dr. solomon's dilemma

producer's notebook by David Murdock

solomon profile
financial incentives
cost v. care

Murdock is the producer of FRONTLINE's documentary, "Dr. Solomon's Dilemma."
We have all had the experience of walking through hospital doors and feeling the normal world slipping away behind us. Between the land of the unwell and the land of the temporarily healthy there lies a wide gulf -- a gulf reinforced by a hospital culture fraught with obscure hierarchies, indecipherable language, and a surreal sense of time.

Stepping into a health care story can be a similarly disorienting experience for a journalist. The combination of medicine, law, politics, and business that is American health care can swamp the most diligent reporter. One common response to the overwhelming mountain of information that attends medical stories is to reduce them to cookie cutter formulas such as: "medical miracle" or "evil HMO." With "Dr. Solomon's Dilemma" we were hoping to deliver something both more human and complex.

Researching a medical story, you soon come to realize that most of the reporting on hospitals is to be found on the business page. The danger facing physicians -- which Dr. Tom Delbanco describes so eloquently in the show -- stands as a warning for journalists as well: "If we forget to keep our eye on that ball which is the doctor/patient relationship we're going to be sunk."It is not easy for doctors or journalists to follow that warning but it guided our approach to the show. Our program would be successful, we thought, if in the end patients learned something about the pressures endured by doctors and doctors could learn something about the anxiety felt by patients.

But getting patients in the story was more difficult that we expected. On some health care stories there are activist-groups eager to provide journalists with patients who have compelling stories to tell. To try and capture the average experiences of patients, however, means entering people's lives at the very moment they are least prepared to deal with outside distractions -- such as a camera crew.

Many patients we approached, already fearing for their health, were reluctant to participate because they feared repercussions that might follow speaking candidly of their experiences. Some were worried about getting a reputation among doctors for being troublemakers, others feared that insurance companies would learn of a pre-condition and deny them care or raise their rates, and still other patients were employed by the health care system and feared for their jobs should they tell their stories. All of these concerns are understandable, and there was nothing we could do nothing to insure that what they feared would not in fact come to pass. But these very real misgivings of patients were an obstacle for us in trying to paint a true picture of how patients people experience the system.

Those patients who did agree to be filmed did so in the interest of educating others about the daunting new world of health care. Risa with her diabetes and pregnancy, Steven Bookbinder with his heart condition, the Humphrys struggling to take care of their elderly mother -- all of them felt compelled to help others prepare for the inevitable contact with the health care system. That they let us in to their lives during such hectic and emotionally wrenching times is a tribute to their courage and concern about the bewildering world of health care.

That same motive to educate the public was, I believe, behind the Beth Israel Deaconess's decision to agree to cooperate with our project. BID has a long and valued tradition of being "patient centered." It developed the first patient bill of rights in the country and constructed the humane model of primary nursing that was copied by hospitals across the country. The administrators at BID -- well aware that patients and doctors are feeling more anxious than ever in these confusing times -- felt a program that would shed light on the challenges facing an academic hospital in competitive times would help patients understand the forces at work behind the scenes. Like the patients, BID and CareGroup, showed enormous courage in allowing the curtains to be pulled back, briefly, on the inside workings of a hospital facing the same enormous challenges. And those challenges are by no means unique to Beth Israel Deaconess or to Boston. Hospitals and academic health centers across the country are struggling with the identical challenge of staying afloat financially without jeopardizing care.

We named the program "Dr. Solomon's Dilemma" because Martin Solomon's personal struggle to balance care and cost grounds the show in that essential patient/doctor relationship. We spoke with many doctors in the Boston area - some quite comfortable with the changes, some absolutely outraged that they were being asked to consider the cost of care at all. Dr. Solomon was somewhere in the middle - and internally divided. One of the most respected physicians in Boston, Solomon is working as best he can within the new system -- in fact, he is leading his pod in their efforts to control costs. At the same time, he is very uncomfortable with how it is affecting his practice. The struggle going in within his own heart, we felt, was an excellent entry point to a complex story with larger economic and policy ramifications. Understanding Martin Solomon's dilemma day in day out as a doctor is the first step in comprehending the enormously complex challenges facing our health care system as a whole.

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