel, veterans and their families. Keeping this bit of background information in mind, here are just a few of the observations shared by our visiting Scotsmen during their time in Asheville, NC.

First of all, our students were impressed by the fact that patients are assigned to one doctor in the U.S. and in many cases can choose their own doctor. In the U.K. by contrast, a patient is assigned to a clinic based on where they live, and rarely sees the same doctor for two successive visits. Consequently, they observed that patients in the U.S. seem to form better relationships with their doctors (and vice versa) as compared to the U.K. This naturally leads to better communication in the exam room and more informed and satisfied patients. Our visiting students were impressed by how engaged and educated our patients were with respect to their healthcare. They surmised that when one pays for something directly, in this case healthcare, (be it through insurance premiums and/or co-pays), there seems to be a stronger sense of personal investment and value derived from the service. According to them, this sense of personal engagement in one’s healthcare and perceived value is often lacking in the U.K.

Secondly, Patrick and Euan were impressed by the relatively short waiting times experienced by patients when trying to secure appointments with their primary care or specialist doctors. Often both of these types of appointments take much longer to obtain in the U.K. But what impressed them even more was how much time we doctors were able to spend with our patients. Yes, even the oft-maligned 15-minute acute or follow up visit is actually twice the time for a typical visit is in the U.K. where primary care visits average 7 minutes according to our students. A 30-minute wellness exam (such as what we have at OFD) is essentially unheard of in the U.K. They found this increased time to be well used by OFD physicians and their patients for things like explaining medical diagnoses, shared decision making, lifestyle coaching and expanded physical exams. In comparison they realized that there is far less focus on prevention in the U.K. where wellness exams are not routine.

Finally, they found the team-like atmosphere at our practice to be very efficient, embracing a workflow paradigm where physicians rely on medical assistants and other ancillary staff to help keep the doctors focused on patient care. They felt this resulted in higher quality health care and improved patient satisfaction. During their one-day experiences making rounds with the hospitalists at Mission Hospital as well as with a local specialist, they observed a similar team-based model of healthcare which really stood out for them.

As for their criticisms of the U.S. healthcare system, well those were fairly predictable. They commented negatively on the high cost of medical insurance and the fact that even with the Affordable Care Act there were still those who could not afford insurance (or healthcare). They were also quite surprised by the many administrative and bureaucratic burdens placed on physicians and their staffs aimed at satisfying the government and insurance companies or protecting physicians from medico-legal risks.

The fact that in the U.S. practices and hospitals use many different electronic health record systems that don’t seem to communicate well with each other was easily recognized as an obvious disadvantage by our students. By comparison, a single E.H.R. system is used within the NHS in the U.K.

Finally, they were both amused and bothered by the ever present direct-to-consumer advertising efforts by Big-Pharma on full display every time they turned on the television. Being big sports fans and watching sports on TV quite often when not at the office, Patrick and Euan were left with the conclusion that every sports fan in the U.S. suffered from Acid Reflux, Erectile Dysfunction and Depression.

The doctors and staff at OFD thoroughly enjoyed our 3-week exchange with Patrick and Euan and will certainly welcome other international students to our practice in the future. While teaching them much about primary care medicine in the U.S., we also enjoyed showing them what seems to be working well within our healthcare system, in spite of the many inherent weaknesses. As our healthcare system limps with anxiety toward what is sure to be a very messy conversion to ICD-10 this coming October, and as we continue to shift away from a fee-for-service to a fee-for-value model of reimbursement, it is helpful to remember that there are still a few aspects of our healthcare system that are both uniquely American and certainly worth preserving.