I am at the First Stanford Symposium on Bedside Medicine, and we have the world's leading experts on the diagnostic examination gathered here. It is a small group who still believe there is value in examining the patient, even in this era of imaging and technology.An anthropologist from Mars looking at our hospitals might conclude that the 'work' of medicine takes place in rooms far removed from the patient, typically in front of a computer screen. The actual patient and the person-hood of the patient is pushed to the margin of medical attention while the 'iPatient', the virtual patient rules.
Last night we talked about the ritual of the exam, and how important that ritual is. Rituals are about transformation, and the careful exam has all the elements of ritual, including a sacred space, a ceremonial garb (white coat and patient gown), a routine that is mysterious to the patient and includes disrobing and touch (which in any other context would be assault). Rituals are about transformation (think wedding, baptism etc) and this ritual when done well, is transformative, it establishes the physician-patient bond, it recognizes the body of the patient (the soma as opposed to the image of the body), and it is therapeutic, particularly in chronic disease, where the ritual repeated at every visit conveys to the patient that we are with them on the journey, we will not abandon them.
Everyone agreed to this aspect of the exam, the importance of ritual. Then why is it that we so rarely emphasize the importance of the ritual when trying to defend and preserve what is a threatened craft? I think it is because this ritual (like love, steadfastness, loyalty, courage) is not easily measured, and in a medical world that seems to be ruled by psychometricians, if it ain't measured it doesn't exist.
But hope springs eternal, and this little group is determined to bring about change.
(Photo: Flickr User mynameisharsha)
The unfortunate politicians who have braved town hall meetings in recent days to talk about health reform seem to have been taken by surprise by the vitriol and volume of the push back. Yes, I know the audiences were marshaled and recruited to shout down the speakers but still the passion on display was genuine and not in the least surprising to me. What the President and our politicians should have known is that our personal health is the one arena of our lives (the other being our love lives) where reason and logic get thrown out of the window. Talk about our health and suddenly our education and civility vanish and we are a mob waiting to be ignited. The incredible thing is you can just as easily incite us to march for reform as you can against reform. All that matters is what button you push. Read More
Ten years ago this month, my wife and I left our youngest son with Grandma at home in El Paso, Texas and we flew to Manhattan to attend the party to inaugurate TALK magazine. I'd agreed to be one of the writers for Tina Brown's new magazine--I'd previously written for her at the New Yorker.
Ferries ran the 1000 or so invitees over to the Statue of Liberty--the island off the island. I felt as if I were in a dream, walking around in the dusk, brushing past the likes of Salman Rushdie and Madonna. Sylvia ran into a chatty Dr. Ruth in the restroom and then it seemed we kept running into Dr. Ruth --she was everywhere on the island just as she seemed to always be on TV those days.
The New York Times reports today on the ten year anniversary of that party, but titles it "An Omen No One Saw" and how we were all "unaware of the sharks circling".
I don't think that's a fair assessment. Looking across and seeing the twin towers standing, could anyone have predicted how the world would change? Or how magazines would fare over the next decade?
Here is how I see that surreal event: as an example of Tina's daring and inventiveness. I've pointed to her career when advising students and others. I say, be bold, be creative, reinvent yourself and dare to reshape the world around you, and most of all be willing to risk failure. Tina's latest venture, The Daily Beast, is like nothing else out there, and she brings to it all her skills in media, in recruiting new talent. But what it does best of all is showcase her own writing--in all the talk about Tina Brown, people don't always appreciate the brilliant writer behind the brilliant organizer.
So Tina, thanks for the memory of a hell of a party. I'm sitting here this morning, looking out of the window and drinking coffee. I am wondering what else is cooking in the mind of Tina Brown. It is commute time here in California, but near noon in Manhattan. She's already ahead of us.
(Photo credit: http://www.flickr.com/photos/patrioux/145381211)
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I attended a wonderful presentation a few days ago by Ajit Varki, a physician and scientist at the University of California San Diego and head of the Center for Academic Research and Training in Anthropogeny. That word, "anthropogeny" was a new one for me. It means, 'explaining the origin of humans, or 'the science or study of human generation.' Varki's long standing interest in sialic acid receptors that are plentiful in all our cells led him to discover that we lost one variety of that receptor some time ago when we diverged from our nearest relatives, the apes.
The work of Varki and his colleagues is particularly helpful in the gene versus environment debate. A spate of recent articles have pointed out that the human genome project hasn't as yet yielded the treasures that were promised. Our science fiction fantasy was that we'd map your
genome, and predict that on a Tuesday in September in 2022, you would
wake up with a heart attack or a brain tumor (and presumably there were thing we could to help you avoid that fate). It turns out that even though we now have identified many areas on the human chromosome linked to diseases like diabetes, they simply are not very useful to predict that the patient will get diabetes.
For example, if I see an overweight patient walk into my office, that sight alone is
a better predictor of their risk for diabetes than any genetic test I
might order. If a pack of cigarettes shows in his pocket and his finger nail is yellow, I know a lot about his risk of sudden death from heart disease. I must say that as a clinician, this is somewhat reassuring, the notion that you still have to use your eyes and senses and earn the patient's trust to learn the kinds of things that may have put him or her at risk for various illnesses. It also says we have much to learn about the environment and its influences on us.
Dr. Varki's group suggests that even 'nature versus nurture' is too simplistic a debate, and that we as humans evolved because of a dependence on learned behaviors and social interactions that may have been advantageous. It may be that even things like breastfeeding among animals are learned behaviors and are not hard wired! His work makes for fascinating reading and it would be folly to try to summarize.
As I was preparing this piece, I read in the NY Times about a bear named Yellow-Yellow in the Adirondacks who has managed to get past a bear proof food container that stymies all other bears. Surely this learned behavior will give Yellow-Yellow a survival advantage if that becomes the only source of food available. The big question is can she and will she teach it to her fellow bears, or to her mate and to their progeny? The fate of the universe rests on such questions.
It used to be you could look into the crystal ball and paint a picture for them of what their life would look like when they were done: it used to be that if they chose primary care, they would probably over a lifetime make perhaps 3 to 5 million dollars less than a colleague in a procedural specialty, be harassed with a lot more forms, longer hours, and unless they retreated to a concierge practice where they set a high dollar bar for admission to their practice, they would be very busy.
On the other hand, if they picked dermatology (and I love dermatology, and find it an intriguing discipline), they could count on a good lifestyle (very few dermatological emergencies), they would do lots of procedures, and make a healthy living. The same was true for ophthalmology, radiology--all very competitive disciplines for students to enter.
But what if:
- You get paid only for managing disease, for caring for a stable of patients--in other words, what if there is no fee for service? (By the way, Massachusetts is bravely going this route.) Doing more procedures then will cost you money, not mint money. Suddenly, many procedure based specialties don't look so hot.
- What if Medicare or insurers stopped paying for MRIs, CAT scans and PET scans on an individual basis, but rather only reimbursed for disease management ? The owners of such facilities (who in many cases are doctors) have counted on business continuing as usual and may fold like Chrysler dealerships. Radiology as a career choice might be less attractive.
- What if the physician who cared for the patient, who had formed a steady relationship with the patient over the years, who knew the family, and who was the one who admitted them to the hospital (and then acted as quarterback and kept a close eye on the consultants called in and ensured communication)--what if that individual got paid top dollar? Yes, what if primary care became the plum? Look at who President Obama picked to be Surgeon General: a primary care physician par excellence. There is a message there.
- the House releases its health care bill
- Center for Medicare and Medical Services (CMS) releases a revised physician pay schedule
- The FDA is about to finally get to rule over tobacco companies
07/07/09 9:02 AM
Medical Tests: "Does it work?" matters less than "Does it pay?"
When President Obama speaks about funding health reform, he keeps emphasizing that the money needed to achieve his goals of covering the uninsured, is already in the system:
"Two thirds of the cost would be covered by re-allocating dollars that are already in the health care system, taxpayers are already paying for it, but it's not going to stuff that's making you healthier." (From his appearance on ABC's Prescription for America).
I recently came across a great resource (thanks A.J.!), the California Technology Assessment Forum whose goal is to assess new and emerging technology. It is edifying to look at the list of tests it has assessed, pages of them, and to see how few meet its criteria for a test that improves health outcomes and is safe and effective. And yet the tests are being done and we are collectively paying for them.
Hats off to the President for taking on health care reform, because if you read the CTAF's list of tests that are ineffective, you are also looking at a list of device manufacturers and others who are doing very well on these procedures and tests--every one of them is going to battle him tooth and nail, primarily through their lobbyists in Congress. I sense the President is doing the right thing by taking the message to the public, to us, counting on our sense of outrage to say it is enough.
One of my former students, a brilliant physician who has gone into a rural practice where he does it all--delivers babies, takes care of children, adults, performs procedures--wrote the following to me (tongue in cheek) and I have his permission to use it:
"I justify ordering expensive and unnecessary tests in the following way: It is clear that the current health system is unsustainable. The sooner it collapses, the sooner we can start over again, hopefully with something better. I intend to do my part to bring the system to its knees as soon as possible. (That's only funny because I'm not that way.)"
It's only funny because he truly isn't that way.
I had the pleasure of being in the East Wing of the White House on Wednesday, one of about 160 people in the audience as President Obama appeared on national television, fielding questions about health care.
It was my first look at the President at close quarters. I came away with the impression that the President was possibly the most knowledgeable person in the room when it came to the current health care crisis. That's no small thing given the people who were there. We have had Presidents whose understanding of issues seemed confined to the precise talking points prepared by aides in briefings. This President knew his material well and was improvising as smartly as a jazz pianist, in response to questions.
The other thing I sensed was the President's tremendous passion for this cause. If there is something more important on his agenda, I don't know what it is. What also came across is that compared to everyone else who was there (physicians like me, the CEO of Aetna, the head of the AMA), the President was probably the only one whose interests in the health care debate were not self serving. His sole motivation seems to be to head off disaster, which seems inevitable if reform does not take place.
An important moment for me personally came when a young woman asked the President the very question that I had been prepared to ask. She wanted to know why we could not emulate the example of other advanced democracies that manage to cover all their citizens for about half what it seems to cost us. The President's answer was revealing; he pointed out that most of those countries had a one-payer system whereas we in America, "...have an employer based system that has grown up over decades. For us to completely change our system, root and branch, would be hugely disruptive and I think would end up resulting in people having to completely change their doctors, their health care providers in a way that I'm not prepared to go. This is one-sixth of our economy. I think that we can build on what works, fix what's broken, and still have some substantial money."
The obstacles in the President's way are considerable: 1) people and businesses who are profiting hugely from the status quo; 2) a general fear of government interference; 3) fear in Congress about the amount of money to be spent on health care reform and finally, 4) the fact that legislators who have to make change happen often serve the interests of the people who gave them the most campaign money--pharma, insurers, organized medicine. These contributions are what taint our political process--call it first world corruption.
I got back to my hotel room at 10pm, just as the session (which had been recorded "live to tape") was finally being aired. I was surprised to see that one commercial shown during the health care debate was on behalf of "Patients United Now"--a group I know little about. The ad was sowing seeds of fear by having a Canadian patient talk about the difficulties of that system. They couldn't wait to hear what the President had to say it seems.
Oh yes, and the other thing on television competing on the other channels was the news of Governor Sanford's whereabouts. As to that . . . less is more.
Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, and writing appeal letters; a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients.
The President's speech even quoted Newt Gingrich:
As Newt Gingrich has rightly pointed out, we do a better job tracking a FedEx package in this country than we do tracking a patient's health records.
The speech reminded me of a conversation a few days ago with a close friend who said casually, "Face it, Abraham, medicine is corrupt." I paused. I sputtered. I was about to say something. But I shut up. I shut up because (as the President explains) whether I like it or not, I am a beneficiary of a system of :
. . incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I'm talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can't spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it's not truly necessary. It is a model that has taken the pursuit of medicine from a profession - a calling - to a business.
We can quibble on the ways the President proposes to fund the changes he proposes, but I don't think we can quibble on the moral imperative to change the way we do business. As the President says,
"You entered this profession to be healers - and that's what our health care system should let you be."
(For another take on the speech from a thoughtful physician who also happens to be in New Hampshire, see KevinMD.com)
Abraham Verghese
