DOCTORING IN MONTANA

Ian Marquand came to my consciousness in Montana thirty years ago as a TV reporter.  I thought at once that here was a true humanist, a keen intellect with a wide interest in what happens and why.  Reporting was an excellent thing for him to do.  Billings TV, ever alert to how to shoot itself in the foot, pushed him out of his job.  They think they're Denver.

This evening I ran across a piece about Ian, a bit of video, and didn't recognize him in spite of his distinguished nose until he began to speak.  He's gray.  A little heavier.  I'm curious to know what else is different.  But it turns out curiously difficult to discover.  He's on Facebook where I refuse to go because it is evil.  He's on Linked In, which I joined in 2014 but can't access because it insists that I'm not human or I'd have two telephones.  Not much on Google.  

He's on the advisory committee for the Mansfield Center, which is a good thing.  He has two formal jobs, one as a public relations consultant in private practice, and the other as Executive Officer for the Montana Board of Medical Examiners ( MT Dept. of Labor & Industry) in Helena, MT.  He is a University of Montana graduate, long enough ago that he probably got a proper education.  He has a YouTube channel but, curiously, is not on it in front of the camera.  He likes Asia and kids, which are promising subjects.

After considering overnight, I've decided to focus on his Montana Board of Medical Examiners role, composed as follows:  Thirteen individuals are appointed by the Governor to serve on the Board of Medical Examiners.  Under Montana law, the Board is made up of:

• Five Physicians having the degree of Doctor of Medicine (M.D.) including one member with experience in emergency medicine.
• One Physician having the degree of Doctor of Osteopathy (D.O.)
• One licensed Podiatrist.
• One licensed Nutritionist.
• One licensed Physician Assistant.
• One licensed Acupuncturist.
• One volunteer Emergency Care Provider.
• Two members of the general public who are not medical practitioners.

There is no provision for Nurse-Practitioners.

I have a number of concerns about medicine in Montana.  None of them are about feet or acupuncture.  I'll number the others:

1.  Lack of transparency or plan of action for plagues like opiods, TB,  AIDS which are still of major concern to the population as a whole.  Would it not be a good idea to include a public health expert?

2.  The number one problem in Montana is also its best feature: vast space and severe weather.  As an old woman with a dubious pickup, living singly and not in happy communication with neighbors, I constantly run into docs etc. who insist that I present myself at their offices, even when roads are closed or ought to be.  I must decide whether to use the ambulance, which is volunteer and understaffed because there are not enough young people.

3.  The above is accompanied by sparse and aging population.  Wealth is unevenly distributed.  But the providers of care and their families want to live in population centers with decent pay.  As in many other contexts, like education and grocery stores, the tendency is toward consolidation.  Hospitals enrol docs from farther and farther away and consolidate so that the governing boards are less and less local.  My doc just sold his practice to his previous hospital which has bought his present hospital, both of which have been subsumed by a Northwest mega-network of hospitals run by a Mormon business.

4.  Much care is needed by older people with chronic conditions like diabetes or heart/lung problems.  Modern care for these people means constant blood testing and reliable compliance on their part, which may mean monitoring. The assumption by docs is that patients will be on a regular schedule, coming in -- not asking for advice by telephone.  In fact, I'm finding that Montana care givers are singularly reluctant to come to the phone and are suspicious of email.  In Oregon I was used to docs who never ended the day without phone contact with those who needed it.  

5.  Money in a time when docs must go into nearly lifelong debt to get through medical school means that the whole system runs on the insurance that guarantees income.  That means the insurance world, a business for profit, controls much of what happens.  A concept called "best practices" imposes a code that defines afflictions and their reimbursement.  A covert agreement with the pharmacy industry means that a code prescribes a med, regardless of price.  This by-passes the doctor and may be controlled by a nurse practitioner.

6.  Group practices employ "specialists" that control the "business" to increase profit.  Since health care until now has always been guided by compassion and personal relationship, this reduces the special status  that once justified religious bodies running hospitals to being just another shop.  Puzzling or difficult cases -- mouthy patients -- are discouraged because they cost money to the practice, but because the cases are sent to bigger centers farther away, they end up costing the patients immense amounts, maybe bankruptcy or just non-treatment leading to death.

7.  Google and other search engines list and provide judgment based on client satisfaction, making a doctor vulnerable to soreheads and shake-down artists.  A medical doctor should not be focused on what makes the patient "feel good."  There's another profession for that.

8.  Montana, Google says, does not provide to the public any info about lawsuits, insurance for malpractice, dismissals for whatever.  Other states do.  This omission makes Montana attractive to medical people who've had difficulties in other practices.  Some of them are perfectly well-qualified but are stigmatized by nonconformity like sexual identity or because they are immigrants.  This sort of thing is vulnerable to political maneuvering and one more source of control over doctors by non-medical people intent on profit.

These observations are based on my life experience, which includes a summer as a hospital chaplain at a major regional center and ward clerk in a Montana hospital that had become a target of state regulation because of one doctor, an aging Doctor of Osteopathy with a cranky retro attitude.  He was much loved by some, esp. those who considered themselves peers -- i.e. prestigious white men with prosperous businesses.  When ousted, he moved one county away and began again.  In my little village that same hospital supervises a once-a-week clinic served by the most recent or least prestigious medical person.  These persons spread over a wide range of qualifications and skills.  They are most often female.

Montana people are often fatalists.  If it's difficult to get oneself to a doc or hospital, it's also difficult for regulators and monitors to get to the locations across hundreds of miles of prairie and over major mountain ranges.  We just do the best we can and die if we have to.

I wonder what Ian Marquand thinks of that?  Does he have a filing cabinet somewhere full of essays, thoughts on the subject?  I'll send this to him and see what he says. 

11/1:  Marquand says nothing.

5:30 PM  After adding this note, Ian's response came in as email rather than a comment. He is not interested in philosophical discussion. OK.

NURSE PRACTITIONERS ARE GOVERNED BY THE BOARD OF NURSING, NOT THE BOARD OF MEDICAL EXAMINERS.

THE BOARD IS GOVERNED BY THE STATUTE ON COMPOSITION. THE GOVERNOR'S OFFICE SELECTS THE BOARD MEMBERS.

THE BOARD DOES ALLOW THE PRACTICE OF TELEMEDICINE BY PHYSICIANS. BUT IT'S NOT REQUIRED.