OPINION

America's Healthcare Crisis, Part II - Physician, Heal Thy Profession

March 07, 2009
Ashoka Chakra

Physician, heal thyself.

One bright sunny day two decades ago, I stood rather nervously in an examination room, taking an oral examination in order to graduate from medical school. The examiner stood a few feet from me and with a curtly nod summoned a patient. The patient shuffled in and the examiner observed his watch. After thirty seconds, he nodded again, and the patient shuffled out. The examiner turned towards me. “Your diagnosis, doctor?”

That was a different era, an era where physicians were scientists, trained observers and good listeners. It was an era when physicians spent time with patients. How times have changed.

In thirty seconds, I observed that the patient’s right shoulder drooped, he took shallow quick breaths, and that he was rather emaciated. Pulmonary insufficiency afflicting the right lung, secondary to either tuberculosis or cancer was my diagnosis and I passed. I was able to make that diagnosis because I had been taught the importance of taking a good history and performing a thorough physical examination. By the time of graduation, those skills had been mastered. Though the two can be time consuming, they are a lot more cost effective than modern tests. But more importantly, they establish a rapport between physician and patient that is priceless.

These days, physicians spend less than 5 minutes with a patient and move on after ordering myriad laboratory or radiology tests. The art of a differential diagnosis that required options to be carefully vetted has been lost to batteries of expensive tests. How many patients can attest to their physicians having spent time with them, and lent a sympathetic ear? Sadly, centuries old sacrosanct trust that existed between patients and physicians has been relegated to history books. A physician is not looked upon as a knowledgeable family friend but as a glorified laboratory technician out to make a bundle.

The mentality of conducting tests rather than dealing with patients directly contributes to the health care crisis. In my last op-ed, I had mentioned that it took a CAT scan to identify my neighbor’s neck mass, something that any physician worth his/her salt should have identified from across the room. If such tests are to replace the eye, is it any wonder that medical expenses have sky rocketed? A gastroenterologist I know brags that he does not even touch a patient any more. He sends them straight for radiological imaging or endoscopy. Since he spends less time per patient, he can see many more patients a day, enhancing his income considerably. Unfortunately patients fall for this, assuming that more tests are better. While directed tests to prove a diagnosis are very understandable, testing simply to replace the process of diagnosis process is very wasteful.

Physicians argue that the legal atmosphere or patient pressure forces them to perform myriad tests. While both arguments are true to some degree, physicians must ask themselves who ultimately dictates standard of care.

The standard of care is not limited to diagnosis. Therapy is perhaps a more important component – after all, the increase in life expectancy over the past five decades is due largely to life saving drugs developed by the pharmaceutical industry. However, despite our appreciation for the pharmaceutical / biotechnology companies and their products, we should also keep in mind that they are responsible for the largest increase in health care costs. In this area, physicians can do a lot to curtail runaway prices. An example would be prescribing generic drugs instead of brand name ones. It is wrongly assumed that generic drugs are somehow inferior to brand name drugs. Generics have to prove their safety and equivalence to branded drugs before the FDA approves them and there is no reason to prescribe expensive brand names while cheaper alternatives are available.

My last comment is to exhort physicians to take back the practice of medicine. To take it back to an era where physicians were respected and the profession was an honored one. To take it back from bureaucrats, lawyers, and insurance company executives whose short term vision is dangerous to patients and the field of medicine. In short, physician, heal thy profession.

Favorite books: Germs of War (Ketan Desai), Moby Dick (Herman Melville), Sherlock Holmes Treasury (Conan Dolye)
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America's Healthcare Crisis, Part II - Physician, Heal Thy Profession

 

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#1
temporal
URL
March 7, 2009
01:09 PM

ac:

These days, physicians spend less than 5 minutes with a patient and move on after ordering myriad laboratory or radiology tests.

reason?

direct and indirect malpractice insurance threats!

#2
kerty
March 7, 2009
01:52 PM

Its hard to pick on only one component of the system for the health-care mess in America. Doctors are at the retail end of health-care delivery system and it is easy to blame it on them.

- You have to be the brightest and most competitive to get in medicine. Those students sacrifice 10 years of their social and youth life and do nothing but study, study and study. The race begins from grade 9th.

- The medical student spends 7-8 years in college plus 2-3 years undergoing residency and than 2-3 years for medical specialization. By that time, they are in student loan debt by 200k-300k. During medical residency and initial several years, they barely make enough to pay back loans.

- By the time they become fully functional doctors, they are in their 30s, getting married or having kids, trying to own their house and cars. They are under tremendous pressure to get out of dent and build some equity. They work two jobs, moon-light evenings and weekends, take on-call duties, and work anywhere from 60-100 hours a week. You a plumber or electrician worked so many hours, they too can make lots of money.

- People in all professions can err, make mistakes. Nobody can be perfect all the time. But in medical profession, a single mistake can wipe everything a doctor might have earned all his life. So he has to insure his life savings against lawsuits by paying 40-50% if his yearly earnings as malpractice insurance. How many other professions have to fork out that kind money?

- And than system treats doctors like carpet beggars. Insurance companies and government burocrats decide what should be the treatment and how much doctors should get paid. Lots of bills never get paid by the insurance and government. Some state governments are behind by 6-18 months paying up the bills. Doctors have to spend upto 10% of their gross billing just to collect small portion of it from insurance and government. Majority of patients are free-loaders - only tiny fraction of money owed by them ever gets collected. And they all blame Doctors. Doctors have become the front-line punching bag - they all take it out on them.

This is the state of most advanced medical delivery system in the world. What about India? Lets not even go there. There are no scared cows there anymore.

#3
Ravi Kulkarni
URL
March 8, 2009
01:27 AM

Dear AC,

Nicely written. I hope more and more doctors think like you and heed your advice.

Often there are home remedies for simple ailments which are not even considered by the doctors. I don't know if AMA prohibits doctors from mentioning those, or doctors don't consider them effective. There is also the specter of pharma companies bribing doctors to prescribe brand name medicines. There is also the practice of doctors owning diagnostic centers and thus contributing to conflict of interest scenarios.

Doctors don't even pretend to practice preventive medicine. I am yet to meet a physician who talks about my diet, exercise habits etc. No wonder some call it a sick care system.

Doctors, AMA, pharma companies, insurance companies, trial lawyers have all conspired to create an establishment that has become a monster. I don't know how anyone can defeat this monster, but surely one can take care of oneself better.

Regards,

Ravi

#4
Ashoka Chakra
March 8, 2009
07:05 AM

Thanks Ravi. You make several valid points. Docs are trained to give medications - not to give lifestyle advice, nutritional advice, or even alternative medicine advice. Therefore except for a few exceptions, you won't find such a perspective from an "average" doc. You are also correct about the nexus between pharma and physicians - in fact, the AMA conducted a study to show how salespersons influence prescribing behavior (but as a counter point, that is the purpose of a salesperson, isn't it?). And of course there is a conflict of interest when a prescriber owns part of a diagnostic facility, whether that be imaging or laboratory based.

I disagree with you on docs being part of a nexus of lawyers, AMA, etc. There is no such nexus and no such conspiracy. Just tremendous amount of incompetence and waste. Each component of the system is milking the system to its full, irrespective of the ultimate cost. And if not reformed soon, the system will be just as dangerous to the US as the banking crisis.

cheers

#5
Ravi Kulkarni
URL
March 8, 2009
01:49 PM

Dear AS,

Yes you are right. Sometimes I get carried away by my own rhetoric. There is no overt conspiracy, and definitely not by the doctors. However, you can't deny the fact that most leaders at AMA, FDA and insurance companies are all doctors.

As for doctors not being trained in nutrition and alternative medicine, what is preventing them? I realize they are busy professionals, but if they can keep up with latest developments in procedures and drugs, why not at least a small percentage of them also go out of their comfort zone? The only specialists who do that happen to be chiropractors, who are probably not the mainstream anyway.

Regards,

Ravi

#6
kaffir
March 8, 2009
02:27 PM

"As for doctors not being trained in nutrition and alternative medicine, what is preventing them? "
=

But don't the doctors make thoughtful and rational decisions regarding nutrition when it comes to their personal diet? At least that'd be the expectation, since they are in the healing profession.

#7
Ashoka Chakra
March 8, 2009
03:51 PM

Well, Ravi, you answered your question with the use of the words "comfort zone". If a doc can have money, power, prestige, etc by staying in the comfort zone, why go outside it?

#8
Ashoka Chakra
March 8, 2009
03:54 PM

Unfortunately not Kaffir - docs have among the worst diet and exercise very little (other than golf, which is of questionable value from a cardiovascular health viewpoint).

#9
Kaiser_Soze
March 8, 2009
10:59 PM




Doctors lobby is very strong in US, probably next only to lawyers lobby among professional bodies.

AMA controls the number of doctors entering the profession every year, all allegedly to maintain quality.

A direct consequence of which is artificially high prices for services rendered and also high costs of medical education.

#10
kerty
March 9, 2009
01:07 AM

Ravi

"Doctors, AMA, pharma companies, insurance companies, trial lawyers have all conspired to create an establishment that has become a monster."

You forgot the key inflationary component - patients. System does not cost anything to the patient - employers, insurance, government foot the bills. So people freeload on the health care system. They want the best care and pay nothing. They want it to be free or have somebody else pay for it. They have created collectivism thru insurance and government to spread the cost, pass on the cost. Patients want the best, so they maximize their use of health care system. Doctors get to bill more, so they too maximize their care of patients. Insurance companies do not have to pay anything out of their own pocket - they simply pass on the costs on as insurance premiums. The employers pass it on to the consumers of their products and serivices. Government does the same - pass it on to tax payers. Thus there are no built in checks and balances against sky-rocketing cost inflation. The cost structure spirals up making it the most expensive system. It creates massive problems for self-employed and uninsured people as they can not afford the inflated health-care costs. Most small companies can not afford the insurance premiums for their staff. Government can nationalize insurance - but that still does not address the root cause that has created the vicious cost inflation in the first place - collectivism without individual responsibility. In fact, government funded/insured health-care system will prove to be even more inflationary and may breed corruption and inefficiency on top of current mess.

#11
Ashoka Chakra
March 9, 2009
04:42 AM

"You forgot the key inflationary component - patients"

That is true. I thought I had explored that in my first part of the series - but maybe I didn't.......

#12
Ashoka Chakra
March 9, 2009
04:44 AM

"You forgot the key inflationary component - patients"

That is true. I thought I had explored that in my first part of the series - but maybe I didn't.......

#13
smallsquirrel
March 9, 2009
04:01 PM

Ashoka, you are missing like 3/4 of the story here. My parents are in the medical profession, as were their parents, and my husband is also a doc.

The issue here in the US is managed care. Physicians do not really own their practices, the insurance companies do. But if you do not take the major insurance companies, you will not have any patients. As a result, these companies start to dictate your every move, how you treat, how long you spend with each patient, etc.

Patients have also come to expect investigations. If you take a good history but do not order any labs they think you are a quack. They only trust labs. Oh, that an unnecessary antibiotics, so you have to prescribe those, too.

And if you don't perform and jump thru all these hoops the patients sue you for malpractise! (and lets' not get into how much per year one has to put out for malpractise insurance for the average 2-3 cases per year filed for no good reason per doc.)

Silly people like kerty think doctors in the US are making money hand over fist, but the reality is that the average doc in the US now is making about 120,000/year and still has HEFTY bills from medical schools and a lot of overhead costs.

#14
Ashoka Chakra
March 9, 2009
04:11 PM

Patience smallsquirrel - I have not finished the series yet. Wait for Part III and IV.

#15
commonsense
March 9, 2009
04:17 PM

Smallsquirrel:


"Silly people like kerty think doctors in the US..."

Silly people all over the world are mortified at being so casually kertified...they will be organizing a dharna at SSs' door. Their sentiments are hurt you see!

#16
kerty
March 9, 2009
05:43 PM

SS

"kerty think doctors in the US are making money hand over fist, but the reality is that the average doc in the US now is making about 120,000/year and still has HEFTY bills from medical schools and a lot of overhead costs."

Please read my post #2 and #10 again. In #2, I actually make the case that doctors are not the cause of health care mess but they get unfair blame.

#17
Kerty
March 9, 2009
06:29 PM

Corrections in #2

- By the time they become fully functional doctors, they are well in their 30s, getting married or having kids, trying to own their own house and cars. They are under tremendous pressure to get out of debt and build some equity like their non-medical classmates have managed to do years ago. To get out of debt trap, they end up working more than jobs, moon-lighting evenings and weekends, taking up extra on-call duties, and working anywhere from 60-100 hours a week - they still don't get to enjoy everyday normal life even after becoming a doctor - I guess skipping the usual teen life, youth life and family life comes as a package deal if one wants to become a doctor. If you are a plumber or electrician or a Joe working 80-100 many hours a week, you too can make more money. So the notion that doctors make lots of money is ridiculous.

- People in all professions can err, make mistakes. Nobody can be perfect all the time. But in medical profession, a single mistake can wipe everything a doctor may have earned and amassed all his/her life. So he/she has to insure his/her life savings against lawsuits by paying 40-50% of his/her yearly earnings as malpractice insurance. How many other professions have to face these kind of risks and fork out that kind money just to make a normal living?

#18
kerty
March 9, 2009
07:25 PM

CS

Slacking off? DC needs your jestful banter and ranters like me need the fodder. DC is getting too dry and boring. Besides, I prefer not to be at the front or center of the class, predictably out-posting everybody else - I like to be behind you, not in front of the DC class. So bring along your fav brew and charminar.

#19
Ravi Kulkarni
URL
March 10, 2009
12:11 AM

So in other words, every one blames every one else and we have come a full circle.

Of course the biggest responsibility always lies with the individual. One can't forsake all responsibility, whether it is health or education or finances, and then turn around and blame the system. There are faults in the system too, but the correction must start with the individual.

Regards,

Ravi Kulkarni

#20
Ruvy
URL
March 10, 2009
05:47 AM

Excellent article! The points about spending time with patients is most telling.

My wife had a chronic series of boils that would keep coming and coming. The doctors would prescribe this drug and that drug, but the boils kept coming anyway, after being driven away.

Finally I got good and disgusted and wanted to know why! It took a lot of jawing and arguing, but finally I got what I wanted - an answer and not just another pill for my wife.

It turns out that she has chronic staphylococcus, an infection centered in her nose, and this is the cause of the boils, which can be prevented by aggressive washing - but never fully gotten rid of.

I have chronic bronchiolitis - probably from being around smokers - and it wont go away either. Every winter, I cough my guts out. A super dry climate might help - but for the sandstorms, which would aggravate the bronchiolitis even more.

Neither of these can be treated with medicine, but require a physician trained in diagnosis, a person who spends time with his/her patients to figure out the problem. Otherwise, we would both be ingesting various medicines to no purpose at all. And until we got these diagnoses, that's exactly what we were doing.

#21
kaffir
March 10, 2009
10:49 AM

"There are faults in the system too, but the correction must start with the individual."
==
Ravi,

You are correct, but changes at individual levels go only so far. Yes, I can change my eating, sleeping, exercise habits and those of my family members, and that is commendable as well as necessary.

But that's not sufficient to change the system - for that, there needs to be a concerted effort aimed at lawmakers and policymakers, since an individual (average citizen) targeting them won't lead to any change.

Even if I take 100% preventive measures, that still won't change the fact that taxpayer money is being wasted, nor will it change the systemic abuses which I will be subjected to if/when I do need to use the system.

#22
Sumanth
March 10, 2009
11:04 AM

This is what happens when humanity is replaced by business and business models.

The whole issue is about Health, family, relationships, old age, emotions and virtually everything being converted into business and seen from quarterly results perspective.

There will be no solution to all these issues, unless humanity is put ahead of business and markets.

#23
kerty
March 10, 2009
11:51 AM

Sumanth

What would be that system like where business model is replaced by humanity? A system run by charities and missions? A system run by government and burocrats? A system run by insurance and businesses? A system where individuals are left to formulate their own devices? If you have ideas, this is the time to present them as debates are raging to fix the current mess and shape something better.

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