American Primary Care and My Soviet Era Class Trip: Sensing the Inevitable Collapse of a Top Down Bureaucracy

From 2020, looking back to a 1977 med school class trip

Swedish Healthcare seemed competent but a bit uninspired and rigid to me but my medical school class trip to the Soviet Union showed me a healthcare system and a culture I could never have fully imagined in a country that had the brain power and resources to have already landed space probes on Mars and Venus by the time my classmates and I arrived in Moscow in the cold winter of 1977.

The first time we sat down for breakfast at two big tables in the restaurant of the big Россия hotel near the Red Square, our two male waiters asked if we wanted coffee or tea and people started stating their preferences. The waiters shook their heads and put their hands up in the air. No, they couldn’t split the beverage order, they explained. We had to all decide on one beverage with no substitutions.

The restaurant obviously had both coffee and tea, and as far as I know, they cost about the same. The only thing standing between the tea drinkers and their favorite morning beverage (the coffe crowd won the popular vote) was convention and attitude. I don’t know if this was a policy set by the hotel management or a complete lack of service-mindedness by he staff, but my classmates and I felt as if we, the customers, did not matter.

(Writing this piece, I came across the news item that the Hotel Rossiya, once the biggest hotel in the world, was demolished in 2006.)

From that first morning on, everything I encountered felt dim, dark and repressive. I saw with my own eyes that Sweden’s degree of uniformity was nothing compared to the Soviet Union’s, which some of my classmates, communists and former Viet Cong supporters, had spoken well of before we got there.

During our stay I saw dilapidated hospital wards and surgical suites with antiquated medical instruments in scarce supply, which we couldn’t even all see because of a lack of scrubs and booties. We saw bare-bones ambulances staffed with underpaid specialist physicians, neurologists for stroke victims, for example. I thought being a doctor in the Soviet Union seemed like one of the most depressing things you could end up doing for a living.

I yearned for the freedom and optimism I had seen back in 1971, when as an exchange student I fell in love with America and a girl I met in my high school sociology class.

During my high school year here, I got the impression that almost everybody in America had a personal ambition, like making music, writing a book or starting a business. I saw a service mindedness I had not seen in Sweden, where years later I saw the epitome of that in a restaurant near the Arctic Circle that closed for lunch (for the staff) from 12 to 1 pm every day.

In America I also got the impression that the rules of society were not exactly cut in stone the way there were in Sweden. Due dates seemed a little flexible, rules seemed to have countless exceptions; even spelling of the American language seemed to offer a few individual choices.

Doctors in America were mostly in private practice. I didn’t see much of American healthcare that year, except the afternoon reruns of Marcus Welby, MD that I devoured. It ran from 1969 to 1976 and it solidified my vision of being a primary care doctor in America.

Fast forward twenty years, to 1991, the year the Soviet Union collapsed. The Planned Economy proved itself to be an unsustainable daydream of the social engineers of communism.

That year I had lived in this country for a decade. My work in a Federally Qualified Health Center, part of a safety net that offered subsidized or free care to people without health insurance, had shown me the inequalities and health hazards of “the other half” of American society. I felt proud to be part of such a clinic, providing equal access to everyone.

During the ensuing two decades, the Federal agencies that paid our grants and provided our preferred reimbursement rates started to micromanage what we did and how we structured our work. My original liberated experience of American healthcare turned into a sense that the bureaucrats mistrusted doctors and administrators of FQHCs so deeply that they had to structure our work for us.

The crowning event was when we all more or less had to earn recognition as “Patient Centered Medical Homes”, which at first sounded like we needed to make our practices Marcus Welby-like. Instead, PCMH was not really about nimbly meeting your patients needs but about creating rigid protocols that in fact made it hard to improvise. This was followed by many other initiatives that to a small or larger degree lacked firm anchoring in the reality of front line medicine and became virtual shackles for medical practices.

This hampering of improvisation in how you meet individual patients needs felt strangely familiar, and brought back memories of that cold December morning in Moscow:

Tea or Coffee, but not both.

Save one same day slot and qualify for easy access recognition, double book freely and fail the access parameter (no “protocol”).

And then when Uncle Sam wanted our “data”, presumably for better central planning some day, we were given grants to computerize our patient records with numerous qualifiers about how to use these computers. “Meaningful Use” broadly sounded like a good idea, except the technology was immature.

One example: Patient information about their medical condition, if generated by the EMR software, often amateurish and rudimentary, gives us Meaningful Use brownie points, but high quality handouts from sources like Up to Date, Harvard or the Mayo Clinic don’t count.

Another Federal shackle: Uncle Sam wants us to deliver comprehensive care, which includes screening for a growing list of clinical and societal issues, like depression, alcohol use, domestic violence, sexual orientation, food insecurity and so forth. If we don’t do all this, we lose brownie points. Consequently, we hesitate fitting infrequent visitors into our clinic schedules, because you can’t possibly do all that in a single visit for a sore throat, so we look better if that patient goes to a walk-in clinic – one ding on the Access parameter instead of numerous dings for all the other ambitious comprehensiveness requirements

I am sorry to report that the well meaning bureaucrats of the Central Planning Office are making American Primary Care feel more and more like the Soviet Union of Lenin and Marx where people mattered as populations, perhaps, but not as individuals. That is not the way Americans think. They don’t want to be told what to drink with their breakfast and they don’t want to be told what the agenda is for their next doctor’s visit.

Collapse or profound disruption seems inevitable.