A recent report considers how physicians should triage patients in the event of a sudden catastrophe that overwhelms the medical system. “The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.”

The full report was published in the May 2008 issue of Chest the Journal of the American College of Chest Physicians. Rationing medical care elicits horror whenever the subject is broached, as it should. But if some sudden and overwhelming catastrophe strikes – a pandemic, an overwhelming act of God, an act of war – we will be forced to prioritize the delivery of medical care so that it matches our resources. There would be no choice after these events.

The report includes specific lists of those who should be denied care following a mass disaster:

_People older than 85.

_Those with severe trauma, which could include critical injuries from car crashes and shootings.

_Severely burned patients older than 60.

_Those with severe mental impairment, which could include advanced Alzheimer’s disease.

_Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

This, obviously, is not an all inclusive list. But what if the catastrophe sneaks up on us rather than appearing in an instant? When a boat starts to leak the first impulse is not to abandon ship – women and children last. Medicare, indeed all of medicine, appears to be on the verge of a mass catastrophe that is marching in slow motion. More and more numbers of old and very ill patients require more medical care at ever greater expense with less and less to show for the effort and expense.

Last month I made rounds on a general medicine service. Most of our patients had multiple medical problems that could only be treated at the fringes. We were barely keeping them alive, but at enormous expenditure of money, time and personnel. Everyone was frustrated, patients, their families, doctors, nurses – all were overwhelmed by impossible expectations. Patients who could not be restored to health lingered on for what seemed an eternity and like those around Tolstoy’s Nikolai in Anna Karenina everyone guiltily wished them dead even as they did everything to prolong finished lives. The dying deserve dignity and succor. But we ought to be able to provide them without mortgaging the future.

Dartmouth Medical School is pioneering a new approach to the care of very old patients which seems both humane and less expensive. “Slow Medicine” prompts physicians to consider the benefits that aggressive medical offers to the elderly and to offer more conservative and palliative treatments. Whether it will catch on is uncertain.

Patients who have problems that could be effectively dealt with are either treated as outpatients or are in the hospital for a brief time. Most of the chronically terminal patients we were caring for were over 65. Consider the following data from The Administration on Aging:

The older population–persons 65 years or older–numbered 37.3 million in 2006 (the latest year for which data is available). They represented 12.4% of the U.S. population, about one in every eight Americans. By 2030, there will be about 71.5 million older persons, more than twice their number in 2000. People 65+ represented 12.4% of the population in the year 2000 but are expected to grow to be 20% of the population by 2030.

Absent some medical miracle the number of very old and very sick people in our hospitals will be the equivalent of a sudden overwhelming catastrophe. How will we care for these patients? Who will care for them? How will we afford the expense? Will any one be willing to triage?

I don’t have the answer to any of the questions. But no one seems willing to seriously discuss them much less provide answers. 2030 will arrive with 80 million people on Medicare who will have a lot of chronic (and expensive) medical problems. How will we provide care for them? The needs of such a population are so far beyond our ability to provide them that a retreat to hopelessness is understandable.

Nevertheless, attempts are being made to deal with this impending tsunami of very sick patients. To analyze how this problem will manifest itself requires a book, but here are a few reasons why the problem is even more complicated than it appears.

Medical schools are increasing the size of their classes and new medical schools are under development. This increase in medical graduates is a response to the anticipated increase in demand which results from what I have described above. But there is much less here than meets the eye.

Increasing the number of graduates without increasing the number of residency slots available for them will not increase the number of doctors in practice. There are about 5,000 more first year residency slots available than there are American graduates of American schools. They are currently filled by foreign graduates. Residency positions are mainly paid by Medicare. Medicare is under such financial stress that it is very reluctant to pay for more doctors in training. Increasing the number of American graduates as things now stand will just decrease the number of foreign graduates in residency training.

Medicare can’t pay for the patients it now has. It will soon have to pay for about twice as many more. If we want more doctors to care for them Medicare will have to pay even more.

Another problem that no one talks about is the applicant pool. American medical schools are not deluged with qualified applicants. The national acceptance rate is about 50 %. This is a sharp increase from what it was one or two generations ago. For whatever reason, increasing bureaucracy, increased training time, life style issues, medicine seems to be a less popular career choice than it previously was. With more and more positions available for applicants the quality of those accepted may well decline. Do you want your doctor to be someone who went to medical school because he couldn’t get into business or law school?

But even if we do increase the number of high quality graduates and figure out how to pay for them and the costs they generate we still have a problem. More doctors doesn’t result in more hours worked. Rather they work less hours resulting in more doctors who work less hours per week than their predecessors. Thus doubling the number of doctors doesn’t come anywhere near doubling the number of hours worked.

There are at least two reasons for the decrease in hours worked. The first is the life style issue touched on above. Physicians no longer seem willing to work 80 hour weeks. This hardly surprising in an advanced society. The second is that about half of our medical graduates now are women. Women doctors work less hours than men. The reason for this is obvious. They want to have families. And despite almost two generations of nagging the responsibilities of family life fall disproportionally on the wife. Hence women doctors choose branches of the profession which have less time demands, work less hours, and are more likely to take prolonged absences (often years) from work.

But it’s not just more doctors that are wanted. More patients require more nurses, more technicians, more clinics, more hospital beds, many more administrators. And lots more money. More money than we’re likely to have.

A national health plan which seems ever more certain with every new election cycle is not going to increase the desirability of medicine, in my opinion. So how are we going to deal with all these patients. A triage system like the one described above will obviously not do. It probably won’t be accepted even for a nuclear holocaust – at least in advance. The only workable solution seems to be rationing by delay. Affluent patients will buy their way out of the system as they do in Canada (they come to the US) or in the UK (they go to private physicians and hospitals). In other words, a two tiered system, grossly unequal, is likely to result from a desire to provide more or less equal service to all. Cost will be the hammer that builds this system.