The Frenetic Physician

9.73 minutes.

According to a recent study, that's how long the average doctor spends with you in the examining room before passing judgment with a prognosis and sending you home with a treatment program. Which is usually a prescription to treat the presenting symptoms, not necessarily the underlying cause. And because so little time and effort is taken to effectively diagnose the underlying source of the problem, very often the recommended treatment doesn’t actually work to relieve the symptoms. Consequently, many patients continue to suffer in silence, confused and frustrated by the doctor’s apparent inability to solve the problem.

Sometimes, after an insufferable escalation of the symptoms, an increasingly uncomfortable and irritated patient might summon the courage and return to the doctor’s office to question the validity of the initial diagnosis and the effectiveness of his treatment program. Whereupon the same doctor might perform another only slightly less perfunctory examination, normally sending the patient home with a new prescription—once again focused primarily on treating the presenting symptoms, not necessarily the underlying cause of the malady.

If and when the doctor finally admits that he doesn’t actually know what is causing his patient to be sick, the standard protocol is to order more tests and/or refer the patient to a specialist. This specialist, whose judgment is normally already biased by the patient history and initial diagnosis passed on by the presenting physician, barely gives the patient more time the second time around, typically averaging fifteen minutes or less. And so the cycle renews, with the patient’s suffering continuing until somebody finally correctly diagnoses the real cause of the problem—or the patient gives up and learns to live with his symptoms indefinitely.

Sound familiar? Each year, an estimated sixty million patients go home with a misdiagnosis of their health condition by their attending physician and needlessly suffer untold pain and anxiety. Hospital autopsies regularly reveal that at least twenty percent of serious patient illnesses are misdiagnosed. One study estimates more than 250,000 persons die every year from one form or another of doctor error, making it the third-leading cause of death in the United States after heart disease and cancer. Yet many of us still ascribe God-like qualities to our physicians—predominantly because we believe them to be the unique custodians of essential medical facts, and because we depend on them for our very lives and everyday health.

To be sure, most doctors are indeed smart—they couldn’t meet the high entrance requirements at medical school, nor pass the many complex and challenging tests along the way to receiving their diploma, if they weren’t. But the fact of the matter is that doctors are very human, and just as flawed as the rest of us when it comes to the practice of their profession. Perhaps even more so―not least because many of them have come to believe in their own infallibility.

Consider for a moment how doctors are trained. According to Dr. Jerome Groopman, who teaches Medicine at Harvard University and who recently penned the New York Times bestseller How Doctors Think, during the first two years of medical training, students are taught to learn basic human anatomy and physiology. In the last two years of medical school, they learn about known human diseases and the normal symptoms that are associated with these diseases. There are one or two courses that show how to gather a patient history and diagnose illnesses based on a method of correlating observed symptoms with known diseases—a technique Dr. Groopman calls ‘heuristics’. But the primary method for learning how to diagnose illnesses occurs after the medical students graduate, when they follow more experienced doctors on hospital rounds during their residency and watch and listen to how these other doctors perform their duties. In other words, doctors at most medical schools and hospitals are learning and being reinforced in the same manner of diagnostic problem solving that has been passed down for centuries (literally since the time of Hippocrates), which is to quickly correlate symptoms expressed during a normally short and cursory examination with a vast body of information about associated diseases—from the top of their head!

Maybe doctors really are God. At least they’d better be, using this technique. Once in a while of course, they get it right. But many of you probably know from your own experience and from the experience of your friends and loved ones, how often they get it wrong. So who can you depend on to look after your best interests, and provide you with the highest quality medical care? Your doctor is largely driven by the immediate demands of his overflowing patient waiting room, which in turn is driven by HMO fee structures that encourage too-short patient consultations, which likewise are driven by short-term corporate profit expectations—the same corporate interests that seem to have beholden and besmirched the motivations of your local Congress member. So who’s left? From top to bottom, it seems everyone in the ‘value chain’ who is supposed to be carefully managing your health care and providing oversight, has lost sight of the ultimate consumer.

It looks like the only one left is you. Like the old adage says: if you want a job done right, you’ve got to do it yourself. But we’re not talking about remodeling your family room or changing the oil in your car; we’re talking about optimizing your personal health, which means trying to fix a system of pipes and conductors that is infinitely more complex than that of your home or automobile. How could you possibly expect to take over the job of your family physician? We’re not advocating, of course, that you fire your doctor and begin self-diagnosing and self-medicating yourself whenever you have an illness. But the fact of the matter is that you are the person who is most motivated to solve your personal health problem - as well as the person who is the custodian of the most critical information of all, which is the history of your own illness and the associated events and experiences that may have caused it. Perhaps, if you really want to ensure your best interests are being taken care of, you need to take a more active role in the management of your health—and the in management of your personal physician.

[Next week: How to optimize the quality of your doctor visit with a little homework.]

The Business of Medicine

Most patients probably think of their personal physician in purely altruistic terms — as someone whose primary motivation is the provision of the highest quality care, where the only consideration is what is in the best interests of their patient. For many doctors, this is undoubtedly the case — after all, every one is required to take a Hippocratic oath that promises much the same thing (although I find it intriguing and somewhat disturbing that it’s always couched in negative terms, i.e. to "do no harm" to their patient).

However, the fact of the matter is that the average doctor graduates from medical school with over $150,000 in accumulated debt, and starts work as a lowly paid Intern for only $40,000 per year. It doesn't take much to imagine that this unbalanced situation weighs heavily on the minds of most doctors, and that they soon begin to contemplate how they can improve their predicament.

For many doctors, the answer is to enter some kind of specialty such as surgery or anesthesiology, where they can normally earn far more than that of a lowly family doctor. (According to the OECD, the United States has one of the lowest ratios of General Practitioners to Specialists amongst industrialized nations.) In other cases, as outlined in my last post, doctors have learned how to take advantage of higher fees to conduct more complicated procedures or tests, or to collaborate with drug companies in holding clinical trials and speaking engagements, to pad their wages.

Unfortunately, the direct payers of medical services in the United States, the private health insurers and government-run Medicare and Medicaid, have structured their payment plans in such a way that doctors are paid the least amount to actually see and consult with patients (in the initial examination and consultation), and the highest fees to conduct impersonal and invasive tests and procedures. Furthermore, these fees are structured to pay relatively less for longer patient consultations than for short ones (for instance, the fee for a thirty minute consultation is less than the price of two fifteen minute ones).

As a result, doctors have learned that it doesn't pay (as well) to conduct a careful examination and thorough consultation as it does to perform a quick and perfunctory examination involving little discourse with their patient, then send them out the door with a shorthand prescription to treat their nominal symptoms, or book a repeat visit for more tests and procedures.

Make no mistake, doctors are in the business of providing health care, and most of them view it first and foremost as a business. And you’ve got to give it them: together with the pharmaceutical companies and health insurance companies (who are amongst the most profitable industries in America), they’ve done a pretty good job of it. As an overall profession, they represent the highest wage earners in America, and according to a recent survey by Forbes Magazine, thirteen physician specialties rank amongst the fifteen highest paying jobs — outranking even Chief Executives! For over a hundred years, the professional organization that represents physicians in the United States, the American Medical Association, has actively controlled attendance at medical schools in order to constrain the supply of doctors and thereby keep their salaries artificially high.

It's no accident doctors usually live in the largest homes in the most exclusive areas, with the most expensive foreign automobiles parked in the driveway. Some people might argue that these health care professionals deserve their perks, given the critical and complex job they perform each and every day keeping us healthy and alive. And this would be true—if in fact American physicians did a superior job keeping us healthy and alive. But as I pointed out in my last blog, America has a sorry record of providing quality health care, at least when compared with other developed countries.

So the next time your doctor tries to rush you out the door with a quick prescription to treat your symptoms after poking and prodding you for a few minutes, barely giving you a chance to explain your problem or the special circumstances surrounding your condition, don't automatically assume your doctor knows what's best for you. Sometimes — perhaps too often — your doctor is acting (consciously or unconsciously) in their best interests, not yours.

[Next week: What you can do to take more control over the doctor-patient relationship.]

The Healthcare Tail that Wags the Dog

A review of the national accounts of thirty industrialized nations reveals that the United States has the highest cost of patient care by far when compared to any other country in the world. As a percentage of Gross National Product, health care in the U.S. consumes over 16% of total productive output, representing almost $6000 per year for every man, woman, and child in America. This is almost double the average of any other country—and it is rising at more than twice the rate of inflation.

This wouldn't be so bad if the United States actually got its money's worth. Unfortunately, the most recent year's annual report from the Organisation for Economic Co-operation and Development (OECD Health Data 2009) shows once again that the U.S. ranks at or near the bottom on a range of key health indicators, from life expectancy to infant mortality, adult obesity, number of deaths from natural causes, rate of medical errors, and number of doctors and nurses per capita. When it comes to the provision of effective health care, it seems our free market system has fallen down in its ability to move goods and services from provider to consumer in the most efficient and cost-effective manner.

Why does this disparity persist? Are doctors better paid in the United States? Do we have more sophisticated equipment, or larger and better hospitals? While it’s true that our privately funded health care system allows for two tiers of medical care, represented by the typical metropolitan (public) hospital serving the general community, as well as the more exclusive (private) institutions such as the Mayo Clinic, these more expensive facilities represent a minority of total doctor billing. And although American doctors do enjoy higher incomes than in most other countries, one recent study estimates this contributes only 6% to the differential cost of health care in the United States.

So what accounts for the large discrepancy? A portion of it can be explained by the far higher incidence of medical malpractice lawsuits that are brought against doctors and hospitals in the United States—due in part to the unique form of lawyer compensation in the U.S. , where lawyers are normally paid as a percentage of the plaintiff award rather than a flat per diem fee for actual days worked on the case. Americans sue 50% more often for medical malpractice than in Britain or Australia—and a whopping 350% more than in Canada. But a lower portion of these lawsuits are settled in favor of the plaintiff, and the average payout is actually slightly less in the U.S. than in these other countries. The net effect is that malpractice litigation represents less than one percent of total health care spending in the U.S.

All of this accounts for less than a fifth of the differential cost of medical service in the United States; so where's the remainder? The main reason health care costs are so high in the U.S. is because HMO and Medicare rates are structured to pay much higher fees to doctors for complex medical procedures and tests, and because doctors prescribe so much more (relatively expensive) medication as standard practice when compared with anywhere else in the world. Fully eighty-five percent of every physician visit nowadays involves some sort of diagnostic test, sixty-four percent involves the prescription of one or more medications, and almost nine percent involve some sort of surgical procedure that is either ordered or performed. Unfortunately, many of these tests and expensive procedures are unnecessary—one Congressional investigation found that as many as 64% of such procedures have questionable merit.

America's drug habit accounts for much of the additional deficit. The United States has the largest and wealthiest pharmaceutical marketplace, representing almost half the globe’s spending on drugs, with per capita expenditures nearly double the rest of the world. The global pharmaceutical industry is now a six hundred billion dollar business, with six of the top 10 largest companies headquartered in the U.S.—and every year these drug companies top the Fortune 500 rankings for industry profitability by a large margin.

These American drug companies have found increasingly creative ways to inveigle their way into the minds and pocketbooks of doctors and patients. Physicians are constantly bombarded by carefully crafted marketing pitches by the pharmaceutical companies to prescribe their latest and greatest drugs, which are assiduously supported by extensive research studies. Some doctors are offered (and accept) generous grants from these companies to conduct new clinical trials of their products. In case that isn’t enough, drug companies regularly invite targeted doctors to lavish and expensive all-expense-paid dinners, conferences, and vacations at the most exclusive venues, where they can hear or speak on the latest findings of the industry. And just to be sure the doctors are issuing prescriptions in sufficient quantities for their products, these companies hire specialized data mining firms to collect information from drugstores concerning which drugs each doctor in their designated sales regions is prescribing.

Even though conflict-of-interest guidelines issued by the American Medical Association (AMA) and the Pharmaceutical Manufacturers Association (PhRMA) in 2002 were designed to curtail many of these activities, an on-going investigation of hidden income arrangements between pharmaceutical companies and doctors by Senator Charles E. Grassley, former director of the National Institute of Mental Health, revealed a variety of influential and high-profile academic and clinical researchers have received millions in unreported income from drugmakers. Just recently, Dr. Frederick K. Goodwin, the famous psychiatrist and host of the popular NPR radio program The Infinite Mind, whom many listeners have relied upon to provide objective and informed advice for treating their children’s mental health issues, and who has long been promoting the safety and necessity of treating various mental disorders with psychotropic drugs, was found to have accepted $1.3 million dollars in promotional fees from nine of the largest pharmaceutical companies—income which he had failed to report under previous required disclosure agreements.

Doctors have learned which side their bread is buttered on, and unfortunately it’s not where many of us would like to see it: in longer and more consultative patient-visits. Our American system of free enterprise has created a powerful structure and system of incentives whereby doctors are consciously and unconsciously encouraged to spend the minimum amount of time with each patient, and the maximum amount of time ordering tests, performing surgery, and prescribing medication. The result is a disappointingly short initial physician consultation, usually ending with a quick shove out the door with a prescription, and/or an appointment to see a specialist to conduct more expensive and invasive procedures. Sadly, this practice is not only causing rising trauma to our national accounts, it is increasingly harming the individual patient.

[Next up: The implications for the doctor-patient relationship]

State of the Union

President Obama's recent capitulation on health care reform puts him in good company. For the better part of a century, illustrious heads of state from Theodore Roosevelt through Harry Truman, Lyndon Johnson, and Bill Clinton have tried and failed to create a comprehensive national system of health insurance. Many of these Presidents had party-aligned Congressional majorities, and still couldn't make it stick.

What is so unique about the United States that makes it the only industrialized nation in the free world (other than Switzerland, which has a blended system) to hang on to its privatized health insurance system? Some of it rests on Americans' - or at least their representatives' - pride and insistence on clinging to their free enterprise traditions, which, at least until the great Wall Street induced crash of '08, served them pretty well.

But surely there are other forces at work to have created such a persistent outlier, for so long. Could it be that those who have had the power to enact change, the legislators in the two houses of Congress, have had competing interests from those of the public (and their nominally-elected President)? Perhaps it's no accident that two of the most profitable industries in America - the pharmaceutical and health insurance industries, plus the organization that represents the highest paid group of individual earners in the United States - doctors - also just happen to be among the three largest spenders of lobby funds directed toward elected officials.

Cynical? Tell that to Billy Tauzin, who as the previous chairman of the House committee that regulates the pharmaceutical industry, passionately (and successfully) fought to deny passage of a bill that would have permitted the federal government to negotiate lower drug prices for Medicaid recipients. As a consequence, prices paid by insurers, and eventually the taxpayer, are considerably higher under federal-state Medicaid programs serving the poor—which also generate hundreds of millions of additional dollars each year for the large drug companies. Mr. Tauzin, who at the time argued that his actions were motivated purely by his fervent belief that the bill did not serve the public interest, was rewarded for his efforts by a grateful pharmaceutical industry shortly after he retired his seat in Congress with the chairmanship of their largest lobby group, which pays him an annual salary in excess of two million dollars per year!

Surely Mr. Tauzin was the exception to the rule? We should be so lucky. Lobbyists representing private insurance companies, hospitals, and the pharmaceutical industry spent over 380 million dollars in the last few months leading up to the combined Congressional vote on the new health care bill. Much of that money went directly into the pockets of those in the most influential positions: $1.5 million went to the Chairman of the Senate committee drafting the law, and other members of the committee received hundreds of thousands of dollars each. While it's true that this money was paid into the campaign accounts of these legislators, not directly into their personal accounts, how do you think these elected officials get re-elected so often? No wonder the House/Senate compromise bills were watered down so much - and eventually had the 'public option' pulled altogether. (What I still don't understand is why President Obama didn't honor his commitment to have these deliberations televised live, so that we could witness the behind-the-scenes scheming straight-up. Perhaps if he had, the legislators would have been less inclined to sell out to corporate interests. We’re still waiting for an explanation on that one, Mr. President.)

Unfortunately, the recent Supreme Court ruling abolishing limits on campaign contributions from public companies will only escalate this malfeasance. In fact, it's sometimes hard to imagine the United States as a legitimate democracy, where the vote of the citizen ultimately rules the land. Those individual votes may still determine who gets elected , but they sure don’t have much chance of influencing meaningful 'change' on a legislative level - apparently narrow corporate interests continue to rule the day there.

So for now, America is stuck in the mud, with little ability to adapt and move forward with the times. Let's hope this disease doesn't extend to some of the other critical issues of the day, like energy, jobs, and environmental policy; otherwise, the country risks becoming increasingly marginalized, an economic and demographic backwater, (ironically) overtaken by its more nimble competitors like Communist China.

God Bless America - they're gonna need all the help they can get.


[Next up: The implications for the future of the U.S. healthcare system, and for the doctor-patient relationship.]