Envelopes and the Greek Medical Business

This post on informal payments from The Physician Executive was one of my most popular. Originally published Aug 15, 2007. Dangerously, I have to note it is one of my favorite jokes. 


If you think we have problems in the US, you should try Greece.

There had been talk of a socialized system several years and a couple of prime ministers ago. There seems to be a modicum of a centrally funded, insurance-based system now. However, the WHO’s description of Hellenic healthcare tells me it still runs the old-fashioned way:

[Informal payments] are especially prominent in the case of in-patient care, and are made to doctors, mainly surgeons, in public but also in private hospitals. These payments are also made in the case of outpatient care. The rationale is to jump the queue or to secure better quality services and greater personal attention by the doctor. Unofficial payments are considered to be a major problem in the Greek health care system. It is estimated that about half the total private expenditure on health care involves informal payments. There is no really reliable estimate of the size of the unofficial market, partly because it is so widespread, and partly because of the complexity of the Greek health care system.

Almost 60% of total out-of-pocket payments (official and unofficial) are made to doctors and dentists, 20% go toward pharmaceuticals, with the rest being mainly expenditures on private diagnostic centres and private clinics. Out-of-pocket payments (both official and unofficial) represent roughly 6% of household income (1990 figures).

So these informal payments are made under the table, usually cash stuffed into an envelope and they are fairly common, even in the out patient arena. Traditions die hard, and the tradition of the “fakelaki” (the Greek word for envelope) is alive and well. I believe these payments are outlawed in the government-run clinics, but common prejudices take effect: Greeks are nearly Italian in their disregard for authority and let’s face it, doctors can’t be any good if they works for the government! You and I may know it’s not true, but there’s no accounting for consumer decisions.

My suspicion is that the lowest risk way of buying a stake in Greek Healthcare is to buy a stake in an envelope factory.

Aide, gela!

Vaccinate, Support Local & Subscribe

Our clinic, Lacamas Medical Group, runs a couple of free immunization clinic for kids in Camas and Washougal who could not ordinarily pay for their pre-school physicals and vaccines. The Camas-Washougal Post Record, supports us in this endeavor, once running a free ad and this year sending a reporter. This is a link to her story on the web, but they held back a significant chunk for the print edition i wish it had all been online, but I understand why they do that.

I think this may convince me to subscribe. It is a very good publication by the standards of a local weekly newspaper. Moreover it is local, with local news and full of information about local businesses. We can complain about the lack of ethics in corporate America all we want, but without supporting local business, like the Post Record and the businesses that advertise in it, all is for nought.

Breast Feeding: Froelich & CDC

This is another old post from The Physician Executive that I expect is still relevant because old habits like supplemental feeding in hospital nurseries die a hard death when they are the path of least resistance. It was originally published on June 16, 2018

Edwina Froelich, founder of La Leche League, passed away last week. La Leche League used to state that the three main obstacles to successful breast-feeding were doctors, hospitals and social pressure.

My experience has been one of utter frustration with maternity nurses, who should know better, but frequently feed their wards sugar water for no reason. Some kids can get hypoglycemic, but certainly not three quarters of the nursery. Some kids may lose weight, but that is a normal phenomenon, with the natural history of birth being a decline in weight and return to birth weight by day 10. It is not abnormal to lose weight, but it is abnormal to get formula or D5 on day 1.

These practices appear to me (on an anecdotal basis) to be widespread in places I have worked in the US, but they would be unacceptable in other places of which I have some knowledge: Montreal, England, or France. I understand from a cousin in Dubai that at least one hospital reflects the US’s breastfeeding dysfunctions, so I am sure there is tremendous variation from country to country, especially by socio-economic class.

The harm done is that by allowing alternatives to breast feeding, we don’t give a woman a reasonable chance of establishing her breast milk in the first place. To establish breast feeding, you need an infant sucking on a nipple, which provides the hormonal stimulus to produce milk in the first place. The more concerned you are that the breast milk may “not be enough”, the more you assure the fact.

The problem with personal observations is the tendency to generalize. Finally, the CDC surveyed hospital infant feeding practices, as reported in MMWR. American hospitals persist in providing alternatives to breast feeding to infants, such as sugar water and formula. I am sure that most well-meaning maternity ward nurses will explain that they are trying to make sure babies gain weight or not become hypoglycemic. Unfortunately, entire wards of infants are not likely to suffer from the risk factors for hypoglycemia and weight loss in the first three days is a natural phenomenon that does not get babies in trouble if skilled observation and timely intervention is available.

So breast feeding suffers for entire populations as we chase the shadows of unusual and uncommon poor outcomes that rattle us to the point that it is easier to just chuck formula into every crying newborn’s mouth.

Hopefully there will be more Edwinas around to take up the cause.