Dear Senator Baucus,

At a forum sponsored by the Center for American Progress Action Fund on Friday, March 27, 2009, you referenced American healthcare as a “hodgepodge” and that the reason at least in part, is that:  “There’s entrepreneurship, creativity, there’s ‘go west, young man’—that’s much more a part of our culture than it is in other countries and various groups; doctors, hospitals, nursing homes, (medical) equipment manufacturers—they’re providing care, but they’re also trying to make a buck.”  I’m wondering Senator if I can offer you a free office visit for diagnosis of what seems to be a serious psychiatric diagnosis?  Let me explain.

According to the current American Diagnostic and Statistical Manual of Mental Disorders, Paranoid Personality Disorder (301.00) is characterized by “a pervasive distrust and suspicion of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts”.  In ICD-10 (International Statistical Classification of Diseases and Related Health Problems), this disorder requires at least three of ten psychological aberrations to establish its diagnosis.  In your case, it appears on the basis of my research of your statements, affiliations and present profession and conduct, that a medical student could make the call.

Of course only a trained psychiatrist can truly diagnose you, pursuant to her training of at least eight post graduate years.  I am just a practicing Ob/Gyn, with a similar length of training, but because we Ob’s are primary care doctors for at least 1/3 of our patients, I do spend a lot of time trying to keep up with many disciplines across the medical spectrum, including mental health, ergo my concern for you Senator.  But since my patients are also my friends, you should know something about me since I’m making such a serious observation from afar.  My training required sacrifice starting in grammar school: Time spent with books instead of baseball bats or hot rods and as I grew older, time away from family and friends during and after training.  There were the missed opportunity costs in lost earnings during med school and residency compounded by huge loans.  In my case I worked two and sometimes three part time jobs from junior high through medical school to reduce our debt burden.  So did my wife, who has sacrificed with me since we met as teenagers and who worked dutifully to further fund my education.  18 years later, country vacation weekends alerted me to the lack of access to specialized women’s care, and in 2006 we moved to rural Missouri, leaving a thriving practice in a metropolitan area to serve 3 critical access hospitals.  We have fewer cultural opportunities, eat at country diners and endure tougher winters than in the city, but feel I’m making a difference, providing quality service to an economically depressed area. 

 But back to your problem, Senator.  Here are but a few criteria for paranoid personality disorder (per ICD-10) you seem to display:

 1)      Tendency to bear grudges persistently. 

 You keep talking about quality problems in health care.  Tell me, Senator, where is the evidence.  In recent remarks to AcademyHealth Conference, you stated that “providers get paid more money for ordering more tests and treatments” and that legislators need to “change payments to encourage the right care-the best care-for every single patient, rather than procedures they don’t need”.   I know as an attorney you probably pal around with colleagues who have a natural disdain for doctors, so I understand your assumption that we make it a practice to overcharge and over-treat.  On the contrary, doctors are constantly reevaluating new tests and procedures on a cost/benefit ratio.  It’s just that the costs and benefits we measure are in terms of resource stewardship and patient beneficence, not just so we can “make bucks”, sir.  Your statements tell a story of visceral distrust for caregivers’ motivations and performance, it seems.  I guess it’s shame on us that for attending to our patients’ individual problems and circumstances, coping with rising costs and decreasing revenues, enduring ever-increasing interventions like mandatory electronic medical records, “comparative effectiveness” mandates and draconian regulations, working an average of 65 hours weekly not including call hours and sacrificing holidays, weekends and many other times with our families that we ask for commensurate (though orders of magnitude less that those you ‘bail out’ in your favored industries) salaries. 

 As an aside, you seem consistently mean-spirited toward the insurance industry, relentlessly attacking them at every opportunity.  Certainly I’m no friend of unethical insurance practices such as selective enrollment and arbitrary unilateral reimbursement underpays for providers, but you and I and the vast majority of insured Americans are sure happy to have insurance when big-ticket illness does strike.  There is room for reform, no doubt, but are insurance companies always the villain, or is it only in your possibly delusional construct, Senator?

 I also notice a tendency in most all your statements and speeches to conveniently ignore how your trial attorney pals continue to obstruct efficient and affordable care.  As an attorney, it seems naturally that you ignore the estimated  $150 billion or more spent on defensive medicine testing and procedures annually in America.  What’s more, the access you claim to want is threatened by doctors of all specialties limiting their practice in both scope and size in order to limit litigation exposure.

 2)      Suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral of friendly actions of others as hostile or contemptuous.

 Senator, you say that doctors, nurses, hospitals and nursing homes “may provide care, but they’re also trying to make a buck”.  You didn’t say “but we must realize they too must pay their bills”.  This seems an implicit contempt for Americans providing an essential service and being reimbursed reasonably, sir. You and I probably agree that great healthcare is an essential need for every American sooner or later.  I noticed you are from a ranching family, an attorney, and a U.S. Senator. It can be persuasively argued that food, legal services, and needed governance are all essential at one time or another to every American.  Will you demean ranchers, lawyers and legislators and smugly indict their hard earned salaries for the provision of these necessary services, too?  Why the selective contempt?  What doctor, nurse, or hospital has ever wronged you while providing compassionate, professional and effective care?  Is this the reality, or is it really a problem in your mind, Senator?

 3)      Tendency to experience excessive self-importance, manifest in a persistent self-     referential attitude.

 You said in remarks to the AcademyHealth Conference, “I believe that this Congress has a duty to reform health care”, and that your “Call to Action” would “show a path forward”.  How Senator can you and your colleagues begin to know one iota about the interaction between a doctor or nurse and a patient.  It’s clear to us who actually care for people that you know very little, and encumbrances you embrace on great medical care prove that.  You can no more claim to be a steward of Americans’ health than I could legislate good legal counsel or productive ranching, yet you and previous politicians have created artificial markets, burdensome dictates on medical practice and taken the patient and doctor increasingly out of the equation.  Based on your deep involvement in the expansion of government-funded care for an ever-expanding class of patients, one can only assume you think you know what’s better for patients than they do.  Why have you ignored vibrant, decentralized consumer-driven, market-oriented systems like Switzerland’s, as espoused by Harvard Business School Professor Regina Herzlinger?  It appears a bit psychotic to think that you and other politicians can create great government directed health care by micromanaging nuanced patient-doctor interactions, when you have had difficulty managing Postal, Financial, Border, Rail and Education matters from your narrow Beltway perspective?  I understand how important it must feel to be a Senator.  I watch how you turn folks who testify to withering bowls-full-of-Jell-O.  Maybe this narcissistic inclination to demean others is necessary to achieve such high and mighty positions as Chair of the Senate Finance Committee.  But as you can see from this diagnostic criterion, it may invite you some counseling too.

 So, Senator Baucus, before you decide for medical professionals and patients how, by whom, and for what recompense they should be cared for, please see your doctor for a thorough psychiatric evaluation.  This condition could worsen, leading to statements heard by others similarly affected in your party, at many levels.  Look in the mirror Senator, before you echo such a phrase, and then ask if “we are the ones we have been waiting for”.

 With deepest concern for you,

 Randy Tobler, MD

 Randy Tobler is a city-turned-country doctor and radio talk show host.