If the rich could hire the poor to die for them,
the poor would make a very nice living. Yiddish Proverb

Air Care: Thoughts on Health Care from 39,000 Feet.
by David J. Elpern

I’m sitting in Economy traveling from the City of Angels the Big Apple. Just in front of me is the First Class (FC) section. The cabins are separated by a curtain and I watch a stylish stewardess hovering over a passenger there. The FC passengers get the best attention money can buy. Food, drinks, a table cloth for their meals! Solicitous smiles from the stews. We, in coach, get a small packet of pretzels, soda, juice or water and our servers’ RBFs.

As a physician, I aspire to treat every patient as a FC passenger on Air Care. It is unachievable to do this, and many doctors don’t even try. Two-thirds of my private practice dermatology colleagues don’t see Medicaid patients.¹ They limit their “cabins” to FC and Economy Plus passengers. Some physicians will only see FC patient-travelers. Then there are the concierge practitioners who are similar to the 0.01% who own or rent private jets. What has happened to our noble tradition?

The recent email from a patient on Medicaid illustrates this problem.*

Although there are many analogies with air travel, and even more with steamship travel of the past, health care should not be like travel. We are all going to the same place on life’s journey. All our travails on this “ship of fools” are moving towards the same port-of-call:

The boast of heraldry, the pomp of pow’r,
And all that beauty, all that wealth e’er gave,
Awaits alike th’ inevitable hour.
The paths of glory lead but to the grave^{. 2}

So, I resolve, in my allotted time to try to abolish class distinctions on this dermatology craft that I captain. It will be instructive to see how this plays out; if, indeed, if this can be done.

*Addendum: Note received the day I had these thoughts.
Hi Doctor,
sorry to bother you but i thought i would get your opinion on something. my girlfriend has seizures and has had an MRI over a week ago and a 72 hour in-home EEG a week ago. she has a neurologist in [X] who is not attached to [our local medical center] and works alone three days a week. [The neurologist] is VERY unprofessional and has not given her any feed back. i told her to call her PCP and say she wanted a referral for a second opinion and they said No, she had to go to the neurologist in X to get a referral for a second opinion. She has Medicaid and is pretty much told she has to settle for what she has. the doctor in X doesn’t even bring her into a [exam] room and talks to her in the lobby with people walking by. this all sounds crazy to me and i thought you may have a suggestion.