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Reinvent the HealA Philosophy for The Reform of Medical Practice
By James T. Hansen
AuthorHouseCopyright © 2012 James T. Hansen, M.D.
All right reserved.
Chapter OneA Portrait Of Catastrophe: Where We Are And How We Got Here
At times meaning simply precipitates out of nothingness and puts a lasting border around the moment. The bus was heading in the opposite direction but anyone could see the malevolent invitation that it conveyed. The brightly colored advertisement clung tenaciously to the side of the bus, carefully conveying a message designed to hit its mark, boldly announcing a new medical test, which would both ensure health and detect illness early in its course. But, a body CT scan? A body CT scan, is a very sophisticated version of snake oil. CT scans have been a very important advancement in the specialty of radiology. They have allowed physicians to use x-rays and penetrate the various layers of tissue to more carefully define an abnormality suspected. Most CT radiography is applied to a specific area, an area of the body identified by other less invasive tests likely to yield additional information regarding a suspected malady. But a body CT scan represents a shotgun approach, more likely to identify innocent variations that are normal and simply part of the individuality so characteristic of human beings. So here was this bus, of all things a vehicle designed to move people from one place to another, insuring safety and security, now conveying a message suggesting that a better way to safety and security is a questionable, but sophisticated test to insure our health.
That an impersonal image, albeit one generated by high technology, could be the answer to our health care issues, is reminiscent of the hucksters who prowled frontier America. It is no different than the useless potions, often laced with alcohol or cocaine, sold to frontier Americans with the promise of improved health. This sinister, malevolent, and subliminal message is a fitting example of how modern medicine has shaken loose from the shackles of its predecessor, now offering another step towards Nirvana by way of questionable technology. In this case the lull of compliancy with a negative test or the rush to even more questionable technology with an "abnormal" test is much the same as the euphoria produced by the elixirs.
Why should that be so bothersome? Buses can and do advertise just about everything from toothpaste to safe sex. People do pay attention to these advertisements or they wouldn't be there in the first place. There doesn't appear to be any message that is too sacrosanct, certainly not personal health care issues, to find itself an advertisement on a billboard, a bus, or a subway-American capitalism at work. Many of the ads raise ethical or moral issues with respect to the message as well as the messenger. In this case where is the science to validate the claims? Has this methodology been carefully studied by medical scientists and put to the test of clinical trials? What is the motivation of the physicians who find the ad useful? The answers, of course, are no, no and the beneficiaries are the few unscrupulous radiologists, cardiologists, cardiac surgeons and the anesthesiologists who stand to prosper.
Body scans often include a "calcium count," calculated in the chest cavity, ostensibly representing coronary atherosclerosis, that is narrowing of these vessels that leads to heart attacks. If the calcium count is "abnormal" it will certainly be an invitation for more studies, including a coronary angiogram, and perhaps cardiac surgery. The question is whether patients with coronary artery disease who have the test and what follows will have better outcomes than those with the same disease without the test. It doesn't seem to make much difference to many patients who have been sold on the value of high technology and happy to get the latest technological test. Of course, we don't have the answer to the question regarding outcomes, but never mind, this scan is marketed to everyone, not necessarily those with symptoms, but to all of us. It is given the same billing as a Pap smear, a mammogram, or a cholesterol test. To join that pantheon of scientifically proven tests it would need to be validated by research, but it is not. It is a case where cleaver doctors reformulate computerized tomography to search for unproven surrogates of coronary artery disease. Since we human beings are imperfect creatures, you can bet your bottom dollar that some abnormality will be found. Mind you, all of this occurs with an asymptomatic individual who may live a long and useful life without this test or any specific intervention in spite of some degree of coronary atherosclerosis. The ad leads us to believe that this is an essential test for continued health. In fact, it is simply a strategy to substitute questionable technology for careful doctoring.
Why do we put up with this?
Why do we let these entrepreneurs rent free space in our brains?
What does this have to do with rising health care costs and the promise of financial ruin for our country?
What does all of that have to do with our health and lives?
This is the path from snake oil to misguided high technology. It is the story of greed, the way that some unprincipled physicians have continued to have their way, now with high technology, often untested, markening "elixirs of health." Instead of offering potions to unsuspecting patients, these modern day charlatans now offer unnecessary or untested procedures as a way to enhance their revenue.
Here are some facts. They are a bit dry, but important if we are to understand the problem. So, bear with me. The Office of the Actuary of the Health Care Financing Administration (HCFA) has projected that health care expenditures account for 16% of the gross domestic product and cost over 2 trillion dollars a year, with per person health spending over $7,000, and rising at a rate greater than the inflation rate. This is cause for concern. In thirty years, at this rate of increase, national health expenditures will increase to 4 trillion dollars, the cost to each American family will be $82,000 dollars, and as a society we will be unable to continue as the leader of the free world, unable to take care of our own citizens, as we fragment and head into oblivion.
At the same time physician incomes have become stagnant or have actually decreased during the past several years. According to the Center for Studying System Change (HSC), Physician incomes, after adjusting for inflation, have dropped 7% across the board during the last 10 years. This is in contradistinction to other professionals whose incomes have risen 7% during this time frame. So it looks like we are being better stewards as physicians. But wait, the devil is in the details. Physician incomes have remained at 20% of health care expenditures during the last decade. Since health care expenditures have risen to around 3 trillion dollars, 20% of three trillion is not chicken feed. The other 80% of health care expenditures, which include outpatient and in-patient hospital costs and pharmaceutical costs and which help facilitate both good and bad high technology, are also a direct result of physician ordering practices. Given that the number of procedures and sophisticated tests have increased during this time period, it becomes clearer how some unethical doctors have managed to maintain a semblance of their incomes. These unprincipled creatures have invaded high technology, have kidnapped it for their own personal use, which we will see is not altruism, but rather greed, and have become the engine driving the increased health care expenditures for reasons that this book purports to explore.
I am not suggesting that most doctors make too much money. I believe that most doctors are honorable. They are passionate about providing excellent health care, they work hard, they are devoted to their patients and to the their profession. They are a credit to the practice of medicine. The doctor who comes in during the middle of the night to deliver a baby or to pin a fractured hip is probably paid much less than his worth given the reduced stipends offered by both public and private insurers. Yet, he or she continues to do it because of commitment. Professor Uwe E. Reinhardt of Princeton writes in response to an article in the Week in Review section of The New York Times:
In "Sending Back The Doctor's Bill" (Week in Review), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark however, would seem to be the earnings of he American talent pool from which American doctors must be recruited.
Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.
He goes on to say that "Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere". This is a central theme of this book.
The conventional wisdom, as noted above by HSC, is that the growth and development of technology is a major cause of these terrible financial facts outlined above. The Centers for Medicare and Medicaid services (CMS) are focused on cost containment and quality improvement efforts. These are noble goals, but tinkering with the health care system, shuffling the dollars, and rationing care are little better than window dressing. These rising costs are principally due to the cascade of events that occur after unscrupulous physicians write an order, an event that is dangerously close to the epicenter of this problem. Henceforth these self-centered physicians will be identified as technophysicians. These are medical or surgical specialists who only see the color of money, whose altruism is negated or adulterated by the focus on personal gain. They have a gimmick to offer, one stanched from scientific investigation, and they substitute this for professionalism. They grab hold of a procedure, one born from science and with a legitimate use, and they subtly adjust the indications for doing this procedure in their favor, making this a profitable endeavor. This path decimates the vocational mandate of serving, caring, and altruism. These physicians are well trained, with good credentials, and aura of authenticity. But, they have bastardized their skills for unsavory goals. Technophysicians are found in all of the medical disciplines. These are the central players in the drama of rising health care expenditures.
As we closely examine the doctor-patient interface, the essential point of service in the health care industry, we come to understand how this happens. But for now, suffice it to say that it is not the growth of high technology per se that is the culprit, but rather cavalier decisions by technophysicians to use this technology, whether validated or not, when ever and where ever. This portrait includes, amongst others, the decision to carry out a complicated and dangerous operation on a fragile, elderly patient, the decision to give chemotherapy to a dying cancer patient in a futile situation, the decision to initiate hemodialysis in a situation where the patient has multiple terminal comorbidities, the decision to carry out a Caesarian section because is more convenient, the decision to apply multiple endoscopic and imaging studies to a patient with wide spread cancer where the information is next to useless, and the decision to do a mastectomy on a woman already with metastatic disease to the liver or brain. This is ground zero, these are the kind of decisions that characterize the duplicity of technophysicians.
The landscape of health care has been fundamentally altered by the recent passage of the Obama health care bill. This changes the focus somewhat and I will discuss the impact this will have on conventional private medicine, the challenge to private health care, and a meaningful response to the gauntlet that has been thrown. But for now, the task is to trace the origin of this monster, this obscene embrace of high technology by some doctors, which I submit is a major cause of the dysfunctional and broken American health care system.
The origin of this financial monster, this broken health care system, lays embedded within the evolutionary events of American medicine during the past 50 years. However, let's turn the clock back further. The concept of dualism, namely the nature of man separated into body and soul, dates back thousands of years, but it was during the period of the enlightenment when western philosophers began to critically study body and soul and where the foundation for dualism was laid. As the age of faith came to a close, men began to question long held dogma regarding the nature of things: the heliocentric universe, gravity, the circulation of blood, as well as the spatial configuration of earth. The age of faith became a casualty of the age of reason. Philosophers struggled to reconcile the soul, the domain of thought processes, and the center of emotion, with the workings of the human body. Scientists found themselves preoccupied with unraveling secrets of the cosmos, the underpinnings of an emerging physical science, ultimately describing a human body whose functions worked automatically, like a clock, with clock-like precision, and seemingly independent of thought, state of mind, dreams, or any discernable metaphysical influence. It was as if a master craftsman had designed man, wound him up like a clock, and let him go. This was the period of time that gave us Darwin, Copernicus, Newton, Voltaire, Shakespeare, Adam Smith, John Locke, and Rene Descartes. It was Descartes, a 17 century philosopher, who led the effort to understand the totality of the mind and body. Finally, perhaps out of frustration, he separated the two, postulating that man's body worked independent of his mind and thoughts. Thus, health simply required restoring or preserving the clockwork of man's body without paying much attention to man's thoughts, emotions, or soul. Other than repairing the clock, there was no need for intellectual inquiry, new knowledge, or new information about the totality of man. The noted Harvard philosopher, Alfred North Whitehead, has identified this bifurcation of nature as the cause of misguided medical inquiry adversely affecting education of physicians and the practice of medicine in our time. We will have more to say about that.
At the same time theological leaders struggled to understand the nature of man, given new scientific discoveries, striving to leave a place for God, a celestial connection, preserving the legacy of the Church. Their consternation was that thinkers stopped asking philosophical questions about the nature of life, the nature of man, God's purpose in creation, and man's purpose in life; rather, they watched in dismay as these great enlightenment thinkers and leaders drifted towards the physical sciences: mathematics, navigation, astronomy, agriculture, and medicine. The scientific method was born; a systematic manner to try and understand the world we live in. The scientific method required the careful observation of phenomena and the development of an hypothesis, a causal mechanism for the phenomena. To validate this hypothesis, so that it could be used to predict other phenomena, experimentation was required. This is where the rub came in; scientists needed physical experiments to make this work. The results of these experiments needed to be tangible and reproducible, without bias. The scientific method paved the way for these new thinkers to successfully understand many observable phenomena, and later phenomena less well observable. Enlightenment thinkers were seduced by an impersonal devotion to the scientific method, relegating the mystery of life to scientifically uncharted territory, simply awaiting the moment when science would explain all. The somewhat conceited supposition was that scientific discoveries, in the aggregate, would eventually add up to a supreme knowledge regarding the nature of life.
Contemporary medical science dates its birth to this era. The new medical scientists satisfied themselves with the study of the structure and function of Homo sapiens as a means for maintaining and restoring health. Man's soul, brain, and emotions were not worthy of scientific inquiry and did not play a pivotal role in health and disease. From the 17th century until the 21st century, answers to human illness have continued to be found as an outcome from scientific investigation.
Excerpted from Reinvent the Heal by James T. Hansen Copyright © 2012 by James T. Hansen, M.D.. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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