"Fix It!" - Amen

JAMA

JAMA

White Coat, Black Hat; Adventures on the Dark Side of Medicine

As we get deeper into election year lunacy, three items this week have reminded me that not only is all not well in health care, but also that people outside, and especially inside, of medicine are not paying attention. Or thinking rationally. These items include an exceptionally lucid editorial “Fix It!" by James Webster, MD, MS, in the Dec. 21, 2011 issue of ; a review in the Dec. 28, 2011 issue of by Joseph Fins, MD, of by Carl Elliott, MD, Ph.D.; and a flurry of emails making the rounds warning

— a la Chicken Little —

of dire consequences of the recent health care law.

I am not going to get traditionally political about the straits medicine is in or the canted suggestions for incremental change, because it is not helpful and we have plenty of wackos of all persuasions avidly trying to fill the bill: to wit, the emails.

But we do need to repeat and be clear about what is going on in medicine; the staggering cost of health in the U.S. is in the process of bankrupting the country to a degree that Wall Street financiers can only dream about and the responsibility for causing it and for allaying it belongs largely to American doctors. That's right, not insurance companies, not pharmaceutical companies, not hospital companies, not tort lawyers and not Congress — although the members are individually and collectively a feckless bunch who have made it mighty easy for doctors to rationalize away our ethical responsibilities.

No, it is we doctors who have fed at the trough of Big Pharma and insurance and government programs. It is we doctors who have leaned heavily on rationalization to pump fee-for-service supposedly in defense of legal threats, "keeping our patients happy," paying down debt, plumping our lifestyles, "trying to keep up with technology" and offering "the best health care in the world."

Our professional lives are vastly more complicated than even a generation ago. But we ignore, or deny, in the face of hard evidence, that we are influenced by Big Pharma's spending on us, that we are able to stay abreast of evidence-based best practices, and that we don't do more when less will do just fine, just because we can. Our sometime arrogance and sense of entitlement are "not our best look," as a teacher euphemistically once told a class.

And there are corollary, and I think wrong-headed, biases in medicine that say better doctors order more and do more. That doctors who don't understand or care about the business structure of medicine are somehow better than those who knowledgeably manage the process to a more efficient patient care standard. Or allowing yourself to think being a "thought leader" — read "front man/woman" — for Big Pharma is a feather in your professional cap. And on and on.

Let's be clear again; doctors in America have been bogged down in a variety of conflicts of interest. These conflicts, representative of issues in the larger society around us to be sure, have been major factors in the health care cost spiral. And the way to reduce costs, deliver demonstrably better care and gain back our traditional responsibility for our nations' health is to "...change our ingrained practice habits" as Webster states. We need a sea-change in the current culture of American medicine to revise the skews that are harming and costing us so much in so many ways.

For instance, how much is the high cost of health insurance restricting job growth? Talk to any businessperson why they aren't hiring and high insurance costs always comes up. And we physicians drive that cost up every day. Or as Webster succinctly puts it, "The central determinants of health costs are physician habits, attitudes and behaviors." Ouch!

As I have written many times before, it all starts with a reassessment and revision of the medical training process. I won't beat that dead horse except to say that few practicing doctors would say their training was optimal and complete in view of what they later learned. And I am not talking about the rush of scientific change we also are struggling to keep up with. In spite of many good doctors' hard work, academic medicine as a structure has fallen far short of the job that is needed and could be done.

And let us not delude ourselves; change will not come without pain all around, as many oxen get gored. Look at how much sound and fury is generated when even modest, incremental change is posited, at any level. Just considering a new Flexner-type revision of medical training, dropping fee-for-service in favor of salaried medical groups, instituting a national no-fault malpractice approach, going to a far less bureaucratic-intensive single payer system of some type, etc., seems utopian and daunting to say the least.

Yet, what are we going to do? We simply cannot go on the way we are now, doing and expect anything except severely limited options in a future crisis situation.

I salute Webster and Elliott for raising their voices in print above the din, if even briefly. I often quote Pogo on these matters when he stated long ago, in paraphrase of Admiral Perry at the Battle of Lake Erie, "We have met the enemy and he is us."

Fellow physicians, let us arise and do our real duty: the sensible reorganization of American medicine and the reclamation of our proper and ethical roles to lead for the betterment of all of us. The prosecution rests.