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Healthcare Reform > Tenured Professor

Physician! Raise Thine Eyes.

This open letter is intended for my fellow physicians and nurses. Every one of us is practicing bad medicine. To make matters worse for us personally, our calling has become a job (more on that in the third segment of this four-part series).

We are all ignoring a critically ill patient who is crying for our help. The patient – named Healthcare – is in worse shape than a cancer patient with liver metastases. The prognosis is bleaker than a someone with glioblastoma multiforme. This dire outlook is based on evidence, not bombast.

(I am happy to provide the citations for every assertion made in my posts. Unlike Washington, you and I are obligated to have proof before we open our mouths, much less act.)

Start with provider shortages. In 1974, 95% of doctors reported they were professionally satisfied: in 2004, the number was 26%. Applications to U.S. medical schools have fallen almost 20% since 1995. More and more doctors are moving out of health care delivery or simply retiring.

Shortages are certainly not limited to physicians. There are well over 500,000 unfilled nursing positions in the USA. Twenty years ago, there were over 14 pharmaceutical companies making childhood vaccines: today there are three. Echo techs are in shorter supply than honest politicians. (You know the definition. An honest politician is one who stays bought.)

While more and more diseases and conditions can be treated, the error rate also escalates. There is at least one drug error every day for every hospitalized patient in the U.S. The medical malpractice system is expected to help patients by compensating those with bad outcomes and by improving quality. It fails at both. Worse, it has converted us from fiduciaries to perps.

As for Healthcare finances, things are approaching a terminal condition. More and more money goes in to Healthcare but less and less is actually available for health care. The cost of the system will soon be literally unsupportable, exceeding 20% of GDP.

The latest treatment applied to our sick Patient, the self-styled Healthcare Reformshould be caring for Patient Healthcare – that’s us – are ignoring their responsibilities. Our eyes are so focused the individual parts of Healthcare, called patients, that we never raise our eyes to see the sick, aggregate single Patient right before us. That Patient needs our help more than any individual human.

Meanwhile, the doctors who are treating Healthcare – Congress – have botched the job. They have ignored and sometimes even inverted our four basic tenets of good medical practice.
1. Recommendations must be based on evidence, and we do not decide – the patient does.
2. Always treat causes, rather than symptoms.
3. Partner with the patient. Corollary: we don’t decide – the patient does.
4. Balance long term benefits against the long-term costs

A doctor practicing good medicine listens to the chief complaint, takes a history, does a physical, and does various objective testing all to develop evidence for an etiologic diagnosis that is the cause of the patient’s complaint(s).

President Obama started the 2009-2010 healthcare discussion giving Patient Healthcare’s chief complaint as bleeding (of dollars). What evidence was developed to confirm the cause(s) of Patient Healthcare’s hemorrhagic diathesis? Without knowing the cause, one cannot cure the patient. Thus, the treatment proffered simply treated an obvious sign of sickness: tens of millions without health insurance. Congress exacerbated rather than reformed the problem of dollar hemorrhage.

Systems thinkers are just like good doctors. They identify root cause and seek to dissolve. In our terms, they identify the etiology and then cure it. Systems thinkers use the phrase “fix that fails or backfires” to describe exactly what happened as a result of passage of the PPAHCA. Rather than staunching the Patient’s bleeding, PPAHCA opened the wound even further causing the Patient to hemorrhage an additional trillion dollars.

Developing a partnership with the patient is the foundation of good medical care. Providers do not make decisions: we advise and patients decide. Providers are not ultimately responsible for the patient’s health: the patient is. Only after the patient decides, do we do anything. Providers and patients must be partners.

Did the doctors for Patient Healthcare – Congress – offer full disclosure and acquire the patient’s consent before implementing treatment (PPAHCA)? Data shows even Congress did not know what was in their treatment when they initiated therapy. Over half of the country did not want the treatment and a larger majority did not understand what was being done to them. That would be grounds for providers of care to humans to lose our licenses.

Possibly the most egregious act of malpractice has been the outcomes analysis, or lack thereof. Positive benefits of health care are not measured at all. No one keeps track of the outcomes that patients want: long life, quality of life, restoration of health when sick, or effects of healthcare on national productivity.

Benefits of health care (the service) and healthcare (the system) are not measured. They are inferred in two ways: as the inverse negative and as regulatory compliance. Thus, surgical success is defined as “not dying for 30 days after operation.” Failure to follow rules and regulation – being “out of compliance” – is considered prima facie evidence of poor quality health care.

Even more egregious is the lack of any long-term thinking. Healthcare does not routinely calculate measures net costs over time such as recurring costs, avoided costs, or productivity gains. No benefits at all, either positive or negative, are measured over time. No private business run in such a manner would ever survive in a free market.

Because of the lack of necessary information, no one – repeat, no one – has any hard evidence about long-term cost/benefit analysis in the U.S. healthcare system.

The people who are currently treating critical healthcare are the wrong people: they are not trained to handle a sick patient. The people who are trained to practice good medicine – doctors and nurses, you and me – are ignoring the Patient. Why?

In the next, second post, I will answer the why? In the third of this four-part series, we need to ask (and answer) what is in it for me? Finally, in the fourth and final post, I will make suggestions about what we can, should, and must do for our patients’ sakes and for our own.

Deane Waldman, MD MBA, author of “Uproot U.S. Healthcare,” your doctors’ guide to curing Patient Healthcare

I enjoyed your article here on Linkedin. I also post regarding health policy and reform on my blog and would like to extract part of your article with attribution on my blog.

Gary Levin MD

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