Complaint Day

Years ago, when the San Jose, California area had GM and Ford automobile assembly plants, I would see patients who told me that they hated their auto assembly jobs.  They said  that they hated the work and the systems in which they were working. They hated having to spend their lives installing the right front tire on every vehicle that came down the assembly line. They hated their dehumanization (my interpretation, not their word),  inability to make decisions and bring about change. They hated the imposed  industrial metrics which governed their work and lives.

Now, I receive complaints about medical care from a variety of  people throughout the country.  Their themes reflect their perceptions that the people who provide their medical care have issues similar to the auto workers I described.  I interpreted their experiences differently from the way they interpreted them.  The common theme for them was failure to receive care, interest, attention and proper treatment.  My interpretation focuses on two issues, business arrangements and professionalism which I believe underlie many of these complaints.

When a physician sends a patient off without taking an adequate history, without performing an appropriate physical examination, and without offering an evidence-based diagnosis and treatment plan, that physician is unprofessional and has not fulfilled his or her responsibility to the profession, to the people who have established a governmental licensing authority providing a franchise for that doctor to provide professional care, but most of all, to the patient who, with a mixture of anxiety and trust, has come to that physician for professional intelligence, wisdom, insight and understanding.  Patients are defenseless  against the professional's "brush off," lack of concern, lack of skill and lack of interest or distractedness.  Unfortunately, for those physicians - and most of all for their patients -  what should be an intellectually challenging and engaging work has become a 9-5 job.

Factors shaping the health care profession which affect providers, patients and payers, include  the "businessification" of medical care.  What was once a single-practitioner or small group practice, marked by strong identification with the quantity and quality of care provided to patients and pride in shared practice skills, now will often be a large multi-location multi-specialty group, operated or controlled by non-physicians,  with standards for practice essentially set by highly-paid non-medical administrators and business personnel enforce those standards through highly paid and carefully placed (and controlled) medical administrators (i.e., directors and department chairpersons) .  The financial bottom line offsets the real quality of care (not the advertised quality of care).  The choice of ancillary staff, productivity per doctor, cost per square foot of space, equipment, range of services, and scheduling have been removed from physicians' decision-making. Marketing-oriented questionnaires substitute as measurements of quality. Return on investment, rather than life-changing high-quality of care, is the measure of effectiveness and efficiency. Your health care has moved into the industrial metrics and control era.  It's not the government's fault. It's our fault.

Quality of care can be measured, but why should anyone bother? If an insurer has a new group of patients every year, why invest in care which may initially cost more, but save their competitors money when, in later years, they inherit the patients on the basis of their "low" insurance premium bid.  If the physician's pay and recognition depends more on the amount of revenue generated than the actual quality of care he or she has provided to non-high-profile patients, the physicians become ground down,  their professionalism suffers and they have neither time nor interest in dealing with your complex medical issues in a 10 minute time slot.

We know what happened to GM and Ford and previous GM and to the sad owners of their industrial-metric produced cars.  What is going to happen to you and your family under the industrial approach to health care?

Failed Industries: the Opportunity Costs of Bail-Outs

We've heard a lot about saving jobs by providing financial CPR to the Big 3 auto manufacturers recently. I won't discuss American auto industries' management incompetence or even whether consumers' car purchases represent a national investment or merely a gigantic wasteful prepaid expense. But I do want to ask: what are the opportunity costs of sinking money into an old-technology industry which cannot manage itself?

I spent this past weekend in San Francisco at the 50th Annual meeting of the American Society of Hematology (ASH), immersed in basic science, current life-science research and development, and the ultimate application of exquisite scientific discipline and research to patient care. The atmosphere was vibrant; the weekend extraordinary. When I joined ASH in 1978 (I am now "emeritus"), it was an organization of about 1400 physicians, basic scientists and researchers. Now, it has a membership of 16,000 with more than 20,000 persons from around the world attending the annual meeting. The discoveries described at these meeting, and the cross-fertilization as experienced scientific researchers, trainees, physicians and other persons concerned with hematology learned from each other and interacted, will revolutionize medical care in coming decades. Hematology has moved from the "black box" era (when we gave drugs without really knowing how they worked), to understanding many of the basic mechanisms of cellular function and disease not just at the chromosomal or genetic level, but at the molecular level.

The money we use to prop up our moribund American auto industry's "yesterday's technology", will not be available to fund scientific medical research which will pay significant dividends, not only through prolongation of life, health and alleviation of suffering, but through financial return on investment. Those missing dollars will not help to keep America scientifically pre-eminent. Failure to fund life sciences research will inhibit new systems of effective patient care.

America should consider its opportunity costs when it commits resources to bail out failed industries. Let's support scientific research and medical technologies which give us a return on our investment, provide significant high-paying employment and opportunity, and harness the brain-power of our country, rather than boost horsepower under the hood.

Who Is Responsible for Patient Health Decisions?

Kevin Sack's New York Times article, p.A14, June 10, 2008, portrays and seems to endorse a philosophy of U.S. medical care which appropriately died in the late 1950s. Under that patriarchal philosophy, physicians assumed full responsibility for patients, including all treatment and connected lifestyle decisions. It was the "don't worry your little head about your diagnosis, disease or treatment, I'll take care of everything since I'm the doctor-expert on your your illness, your treatment and what's best for you" school of medical practice.

According to Sack, The Archives of Internal Medicine Article, authored by Dr. Thomas Sequest of Harvard Medical School, made the point that physicians "do not discriminate in the way they counsel patients." Sequest was quoted as saying "Our one-size-fits-all approach may leave minority patients with needs that aren't being met." Sack cited standardized dietary advice as not realistic for the cultures being advised, including black or Latino patients, apparently under the uncritical acceptance of Sequest's inference that doctors should be conversant with the dietary, lifestyle and health habits of every culture, subculture, ethnic group, religious denomination, race and individual in America.

By the mid-1960s, physicians had changed their traditional patriarchal behavior to recognize not only that patients needed to be told about their conditions, treatments available, and prognosis, but that patients had a right to make decisions about their care which could be inconsistent with advice given by physicians, nurses or health care system. Any adequate review of modern literature on medical ethics, including legal texts reviewing U.S. Supreme Court cases, recognizes the importance of patient autonomy. Patient autonomy, a common issue in biomedical ethics consultations, invokes respect for a patient's understanding of salient facts about an illness, diagnosis, treatment course, alternatives, side effects and downside risks and respect for his or her informed decisions even if those decisions may cause illness and death.

When a patient chooses to eat rice and beans notwithstanding physician advice to eat fruits and vegetables, that does not mean that the physician has not given proper advice. It may mean that the physician lacks time for discussion because he is overscheduled, or that the patient does not have sufficient income, or a safely accessed well-provisioned neighborhood store, to allow the purchase of fruit and vegetables. If a black person chooses foods, practices, activities or medications (or not to take medications), which are not optimal for health, it is the height of condescension to assume that the person did not understand the doctor's recommendation and has made a dumb uninformed choice. And if a Jewish matron (who has been clearly told by her physician about the effect of salt intake on her health)chooses to eat a bagel, salty lox and creamcheese and provokes congestive heart failure, she is expressing her autonomy.

A condescending physician, or one who evokes guilt in patient for failure to follow advice, will find that the that patient will not return.

The physician's job is to apply science to patient communication, care and advice. The patient's responsibility is to listen to and consider that information and advice, and to act consistent with his or her autonomous decision.