The quality of health care depends on many things, but certainly medical education is uniquely significant. Following four years of medical school, the additional years of internship, residency, and fellowship are not simply a time for acquiring the latest insights into the nature and treatment of disease. This is when fledgling doctors imbibe the values and priorities of the medical profession from the attending physicians who mentor them. If attendings have no time to mentor the doctors they are presumably training, the quality of doctors who emerge from such a system will suffer. And if the priority of an academic medical center is to increase profits rather than care for patients, patients will also suffer, first at the hospitals associated with these centers and later as patients of the doctors who trained there. The decline in the residency system for training doctors is the subject of Kenneth M. Ludmerer’s Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
From mentorship to profits
Sir William Osler established his ideal of medical training at Johns Hopkins Hospital in the 1890s. The guiding principle was that doctors should learn to care for patients under the close supervision of highly experienced attending physicians. Right up to WWII, the highest priority of teaching hospitals remained education. Faculty members formed intense mentorships with their students, often lasting a lifetime. Lara Goitein, in an essay/review of Let Me Heal, writes: Read more
Back in June of 2009, when Congress was just beginning to formulate and debate the Affordable Care Act, Atul Gawande wrote an article on the rising (and exorbitant) cost of US health care. He focused on how waste contributes to cost — not just the usual fraud, high prices, and administrative fees, but unnecessary care: Drugs that are not helpful, operations that do not make patients any better, scans and tests that not only have no benefit, but often lead to harm. Waste accounts for a third of health-care spending. More disturbingly, it can cost people their lives.
Gawande used the town of McAllen, Texas to illustrate his case. McAllen had one of the highest costs in the nation for Medicare — twice as high as El Paso, another Texas border town with similar demographics. And it’s not as if patients in McAllen were receiving better care. Compared to El Paso, patient care was similar or worse.
It turned out that many specialists in McAllen had financial stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital. One local doctor told Gawande: “Medicine has become a pig trough here. … We took a wrong turn when doctors stopped being doctors and became businessmen.” Read more
Here are more articles of interest I’ve come across recently while reading NEJM, JAMA, and New Scientist. These items all relate to for-profit medicine.
Bulleted titles in the following list link to the individual items below. Under References I indicate the accessibility of articles: OA means open access, $ indicates a pay wall. Note that emphasis in quotations has been added by me.
A complaint one often hears about electronic medical records (EMRs) is that the doctor pays more attention to the computer than the patient during an office visit. Among nations using EMR, is this a characteristically American problem?
I read an illuminating letter to the editor recently that compares the doctor/patient/EMR experience in the US and Canada. The letter was from Dr. Alan B. Astrow, a hematologist/oncologist who practices in Brooklyn, NY. He writes: (emphasis added)
Many American physicians agree that recording patient data electronically has interfered with “a deeply human, partly intuitive and empathetic process,” and has led to inefficient care. Since no one wants to revive illegible paper charts, however, the indictment encourages us to ascribe these harms to the price of progress.
A Canadian physician friend, though, says he uses an electronic record that does not disturb his rapport with patients. He also sees more patients hourly than American counterparts without compromising quality.
Why the difference? American physicians must choose from five levels of service when submitting bills. Of necessity, we tend to include extraneous information to justify higher levels and satisfy potential insurance company audits. Canada has only two levels, so doctors’ notes are short and succinct. Read more
[I don’t seem to be able to display that image anymore, but here’s a link to what I’m talking about.]
This superb graphic was created to dramatize what’s happening these days in the UK, where the National Health Service is being ruthlessly privatized. Here in the US, for-profit medicine is so taken-for-granted that we barely notice it. It’s true, we hear a good deal about conflicts of interest involving pharmaceuticals. Doctors get paid — in one way or another — to increase the profits of Big Pharma, a practice that is detrimental to the financial and/or medical interests of their patients. We hear less about scaring healthy patients into using doctors and services that increase hospital profits (also known as fear mongering). So it was nice to see a recent opinion piece in JAMA that discussed precisely this. Read more
Jill Lepore has an article in a recent New Yorker called The Disruption Machine: What the gospel of innovation gets wrong. Her target is Clayton M. Christensen’s book The Innovator’s Dilemma and, specifically, disruptive innovation. As usual with Lepore, her essay is personable and well-argued. What I liked most about it, though, was its brief discussion of how unfortunate it is that professions such as higher education and medicine are being privatized (if they’re not already) and administered to maximize efficiency, making profits more important than students or patients. (emphasis added) Read more
The shortage of pharmaceutical drugs is a serious problem in the US. The number of drugs in short supply has tripled since 2007. In an article in The New York Times, Sabrina Tavernise reports that the number of drugs in short supply in 2012 was 456.
The types of drugs affected cover a very wide range and include such things as cancer drugs and nitroglycerine used in heart surgeries. The situation is quite disruptive for hospitals, doctors (especially oncologists), and patients.
IV fluid shortage threatens patient care
This year, in addition to drug shortages, there is a nationwide shortage of IV fluid. Intravenous therapy is essential for treating dehydration and electrolyte imbalances, for blood transfusions, and for delivering medications such as those used in chemotherapy. IV fluid is a hospital staple.
A recent JAMA article quotes Erin R. Fox, director of the Drug Information Service at the University of Utah in Salt Lake City: (emphasis added in the following quotations)
“It’s maddeningly frustrating that we don’t have these basics.” … Fox said that although shortages of drugs, particularly sterile injectables, have become common in recent years, it is unheard-of to have a shortage of such a basic supply. …
“Why is the supply chain so fragile that it creates a national crisis? asked Fox. …
“Physicians, nurses, and pharmacists are working together to minimize the harm to patients, but it is really a challenge,” she said.
Megan McArdle spoke on antibiotic resistance at the Economic Bloggers Forum yesterday. McArdle is a journalists who writes for the The Atlantic, primarily on economics, finance, and government policy.
Her presentation, “Antibiotics: The world’s most broken market,” was interesting. Notice (in the video below) that she never questions the market-driven premise of pharmaceuticals – and by extension, the for-profit nature of medicine and health care. That’s not her politica/economic persuasion.
Here’s an excerpt from the talk where she discusses the patient/doctor end of the antibiotic resistance problem. What she says is already quite familiar. What’s interesting is her frank description of how doctors behave and how patients in turn regard doctors.
People love to get antibiotics. They go to their doctor and they’re like, “My kid has an earache. Give him antibiotics.” Now the doctor could say, “No we shouldn’t. We should wait and find out if it’s bacterial. Almost all ear infections are bacterial. Due to throat infections. Due to almost anything you can name. But to do that, the doctor has to sit down and deal with an angry patient who may pick up and leave their practice.
If you look at the way that the current insurance industry is organized, right, what do doctors need? They need volume. They get paid by volume. Reimbursements for primary care physicians, who are where a lot – by no means all – but where a lot these vaccines go through, are very low. They’ve made up for that, and you all know this, right. You go into your doctor, and the minute you start talking, your doctor exudes an almost visible — like — desire for you to leave now. So that they can go on to the next patient. So what do they do? They give antibiotics to patients to shut them up. It takes too much time to explain and the risk of losing the patient is high.
Medicine is a profession. Economically, it’s sufficiently different from other marketplace transactions that it shouldn’t be run as a for-profit business. When I made that argument in a recent post, I mentioned: “The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.”
That may still be true of brain surgery, but it’s obviously not true of plastic surgery. Here’s an excerpt from a recent press release:
Though the recession is slowly lifting, desired cosmetic surgery is still out of reach for some. And with winter almost over, time is running short for those who want to receive plastic surgery in time for summer. That’s why Dr. Lapuerta of the Plastic Surgery Institute of Southeast Texas, sympathetic to both his patients’ time and finances, is offering a very special offer of $500 off the very popular surgery, tummy tucks.
Just to make sure you understand how sympathetic Dr. Lapuerta is, the release continues:
With cosmetic procedures slowly but surely on the rise, Dr. Lapuerta wants to ensure that those who desire the procedures are more able to attain it. He appreciates the present circumstances stating, “I know that a tummy tuck or any cosmetic surgery can seem out of reach of many. Even though the procedures are on a rise, a lot of people who want the surgery are unable to get it because of finances. I hope that offering this special deal will help.”
You could argue that medicine was never meant to become a for-profit business the way selling cars, cosmetics, and fast food are businesses. Among the differences between being a patient and being a consumer of non-medical goods and services:
There’s an asymmetry in the knowledge available to patients and doctors – a patient can’t possibly be as informed as a doctor about what’s wrong and what’s needed.
Patients can’t predict when they’ll need medical care and often seek care when their health is threatened and when decisions must be made quickly.
It’s the supplier – the doctor – who determines what the patient needs.
There’s an ethic that assumes doctors will not sacrifice the medical needs of a patient to make a profit.
There’s a very steep entry cost to becoming a doctor.
The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.
What’s at stake in health care – the consequences of making a mistake – is death and disability, not simply a case of buyer’s remorse.
And yet, in the United States, health care has become a for-profit business. The story of how this happened is complex, but decisive elements include the advent of Medicaid and Medicare in 1966 and the widespread availability of employer-sponsored health insurance, which got a boost during the wage freeze of World War II. Once patients no longer needed to know the true cost of health care, business interests were free to create what Dr. Arnold Relman called the “medical-industrial complex.”
Regardless of how and why it happened, we now accept that medicine in the US is a profit-generating business, where many segments of the “industry” aim to reward investors, not patients. As a result, health care has become too expensive for many patients, for employers, and for the government. Everyone agrees that costs are out of control, but – with so many competing economic interests — the solution is extremely elusive.