America’s health care delivery system is in disarray. Politicians on both sides of the aisle believe that they have the answer. But, fixing this problem does not lend itself to a political solution. Ultimately a meaningful solution is one that only physicians can offer. This is as it should be, but it is not happening. This book is my attempt to recast my journey in medicine as one that I believe has isolated the problem and found a solution. It begins with my observations in medical school, my fledgling attempt to be a good doctor, and ultimately my discovery of the problem and its solution. There is no question but we have the most marvelous and sophisticated health care system in the world, but our patient outcomes leave much to be desired when compared with those of other industrialized countries. Our rising health care expenditures, the asymmetry in the delivery of our health care system, and the calcified ideology of both the political right and left are sources of concern. I have attempted to share my insight with our citizenry in hopes that a concerted voice will be forthcoming demanding those changes from the health care industry that it and the government have been unable to accomplish. Without these changes a political solution will win out and mediocrity will replace quality. Time is short. Both political parties are sparring in an effort to imprint their ideology on a roadmap ostensibly designed to fix the problem, but one that does not come close to dealing with the salient issue. The strength inherent in a unified voice of the people will galvanize the industry and my hope is that this book will serve as a stimulus.
Reinvent the Heal
A Philosophy for The Reform of Medical PracticeBy James T. HansenAuthorHouse
Copyright © 2012 James T. Hansen, M.D.
All right reserved.ISBN: 978-1-4772-1148-9Chapter One
A Portrait Of Catastrophe: Where We Are And How We Got Here
At times meaning simply precipitates out of nothingness and puts a lasting border around the moment. The bus was heading in the opposite direction but anyone could see the malevolent invitation that it conveyed. The brightly colored advertisement clung tenaciously to the side of the bus, carefully conveying a message designed to hit its mark, boldly announcing a new medical test, which would both ensure health and detect illness early in its course. But, a body CT scan? A body CT scan, is a very sophisticated version of snake oil. CT scans have been a very important advancement in the specialty of radiology. They have allowed physicians to use x-rays and penetrate the various layers of tissue to more carefully define an abnormality suspected. Most CT radiography is applied to a specific area, an area of the body identified by other less invasive tests likely to yield additional information regarding a suspected malady. But a body CT scan represents a shotgun approach, more likely to identify innocent variations that are normal and simply part of the individuality so characteristic of human beings. So here was this bus, of all things a vehicle designed to move people from one place to another, insuring safety and security, now conveying a message suggesting that a better way to safety and security is a questionable, but sophisticated test to insure our health.
That an impersonal image, albeit one generated by high technology, could be the answer to our health care issues, is reminiscent of the hucksters who prowled frontier America. It is no different than the useless potions, often laced with alcohol or cocaine, sold to frontier Americans with the promise of improved health. This sinister, malevolent, and subliminal message is a fitting example of how modern medicine has shaken loose from the shackles of its predecessor, now offering another step towards Nirvana by way of questionable technology. In this case the lull of compliancy with a negative test or the rush to even more questionable technology with an "abnormal" test is much the same as the euphoria produced by the elixirs.
Why should that be so bothersome? Buses can and do advertise just about everything from toothpaste to safe sex. People do pay attention to these advertisements or they wouldn't be there in the first place. There doesn't appear to be any message that is too sacrosanct, certainly not personal health care issues, to find itself an advertisement on a billboard, a bus, or a subway-American capitalism at work. Many of the ads raise ethical or moral issues with respect to the message as well as the messenger. In this case where is the science to validate the claims? Has this methodology been carefully studied by medical scientists and put to the test of clinical trials? What is the motivation of the physicians who find the ad useful? The answers, of course, are no, no and the beneficiaries are the few unscrupulous radiologists, cardiologists, cardiac surgeons and the anesthesiologists who stand to prosper.
Body scans often include a "calcium count," calculated in the chest cavity, ostensibly representing coronary atherosclerosis, that is narrowing of these vessels that leads to heart attacks. If the calcium count is "abnormal" it will certainly be an invitation for more studies, including a coronary angiogram, and perhaps cardiac surgery. The question is whether patients with coronary artery disease who have the test and what follows will have better outcomes than those with the same disease without the test. It doesn't seem to make much difference to many patients who have been sold on the value of high technology and happy to get the latest technological test. Of course, we don't have the answer to the question regarding outcomes, but never mind, this scan is marketed to everyone, not necessarily those with symptoms, but to all of us. It is given the same billing as a Pap smear, a mammogram, or a cholesterol test. To join that pantheon of scientifically proven tests it would need to be validated by research, but it is not. It is a case where cleaver doctors reformulate computerized tomography to search for unproven surrogates of coronary artery disease. Since we human beings are imperfect creatures, you can bet your bottom dollar that some abnormality will be found. Mind you, all of this occurs with an asymptomatic individual who may live a long and useful life without this test or any specific intervention in spite of some degree of coronary atherosclerosis. The ad leads us to believe that this is an essential test for continued health. In fact, it is simply a strategy to substitute questionable technology for careful doctoring.
• Why do we put up with this?
• Why do we let these entrepreneurs rent free space in our brains?
• What does this have to do with rising health care costs and the promise of financial ruin for our country?
• What does all of that have to do with our health and lives?
This is the path from snake oil to misguided high technology. It is the story of greed, the way that some unprincipled physicians have continued to have their way, now with high technology, often untested, markening "elixirs of health." Instead of offering potions to unsuspecting patients, these modern day charlatans now offer unnecessary or untested procedures as a way to enhance their revenue.
Here are some facts. They are a bit dry, but important if we are to understand the problem. So, bear with me. The Office of the Actuary of the Health Care Financing Administration (HCFA) has projected that health care expenditures account for 16% of the gross domestic product and cost over 2 trillion dollars a year, with per person health spending over $7,000, and rising at a rate greater than the inflation rate. This is cause for concern. In thirty years, at this rate of increase, national health expenditures will increase to 4 trillion dollars, the cost to each American family will be $82,000 dollars, and as a society we will be unable to continue as the leader of the free world, unable to take care of our own citizens, as we fragment and head into oblivion.
At the same time physician incomes have become stagnant or have actually decreased during the past several years. According to the Center for Studying System Change (HSC), Physician incomes, after adjusting for inflation, have dropped 7% across the board during the last 10 years. This is in contradistinction to other professionals whose incomes have risen 7% during this time frame. So it looks like we are being better stewards as physicians. But wait, the devil is in the details. Physician incomes have remained at 20% of health care expenditures during the last decade. Since health care expenditures have risen to around 3 trillion dollars, 20% of three trillion is not chicken feed. The other 80% of health care expenditures, which include outpatient and in-patient hospital costs and pharmaceutical costs and which help facilitate both good and bad high technology, are also a direct result of physician ordering practices. Given that the number of procedures and sophisticated tests have increased during this time period, it becomes clearer how some unethical doctors have managed to maintain a semblance of their incomes. These unprincipled creatures have invaded high technology, have kidnapped it for their own personal use,...
