by Charles Hugh Smith
A number of physicians and nurses read this site, and I often reprint their commentaries on the state of U.S. "healthcare", which I call sickcare. I don't expect everyone who works in the system to agree on specific solutions, and I offer this insightful essay from a practitioner in the spirit of open discussion of a critical issue facing the nation, and with an eye on educating those of us who know only a patient's perspective.
I think this is one of the finest, most comprehensive and informative essays on the fundamental problems of the U.S. sickcare system in print. Reading it helps us understand why all the thousands of pages of tweaks instituted by the recent "healthcare reform" bill will necessarily fail, as will the entire system within this decade.
What Is Good Medicine?
by Michael Horowitz
This can’t be simply defined in words, it must be described. Medicine rests on the fundamental ideas that it is better to be alive than dead and healthy rather than ill. For medicine to be good, it must also rest on a wholesome conception of what a human being is and on a sound understanding of the foundations of our physical and mental existence. These conceptions vary with culture.
For example, it has been said of psychiatry in Japan that its chief ideal is re-integration of the patient into the group; that is, the family or greater community. In our own culture this is not primary. The chief goal of medicine in the tradition of Hippocrates is the service of the individual human personality, independent of the preferences of any social organism and constrained only by the physician’s own ethical code.
The foundation of this medicine arises not from tradition or authority, but from the results of free, rational, thoroughly objective inquiry and a moral basis which places the patient’s well being ahead of the physician’s material self-interest.
One of my finest teachers taught me that the most important tool at a physician’s disposal for diagnosis and treatment was their relationship with the patient. This began as a sort of slogan for me but in time I understood the profound reality the words pointed to. Experience has taught me that the most important part of diagnosis is a subtle history taken by the doctor and the key to treatment is a well-founded sense of trust on the part of the patient.
Medicine is appallingly complex in its demand for knowledge, experience and judgment and technically informed consent is essentially impossible, even when the patient is a sick physician. Informed consent arises from the patient’s own character and experience, or not.
When all these elements - knowledge, judgment, ethics, compassion and relationship-are coupled with access - then good medicine is present.
In its origins, Hippocratic medicine emerged independent of religion, the state or any financial institution: there was no licensure, no insurance companies, and no malpractice law. Medical practice was taught by master to apprentice and conveyed from healer to sufferer.
This simplicity is gone. The first profound complication in medicine came in the form of licensure by the political state. The state was put into a position to decide what medicine was. This gave one group of physicians the power to eliminate a mass of competitors, whose method was at variance with their own, by excluding them from endorsement by the state.
Another complication has been in the economic realm. Over the last several decades physicians have been forced to arrange their practices to meet the demands of large economic organizations, especially insurance companies. In the 1970s roughly 95% of primary care physicians were in solo practice; the same percentage as in Canada today with a completely socialized health system.
Today this number is almost exactly reversed, with solo or very small group practices restricted to rural areas of no economic interest to insurers. The vast majority of physicians are now in large groups or are employees of practices owned by large corporate entities. This was not a spontaneous development in a free market.
When I was in training, my university family medicine residency program staffed an inner-city community hospital to which a six-physician primary care group admitted patients. They were the original physicians in what became, for a time, the largest HMO in the US. All, I recall, became multimillionaires. They had obtained a huge federally guaranteed, low-interest loan to start this HMO. Without this access to capital the venture could not have succeeded.
The federal government, in fact, intervened in the medical marketplace in a way that guaranteed the emergence of large corporate entities dominating medical practice at the expense of individual physician autonomy.
Though much less prominent in recent years, the original model for the HMO was capitated risk sharing. In this business scheme the insurer would collect premiums and pay a contracting physician a set amount per patient per month. If the physician provided more services, he would experience no rise in income, thus discouraging the “more is better” mentality. In addition, the primary care physician was appointed “gatekeeper”; being given the right to restrict the patient’s access to services from others such as specialty visits or various tests. Money was set aside to cover such costs. If not used, the physician would receive a portion as an efficiency bonus.
This had terrible effects on medical practice. The implicit contract in the simple doctor-patient relationship of old was this; the patient pays an agreed fee and the physician then acts as he “professes” in his oath. That is, the physician’s own material self-interest , or at worst mere greed, meets with his professed ideals on the field of his own soul life; his conscience.
With the capitated HMO, a third person is now, in a sense, a party to this process. The physician may do what he thinks is right, but if it fails to meet the economic agenda of the insurer, he will be harassed and eventually excluded from participation in a scheme that “captures” a significant portion of the population he hopes to earn his income from. This captivity results from the massive power advantage the corporate insurers have in negotiating with employers and other premium payers. The truly free choice of physician is thus largely abolished.
Many other arrangements are in effect which intrude upon the relationship of doctor and patient. Some involve limiting the physicians to be fully covered to a “panel” which agrees to fee restrictions, paperwork demands and other requirements of the third party payer.
This is moving towards a kind of additional layer of licensure — if a physician does not meet the requirements of the insurer, he is excluded from effective access to their customers; most of whom have no real choice in the matter. Where the third party is a government agency, as in Medicaid, there is a persistent growth of similar demands to limit care and meet endless administrative criteria.
The injury to the doctor-patient relationship from advertising by insurers and drug companies, with their extravagant claims of compassion and competence, cannot be overstated. There are still strong ethical and legal constraints on physician self-promotion. But look at the billboards all over Portland claiming that this or that insurer, hospital system or large group has better people, better equipment and better morals than the others. The power of manipulated words and images in mass media is immense, with virtually no respect for the truth.
It has been essential in seizing and degrading the culture of Hippocratic medicine over the last quarter-century in this country. Physicians have been pandered to by drug companies for many years with many unhappy consequences. Hand in hand with this has been the new snake-oil advertising to consumers of the purple pill cure-all fantasy (“take it and life will be wonderful”) by the pharmaceutical giants. The Vioxx scandal exemplifies this evil.
Let me try to make this concrete. Imagine a new drug, Curallacillin, is marketed. It has largely been developed by scientists supported by public funds, but a giant company owns the patent. Curallacillin is lifesaving for a small number of illnesses. It costs $150 for seven days of therapy. Its risks are under-studied due to weakened FDA oversight.
The drug company, at immense cost, markets the drug to physicians. The marketing is done by attractive, charming and articulate people, trained in the art of persuasion. They are aided by slick advertisements in medical journals, paid experts (hired guns) from the academic world supposedly presenting unbiased opinions at company sponsored lectures, fancy free dinners and many other blandishments. (Many idealistic physicians open their doors to drug representatives, out of the best intentions, to get samples of Curallacillin for people who really need it but can’t afford it.) The drug gets some “buzz” among physicians and gets some bandwagon momentum.
Now picture this. The HMOs, Medicaid, Medicare and other insurers who have an incentive NOT to spend restrict the physician’s right to prescribe Curallacillin. To combat this the drug giant will go directly to the brain of the patient through mass advertising. Then what happens? The patient comes in with two weeks of cough from a cold. The doctor says it’s a virus—take Tylenol and wait a while. Being human the patient thinks they know better. “What about Curallacillin? I hear it’s really powerful.”
In the old days, when a doctor discouraged use of an expensive drug the patient usually would sense that this was objective, selfless advice in their best interest. Now, almost unconsciously, the thought creeps in that the physician, in not prescribing the wonder drug, is serving an invisible being lurking outside the exam room; that “third party” insurer or the physician’s employer.
When a sick and worried person senses that the doctor does not have their best interest at heart, trust vanishes. This comedy is not over. If the doctor relents under pressure and prescribes Curallacillin, the patient’s drug coverage declines to fill because it is “off formulary.”
But it is in the very nature of modern third party insurance to evade any final responsibility for any decision. The patient has read their policy--they demand the physician submit a Prior Authorization request (i.e. a special exemption) to get the Curallacillin.
If this is declined, the patient invariably includes their doctor in any blame. If the doctor submits too many or pursues too vigorously such requests, he will become persona non grata with the third party insurer, who controls his income, work conditions or even employment. (Imagine further that the patient gets the drug and has some horrendous side effect OR doesn’t get the drug and has a bad outcome-- it is the doctor who will suffer the tremendous trauma of a malpractice suit.
Through their political influence the drug companies, HMOs, insurance companies and government agencies have insulated themselves from liability. Think seriously about such tensions being a constant part of your own work. Now, finally, I ask you to imagine a daily drumbeat of such absurdities day after day for years! I hope you begin to see how the very nature of medicine itself would gradually yet profoundly change under such an assault.
Physicians are first and foremost human beings. They are susceptible to coercion by fear of want, exhaustion and the inability to practice the art that most of them love and gives their life much of its meaning and purpose. They have largely surrendered their youth to an exceptionally demanding course of training. This tends to make them overly conservative in their political views. They also tend to be excessively individualized, making it difficult to participate in cooperative efforts. When faced with large businesses intruding themselves into the practice of medicine, they had great difficulty organizing a collective response.
The Justice Department, through anti-trust prosecutions, promptly destroyed the few efforts to resist and dispossessed the physicians involved. In a sense, the medical community has largely collapsed in the face of incessant and growing pressure.
I have decided to append some illustrative stories to the above before moving on to solutions. These stories are all real cases of mine from the 1980’s while I was in solo practice near Philadelphia. They are slightly modified to prevent the remote chance of revealing someone’s identity, even at this distance in time and space.
This first story is a simple example of what an unfettered doctor-patient relationship can accomplish. John was about 26 when he first came to me. He had been rather wild in his teens, a heavy drinker and drug user, temperamental, somewhat violent and had had some minor run-ins with the police. At 19, while drunk and walking home, he was stuck by a train. He suffered a spinal chord injury that left him weak in both legs but not fully paraplegic. His gait was grossly abnormal and nerve root damage led to severe burning and stabbing pain in his right leg.
Fortunately he received federal disability and Medicare, allowing him excellent access to medical services. He came to me because of pain. He had continued to drink and had burned out a number of physicians in his demands for narcotics. I had trained in inner-city hospitals in Philadelphia and tended to be skeptical of such demands and on the look-out for manipulation.
A thorough interview suggested to me that he was honest about his pain. He had been through a series of pain-mitigating procedures he himself had insisted upon. All had failed. I placed him on long-acting morphine and referred him to a neurosurgeon specializing in pain management who was quite famous locally. John came back with a description of a short, abrupt visit. He underwent a procedure to implant an electronic stimulator to reduce his pain, but without benefit.
When I spoke in follow-up with the neurosurgeon, I also found him short and abrupt and he blamed the failure on the patient’s attitude and personality. In turn, John became more depressed and, I suspected, was considering suicide. By now I knew him very well. Despite superficial resemblance to a drug addict and sociopathic manipulator, I knew him to be a desperate, bewildered and despairing young man, suffering from genuinely intolerable pain.
As far as I knew from local specialists, there were no more therapeutic avenues to explore. I began to review the research literature at a medical school library (this was pre-internet). I discovered that the premier research group in neurosurgical pain control was in Baltimore at the Johns Hopkins medical school.
I called their director and told him John’s story. He was unrushed and clearly interested. They accepted him as a patient and, after a thorough evaluation, he underwent an experimental procedure involving inserting a small probe into the relevant nerve root and heating it with radio waves. This single procedure was curative. Over the following months we weaned him off of narcotics completely and his depression resolved, and with it his alcohol abuse. I saw him occasionally for years afterwards and his relief was permanent.
Doing something similar today would be much more difficult. Hopkins was able to bill Medicare for his treatment and I was not restricted in my actions. Today it’s a different world in a more fundamental sense which I find difficult to describe. The very idea of what a doctor is, the civilized conception of medical care, has been severely degraded by corporate systems and image manipulation. Only a few of us, with difficulty, can remember what the freer atmosphere of decades past was like.
Richard and Janice were a young couple with a new-born. She was an RN and he was the epitome of a computer geek. They were well-to-do and quite healthy. They had top-notch traditional insurance. One day they switched to an HMO since it was cheaper and so upbeat - who can argue with maintaining health? A few months later he suddenly collapsed. He was taken to a local hospital where the diagnosis of a brain hemorrhage from a congenital aneurysm was made. He was deeply comatose and maintained on a ventilator. I was away at the time and the physician covering for me referred him to one of the handful of neurosurgeons who had signed on with the HMO. Richard was transferred to a somewhat larger hospital nearby.
When I returned the day after Richard’s collapse, I contacted the neurosurgeon. It was a strange and distressing conversation. He spoke rapidly in a thick, almost incomprehensible accent and seemed unwilling to discuss the case in detail. He told me he would operate on Richard the next morning.
My understanding was that a recent study strongly suggested that a delay of 10 days or more tended to lead to much better outcomes and I asked him about this. He became abruptly hostile and ended the phone call. I then called the neurosurgeon I routinely referred to (and who years later operated on me). He had a national reputation and had established one of the first neurosurgical ICUs in the country at one of Philadelphia’s premier teaching hospitals. I reviewed the case with him and he confirmed my impression that early surgery was rarely appropriate and probably dangerous. He offered to take Richard as a transfer.
I called Janice and explained the situation and my own recommendation for transfer of care. I also explained that this would require an authorization from the HMO. She agreed. In brief, the HMO turned down my request and then was faced with Janice, an exceptionally strong willed and combative person. She refused to allow the surgeon to proceed and assaulted the HMO with threats backed by an attorney. The squeaky wheel gets the grease, as they say, and they gave in within the day. I myself received a storm of calls from the medical director of the HMO telling me I was wrong, trying to order me to change my advice coupled with vague threats.
Richard was transferred and, on arrival at the teaching hospital, was found to have a dangerous pneumonia caused by inhaling vomit at the time of his collapse. He was treated and after his pneumonia had improved, he was operated on about two weeks later. He had multiple congenital aneurysms at the base of his brain. His surgery lasted over 12 hours. The only lasting neurological deficit was a slight weakness in his foot due to a pressure injury of a superficial nerve in his leg, caused by lying in surgical stirrups for so long and this resolved in a few months. I am certain the choice of neurosurgeon made all the difference. Immediate surgery, compounded by pneumonia, would likely have killed Richard.
The HMO’s claim is essentially that a doctor is a doctor, a surgeon a surgeon or that corporate management somehow has the will and insight to insure “nothing but the best”; profit and cost control are secondary. Do you believe that?
Marian was a 50 year old woman with deep roots in the rural area I practiced in; an area with much in common with the traditions of old New England. She was accustomed to good manners and long-standing relationships with the grocer, dentist, doctor and so on. She was also a senior speech therapist at a nearby hospital. She was one of my first patients after residency and, in time, her extended family and friends had come to me. We had lots of long conversations and I felt I knew her quite well. She was in relatively good health and I saw her three or four times a year for mild hypertension and the occasional minor infection. She had been my patient for eight or nine years when my office manager told me she had requested the transfer of her records to another physician.
As was my custom, I called her and asked if we had in some way disappointed her expectations or failed to meet her needs in some way. Marian told me that she had felt too embarrassed to tell me, but that the insurance offered by her employer had changed, and her new HMO did not cover my services. Any alternative coverage was beyond her means. She had picked her new primary physician randomly from a list sent to her by the HMO.
I asked to her not to feel badly about this but also offered to reduce her fees if she wished to keep using my services. (Primary care fees are, in any case, minimal compared to other medical costs. The cost of her care from me never exceeded $200 per annum.) A year later she saw the new physician, whose reputation in the local medical community was at best mediocre, for a “cold” associated with a nagging dry cough. The cough failed to resolve and became associated with gradually worsening shortness of breath on exertion.
She returned for follow-up several times over the next twelve months. Blood tests were negative and a chest X-ray taken a month after her cough started was read as normal. In spite of her own forebodings, her habitual refined manners kept her from challenging the physician’s repeated reassurances. She returned to see me at the urging of her children, after a year of seeing their mother deteriorate.
She was seriously ill, with obvious shortness of breath at rest. A chest X-ray the same day revealed extensive lung cancer. Marian had never smoked and a biopsy revealed adenocarcinoma, a type of cancer not associated with smoking or other inhalants. If detected early, this cell type is associated with somewhat better treatment results and longevity than other forms of lung cancer. Despite treatment, she died within a few months.
Because of financial coercion by the insurer, she went to a physician with whom she had no human connection, no word of mouth referral from someone she trusted, and because of her well-bred politeness and deferral to authority, she went undiagnosed until she was beyond effective treatment.
What We Can Do
The problem we face is, in essence, a kind of infestation with parasites (like tapeworms) which diverts the healthy energies of our societal organism for private, destructive purposes and gradually destroys the host.
The doctor-patient relationship is one example. The corporate intruder demands its “cut”. It demands obedience and it takes the image - the idea of a healing relationship - to hypnotize a target population through advertising, while inevitably eroding the freedom, trust and goodwill that is at the heart of such a vital human alliance.
It is also unsustainable in its insatiable need for money and power. Like all parasites, it tends to work toward the destruction of the life off which it feeds.
Part of the solution, it seems to me, is to stop feeding the parasites! This means gradually ceasing to do what doesn’t work.
Stop participating in an insane system, stop paying into the vast corporate, energy sapping superstructure, stop watching and listening to untruthful nonsense.
This means taking risks. In our medical practice we will start by not paying the massive cost of paperwork and phone calls to insurers (only to be put on hold or addressing a machine.)
We will be available, we will be affordable and we will remain conscious of the economic reality of ordinary people.
We will serve our own professional ideals and remain true to the humanistic traditions of Hippocratic medicine.
We will strive to form alliances with others - volunteers, other care-givers, local businesses and civic institutions - who share this ideal of re-localization, sustainability and community to help create the basis for a worthwhile life for all of us.
Thank you, Michael, for a cogent and moving depiction of our very perverse "healthcare" system. I posted my own "solution" last July: The "Impossible" Healthcare Solution: Go Back to Cash.
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