It's Enough to Make You Sick: The Failure of American Health Care and a Prescription for the Cureby Jeffrey M. Lobosky
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It's Enough to Make You Sick explains how the American health care system developed and how it has deteriorated into a national disgrace. Lobosky indicts the special interests who have played a role in the demise of American health care, examines the current attempts at reform, and offers a practical, compassionate blueprint for effective change.
Dr. Lobosky is not your typical East L.A. name, but hale from there he does, and he provides the Grand Canyon view of health care in America through his career as a doctor on the front lines of health care delivery.
Moreover, he does not spare any punches with his contemporaries, either, making the book both a good read as well as objectivenot always the case in the health care furor these days....
As the stench from the election year permeates our air, keep this book on hand for some straight talk on the real machinations of the U.S. health care system when one of those pundits comes a-calling.
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It's Enough to Make You SickThe Failure of American Health Care and a Prescription for the Cure
By Jeffrey M. Lobosky
ROWMAN & LITTLEFIELD PUBLISHERS, INC.Copyright © 2012 Rowman & Littlefield Publishers, Inc.
All right reserved.
Chapter OneGreat, Another Book on America's Health Care System. Don't You Have Better Things to Do, Doctor ... Like Play Golf?
I was eleven years old when I decided to become a doctor. While playing baseball with my neighborhood buddies, I fell in the street and split open my chin, prompting a visit to the local emergency room near my southern California home. I had been to a hospital before, as a very young child when another accident resulted in a laceration to the back of my throat and an emergency surgery was required to stop the bleeding and repair the cut. I was three at the time, and had little recollection of the event other than the sweet aroma of the anesthetic agent utilized to put me to sleep.
This time it was different. I was fully conscious and keenly aware of my surroundings. Although injured, as an eleven-year-old boy, I wasn't about to betray my fear, so as I concentrated on projecting a brave demeanor, I became fascinated at the milieu into which I was propelled. I remember the bright lights, the rows of gurneys covered in crisp, white sheets. I was intrigued by the myriad of technological wizardry that surrounded me (obviously modest compared to today's standards) with flashing colored lights and beeping alarms.
I was impressed with the gleaming silver trays that supported what seemed to be an endless array of steel instruments that I knew, with some trepidation, would be used to close the gaping wound in the bottom of my chin. I was mesmerized with the bevy of pretty young nurses who whisked in and out of my cubicle in their starched white dresses, white nylons, and uniquely shaped white caps, assuring me that all would be well. Although ten to fifteen years their junior, I was certain that the attention they lavished upon me reflected their recognition that I was remarkably handsome and mature for my age. It never dawned on me that they were just doing their job. Forty-nine years later, it still doesn't.
Yet, what I most vividly remember about that Saturday morning encounter was the emergency room doctor. The forty-nine years since have erased his name and face from my memory, but his impact upon my life and career is etched indelibly. He projected both confidence and authority, but at the same time, a kindness and compassion that allayed my fears and filled me with trust and awe. Within minutes, my chin was repaired and I was sent on my way. In that one instant, I imagined how rewarding it must be to devote one's life to relieving suffering and how gratifying it would be to have patients filled with such admiration as I was that day. I was hooked. I knew then and there that I wanted to be a doctor.
I never wavered from that objective, and that singular goal defined me for years to come. My desire to go to medical school endowed me with the discipline and work ethic necessary to succeed in high school and college and gave me the strength not only to survive, but actually to thrive amid the tremendous challenges, both intellectual and physical, of medical school and a neurosurgical residency.
It is remarkable that the rigors of medical training do not completely extinguish the idealism that characterizes most young physicians. The long hours, the enormous amount of required knowledge, the sometimes sadistic abuse by superiors, the cutthroat competition among peers, the psychological trauma when patients do poorly, and the immeasurable stress on family life all conspire to replace that idealism with cynicism and compassion with indifference. But fortunately, the majority of my classmates and I emerged unscathed, and I entered practice in 1984 ready to live my dream.
I was fortunate to associate with a truly outstanding partner, Dr. Bruce Burke, who for the past twenty-seven years has served as mentor, teacher, role model, and above all, friend. My wife and I were blessed to settle in a community where we could raise our children in a safe and nurturing environment and I could practice state-of-the-art medicine as a member of a progressive and highly talented medical staff. As the years passed, our good fortune at finding this opportunity became increasingly apparent.
Throughout the '80s and early '90s, the practice of medicine for me remained idyllic and I suspect the same could be said for most of my local colleagues. However, there were forces in motion that had the potential to significantly impact the way we practiced our craft, and I began to hear rumblings from friends and colleagues in the larger metropolitan areas about how "managed care" was beginning to infiltrate their medical communities. The result of this new medical model was diminishing reimbursement, increasing paperwork and red tape, and an entirely new competition for patients based not on medical quality but economics.
Insurance companies were awarding contracts to provide care for their clients to the lowest bidder, pitting one physician against another and replacing the traditional referral patterns based on clinical reputation and word of mouth. Soon, physicians of all specialties who were considered among the most talented in their communities saw their patient bases eroded as insurers required clients to see only selected practitioners who agreed to treat patients at a reduced fee. Suddenly, the surgeon or internist who the week before was struggling to maintain his practice because of a less than stellar reputation found his office overflowing with patients, while the pillars of medical quality were forced to either relocate or reduce their fees to unsustainable levels.
As reimbursement for medical services began declining, the only way that physicians could maintain their incomes was by increasing the volume of the patients they saw or the number of procedures they performed. Patients began complaining that they were feeling rushed by physicians who could no longer afford to take the time to listen carefully to their complaints and analyze their problems. Many physician offices began hiring "physician extenders" such as nurse practitioners or physician assistants, who were utilized to significantly increase the volume of individuals seen, further isolating the doctor from his or her well-established patient base.
With the competition for managed care contracts becoming more frenzied, doctors experienced a significant decline in the collegiality that characterized long-established medical staffs, with a resultant loss of civility and cooperation that further diminished the quality of care that was being provided. Physicians began looking for unique ways to succeed in this new environment and began forming multispecialty groups, selling their practices to larger medical conglomerates, and creating Independent Practice Associations (IPAs) so that they could better negotiate with the large insurance carriers. These efforts most often failed as primary care physicians and specialists found themselves at odds over utilization of services and reimbursement.
Experience with these new paradigms expanded, with more and more physicians becoming disgruntled, cynical, and downright angry. Discussions in physician lounges at lunchtime across America took on a distinctly different tone. Debates about the latest treatments extolled in The New England Journal of Medicine for hypertension or whether Joe Montana was the greatest quarterback of all time were now superseded by complaints about the dismal reimbursement rates offered by Medicare and Blue Cross, the skyrocketing malpractice insurance premiums, and the overwhelming frustration at having to call a nurse in some distant office in order to receive permission to order an MRI scan on a patient with a suspected brain tumor.
Doctors developed a foreboding sense of impotence in their ability to combat this assault on both their income and autonomy. Antitrust laws prevented them from legally discussing what they extracted from insurance carriers or from collectively bargaining with the carriers outside of a formal IPA or large group organization. Physicians became depressed and despondent, and after realizing they were unable to successfully contend with insurers, they began lashing out at the only entities with whom they still had some influence—their hospitals and their patients.
Over the past decade, primary care physicians have, with an alarming increase in frequency, refused to provide emergency room coverage or inpatient services for their patients and relinquished care to "hospitalists." A hospitalist is a physician who practices full time within the confines of a hospital, admitting and caring for patients whose own doctors no longer provide those services or who are without a primary care physician. Generally a number of hospitalists constitute a given group within the institution and care is handed off among members of the group as their "shift" ends. So, although you have been a patient of Dr. Jones for twenty-three years and he has provided the best of care for you and your family over that period of time, you can kiss those days good-bye. Now when you are sick enough that you require hospitalization, your care will be provided by a group of doctors you don't know and who don't know you. Welcome to twenty-first-century medicine in America.
In addition, many trauma centers across the country have been forced to close as more and more specialists in the critical fields of general surgery, neurosurgery, orthopedics, and anesthesia opt out of emergency room coverage and limit their practice to more lucrative elective care. Many of the hospitals that have been able to maintain their emergency departments have done so by providing "on-call stipends" to physicians, which can range from $25 to $5,000 per day depending on the geographic region and specialty involved.
With the emergence of this model for supplementing income, hospitals and their medical staffs have been placed in adversarial positions. Physicians increasingly expect their hospitals to make up the difference between what they think they should earn and what they actually make. When those demands are not met, physicians are threatening to forgo on-call responsibilities, jeopardizing not only the hospital's continued survival but patient lives as well.
Hospitals respond to these challenges with threats of their own. Oftentimes they try and recruit new physicians to an already saturated market to displace the "troublemakers" whom they perceive as unreasonable. They may restrict the uncooperative physicians' privileges by providing less operating room time for their elective schedule or denying their requests for new equipment or services. Hospitals become desperate and are forced to hire "locums" or temporary physicians to provide services, often at a much higher cost than the original demands and not uncommonly with a reduction in quality of care. A vicious cycle ensues that insures a lose-lose situation for the hospital, the physician, and most importantly, the patient.
Physicians have also responded to this crisis by developing their own freestanding care centers, which compete with their local hospitals for the most desirable and well-insured patients. These facilities may specialize in providing kidney dialysis or chemotherapy infusion. Many offer surgical treatments that may cover a single specialty such as spine surgery or a variety of differing surgical disciplines. Physician "investors" in these centers traditionally send their well-insured patients to these mini-hospitals and reap the economic benefits while they refer the uninsured or underinsured to their community hospital for care. This "cherry-picking" further erodes the financial viability of the community hospital as well as the professional relationships with the physicians. However, with reimbursement declining at such an alarming rate, many physicians are forced to resort to these alternative sources of income to pay the bills.
When physicians turn fifty, inevitably we ask each other how long we plan to keep working. My practice has been wonderfully successful for the past twenty-seven years, at least successful by my definition. I may not earn the most money, have the largest house, or most elaborate toys; I don't define that as success. But throughout my career I have been able to practice my craft in a community with outstanding colleagues who have been as dedicated as I to providing state-of-the-art care to the population we serve. Our hospital has also been committed to the same mission. I have especially enjoyed my patients and the opportunity to relieve their suffering when I could and to assist them in other ways when I could not.
My answer to the "How long do you plan to work?" question has always been, "Until it is no longer fun and rewarding." A few years ago, for the first time in my life, I became fearful that time may be approaching and I began yearning for the bygone days. Yet, I found it difficult to accept the finality of that conclusion and I keep fighting to maintain that flame of idealism, not just in my own practice but in our larger medical community and on a national scale as well. In doing so, I am encouraged by the number of physicians who, like me, are frustrated with the direction medicine has taken but refuse to surrender to the forces that threaten how we practice and, ultimately, the quality of care provided to the American population.
It is easy to assign culpability for the sad state in which we now find ourselves. There are certainly plenty of villains to go around. Managed care programs, HMOs, Medicare, Medicaid, pharmaceutical companies, for-profit hospitals, illegal immigrants, malpractice lawyers, greedy doctors, the uncaring business community, insurance companies, politicians, lobbyists, Democrats, Republicans, Buddhists, Catholics, Muslims ... the list is endless. Pick one ... or two ... or three ... as long as it isn't you or I.
And therein lies the problem.
Before we are able to effectively address the issues of medical care in the United States, each of us must examine our own contribution to this crisis and accept collective responsibility. Only when the finger pointing and rhetoric subside will we be in a position to collaboratively face this challenge as a nation and craft sustainable solutions that involve, by necessity, all the factions that got us here in the first place.
My colleagues and I have deliberated these matters ad nauseam in the operating room, in the doctors' lounge, at national meetings, and over our own dining room tables. However, we are only one component of the greater debate and only one component of the ultimate solution. It was my wife who suggested I write this book, initially as a catharsis, in hopes that giving a more formal voice to these frustrations would somehow reverse the cynicism she had observed surfacing in me. But more importantly, my goal is to catalyze a national debate where all of us can discuss and understand the complex forces that define and direct the delivery of medical care now and in the future. Hopefully, the interested reader will appreciate that there are no absolute villains nor heroes and that together we just may be able to constructively solve the health care crisis and provide all our citizens with the quality of care and quality of life they so richly deserve.
That is why I wrote this book.
Excerpted from It's Enough to Make You Sick by Jeffrey M. Lobosky Copyright © 2012 by Rowman & Littlefield Publishers, Inc.. Excerpted by permission of ROWMAN & LITTLEFIELD PUBLISHERS, INC.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Meet the Author
Jeffrey M. Lobosky, M.D., is associate clinical professor in the Department of Neurological Surgery at the University of California San Francisco and is co-Director of the Neurotrauma Intensive Care Unit at Enloe Medical Center in Chico, California. He has served on the Board of Directors for the Joint Section on Trauma and Critical Care for the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. He was also appointed one of organized neurosurgery's representatives to the American College of Surgeon's Committee on Trauma which advises national policy makers on health care issues. Dr. Lobosky has served as Chairman of the Board of the "Think First" National Injury Prevention Foundation and has received both national and international acclaim for his work on injury prevention. He is the author of numerous research articles in respected journals as well as several book chapters addressing the health care crisis in America. He is the recipient of numerous awards for his contributions to the field of trauma prevention and is an invited lecturer throughout the United States and abroad.
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Dr. Lobosky won't make any political side happy with this book, but everyone should read it. He dispels many misconceptions about our health care system and provides the history of how things have become so messed up. Very thought provoking discussion of a critical subject.
Synopsis: The book examines the current dismal state of health care in America and offers hope and suggestions for fixing it. Jeffrey M. Lobosky is a neurosurgeon with almost three decades of practice in his field. This gives him both experience and a unique perspective for viewing the health care system which allows his well-off and well-insured patients excellent care and prevents the poor, uninsured and underinsured from sometimes receiving care at all. Started as a catharsis for his frustration with the expensive, exclusive system he worked in, the book grew into an overview of the entire health care system, its weaknesses (and they are many, as most of us recognize), and prospective methods for creating a better, fairer system for all. His chapter headings are intended to provoke interest, e.g., The Politics of American Medicine: Show Me the Money and I’ll Show You the Problem; Crisis in America’s Emergency Rooms: Take Two Aspirin and Call 911 in the Morning; The Great American Patient: You Didn’t Really Think I Would Let You Off That Easily, Did You? Lobosky also covers the ranking of America’s health care system according to WHO (way down on the list), managed care, hospitals, physicians and their replacements, malpractice. His final chapter, where he offers some hope for healing the broken system, he titles, Solutions to the American Health Care Crisis: My Wife Has Always Accused Me of Being a Know-It-All, So Here’s My Chance to Prove It. I feel this is an important book. Although his frustration leaks through the writing, he covers the entire field in most readable fashion, helping this reader to finally, in one place, get an idea of the scope of the problem with its interlinking pieces. I enjoy the humor, sardonic though it sometimes is, that lightens an otherwise heavy, depressing read, and his final look at solutions he considers would help heal this mess of a situation contains hope for us all, if we have the will to try. Review first published in Journal of Humanitarian Affairs, July 2012
This review from Booklist is in stark contrast to the Publishers Weekly review which, for unknown reasons, harped on the tone rather than the content of Dr. Lobosky's book. He received a standing ovation after a book signing in the Chico, CA Barnes & Noble the first week in June. Definitely worth a look .It's Enough to Make You Sick: The Failure of American Health Care and a Prescription for the Cure. Lobosky, Jeffrey M. (Author) May 2012. 284 p. Rowman & Littlefield, hardcover, $27.00. (9781442214620). 362.10973. Lobosky is not a health-care-policy expert, but rather a practicing neurosurgeon with nearly three decades of experience caring for the ill and injured. Written at least partly as an act of catharsis, his book condemns the contemporary state of the American health-care system and offers well-reasoned remedies. Lobosky bemoans the breakdown of the traditional doctor-patient relationship. He finds collective fault with the current system; everyone is responsible for its failure. In his view, there are “no absolute villains.” Money is the source of much of the trouble. In 2010, more than $2.5 trillion were expended on the country’s health care. The chief cause of bankruptcy in the U.S. is catastrophic medical debt. This doctor finds the emphasis on profit in medical care problematic. The system needs an infusion of compassionate care. In his timely book, Lobosky makes a sound diagnosis: “market-based, profit-driven medicine has for the most part proven to be a colossal failure on many fronts.” The cure remains frustratingly elusive.