Why I am Leaving Medicine
Kenneth A. Feucht, M.D., Ph.D.
I formally decided to quasi-retire in October of 2016. This meant for me, getting out of the surgical oncology profession. My intention is to continue working until 31MAR2018 in an outpatient wound care clinic associated with the hospital in Puyallup, WA where I live. Remember that training in my profession consisted of 15 years past the 12 years through high school, so that I have completely identified myself as a surgeon, making my profession not easy to give up. I would have liked to continue practice until I was 65 or more, but frustration with medicine and the changes which have occurred since becoming a physician have led to my desire to leave medicine. This is not an easy decision. I have a deep love for my patients, and found the profession to be quite rewarding. It was particularly satisfying dealing with patients not only for the relief of their physical ailment, but also to help them psychologically and spiritually through a major crisis in their life, which is usually the situation when somebody is given a diagnosis of cancer. With my decision to retire a bit earlier than I had wished, I felt that chronicling the root causes for my decision would be appropriate. The list of my grievances with the health care profession is in no way intended to be comprehensive, but to cover the major areas of frustration for me as a surgeon. This is NOT an in-depth, heavily researched paper with references and documentation, but an off-the-cuff rendering of my feelings regarding the status of health care. Perhaps someday I will take the time to render a more academic version of this treatise.
Health Care Orientation
Hospitals began in the fourth century in central Turkey in a region called Cappadocia. At that time, the poor and destitute who were ill were abandoned by the community and sent away into the woods, where they were often eaten by wolves or other forest beasts. This allowed for containment of communicable diseases, but did not reflect well on the care of the ill patient. It was St. Basil who took these poor people and reincorporated them into a caring community environment. Thus, we get our word “hospice” or “hospital” from the latin word which would be translated as “hospitable”. Hospitals became defined as an agency that attended to and offered the patient an ability to return to the community of the faithful while under care.
Germans have two names for hospitals. The most common is “das Krankenhaus”, though they also use the term “das Hospital”. Translated literally, “Krankenhaus” simply means “sick house”. It is a vastly more fitting word for what we have today, and the term “hospital” should go out of existence. Hospitals are no longer places of caring, and they do not offer the patient a gracious return to the community, or hospitality. They are places where patients are treated with sterile rigor, where children dump aging parents once they have become a nuisance, where occupants are considered to be more work for already overworked nurses, where physicians rapidly fly by patients, knowing that they dare not say either too much or to little, but where everything needs to be documented in a complex electronic database, and where nurses spend most of their time making sure that those databases are replete with boilerplate (and thus useless) data to fulfill various government mandates over what needs to be documented. The entire orientation of healthcare is a narcissistic reflection on themselves looking past and ignoring the raison d’être for their existence, the patient!
What is healthcare? What is involved? What is health? What is wellness? How do you define something nebulous? The dictionary defines it as “the maintenance or improvement of health via the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings.” This definition can be strewn out to as broad of meaning as life itself. Is my mental stress over an upcoming test in school a part of healthcare? Is my desire to become and identified as a female when I started out genetically and physically a male a part of healthcare? Is my carelessness in attending to my mental state when I accidentally kill somebody while driving a motor vehicle under the influence of alcohol actually a healthcare problem?
But, why do we even waste the time to precisely define the full nature of healthcare? Is it really important that we have a narrow versus broad definition of healthcare? From a personal point of view, the manner of defining healthcare is unimportant, but from a health care policy perspective, it is vital. The government promises that healthcare will be paid for, but exactly what that means is quite vague. In Germany, going to the spa for a week or two rest is covered. In the USA, the breadth of coverage constantly changes according to what is politically expedient. Oregon attempted to identify and rank cost-effective treatments to determine what might be covered. Since physician assisted suicide is very cost effective, it ranked quite high up. Is this proper? Assisting somebody in suicide seems to be counter to the entire goal of the medical profession, but nobody could doubt that much expense is saved by terminating the patient. If trans-sexual surgery is covered by government policy, why isn’t all cosmetic surgery covered, since it is aiding to personal well-being and how a person defines themselves? Why isn’t food free, since it is really taken to prevent healthcare problems? Why isn’t our housing and the cost of maintaining housing covered, since it all contributes to me maintaining and improving my health?
What about health itself? How do you define health? Is it just the absence of sickness? If so, then obesity would not be a health problem, or smoking, or any other dangerous activity, until it caused a problem. Some people choose to live through disabilities that would be viewed as insurmountable by others and refuse to identify their disabilities as an “illness”.
A frightening result of having an all-encompassing definition of healthcare that is provided for by government, is that they then must adopt the role of supervising our behaviors in order to maximize the government definition of health and well being. Does somebody really want the government telling them that certain activities are forbidden? Does anybody really want government prescribing exactly what you can eat and how much you can eat in order to stay healthy. When Michelle Obama attempted to regulate school lunches in order to decrease obesity, it was found that the children actually became more obese who were on the lunch program. When do we decide that decisions in our life become none of the government’s business? If we allow that government is responsible for health and well-being, we must realize that we are then completely giving away our freedom.
In reality, the public definition of healthcare is impossible and it would be best if we remove any attempt at defining the realm and coverage of what we think as healthcare.
We are constantly being bombarded in the news that a new regime of politicians will correct the messes that former regimes have created in federal health care policy. I will speak of ObamaCare specifically a bit later, but here address specifically issues of government policy in health care. Over the course of the last century, we have gone from a situation where there was no government involvement directly in healthcare, to where government pervades virtually every aspect of the healthcare scene. Government first became involved in healthcare in Germany during the tenure of Bismarck. In 1883, he created a national healthcare system which provided insurance to all citizens. Many countries today follow the Bismarck model, though we do not in the USA. (ObamaCare seemed to be a model that attempted to simulate the Bismarck model though not utilizing many of the most important aspects of the Bismarck model.) Through the introduction of Medicare by president Johnson in the 1960’s, there has been a slow invasion of government into the healthcare scene. Government continues to fund increasing amounts of healthcare, and thus has taken an increasing stance toward controlling health care costs. At the same time, the innocent introduction of internal means of quality improvement (such as the JCAHO, which was started by surgeons as a means of voluntarily improving surgical quality across hospitals in the USA) has evolved into a beast that neither improves the care of patient nor the quality of healthcare delivered. More will be spoken on JCAHO later.
In times past, physicians generally took the Hippocratic oath on graduation from medical school. If not the Hippocratic Oath, then a somewhat similar oath (see article on the Hippocratic Oath, referenced below) was offered. In the Hippocratic Oath, three parties are involved, which include the patient, the physician, and the god(s). Glaringly omitted from the ancient oaths were the health care system, insurers, the government, and anybody else outside of the three mentioned. This is only right, and an article I’ve written on the oath covers why such an arrangement is so vital to the doctor-patient interaction (http://feuchtblog.net/die-veroffentlichungen/the-hippocratic-and-other-oaths/ ). Healthcare is now run by a multiplicity of bureaucrats and idiot savants who love to tell physicians and patients what is best for them without any knowledge of either the patient or physician. Government makes a cookie cutter mold that all diseases and persons are supposed to fit into. Diagnoses have a number assigned to them according to the ICD-10 manual, and no diagnosis will fail to have a specific number. Treatments and procedures also have their number, called the CPT code, with a one-size-fits-all mentality.
Government healthcare is run by bureaucrats. These are the self-serving policy wonks and bean counters that control the health care of all occupants of the United States, citizens and non-citizens, consenting and non-consenting, the sick as well as the healthy, the only exception being the politicians themselves. Most often, these healthcare pundits have been in the health care profession as either physicians or nurses, but are now removed from actually providing care, and thus not experiencing the consequences of the policies they implement. Being removed from health care, they may act with heartfelt concern for their colleagues in the trenches, but will never be able to properly address the constantly changing healthcare scene that affects healthcare delivery. In addition, their policies will fail to address all contingencies and variations in the disease process or patient goals and needs.
The government, since they intend on paying for healthcare, are obsessed with the cost of healthcare. Yet, they strangely seem to be the most clueless as to why healthcare costs so much. Perhaps healthcare costs are high because of government interference?
Two organizations from the federal government have been particularly harmful to healthcare, that of the food and drug administration (FDA) and the other the center for disease control (CDC). The FDA started as a well intentioned idea to protect the public from potentially dangerous drugs. The thalidomide incident in the 1960s is instructive. Thalidomide is a medication designed to decrease morning sickness in pregnancy, but was noted well after the fact to occasionally cause phocomelia, very short limbs, in some of the babies exposed to this drug in utero. I’m not sure that thalidomide babies could have been prevented even if the FDA was functioning as they do now, but a good crisis has not gone to waste by the government. It now takes many more years for a drug to go from creation to market in the USA as compared to Europe and other countries in the world. Drug development costs have risen to exceed a billion dollars to get an new drug to market in the USA. Yet, American patients are not safer than European patients, though we are denied rapid access to potentially useful medications.
While the FDA “protects” us against dangerous drugs, the CDC is here to “protect” us from various communicable diseases. I have less of a problem with the CDC than the FDA, though the CDC remains over-reaching in so much of what they do, and persist in trying to justify their own existence. The flu vaccine is a perfect example. It is close to impossible to predict which flu antigens would be dominant in any flu season, and the antigens of choice are made by “educated” guess. I know of no randomized trials that have proven within reasonable doubt that mass forced administration of the flu vaccine decreases morbidity or mortality from the flu. Health care personnel that work for hospitals are mandated to take the flu vaccine, and we have no other options. It matters not that we might have strong personal preferences against the flu vaccine. Another example, Gardasil, the vaccination against HPV, is sold to prevent genital warts, and thus cervical cancer, and is recommended for all males and females between 10-12 years of age. It is of value only for the sexually promiscuous female, but is strongly encouraged that all children receive this vaccine. Long term effects of the vaccine are essentially unknown. The CDC would love to have this vaccine mandated, and there is great pressure on all children to receive the vaccine, even from family physicians. This represents an over-arching hand that doesn’t allow for patients to make personal choices regarding their behaviors and actions, but assumes that all patients (or children) will be irresponsible and not have to take account of their actions. The CDC in effect takes the roll of parent, and displaces the biological parents as having a say in the behavior of your children.
ObamaCare is presented as the great revolution in healthcare, the solution to all of our problems, the defining policy that will allow all people in America to have adequate health care without obstruction from inability to pay. The health care bill was so voluminous that nobody in congress was able to read it in its entirety, and the proponents demanded that the bill be passed before one could discover what was in it. I won’t belabor the nature of ObamaCare because I have not read the bill, nor have any interest in reading the bill. What I will discuss is how it has affected physicians attempting to care for patients.
Obamacare wished to improve everybody’s access to healthcare, including that of illegal aliens. To do so, health care insurance was mandated to all. If you didn’t purchase healthcare, you were fined. You could either purchase private insurance, or the state would provide options. The rules were tightly defined for enrolling or switching health care plans. The presumption is that all people then had health care. Wrong! The cost of healthcare has continually escalated, and all plans had a copay for any service rendered. Copays were intended to prevent flippant and casual care. In actual fact, it has served to be more restrictive than anything to actual access to care. There are many patients that have turned down a proposed treatment plan for them simply because they could in no way afford the copay. In essence, care became more difficult to get.
ObamaCare also sought to assure that increased value was offered. This had multiple aspects, including patient satisfaction surveys, increased demands on providers to be fully “educated” through CME (more on this later), and increased demands of JCAHO. Patient satisfaction surveys were reported through what are called Press-Ganey scores. For employed physicians, bonuses were heavily dependent of the Press-Ganey scores. While Press-Ganey scores reflected how patients feel about their physician, it had minimal correlation with the competence of the physician. A physician that is the bearer of bad news, no matter how well it is delivered, will often be viewed with less favor than a physician bearing good news. Physicians oftentimes need to reprimand patients or cajole them into healthy behaviors, which is usually not viewed favorably by the patient. Some physicians are quite excellent, but do not have jovial personalities, which patients don’t like. Or, they have a jovial personality but are incompetent, something that a patient might not realize until it is too late. ObamaCare has allowed feelings to supplant honesty and truth, and the end-result will ultimately be disaster. Meanwhile, ObamaCare has flunked in its attempt to define quality in health care, and I’m not sure the ObamaCare act really cares about quality; they simply want the illusion that everybody is getting quality healthcare.
Are people truly having good coverage of their health care problems? The answer is complex, as there are a few people that have coverage that otherwise would have been out. Before government got involved in healthcare, most large cities and all counties had a county hospital that would take care of the indigent. Everybody ultimately received health care. Pharmaceutical firms were good about providing reduced rates on expensive drugs to the poor, and almost all people were able to survive. Now, coverage is actually worse, and many no longer have actual coverage of expensive treatments because they are responsible for a copay, which might be unaffordable. The only group of people who are better covered are those who should not have coverage, such as illegal aliens, or those who are mostly responsible for their own illness, such as burned out drug addicts.
Are the physicians getting rich? Definitely not! Over the last thirty years, physicians had to work harder and longer and more hours to make commensurate pay of the past. As a result, physician burn-out has become a true problem. The solution for physicians has been to become employed. I won’t belabor the problems of employed physicians, save to mention that employment essentially strips them of the definition of a true professional. They are nothing but expensive, sophisticated hired hands, and they will behave as such. People who serve administrative positions in health care are getting rich, and hospital CEOs as well the insurance companies are making out quite well. For the most part, physicians are getting poorer.
ObamaCare has not addressed the reason why healthcare is so expensive, and has diverted the attention from health care costs to health care availability. I am grateful that illegal aliens can receive the best health care in the world for free at my expense. In fact, I am waiting eagerly for anybody to provide an honest analysis of health care costs, and an explanation as to why health care costs in the US are much higher than in Europe or the rest of the world. I can think of many reasons, and simple explanations such as the absence of free markets deflects from serious analysis of costs, which has multifactorial roots.
The state has deemed it vital to make sure that physicians are competent. In order to define competence, the state has had to set some sort of prevailing standard, which is an amalgam of current practice and best practice recommendations based on the latest research. This assumes that best practice can be codified and then enforced. It assumes that current prevailing practice is the standard for all physicians and all patients, and that our knowledge of disease pathology and physiological processes for disease are correct and well understood. Sadly, history is replete with countless times where the medical profession has been wrong and has had to eat their words. It is no wonder that much of what I had learned in training had to be unlearned as simply wrong. Medical practice is in constant change, and not necessarily in the correct direction. One dares not fight the system if the system is going in the wrong direction.
The state needs a way of making sure that physicians are keeping up with the latest and greatest developments in health care. The current standard is to require physician recertification, usually every ten years. The other is the requirement for continuing medical education, or CME. There are serious problems with both of these systems. For recertification, the physician needs to be placed in a box that defines who they are. These boxes are the selected specialties that the physician identifies with, whether that be in family practice, pathology, internal medicine, general surgery, or a host of other specialties. But, these specialties are too vaguely defined, such as in my specialty of general surgery. I am a surgical oncologist, and the American Board of Surgery only recently created a board specific for surgical oncology. Surgical oncology itself is heavily fragmented, between melanoma surgeons, breast surgeons, hepatobiliary surgeons, sarcoma surgeons, and a smattering of other organ specific surgeons. Within the last 20 yars, surgical oncology has essentially lost head and neck surgery, endocrine surgery, thoracic surgery, and colorectal surgery. True, one would like their surgical oncologist proficient in all aspects of cancer surgery, yet reality states otherwise. Regional referral patterns and practices also affect a surgeon’s expertise. Certain diseases are just more prevalent in some areas as compared to other areas of the county. In Chicago, I saw much pancreatic pathology. In Seattle, there is very little pancreatic disease, but a proliferation of other diseases. The truth is that as a professional, one is always reading and educating oneself, and each individual physician will develop a differing broad area of expertise. A simple test imposed by the state is not capable of defining what only the test of real life scenarios can clearly define. Recertification has become a horrid pain to take. I’ve re-certified twice, have done well in my re-certifications, but swore on the last re-certification that I would never do it again, ever, for any reason. Most physicians reach the same conclusions as I have, and the net result is to drive out the aged but experienced physicians. The only exception is in academia, where the surgeon is somewhat protected.
Keeping up with CME is a pain. It is not enough to simply subscribe to various specialty journals and read them on a regular basis. Now, one must answer sets to test questions to assure that you’d acquired the information attempted to be taught by the article. The Journal of the American College of Surgeons would do this for four articles each month, and I dutifully answered their questions for a number of years. About 2 years ago, I realized the stupidity of most of the questions, and how they were usually completely unrelated to my field of practice. The questions were intended to quiz whether you had read the article, but often assumed you had knowledge well beyond that of the article; thus, there was no education of the physician, and failure to judge whether I’ve read and learned from the article. The problem is compounded when articles relate to my own specialty, since I usually read into the question the controversies involved and uncertainty about the information in the article. The multiple guess questions really fail to assess my true knowledge of a subject, yet is mandated in order to assess whether I’m actually staying on top of my specialty. CME updates are demanded by the American Board of Surgery every three years, and I will be letting the next update slide.
Increasing surveillance of physician behavior is happening. This relates to both social behavior, as well as practice outcomes. Hospitals are simply not turning a blind eye to behaviors that would be publicly unacceptable. There has been a change from historical norms, where previously the physician acted mostly without accountability. This is a good thing, and physician antics with the treatment of patients, colleagues or nurses must be now accounted for. The only problem is that it is the hospital that is performing most of the policing, and they have a very strong bias for protecting themselves. Thus, there is predictably unfair judgement against unemployed physicians, and usually it is by someone clueless. I recall, for instance, being reprimanded by the chief medical officer at my hospital for not responding in person to an emergency room call, even though I was in the middle of a case in the operating room. I informed the CMO to no avail that it would be considered unethical and immoral by the American College of Surgeons for me to leave a patient open on the table to attend to another person. Such madness has only gotten worse under ObamaCare. Physicians are still held liable as “captains of the ship” yet are not given the power or authority to maintain that captainship. We are constantly being told to alter our behavior or practice in the most minute ways that have no real bearing on patient outcomes or hospital well-being. The focus has turned from outcomes to process, without any evidence-based data to suggest that behavior changes would be good.
The discussion of “captain of the ship” bears more intensely on issues of hierarchy within the hospital structure. Traditionally, physicians were the main drivers for hospital decisions, dominated the board of directors of a hospital, and were held as primarily responsible for the success or failure of the hospital. Now, responsibility falls to the CEO and his minion of subordinates, most of whom are not physicians, though they might be nurses, pharmacists, physical therapists, or simple business types with no training in medicine. Because of the increasing commercialization of medicine, spread sheets and the color of the bottom line have become the most vital aspect at determining the survivability of a hospital. The physicians have silently gone from being the leaders of the hospital to being nothing but another cost center to be dealt with.
Until recently, documentation was performed in paper charts, usually a combination of typed text and handwritten notes along with printed reports, lab work, and outside information. Marginal notes would be made in the chart to facilitate jogging the memory of the physician. A typical note would take a few minutes to write, but would be highly effective at documenting an encounter. With the rise of third party indemnification (insurance), the desire to have confirmation of services rendered demanded improved documentation. The saying, “If it isn’t documented, it wasn’t done” became the hallmark message for mass documentation. This led to automation of means of documenting, including boiler plating encounters and procedures. This naturally led to the reverse problem of the past, in that much “documentation” might not have ever been performed. Because boilerplating made possible getting information quicker into electronic format, and with the rise of improved databasing and need for distribution of data, the electronic medical record (EMR) saw its rise. What was once a convenience became a mandated necessity. Many payors no longer accept handwritten charts, and the federal reimbursement systems require EMR for full reimbursement. EMR systems are very expensive, not only to implement, but also to maintain. They solve the problem of a plethora of charts and storage of these charts, as well as issues of lost charts, and the need for multiple simultaneous access to these charts. The down side is harder to see but more destructive. With a combination of requirement for increased documentation, and through the use of boiler plating, excess information now exists, and it is quite challenging to quickly identify the relevant information on a patient. Because of multiple sources for input to the EMR and restricted ability of access users to correct faulty information, the EMR slowly becomes less and less reliable. Errors become quite plentiful, from basic patient information, to diagnoses, medications and treatments.
Meanwhile, privacy of the data has become a greater concern. Physicians were instructed not to talk about patients in the elevator with outside people present, or to share patient data with people outside of the immediate family, unless given permission by the patient. Now, privacy has become a fanatical issue. In the past, I would walk onto a ward, and at the nurses station, a chalkboard list of all the patients and their room number was present. At the door of each room, the patient(s) name(s) were again posted, allowing for re-identification of the patient. This doesn’t happen any more, all in the name of patient privacy. The problem is that it is now easier to confuse or mix up patients, and more errors occur because of that.
Privacy in electronic data is a greater issue. The need for highly secure servers to manage patient data has become the norm, all mandated by HIPPA (federal policy). Yet, the skill of hackers has not been thwarted from obtaining any private patient data that they wish. True privacy is a myth, but the expense that we go through to maintain this illusion of privacy is astronomical. Indeed, true privacy is impossible. Perhaps all patients should present themselves to the physicians office or hospital in full covering like a Burqua or KKK outfit? Yet, the one area where privacy is zilch is with the government. They now know EVERYTHING about you. I fear the government more than I fear some stranger knowing that I happen to be on a β-blocker or some other medication. Yet, the feds have access to every aspect of my health care record.
I don’t view big pharma as an intrinsic evil, and much of their perceived evil comes from government and legal policy imposed upon them. There is no doubt that the large equipment and pharmaceutical firms have vastly improved the quality of healthcare in our country, as well as throughout the world. It is without a doubt that drugs exist and are available today that never would have been possible without these large companies. But, the large pharmaceutical and equipment firms comes at a terrible cost to all of us.
The large pharmaceutical firms must deal with a host of regulatory agencies, the FDA being the largest of them. One would think that big pharma would be fighting the FDA tooth and nail, yet the opposite is the case. The pharmaceutical firms have seen the FDA as a wonderful means of keeping out smaller competition, which is why you don’t see small pharmaceutical firms in this country. The assistance of the FDA in the assault on the nutritional supplement and vitamin industry is shameful. Big pharma has relished the protection to their industry by the FDA, leading them to become even more powerful at controlling the drug market. Concomitantly, we see larger firms buying up the smaller pharmaceutical firms, and thus becoming ever more powerful.
A secondary problem is created when insurers pay for medication costs, so that the consumer never sees those costs. This becomes problematic if a patient is unable to perform a cost-benefit relationship to determine whether a drug is worth taking. A perfect example are the statin drugs to lower cholesterol. I wait eager to see any statin demonstrate improved survival over the best alternative therapies out there. Statins have a high chance of significant side effects, yet has never been shown to be significantly effective at preventing death from atherosclerotic heart disease. And, they are expensive drugs. Too often, the patient assumes that the physician is using critical judgement in determining the need for a drug, yet the greatest determinant tends to be how good of lunch the drug representative brings to the doctor’s office.
A system of third party payment for health care has created the worst possible solution for healthcare. It is a serious misnomer to title health insurance as such, since it does not operate like insurance, but simply as a mode of funding. Insurance supposedly should be most active when there is an acute need, such as with a car accident or a heart attack or a new diagnosis of cancer. Instead, it covers every possible aspect of health care, including runny noses in kids to health maintenance examinations. Under ObamaCare, health insurance is not an optional decision, but mandated by the state. In such a situation, you would expect the health care insurers to making out quite well, and for the most part, they are, with executives of the major insurance companies making exorbitant profits. Yet, there are strains on the system. Insurance is not able to reign in the ever-rising cost of health care, and can only raise premiums and copays to a limit before the system breaks. And, the system is about to break.
Ultimately the big winners in todays system are the insurance companies, but that is a bittersweet win, as they continue to merge with other systems in order to survive. Time will ultimately pass a severe judgement on insurance companies.
If you read the popular press, they would suggest that legal issues are a small portion of what’s “broken” in medicine. Whenever malpractice tort reform becomes a subject of referendum up for vote for the public, the advertisements and press attest to litigation being a small part of costs for doing medicine. Yet, those most entrenched in the health care system and actually paying attention what is going on realize that legal aspects of medicine are probably our worst enemy, and that politicians and lawyers who know little of the actual functioning of healthcare are essentially orchestrating how things should be done in the health care world. If a physician suggests changes in the legal world, lawyers tend to attack the physician as ignorant, befuddled, or clueless as to how law actually works. Perhaps outsiders see the legal world a little more clearly than lawyers? Yet, it is most true that lawyers and political meddling in the world of medicine have only left medicine far worse off.
When a physician attends conferences, there are numerous sessions offered on how to avoid or deal with lawsuits. It is made very clear that the physician should understand that everybody gets sued, and that a lawsuit often is the “luck of the draw”, and that a physician should never take a lawsuit personally. Yet, in court, it is presented as just the opposite, and the claim is that there is something wrong with the physician that caused the medical “error”. I place the word error in quotes because it is too often that an error is not an error at all but simply the course of the disease. The lawyer presents a disease process as an entirely controllable phenomenon, and that good outcomes will happen when the standard of care is closely followed. Of course, they will deny this mentality until they are in court, where acts of “nature” serve to reward the lawyer quite generously. In public referenda regarding tort reform, there are usually two most serious claims. The first is that bad physicians need to be punished in order to improve the system. This goes contrary to all evidence yet seen. The second claim is that the tort system preserves patient rights. In actual practice, it does just the opposite, and patients end up with less options and choices in their care because of the malpractice climate which physicians and hospitals have to work in.
Whenever a referendum for tort reform hits the public, the claim defending current practice is that malpractice claims are actually decreasing and that malpractice premiums continue to be less expensive on the physician. Especially after a referendum, this is briefly the case, until the public forgets about matters, after which lawyers come back in force, hungry for more litigation. The malpractice situation has not improved, but remains a crapshoot, where a physician remains highly likely, no matter how excellent they are as a physician, to get sued and lose. The tragedy is that physicians can oftentimes see colleagues that truly are dangerous and yet manage to avoid suits. Cases that hit the public scene are often the most revealing. A few years ago, the leading transplant center in the USA made an error in typing an organ, leading to a hefty lawsuit. But, to what avail? This transplant center defined excellence in care for their service. Does human error necessitate lottery type outcomes for the lawyers and unfortunate patient? That is what happened in the transplant error to a distinguished center of excellence. There are many more similar stories.
What about if the legal profession is eventually proven to be wrong? Do they refund their ill-gotten gains then? I recall the colossal sums won against Dow Corning for the silicone breast implant lawsuit. Not very long later, it was proven beyond doubt that the manufacture of the implant or the nature of silicone did not lead to the alleged autoimmune diseases that the lawsuit purported to have happened. In this situation, the funds should have been returned, at least in part. This only shows that truth and justice are not served in courts of law, and the legal system has no interest in pursuing what is right.
My claim that litigation raises cost of everything is quite easily supported. Think about matters for a brief second. When you stay overnight in the hospital, with minimal attention rendered to you, you could expect a bill for upwards from $20K. I cannot think of any but the most exclusive hotels in the world that would even approach a fraction of that cost, even with servants and the most lavish attention. Why does it cost so much? Medications that are sold for veterinary use typical cost under 10% of what they charge for exactly the same medication with adults. Why? Medical equipment tends to be quite unreasonable in cost compared to similar products in the non-medical market. Oftentimes it is absurd, from a simple little staple gun costing several hundred dollars which if sold as a non-medical item would be several dollars. Why? Incorporated in those costs are both the higher cost of development for the human market, and the potential for litigation. Cows don’t sue, but people do. Yet, there are other subtle cost drivers. Physicians assuredly often act against their best judgement by over-ordering tests and x-rays, and over-treating, all in an effort to protect themselves against litigation. The patient is not given a choice in the matter, or allowed to assume risk. This is because with informed consent, it is still assumed in court that physicians should know better and not have offered choices to the patient if one choice was not assumed to be “standard-of-care”. The physician can’t win, and so plays the game by following the rules, even when the rules are wrong or don’t make sense.
This actually belongs in the “government interference” paragraphs, since the JCAHO is a government organization. Yet, it is so pervasive to all aspects of healthcare, with such overreaching influence on the way medicine is practiced, that it deserves a category of its own. As I write this, my hospital is currently undergoing a JCAHO inspection, and the anxiety of the administration is sky high. They have come by, and declared how various improvements must be made, how there are defects to the system which has so capably served patients. In essence, they are fixing “issues” that are not problems, never were a problem, and never will be a problem. Typically, the fixes are expensive, time consuming, but also require extensive documentation to prove that the fix is actually implemented by the hospital.
One of the most troubling changes in recent years has already be discussed, which are regulations imposed by HIPAA in order to preserve patient privacy. Sadly, HIPAA has failed to recognize that if somebody wishes to bust into the system, it can be done regardless of how intense the security measures are applied to the electronics of the system. The result is the physicians can no longer speak easily with each other about a patient’s care, and the detriment is ultimately to the patient.
JCAHO has long filled any possible useful purpose for itself. Yet, it has become a burgeoning business that must be sustained at all cost. Thus, they have sought desperately to find ways of justifying their own existence. They have accomplished that by creating new and novel regulations each year which they impose on hospitals. They will review hospitals every third year, and if sufficient inadequacies are found, will return a year after their visit to review the hospital for correcting their “mistakes”. During the triennial visit, they will disclose the new regulations, holding the hospital immediately responsible to correct their behaviors and adapt to the regulations. This causes a fleury of anxiety, panic, and hasty development of new hospital policies to match the new regulations. One year, they decided that if a patient was placed in restraints (usually in the ICU), then the order for that had to be renewed weekly. This had never before been a problem, and when there were restraint problems, they were of a nature that a policy would not fix. Another year, it was decided that used instruments or laundry could not be transported to their appropriate destiny in an open environment but had to be completely enclosed. One could hypothesize that bacteria could be spread with these instruments and laundry in open air, yet there has never been an instance where this had ever been a problem. The fix is indeed costly, and must be done in order for a hospital to continue operations. But, the hallway transportation rule defies notion that the hallway itself or the patient room could be transmitting disease between patients. Perhaps the entire hospital needs to be systematically sterilized between patients?
But, JCAHO will continue to work their evil deeds. Health care will become more complex, impersonal, and expensive, and ultimately, less safe. JCAHO is an organization that holds others responsible, but submits to nobody else’s authority. It is a true creature from the black lagoon.
Commercialization of Healthcare
It used to considered immoral for physicians or hospitals to advertise. Pharmaceutical firms were forbidden to advertise prescription products to the public. The American Medical Association held policies forbidding their members from advertising, as found in their code of ethics. The goal for these rules was to keep medicine out of the realm of commercial enterprise. All of that changed in the year 1975, when the federal trade commission considered the AMA policy as an illegal restraint of trade. The AMA rolled over dead. What was immoral one day was considered right and proper the next day. Advertising among health care emerged slowly. Early in my private practice, there was a rule that physicians in our community would not advertise, or even to have their name in bold print in the yellow pages. That disappeared slowly. Soon, one could see a plethora of drug advertising, with elderly patients in perfect health dancing vigorously across the tv screen, proclaiming the miraculous benefits and health giving effects of a medication with multiple side effects and toxicities. A few little lies won’t hurt, would they?
The end result of healthcare commercialization is that it has caused anybody and everybody to seek for a portion of the health care dollar. The highest paid person in a medical community is often the CEO of the hospital. While hospitals still designate themselves as “not for profit”, the non-profit hospital has gone the way of the dodo bird. Quite often, the most vigorously trained physician taking the greatest risks and responsibilities get the least cut of the health care dollar. The pharmaceutical and medical equipment suppliers are making massive profits unheard of in yesteryear.
One could argue that commercialization has led to improved competition and desire for innovation. Yet, competition has always occurred in health care, and innovation has also taken a great toll on our profession, not commensurate with the benefits offered. The most heavily advertised physicians are oftentimes the most marginal physicians. It would be hard to argue that patients are truly better off with advertising. For the reader interested in a erudite discussion of this issue, please read this article… https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563279/ .
The Flexner Report and its Evil children
The Flexner report was funded by the Carnegie foundation, supporting Abraham Flexner in a review of the existing medical schools in the early 20th century. The report was published in 1910, and intended on promoting standardization of medical education and the removal of marginal medical schools. We now see the evil children of the Flexner report, with regulation of the health care professions at an unprecedented level. The net effect we have had on physicians is increased regulation and requirement for continuing education, which was previously discussed. It has restricted the number of physicians in the health care community, and medical schools have not been able to keep up with the demand, especially in an age where increasing numbers of physicians retire early. It is difficult to just build more medical schools, since the cost of medical education is prohibitively expensive, and the state has had to bear part of the burden of these costs in order to keep the supply of physicians at adequate numbers.
There have been several ways in which the health care community has met the demand. First is through the influx of ever greater numbers of foreign medical graduates (FMG’s) from countries where health care education is not so aggressively monitored. The second is the rise of alternative providers, which include physician assistants and nurse practitioners. Both of these groups of providers have much shorter training periods, which would fail the current minimal standards for medical school training as defined by the results of the Flexner report. In essence, the Flexner report has forced its own extinction, and bred an alternative to the physician.
I am not unhappy that I ever became a physician, and feel that it has been a rewarding career. I am very unhappy with what has happened to medicine. It is like a public good has been stolen and no hope for recovery.
I am particularly sad that most people do not identify root causes for problems, but continually ask for immediate, self-serving, quick fixes to the health care problem. It is a truism that until congress and all of government has to live under the same health care plan that they impose on others, there will be no hope for improvement. I wouldn’t count on it ever happening in my lifetime.
Ultimately, health care will kill itself. It is unsustainable. It has lost its soul. Its original driving force was a Judeo-Christian Weltanschauungen, specifically, the belief that all people, young and old, born and unborn, of all races and creeds, were created in God’s image and of intrinsic value. Humans were not viewed as the accidental product of the primordial slime. Human relations were viewed as important as health itself. Suffering had meaning, which oftentimes led patients to delay in seeking a remedy. Pleasure and euphoria (feeling good) were not considered goals of worthy pursuit. Among health care professionals, the pursuit of “health” and prolongation of life seem to be more in line with personal challenges and a game to be played, the chance of honor for a great discovery, rather than the sympathetic concern for the whole person, body and soul. Purpose and meaning in life are oriented around maximizing pleasure and minimizing pain and suffering. Healthcare is the agent responsible for restoring maximal pleasure, either to the individual or to the community, when things go mentally or physically wrong. The greatest creed of healthcare, the Hippocratic Oath, provided the framework for practicing our profession. Without either a framework or a direction, we flounder. Healthcare, rather than being a true profession, becomes the utility of the state to maintain function and order, rather than the pursuit of a higher good. We have lost our soul in medicine. I am leaving medicine because my profession no longer is a profession of Hippocratic orientation. I have no interest in being a duped servant of an evil state.