With supersize wants, it's time to ask:
Do we need it?

by Eric Anderson

Both of my grandmothers lived in our Scottish village when I was young.

One was a compassionate soul who loved all the grandchildren her 11 children had given her but, a poor farmer's wife, she could offer the kids she adored little except kindness and affection.

The other grandmother was a stern, flinty woman who believed her grandkids were always after her money. Any time a child murmured wistfully that it would be nice to have, say, a toy soldier or a comic book, she would pierce the kid with her eagle eye and ask, "Would you like it?" Then would come, "Do you want it?," and finally the killer phrase delivered so triumphantly: "But do you need it? Hah!" That closed the matter.

It wasn't a secret which grandmother was more loved, but we all learned things from the second grandmother, such as: You shouldn't want things you don't need.

Indeed, "Do you really need it?" is a phrase I sometimes hear in my own mind when I put aside ingrained Calvinistic doctrines and enjoy life. Frugality seems embedded in the Scottish character, and it's one of many reasons why health care costs can, to a degree, be contained in Britain.

And how does all this compare with America, the land of which I'm proud to be a citizen? You gotta be kidding! The countries are poles apart -- which is why the United States will never tame the multibillion-dollar beast, the cost of health care.

America is a nation of excess that makes Imelda Marcos' 1,220 pairs of shoes seem a modest eccentricity in comparison. We have too much of everything: gas-guzzling cars, home supersonic video systems, riding lawnmowers and things. And too many rock stars, too many kids with money, too many politicians, maybe even too many people, some with demands that would surely embarrass Oliver Twist.

Nowhere is this seen more starkly than in the "Why can't I get my share?" approaches of some supplicants to the health care system.

The latest demand from our Medicare HMO patients in California? Scooters.

Not the kind Andy Rooney hopped on one working day in New York for "60 Minutes." Not the things kids bounce on our sidewalks, those contraptions that keep emergency department orthopedists busy. No.

Scooters like golf carts, doctor -- and my wife would like one, too.

It's a natural enough progression from those items our older patients formerly wanted from their health insurance companies: armchairs that elevated patients to a standing position at the touch of a button.

Rising chairs, like hula hoops, are now a bit passé. But scooters are cool even if they would make the Third World gasp in astonishment at what industrial nations consider essential.

I have no argument that we are here to care for our patients and to attend to their needs. To their needs, yes, but the specter of my grudging grandmother looms over me. Who is to judge our nation's health care needs? Should it always be the hallowed needs of the individual, or should not society have a voice?

Our resources are not infinite, although some in San Francisco might dispute that. The Golden Gate city will soon be the only governmental body in the nation to make sex-change operation benefits available for municipal employees.

San Francisco's estimated transgender community numbers about 15,000, and at least a dozen work for this liberal city. The costs of the proposed benefit will be shared among the taxpayers, and all 37,000 city employees will pay an extra $20 or so a year in insurance costs.

Where does it end?

Indeed this is the basis for insurance in general: Share the risk, share the costs. But where does it end? What if all the transgendered people in town go after city government jobs? What if all those people so inclined in California head for San Francisco?

Perhaps that is a bad example. A nation is judged by the compassion it accords those who are less fortunate, those who have needs. And the best doctors have always fought for the rights of their individual patients. It's an inherent principle in our profession. It's what we'd want for ourselves as patients if we were ill.

Nevertheless, our patients get a lot they don't need. They get it for different reasons -- some because they play one doctor off against another, some because they are medical sophisticates and have a brother who is a plaintiff's lawyer and some because they simply wear us down.

Our patients don't need an MRI for low back pain or knee imaging if they're going for arthroscopy anyway. They don't need a stress test if they insist, after thorough explanations, that no matter the result, they won't accept any procedure offered as a result of it. They don't need executive-style annual ECGs if the previous one was normal and symptoms are absent. They don't need Pap smears if they are elderly and have had a hysterectomy. But they get 'em.

And if we are going to talk about the elderly, in my opinion they don't need regular tests for their cholesterol level.

I recall one elderly gentleman who came to urgent care with abdominal cramping, black tarry stools and a face as white as a toilet bowl.

While putting up his IV drip, I drew blood, labeled the test tube carefully and handed it to the ambulance crew. Desperately worried, I said, "This will save cross-matching time at the hospital; he's going to need blood in a hurry."

The patient saw the tube of blood and seemed to nod sagely. But when the ambulance door slammed shut and the vehicle took off in a shower of gravel, his shouted question still hung unanswered in the cold night air: "What was my cholesterol?