Medical Care:  What and Who is the “Very Best?”

I’m easily satisfied by the very best.

Winton Churchill (1874-1965)

The real problem isn’t money. It’s the culture of medicine.

Peter Bach, MD, senior advisor at CMS, 2005 to 2006, director of Centr for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center, “The Trouble with Doctor Knows Best,” New York Times, June 5, 2012

June 8, 2012 -  What and who are the “very best” in American medicine?  What is the “best care” in the world,  and who provides it?

It depends on whom you ask. 

If you ask conservatives,  they will say, “ American, of course.”  They will argue we lead the world in quick access to high tech care, in medical innovation, in research and outcomes for such dread diseases like heart disease, cancer, and diabetes?  They will point out doctors  from around the world flock here for training, and kings, potentates, and celebrities come here for the latest and best in treatment.

If you query progressives,  they will respond, “Other nations.” Nations with universal low cost coverage. Nations in which taxpayers and the wealthy and the healthypay the freight for care. Nations in which medical bankruptcies are unknown.  Nations in which care is equitable, regardless of wealth, status, or political connections. As comedian Milton Berle once said,  “When it comes to my health. Money is no object.”  Except,  of course, to governments, who ration care and who provide it to those with the number of years left, quality of life left,  and outcomes per bucks expended.

It  depends on how you define what the “very best” is.   As President Bill Clinton remarked when asked about sex,  it depends upon what “is” is.

It depends on where you sit. 

·         If you are a government management or policy expert,  responsible for managing federal dollars,  you need data on outcomes to justify federal expenditures.

·         If you are a politician seeking re-election,  you want to satisfy most of the voters most of the time, and traditionally the best way to do this is to offer “free” entitlement programs with no questions asked using other people’s money, i.e, taxpayers at large.

·         If you are a physician, you tend to want to offer what you think is best for your patients,  i.e. what satisfies them and meets their expectations,  at either financial gain or no financial loss for your practice, and at miminal expenditure of your time.

·         If you are a patient,  or a member of a patient’s family or his/her dependents,  you want the very best that medicine has to offer, as long as it does not drain your pocketbook or consume an inordinate amount of your time and other resources.

Lastly,  it depends on what you’re talking about.  In a recent New York Times piece,  Peter Bach, MD, a former CMS advisor and a cancer expert with impeccable credentials, commented,

It is time to own up to shortcomings in cancer screening, and we must start by acknowledging a hard fact:  Doctors sometimes don’t know best.  We are terrific at inventing  new tests that can be performed on people.   But we are less good at figuring out which people should have them?

If not doctors. Who?  Patients?  Maybe if doctors tell them, the yield of certain screening tests - PSA for prostate cancer in men over 65,  mammograms in women in their forties, Pap smears in healthy women of all ages,  CT scans in smokers, annual chemistry panels for cholesterol or blood glucose,  annual ECGs in asymptomatic patients,   yearly physicals,  imaging tests for low back pain or headaches – do more harm than good.  Positive or false-positive results may indeed create unnecessary complications from biopsies or treatment and may not prolong life.

Doctors?   Well, maybe.   Being scientifically trained, they are susceptible to rational arguments about low yield of screening tests.  Still,  in the current culture,  their patients have come to expect and believe in annual checkups to detect early disease or disturbing metabolic trends.    Anyway,   profits from screening tests and the joy of finding something preventive  that can be tended to is worth doing.

Malpractice attorneys?  Please tell them that the modern medical and societal culture rewards obsessive-compulsive behavior and punishes those who do not indulge in it.    And it may help to institute tort reform to limit malpractice rewards for not doing what society expects doctors to do.  Defensive medicine exists for a reason.

And while you’re at it, try to change the culture of Americans who have come to expect the “very best” of procedures and tests to ward off and spot early disease that may limit their life expectancy or interfere with their life style.    Tell Americans an ounce of prevention is not worth billions of dollars of early or potential cures.

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