Friday, January 9, 2009

Reece, personal musings, culture, effect of, physician cutture Confessions of A Cultural Anthropologist: Cause and Cure of High Health Costs

"Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms. Add in such pressures as the need to pay off enormous debts, and it is not surprising that students’ choices are dictated by the desire to maximize income and minimize work time."

Pamela Hartzband, MD, and Jerome Goodman, MD, “Money and the Changing Culture of Medicine, “New England Journal of Medicine, January 8, 2009

I have a confession to make. I think the cause of high American health costs is simple. It is American culture in general and the physician culture in particular. There is nothing wrong with this, and I point no fingers.

The Way We Are

It is our culture. It is the way we are, the way we’ve been for 232 years. It is our distrust of government. It is our desire to be free to choose. It is our belief in equality of opportunity for access to the latest and best of care. It is the notion, stemming from frontier days and conquering of the West, that action speaks louder than words, that if you do something specifically, it is better than doing nothing generically. “Do something, don't do nithing,“as the saying goes.
Specialty-Dominated Care.

Nub of Essay

Which brings me to the nub of this essay: specialty-dominated care. We are the only nation in the Western World with more specialists than generalists. Our health costs are roughly twice those of other cultures, and our health statistics lag. I do not reflex attribute these results to our health system faults – we have a richer mix of immigrants, who come from different medical culturee; we have larger numbers of minorities, who tend to have poor health outcomes; we have higher accident rates and levels of violence; and our market-driven culture lets some people fall through the cracks. And our blind belief in specialists lead to a sometimes crazy quilt system that may good for certain problems – advanced cancers, rare diseases, heart disease, and debilitating crippling arthritis – but bad for the health of the general population.

Educational Costs

And let’s not forget our educational system. It’s expensive. The rate of rise of costs of college tuitions exceeds health inflation. Our government does not subsidize undergraduate or post-graduate care as generously as other nations. Yes, Congress indirectly helps academic centers finance medical education and residencies. But it’s often too little and too late. Upon graduation, the average medical student carries a debt of $150,000, and many students are married to one another, doubling that debt load.

Small Wonder

Small wonder, then, that our culture leads medical students to favor high paying specialties over low-paying primary care. Small wonder, then, that our culture peopels primary care doctors to re-enter specialty training, perform procedures in their offices in search of more revenue, become hospitalists and proceduralists in hospitals, and seek refuge in newer, more lucrative and less time demanding practice models.

Small Rewards for Cognitive Services

But alas, there is no easy way to change American culture, and its rewards for doing and performing rather than talking, commiserating, advising, or just plain discussing. It is easier and quicker and often more appreciated to biopsy a skin lesion, prescribe a highly promoted drug or antibiotic, order a CT or MRI scan, than to counsel watchful waiting or behavioral change, or to click onto an EMR armed with best practice information, refer to a specialist, or do something, anything, that can be defended in court.

Concierge Practices

There are options, of course, out of the primary care rat race. Here is what two Harvard medical school professionals, quoted in the introduction, have to say about primary care.

“Some established primary crew physicians are making career choices in response to this new culture and fleeing to concierge practices, often citing their desire to escape the constant pricing of every aspect in their days. Since concierge practices collect yearly premiums from patients, such doctors may ironically be less “primed” by money at each encounter and may avoid feeling “nickeled and dimed” by insurers. This arrangement creates an environment that can foster social interaction more than market exchange. But concierge medicine is unaffordable for most Americans, and it drives much-needed primary care providers away from the larger populations.”
Medical Homes

Our two Harvard professors suggest a more reasonable answer to the specialty-dominated culture may be medical homes. “The medical home,” they say, “is envisioned as a ‘compassionate partnership’ of primary care providers and patients, with coordinated care for patients’ ongoing problems and increased attention to preventive measures.”

The medical home is a good fit for the American culture, which years for the good old days of Marcus Webby, and for the family doctor who knew everybody in the family, its history. and its dynamics. “Success in such a model,” assert our Harvard commentators, “will require, collegiality, cooperation and teamwork – precisely the behaviors that are predictably eroded by a marketplace environment.”

More Needed Than Good Relationships

In my view, it will require more than “collegiality, cooperation, and teamwork." It will require solid backing by state and local government, major employers, and specialists; reimbursement to the tune of about $50 for each patient managed, shredding of bureaucratic redtape for medical home physicians, and simpler, less expensive, more utilitarian, electronic records.

American health authorities will have to come to grips with the reality that broad based primary care systems, abroad and in the U.S., are less costly and have better outcomes than specialty-dominated systems. We also need to pay primary care doctors more and to reward them for the right reasons – more prestige within the medical establishment, more time spent with patients, and more compensaiton for quick respond to one day appointments, prompt answering of e-mails and phone calls, proper guidance through the medical maze, and more efficient, e4ffective, personal, and practical care.

1 comment:

2healthguru said...

Love the thoughtful reflection and anthropological insights, and could not agree more!

We are beyond the point of diminishing returns for this so "called cottage" industry aka the health care system - or perhaps more accurately non-system.

As a contrarian, I am cautiously optimistic, that we face an opportunity here. Yes, economic contractions in conventional terms don't augur well for systemic (i.e., expensive) health care reform. However, the current status quo and financial meltdown may be the perfect enabling storm to actually see something beyond incremental tinkering of a failed finance and delivery model.

I am following, and actively participating in this very over due conversation both in blogs forums and via the Twitter universe @2healthguru. Bravo!