The current exodus of good, smart, talented people from the American medical system
reminds me of my first experience as a “field clinical engineer” in
medical devices in Colorado. Starting in early 1002, through an odd
series of career plans gone bad, I ended up taking an offer from a Denver pacemaker company, Teletronics,
in their Technical Services Department. I was offered the job because
the department was overstaffed with nurses and understaffed with people
who understood how the technology worked; engineers. The department
manager was a nurse, by training, and every employee in the department
was trained as a nurse, except for an old friend who had recommended
hiring me, and was the group’s supervisor, and me. When I started,
Technical Services was part of Training, Field Clinical Engineering, and
a few other counter-intuitive operational groups with a manager who
didn’t know much about any of the people or technology or customers. He
did, however, know how to spend money like a Republican President and he
introduced me to extravagance that made the 1992 “me” understand the
true meaning of “decadence.”
I don’t remember how this
happened, but early on I made a friendship with one of the Denver area
sales reps and he decided to help me move from Tech Services to Field
Clinical Engineering. Telectronics didn’t have much of a training
system, considering the size of the company, the complexity and newness
of the products, and the criticality of the products and applications.
In fact, the “process” was pretty much toss the victim into the fire and
see if they burn or escape with a few injuries. I was actually one of
the instructors in my own training class. A few months after I’d started
my new job and career, The sales rep asked me to cover for him at a
hospital in Glenwood Springs, Colorado. To help me get ready for the
implant, he let me follow him for a couple of days and about a
half-dozen pacemaker implants, a few days before I was due in Glenwood
Springs.
Glenwood Springs was, and is, a rich person’s town. It’s a
10,000 person city with average household incomes above $120,000 and
lots of homes owned and unoccupied by millionaires and billionaires
(probably none of them in 1992). There are five expensive private golf
clubs in Glenwood. The overwhelming majority of houses in Glenwood
Springs are over $350,000 with no shortage of $500,000 to $1,000,000+
homes in the city. If there was ever a city that epitomized the
lifestyles of the rich and infamous, it would be Glenwood Springs. It’s
where Doc Holiday withered away his TB-infested lungs and is buried.
As
a western Kansas small town kid with a lot of rural relatives, I’d shot
and butchered a fair number of small animals. I have never been much of
an entrails or organs gourmet and I never bothered learning to identify
organs because I was just going to toss them. Starting out in my new
career, I often joked (sort of) that “I couldn’t find a heart with an
axe.” I had, however, studied hard, learned to answer telephone
questions about devices and implant procedures, and knew as much about
the technical side of Teletronics’ products as anyone in the department.
The sales rep and my boss thought I was ready to field test.
When
I arrived for surgery, I discovered that the cardiologist had blown off
the implant procedure because he’d scheduled a golf game some time
earlier. The surgeon was not a cardiology specialist, but about as
general a surgeon as a doctor can be. He managed to place the first
lead, of two, fairly efficiently if not ideally. Positioning the second
lead, the atrial lead, was far above his pay grade and he’d never done a
dual chamber pacemaker before. After several attempts, it was obvious
that he’d managed to incorrectly entangle the atrial lead in the
coronary sinus, which did not properly synchronize the atrium and
ventricle. The surgeon had an argument with the anesthesiologist about
the structure of the heart: the surgeon was wrong, the anesthesiologist
was right, and I stayed out of the argument. After failing multiple
times to get good numbers from the atrial lead, the surgeon threw a pout
and left the surgical suite and a nurse sewed up the patient.
Before
I left the hospital, I left a message for the sales rep that the
implant had gone poorly and that I suspected a follow-up surgery would
be necessary. Two days later, I was invited to a Denver hospital to
watch an actual cardio-vascular surgeon remove the atrial lead and
implant a new lead in a functional position. There were a lot of jokes
in the OR about the Glenwood Springs surgical staff (I stood up for the
anesthesiologist) and rural hospitals in general.
Glenwood Springs
is a hyper-rich community with as many idle rich “residents” as humans.
Still, all that being true, two of the three doctors involved that
procedure were among the worst I experienced in ten years of attending
implants, “battery” replacements, lead extractions, follow-ups, and
pacemaker/ICD troubleshooting sessions. The surgeon was absolutely
clueless about cardiac structure and had no more business trying to
implant a dual-lead pacemaker than does a veterinarian who specialized
in horses and cattle.
All that was in 1992, post-Reagan but before
the US tax system’s mangling from that period started spitting out more
money-fondlers than doctors, engineers, scientists, and other useful
professionals. Since then, almost anyone with less-than-perfect idealism
has been drawn into the equity capital/money manager/hedge fund gold
mines, leaving the country with a giant hole where national expertise
used to be.
While it’s true that rural hospitals are dying
off because they’ve been absorbed in the vulture capital nightmare, they
are also unable to attract talented doctors and physicians’ assistants.
Once you get any distance from a major city, hospitals are typically
“sharing” physicians and specialists across long distances. Odds are
that in any sort of emergency, those hospitals are not much more than
helicopter pads with semi-skilled EMTs providing first aid, until the
patients can be evacuated to a city. Even major cities are having
problems staffing their hospitals with doctors and specialists and some
specialties (family medicine, internal medicine, dermatology,
cardiology, neurology, psychiatry, gastroenterology, endocrinology,
oncology, infectious disease, orthopedic surgery, plastic surgery,
urology, and pediatrics, for example) are in desperate
shortage. There are no solutions in the foreseeable future to a drastic
shortage of new doctors in the medical school pipelines.
The Republican’s Big Godawful Bill
is about to make all of that move from desperate to disastrous. Cutting
the heart out of federal support for the ACA and Medicate and, soon,
Medicare will accelerate rural hospital closings in the short term and
eliminate any sort of future revival in the much longer term. For a lot
of rural communities, this is very likely an “extinction event.” As
Republicans have proven, repeatedly since Nixon, breaking things is easy
and “fun,” but building and repairing things takes time and skill.
Republicans and Republican voters are notoriously short on either
patience and talent.
