Part 3: Medical System Overview

Part 1

Introduction

When you think about medical practice and how it can be improved, you necessarily turn your attention to the relation between the health care system and those who use that system. You become aware of hidden factors that govern medical care at this point in history…

• Complexity
• The modern awe of "science"
• The Medical Profession's Self-Centeredness (Medico-centrism)
• Marketing of Medical Procedures
• The Media and Advocacy Groups
• Corruption in Medicine
• Liberty and Equality

A healthcare system is complex

A sixth of our national economy is devoted to healthcare. By now you know that the healthcare system has complexities similar to those in other major social endeavors. Too, often, proponents of universal health care evidence little awareness of these complexities, which include the acts of national legislators. Our congress and its forebears set a tax policy that penalizes non-employer based health insurance, set up the HMOs, and managed an ever more dysfunctional Medicaid and Medicare system. Pressure groups, now including the AMA and the corporations, press for national health insurance. As Dietrich Dorner, a German psychology professor notes, "An individual's reality model can be right or wrong, complete or incomplete. As a rule it will be both incomplete and wrong, and one would do well to keep that probability in mind."¹

Can we get real about how best to improve this complex system? First, incremental measures allow planners to more accurately determine the effect of different changes. Second, careful analysis of the results of these changes allow more successful achievement of goals.

Boeing doesn't just come up with an entirely new airplane design each time. Each new model builds on the lessons learned from the last. Change is incremental. If we try to build an entirely new healthcare system, we're going to keep on seeing crashes.

Scientism

We as a nation suffer from the disease of "scientism." We believe, erroneously, that science can meet every need. I frequently tell patients that "there must be a reason for your problem; let's work together until we find it out." But I realize, and my patients sometimes find out, that we don't always win. Similarly, as a nation, we need to realize that intellect must be balanced by other human qualities or, as Rabindranath Tagore said, it becomes like the knife that is all blade, "it cuts the hand that holds it."

To repeat, medicine is not a science. Medical care is a service, performed by people for people. National databases and national protocols may sound good to those who know no better. Averages and statistics conceal the individuality that is the governing factor in people's satisfaction with their health care. As King Lear cried as his ungrateful daughters haggled with him over his last few possessions, "O, reason not the need! Our basest beggars are in the poorest thing superfluous. Allow not nature more than nature needs, man's life is cheap as beast's."² There are many times when what the "medical evidence" calls for is not what the patient needs.

Medico-Centrism

Medico centrism describes the habit of seeing everything from the doctors' point of view. As a result, the physician may speak a language the patient doesn't understand or may act as if that patient hasn't a clue what ails him. Too often the patient comes to the doctor with a pain in their shoulder, and walks out with treatment for high blood pressure. The shoulder still hurts, but the doctor has forgotten all about it because she is so busy trying different blood pressure meds. Often, if you look at our treatments, they are just marginally necessary. We treat hypertension at much lower levels than the Europeans, we are much more aggressive at treating cholesterol, and whether the game is worth the candle is arguable. We feel very free to put our concerns, hypertension and cholesterol, ahead of the patient's concern about his shoulder.

The antidote to medico-centrism is to empower the patient. National health care will empower not the patient, but the profession.

Over-Selling Medical Treatments

Nortin M. Hadler, a rheumatologist, describes this in Last Well Person: How to Stay Well Despite the Health-care System. He points out that many of the treatments we offer provide much less benefit than we promise. For example, we spend billions on the treatment of prostate cancer and yet the net increase in life span is probably nil. We spend huge amounts on heart transplants; again the net benefit is much less than the resources expended.

Over-Selling Cancer Screening

Cancer screening in general is oversold, as described by Gilbert Welch, MD, of Dartmouth Medical School in Should I Be Tested for Cancer? : Maybe Not and Here's Why. We review that subject in the April 2005 newsletters, "A Second Look at Mammograms".

The Media and Advocacy Groups

Richard A. Deyo, MD, of the University of Washington wrote Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises. He describes how marketing, media, advocacy groups, and politics influence medical practice in such a way as to raise costs and reduce quality of care. For example:

Advocacy groups push treatments before they have been proven safe and effective. Hi-tech improves hospital margin, so doctors and hospitals are motivated to comply. As an example, we spent three billion dollars on bone marrow transplants for breast cancer patients. Studies eventually showed it to be no more effective than safer and more established treatments.

Media talk of 'breakthroughs' and 'catastrophes' sensationalizes medical news. "Breakthroughs?" Real life advances are slow and steady.

"Catastrophes?" The more we attempt to achieve, the more painful and less understandable are our failures. For example, "medication errors" make great headlines. Take over-worked doctors and nurses in a major medical center. The patients usually have several severe diseases. Many of these patients might have died years ago but for a dozen or more medications and numerous previous medical interventions. Their kidneys are marginal; their hearts prone to fatal dysrhythmia; their acid-base balance questionable; and their immune system on its last legs. Doctors face no-win choices. Do we let the blood pressure rise a bit or do we add one more medication with the attendance risk of an adverse drug reaction or interaction with a current drug? Hydrate them a bit more to improve the kidneys, or a bit less to lessen stress on the heart? Bust that clot to reverse the stroke, or avoid the risk of starting bleeding somewhere else? Push that anti-cancer drug dose higher to kill the tumor, or keep it a bit lower to ease damage to the immune system?

Comes the case reviewer after the dust has settled, use that 20/20 hindsight, and there will be errors to tot up.

We do make preventable errors, certainly, but the idea that doctors and nurses are running wild misadministering drugs willy-nilly is nonsense, and should not be used to sell newspapers.

Corruption in Medicine

While most physicians, like most other workers, engage in honest toil, some engage in quiet larceny. Read On The Take: How Medicine's Complicity with Big Business Can Endanger Your Health by Jerome P Kassirer. Unfortunately, the academicians and opinion leaders are more likely to have excessively close ties with corporate interests. These are the folks who are big on "evidence-based medicine." They are in a position to pick the evidence. Give us national health insurance and you'll see even more of the same.

Liberty and Equality are at Odds

"If we understand ‘liberty' to mean simply a condition under which there are very few constraints placed on the actions of individuals and if we understand ‘equality' to mean the right of equal access to the material and nonmaterial resources of a society, then ‘liberty' will quickly result in great inequality because those who are better equipped for certain activities (for example, those who are more intelligent) will be more successful at obtaining the resources they want, while others will be less successful. Thus, more liberty will mean greater inequality. On the other hand, the attempt to achieve a high degree of equality in a political system will produce a correspondingly high number of constraints on the individual, and that is not liberty."³

Conclusion

Running all medical bills through a single bureaucracy will only make our complex medical system more arteriosclerotic than it is now. People need a more local relationship to the system, not one more distant. Medical procedures are like a stove: awe of the stove does no good, but ignorance of what that hot surface can do is dangerous, too. We need to realize that in some regards, the emperor has no clothes. The doctor is nothing without the patient. The health profession exists for the service of patients, not the convenience of doctors. Journalists are not doctors; they are going to sensationalize. Things are rarely as bad or as spectacular as they portray. And doctors are no more immune to the lure of the dollar than anyone else. Caveat emptor!!

Finally, you can have an equal share of the common pie, or you can have the freedom to try to get yourself a better pie. If you want a bit of both, you need to compromise somewhere.

In other words, we can't have perfect freedom or perfect equality both, so let's have some of each. How about freedom for those who can use it responsibly to care for themselves and others? Combine this with some sharing to give all an equal shot to get ahead, with better education and better health. And, in the end, we must recognize that some people are just going to want to live under the bridge, and we are going to have to accommodate them, too.

When it comes to healthcare reform, that means, instead of one grand government system, a mixture of programs, each best for a certain segment of our people, each able to evolve on its own, as time and circumstances dictate.

1 The Logic of Failure: Recognizing and Avoiding Error in Complex Situations by Dietrich Dorner. Page 42. http://www.amazon.com/gp/product/0201479486/sr=8-1/qid=1153172725/ref=pd_bbs_1/002-9668629-1083258?ie=UTF8

2 The Tragedy of King Lear, Act II, Scene 4.

3 The Logic of Failure: Recognizing and Avoiding Error in Complex Situations Page 65.