Elisabeth Rosenthal, a reporter with the New York Times, is doing American doctors a favor. Her series, Paying Till it Hurts, is forcing us to face our role in the US healthcare problem. Thatâ€™s a good thing, because, as it goes in the practice of Medicine, the first step to achieving good outcomes is identifying the problems.
Ms. Rosenthalâ€™s most recent piece, Patientsâ€™ Costs Skyrocket; Specialistsâ€™ Incomes Soar, published today on the front page of the Sunday Times, aimed its scalpel on the lucrative specialty of Dermatology. But one mustn’t focus too much on the skin, there are ample areas of healthcare in need of debridement.
It’s always best to start with matters of agreement:
The United States of America has a problem with healthcare. Americans pay too much and get too little. Our difficulty in fixing the healthcare mess sheds light on another recent cultural phenomenon: as a people, Americans seem to have lost their gumption. Rather than confront the obvious and embrace common sense, we line up like sheeples and accept faux solutions like the Affordable Care Act. In that way, there is blame to share.
For me, this complacency is depressing. For such a competitive lot, the American people, including, yes, doctors, should be ashamed when we look at how our outcomes and costs compare on a worldwide scale.
How do doctors fit into the healthcare equation? We can’t fix everything; but we can help–or at least we can stop making it worse.
Iâ€™ve long staked out the position that doctors are not special. We are human, and therefore, human nature governs our behavior. Iâ€™m sticking to that claim. And this is why I think Ms Rosenthal is doing us a favor.
Her investigative journalism shines light on sores that need exposure. Some of the good guys in Medicine, take offense to such exposure. One of those playing by the rules, my friend and colleague, Dr. Wes Fisher, defends the role of the specialist. He emphasizes problems with the system. And he is right, politicians, with their selfishness, leadership failures and dependence on policy wonks, play a major role in the US healthcare malady. Again, there is blame to share.
But Iâ€™m not a politician or policy wonk. Iâ€™m a doctor. I canâ€™t change the fact that the AF ablation I do in Louisville KY costs $100,000 while the same procedure in Hamburg Germany costs $10,000. These are big policy issues that Iâ€™ve written about before.
Yet, as a doctor, working at the contact point of healthcareâ€”where patient meets caregiver–I have the opportunity, the responsibility, to make US healthcare more effective and efficient. Here are four thoughts that come to mind:
Facing our problems — especially paternalism:
Somehow doctors must find the strength and courage to confront our human nature. Rather than ignore, deflect or defend problems that journalists like Ms. Rosenthal expose, we should look inward as a profession.
What disturbed me most about today’s piece was that patients did not receive patient-centered care. Doctors hold a powerful position in the patient-doctor relationship; such power demands our respect. The patients Ms. Rosenthal described felt powerless. They couldnâ€™t question the doctor because they were told they needed a procedure. Case closed. That sort of narrative makes me cringe. Whenever I recommend an AF ablation a bell goes off in my head telling me that I could be construed as a roofer telling a person they need a new roof. I hope all my patients understand that they don’t need anything I have to offer. They may benefit, yes, surely, but they have a real choice.
In 2014, any report of paternalistic decision-making deserves our attention. As Dr. Dan Matlock and I wrote recently in JAMA-IM, â€œ[doctors] are consultants in the service of people. We are the experts in medical science and patients are the experts in what is important to them. A caring clinician recognizes that patients are free and equal.”
Paying heed to science:
Doctors must become better stewards of science. That means actually knowing the evidence for what we recommend. Ms. Rosenthal points out that the use of Mohs surgery has â€œskyrocketedâ€ in the US despite little evidence of its value. Though algorithms canâ€™t replace clinical judgement, evidence–not eminence–should guide our recommendations. A good example in my field of cardiology surrounds the new anticoagulant drugs. The hype is that these expensive drugs are â€˜superiorâ€™ to warfarin. But if we carefully look at the scienceâ€”rather than believing the party line–we would find a different story. Namely, that the percent same result (PSRâ€”if you will) for the two classes of drugs approaches 99%. If two approaches to the same problem are 99% the same, why would we recommend the expensive one?
No doubt, there will be headwinds to this clear-eyed view of practice. When the big machine roars, say about mammograms, prostate screening, statins and the like, doctors will have to stay strong.
Inappropriate use must go:
The saying, “with great power comes great responsibility” fits the doctor’s role in healthcare. Ms. Rosenthal writes that a spokesman for the American Academy of Dermatology agreed that Mohs surgery is sometimes used inappropriately, but he then defended his colleagues, and blamed health care reformers, saying they are unfairly targeting dermatologists. To be sure, many dermatologists are doing the right thing, but there is no way to defend any inappropriate use of medical procedures. A few years ago, Cardiology got itself into the same problem with inappropriate use of lucrative procedures. And our initial complacency in dealing with the issue contributed to the giant swing of the pendulum towards the current climate of excessive regulation.
Doctors would do well to consider the image we cast. It’s not too late. I believe the public still respects our commitment and professionalism. I would even bet there are many who donâ€™t begrudge orthopedic surgeons for the money they make. Heck, knee and hip replacement promote mobility–a great gift indeed. And this too: the public inherently understands that at some point every person is going to need a doctor on that wall. It may be a surgeon, an oncologist, a radiologist, a hospice doctor, or yes, a really smart primary care doctor. People are willing to pay for our expertise and compassion. They aren’t ready to make us commodities.
But come on alreadyâ€¦can we not employ some Hoosier common sense in the way we conduct “business?”