Sign Out: Keeping track of the bass line

August 1, 2007

Medicine's backbeat has changed. Physician recommendations never used to be questioned. Then, managed care entered the scene and third party payers became reticent.

Yet throughout the years, I've had a thing for the bass. The way it subtly provides substance to the music, grounding it in a primitive, subconscious way... Almost never in the forefront as a solo instrumentalist, the bass player is the girl/guy with sunglasses and a hat, rocking on his or her heels next to the drummer, in a trance-like state of contentment. . . .

And this is what I love about it. I'm not a social bass player yet. I set up my amp and drum machine in the basement, play some bass lines and slip into alpha brain rhythm almost instantaneously. The repetition is reassuring. The perfect fusion with the drumline is satisfying. I didn't realize the bass is considered a percussion instrument until I began playing, but of course, there it is. You can't help but twist your neck, tap your toe, rock and shake a bit when you play.

So, not to make too awkward of a segue, it occurs to me that this is what we are beginning to miss in medicine today. That sense of security that comes when one knows the backbeat. The feeling that the backbeat never changes. Throughout all of the cataclysms of the past 15 years, the drumbeat and bass line of medicine, for me at least, always contained one reassuring element: we, the physicians, we are advocates for the best care for our patients. Physician recommendations never used to be questioned. The bass was playing the melody then. We could order whatever we wanted, evidence-based or not, reasonable or not, and the patient would get the test/operation/prescription. Then, managed care entered the scene and third party payers became reticent. The volume on the bass had to be turned down, but the bass player was still in the band. We could make rational requests for medical tests or procedures for our patients and most of the time, despite the inconvenience, permission would be granted.

Lately, there's a tinny hollowness to my recommendations. Prescriptions I write are questioned almost routinely by the pharmacist, the insurance company, or both. Are you sure you want to give this much pain medication? The patient only gets a 30-day supply, not a 90-day supply, so you will have to rewire/re-phone/re-FAX a new prescription. . . . Do you want extended release or regular? Is that a 21-day, 20-μg pill or a 28-day, 30-μg pill? Because the insurance policy pays for the 30 μg but not the 20 μg . . . Are you sure you want to give this patient estrogen, doctor? I have a printout here that says that estrogen is bad for menopausal women . . .

The static is beginning to drown out the music

Does it really matter if that estrogen is transdermal or oral? Is extended release really better than the regular stuff? Is that 5-mm thick, opaque estradiol patch really that much worse than a sleek, thin, clear dot that's a quarter of the area? Especially if it means yet another letter-writing campaign and series of phone calls? Do I really want my nurses to hunt to the ends of the earth for the least expensive gonadotropin drug for my cash-paying patient, knowing it will take hours?

These are the dismal daily battles that I fight at the front lines of 'value-based medicine.' Because what will we become if we fail to continue to fight these little fights, day in and day out, with a system that nobody made and nobody can control? Yet this is the bass line for our patients, too-it's their reassuring backbeat, too-their understanding that no matter how petty the system gets, we will be there for them, that we haven't given up, extended release is better than three-times-a-day dosing.

Excuse me, I've got to go practice the bass.