Monday, July 29, 2013

The Age of Superficiality



C.P. Snow wrote with insight about the different worlds, the different cultures of science and the humanities.  As his country, Great Britain, embarked upon a government run health service, this great divide was faced directly by the United Kingdom,  and the Brits continue to struggle with it.

The Brits, of course, have a fundamentally different class structure from ours, and that has directly affected the work force which delivers health care in the U.K.. Physicians as public employees can do well, if they are among the elite specialists, but they do not, in general, make as much money as their American counterparts; nor do they expect to. British high school students go directly into medical school at age 18 and they graduate with a MB, (Bachelors in Medicine.)  The vast majority go into primary care, and function on a level somewhere between our primary care physicians and our new class of practitioners non-physician providers of primary care. 

For the Brits, most doctors are decidedly middle class, and do not expect to be living in the biggest houses, taking luxurious vacations or driving expensive cars. They know this going in, and so  people who seek an upscale life do not go into medicine. Entering the medical profession in England is not a way toward social or economic upward mobility.

This is now occurring among primary care practitioners in the United States. There are new groups of people who have not gone to medical school who are setting up independent practices or joining practices with physicians who have not gone to medical school or done residencies. They can write prescriptions and do in office surgeries, but they have less training than doctors and they know they cannot charge as much as doctors. "Advanced Practice Registered Nurses" (who have gone to nursing school, then another 2 years in a training program) or "Physicians' Assistants" who have typically gone to college and then a 2 year program after college are two of the most numerous types of "practitioners" without doctor of medicine degrees.


The emergence of these different levels of practitioners-- nurse practitioners, certified diabetes educators, physician's assistants, certified nurse midwives-- came from many different places, but surely one interest group which gave rise to all this was the  university/medical school,  seeing another way to make money, minting new diploma holders.  They, of course, loudly proclaimed they were minting these diplomas for the most commendable reasons:  more practitioners were needed to meet an urgent need in the health care system: waiting times for appointments with doctors could be reduced if there were more providers of medical care. Increase the number of bodies in exam rooms available to see patients,  and waiting times would diminish.

And there was another benefit touted by the alternative practitioner model: since these practitioners were paid less, it would cost the system less. 
If less serious, simpler illnesses could be seen by the "barefoot doctor" equivalent, i.e., by people who trained fewer years and could be employed at a lower cost or could enter into private practice, but they would be reimbursed by insurance at  a lower scale, thus lowering overall costs of medical care in this country which spends more on medical care than any other without seeing a commensurate elevated level in the quality of that care.

The problem is, in our wild and wooly medical care "system" nobody has ever really bothered to critically evaluate  that hypothesis: Lower paid practitioners seeing patients will lower the overall cost of medicine.

What Mad Dog has seen from his worm's eye view is no such thing is happening. In fact, in medicine, more practitioners has always meant more referrals and more consultations and the patient who would have seen one doctor for a complaint now sees three.  In fact, lower cost practitioners may order more tests, may order expensive tests which are unnecessary . They often function as traffic cops, seeing large number of patients every day, and doing triage--the patient goes out with a referral to the cardiologist for his chest pain, the endocrinologist for his high blood sugar, the rheumatologist for his joint pain and the orthopedic surgeon for his knee pain.  It is possible these triage people actually add costs by charging for their match making services and then sending patients along to more expensive specialists at a greater rate than the physician who takes care of more problems in his office at the first visit.

In fact, consultants will say, behind closed doors, the number of inappropriate referrals they get from the barefoot doctors is much higher than they ever got before such a class of practitioner existed. Patients arrive with the wrong preliminary tests ordered, having had expensive tests done which did nothing to answer the real questions central to the solution of their cases. 
Alexandre Yersin

All the fuss about Obamacare, about electronic medical records, may well be much to do about nothing.  As long as the primary driving force of medical care remains commerce, the profit motive, everything else is nibbling around the edges. Each new group of practitioners will struggle with the same demands of costs, profits, overhead, cash flow and the needs of the patient will always remain secondary.

When Alexandre Yersin went to Hong Kong in 1898 to investigate the cause of the outbreak of plague, he established his lab in a bamboo hut . He collected samples as he was trained to do by Louis Pasteur. He had to work in a bamboo hut because the British, who ruled Hong Kong, had invited a famous Japanese scientist and his huge retinue and they installed this great man in a hotel and set him up in the largest hospital to do his work. He had the "big name." He was the man all the people in the British hierarchy knew. He was the man people in power listened to.
And he missed the organism cold. 
Yersin, working humbly in his hut,  knew the science, and he got the right bug, made the diagnosis, and he actually raised the first vaccine, the first effective treatment for the Black Death,  which once wiped out half the population of Europe and still lived among rats in the Orient, to emerge every few hundred years to wipe out a few cities.

The implacable thing about medicine is:  There is a correct diagnosis and there are incorrect diagnoses.  

So far, it appears to Mad Dog, the Atul Gawandes and the big names in  the world of health care delivery and health care systems have simply missed the diagnosis, when it comes to what ails the American medical delivery non system we all live with today.
Dr. Gawande, a very well meaning man, a MacArthur fellow and a surgeon at one of the Harvard hospitals, writes in the New Yorker and he is widely read by people outside of the world of medicine. Francis Collins, who heads an institute at the National Institutes of Health, but who has no idea what the practice of medicine in the trenches is all about,  says Gawande is one of his favorite authorities. President Obama reads his articles and he was thrilled by Gawande's article about two hospitals in Texas, one wasteful of resources, one efficient and lean. All we had to do was to follow Dr. Gawande's advice, and the whole health care system  could save billions. 

Sad to say, he, like the Japanese star,  chasing plague in Hong Kong, was chasing the wrong bug.

But how do you get the people who do not know the world of science,  who have the power of the purse, to know which scientist to believe?

Somehow, the United States government managed to figure out which scientists could build an atomic bomb before the Germans could.  After being outclassed by German engineers the entire war, the United States managed to gather a group of Italian, German ex-pats and  American scientists,  and they got it right.  The Japanese built a fighter air plane, the Zero, which was vastly superior to any American fighter. But the Japanese economy was only 1/20 as large as the American economy and the Americans could build 20 times as many airplanes.  America has been able to muddle through to the right answers, or at least to answers which worked well enough. 

But in the case of designing a system for health care delivery, we have not succeeded. It is easier to destroy than to create. We have been great at blowing up cities and destroying but not so good at creating life saving systems.

Part of this failure can be laid at the door of politicians who think of health care,  or resisting changes to health care,  as a vehicle for re election. Part of it can be laid at the door of well meaning people, who just cannot fathom what goes on behind the exam room door. 

The people in positions of power can persist in getting it wrong but saying it's all right.  Until that changes, we are pretty much stuck with the wrong bug.

 




3 comments:

  1. Mad Dog,
    Don't you think that one of the primary reasons we were so successful during WWII, developing the atomic bomb and mass producing planes,tanks etc. was that it was in everyone's best interest to defeat the Japanese and Germans-we were all on the same page. But when it comes to our healthcare system there are quite a few players that are rewarded lucratively and effectively by our "broken" delivery system. Yes, it may seem broken to the patient, but probably not so broken to the hospitals and their administrators. insurance companies, drug companies, medical testing and medical device companies etc. who do very well with the status quo, thank you very much..Makes one think any real and meaningful changes in the healthcare system are a long way off. Instead we have the "supposed" fixes, like the introduction of nurse practitioners and physician assistants into the system. But as you point out, this proposed cost saver will probably turn out to be the opposite- I would bet you're right...
    Maud

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  2. Maud,

    History is one long argument. So, I'm not sure I really understand how we beat the Germans to the bomb when Germany was the center of science and technology.
    As for the health care system, there certainly are vested interests making out like bandits, and I use that phrase advisedly. One thing about America which makes change difficult is that those making money from what is, tend to pump money to elect and keep in office those who will protect them. So there is always a wall of moneyed interests arrayed against the greatest good for the greatest number.

    Mad Dog

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