Cultue, Effect iof It’s The Culture, Not the System

What Shapes American Health Care Values

Q: You’ve now submitted 214 consecutive daily blogs on medical innovationblog.blogspot.com on the health system. That must be a real grind. Why punish yourself? What are you trying to do?

A: I’m trying to prove beyond reasonable doubt the U.S. culture – not government policy, not consumer-driven care – that shapes U.S. health care and how health professionals and patients behave. I’m suggesting constructive solutions, like innovative public-private partnerships, as one of the solutions. In the U.S. culture, the marketplace, not the government, usually determines what people do and where they go for care.

Q: That must be an uphill battle.

A: It is. Everybody, for ideological reasons and to preserve their status quo position, believes they have the right answers. They don’t. The answers transcend ideology and their stake in the system. Liberals will be liberals, conservatives will be conservatives, bureaucrats will be bureaucrats, and innovators and entrepreneurs will be innovators and entrepreneurs, and never the twain shall meet. It’s a stand-off. Control, equality, choice, and freedom have unpleasant trade-offs

Q: As a physician, what’s your position?

A: I’m a cultural anthropologist at heart. But I appreciate how important the physician culture is. Physicians, after all, are the second oldest profession – or culture – if you prefer to think of doctors that way.

Medicare, then Managed Care, and now Market Forces, have sought to change physicians from being independent professionals to businesspersons and corporate personages. These various controlling forces want doctors to cross the t’s and dot the i’s of practice management, serve as quasi-employees of government or health plans, or become team members in large multispecialty clinics or academic centers.

Being led by other physicians in teams has worked best, but independent physicians don’t widely accept being led by other physicians in big organizations. They don’t like the overhead or the politics. That’s why 75% of physicians are in practices of 5 or less. It’s possible independent doctors will go the way of the corner grocer, and become submerged as employees of hospital grocery chains, or as professional technicians for corporations, but it hasn’t happened on a large scale yet.

The general thinking of medical outsiders seems to be, if we grab doctors by the tender parts of their anatomy, their hearts and minds will follow. It hasn’t worked, not yet anyway.

Q: What is the health care culture like?

A: You ask excellent questions, if I don’t say so myself. Here’s how I explain it.

Healthcare cultural problems exist at three levels:

1.The Culture of American Society

As J.D. Kleinke has written:

"Such is the culture of medicine in America. We demand the best, accept nothing less and reward lawyers handsomely for making sure we get it. Even the imminence of certain death does not attenuate this cultural fact, as the clinical behaviors, costs and outcomes of typical intensive care illustrate. Our national consciousness is steeped in optimism, hostile to all processes and manifestations of aging and enraptured by a limitless faith in technology; as a people we have come to revile death as much a personal defeat as a personal loss.”

In other words, given America's medical culture, physicians, patients, and lawyers are likely to keep on doing what they're doing.

2.The Culture of Large Health Organizations.

Remaking Health Care in America: Building Organized Delivery Systems is an excellent book on the culture of large health systems. The authors – Stephen M. Shortell and four other consultants – describe the cultures of 10 large multi-hospital systems, which had 1994 total revenues of $500 million to $1.5 billion. These hospital systems have worked hard, with mixed success, to create physician group cultures stressing teamwork, cooperation, sharing of information, pride in the organization, and attentiveness to physicians.

Salaried physician stakeholders drive certain tightly integrated organizations – nonprofit HMOs such Kaiser and clinics such as Mayo. These successful models, led by physicians selected for their dedication to the organization's mission, have not been replicated on a broad scale.

Academic medical centers have special cultural problems. These centers, burdened with educational expenses, are fragmented, overspecialized, notoriously difficult to organize, and not very enthusiastic or good at training primary care doctors in outpatient settings. Too often the culture of academic health centers consists of sharply departmentalized and overspecialized independent fiefdoms, connected only by a common plumbing systems and grievances over parking.

3.The Culture of Physicians

Health industry leaders have repeatedly told doctors they must consolidate into larger groups or integrate with hospitals to survive; achieve greater size, critical mass, and scale; cultivate managerial care expertise; work in multidisciplinary teams; seek capital offered by large companies; follow evidence-based or standardized guidelines to practice good medicine; practice preventive medicine; develop systems approaches to managing chronic disease; enter into primary care specialties to assure a less costly health system; install information technologies in their offices; establish practice web sites; offload business functions to the Internet; communicate with patients through the Internet and by e-mail; convert to paperless offices, prescribe electronically; standardize codes and transactions for diagnostic procedures and develop leadership skills.

These admonitions from health leaders have left many clinicians unmoved. Physicians have not bought into the argument that bigger is better or that managed care and corporate models for achieving quality are in their best interests or their patients’.

To understand why physicians have resisted, you have to get inside their minds and skins. The way many physicians think can be illustrated in the following list of ideas:

1.You became a physician to serve patients, not hospitals or business corporations.

2.Your customers are “patients,” sick individuals who need your help, even when that help is expensive and experimental.

3.You're "the patient’s advocate," a protector and a guide through a world fraught with obstacles to care.

4.You see patients one at a time, and you don't feel responsible for "population health."

5.You don't really care about the financial health of investor-owned HMOs who profit from minimizing care.

6.You realize patients spent 99 percent of their time outside your office, and you know ill health often stems from flawed life styles and rarely rests on your advice, which you are not paid for offering.

7.You distrust group activities. Your success has always been by dint of your individual effort, whether that effort has been getting good grades in college, doing well in medical school to qualify for the residency of your choice, or caring for sick patients in academic medical centers or inner-city hospitals.

8.Your rewards have come through working hard, mastering your specialty and impressing colleagues, not through participating in hospital, HMO, or corporate bureaucracies.

9.You dislike organizational politics. You detest meetings. You turn a wary eye toward any activity that takes you out of the operating room, off the wards and away from your office, for those locations are where the patients, your joy in doing well and your income are.

10.What has any managed care organization, hospital or business corporation done for you? HMOs, in your mind, manage cost not care. Has any HMO medical director or health executive ever helped you care for a patient better? Has any HMO policy improved quality of care for your patients? Has adherence to clinical guidelines really helped you find the right answers to your patient’s problems? Has any managed care organization placed at your fingertips in the waiting room, at the “point-of-service,” an easy-to-use information system that saves you time by telling you what drug to use, what diagnosis to consider and or whether the patient can pay?

11.Everything that relates to the new competitive environment has discounted your fees, driven down your revenues, compelled you to hire more personnel to deal with HMO clerks or “Doctor Denial” HMO medical directors and forced you into organizations where autonomy is less, rules are stricter, income is lower, work is harder, and a production-line mentality is at work.

12.You are a professional. Not a "provider" to be ordered about. What do these health care executives and those on the other end of an 800 line know about practicing medicine anyway?

Q: Your explanation reeks of physician tunnel vision. You can’t see the light in your dark tunnel. What about the common good? What about guaranteed and consistent quality and better outcomes? What about equity and equality? What about providing affordable care for all? Health care culture is just a sub-segment of the greater American culture. Where does the health care culture fit into our egalitarian culture?

A: That, of course, is a philosophical as well as an historical question. It goes back to Adam Smith and his theory that everyone acts in their own-self interest and to the tenets of our founding fathers in establishing American Democracy 231 years ago.

Our health system is a creature of our culture. When asked what Americans believe, Garry Orren, a professor of political science at Brandeis, who polls for the New York Times and the Washignton Post, said,

“A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially anti-authority and tend towards self-regulation. If there were an American creed, I think it might begin.

One: Government is best that governs least.

Two: Majority rule.

Three: Equality of opportunity.

Q: What does that set of values portend for the health system?

A: I don’t know, but it explains why Americans,

•prefer local health solutions,

•health care varies from one region to the next,

•so far have rejected sweeping universal coverage with rationing,

•feel capable of making their own health care decisions,

•seek equal opportunity access to high technologies,

•prefer choice of pluralistic payer systems,

•allow market-based and public-based institutions to co-exist and compete,

•permit doctors to behave democratically, seeking their own locales to practice, often acting independently of hospitals, health plans, and government, and making their own decisions;

•are reluctant to jump into a government-run system;

•do not embrace a tax-based system that punishes the rich and rewards the poor and that assures equality of results but dampens equality of opportunity,

•want to be free to make their own choices of doctors, hospitals, and other providers, based on their own judgment.

American democracy is full of cultural conflicts, paradoxes, and tensions. That’s what we seem to like -= controlled chaos with a mix of choices and opportunities. We want our care when we want it, where we want it, on our individual terms, not the terms of the government, the insurance companies, or the market. That cultural mindset causes profound problems – as well as unprecedented opportunities.

Q: You haven’t mentioned the role of government.

A: Ah, yes, government. It’s a subject that lends itself to metaphors – the bloated and ballooning bureaucracy, the elephant in the room, a sun never setting on government programs. The role of government, in my view, ought to allow public-private health partnerships to flourish in areas like disease management and prevention.

Look, government in health care isn’t going to go away. With aging babyboomers, Medicare’s slice of government expenditures will only grow. It may even lead to a national bankruptcy. Already the CMS budget is the fifth biggest budget on the planet – behind Germany, France, China, India, and perhaps California. The government has shown no talent for containing costs over the last 40+ years. As a nation, our government spends more per capita than any single-payer system. If the U.S. were to adopt a single-payer system, it could easily bankrupt us and would be subject to severe political manipulation. Congressmen and senators and president wanna-be’s need money to run, and a lot of that money comes from health care special interests.

Q: And what should be the physician’s role?

A: It ought to be constructive, and it ought to be based on innovations – creative public-private enterprises, new forms of practice, new technologies, new, less costly, more convenient sites of delivery, new collaborations and partnerships with hospitals. Much of this will only happen if the government gets out of the way with its Stark laws, Certificate of Need, IRS and OIG regulations, and its traditional compulsion to regulate and make rules.

Perhaps naively, I believe the best options for doctors are to pull themselves up by their own innovative bootstraps by pleasing patients and improving their care, rather than depending on federal largess. Doctors have little choice. The government will continue to cut doctor reimbursement, perhaps as much as 40% in the next five years if the current reimbursement formula holds. Outside of the VA, few really wants care at government facilities. They want government benefits at someone’s else’s expense. But my thoughts on government are not all negative. We need government, and we need government innovation. I’m an optimist. I like Winston Churchill’s observation. You can always trust the Americans. In the end they will do the right thing, after they have exhausted all the other possibilities.

Home Care - Multinational Electronics Giant Philips Seeks Innovative Health Care Solutions for Aging International Populations

Philips See Market Opportunities in Home and Independent Living Care

“Patients are behaving more and more like consumers. They go to the Internet and get second opinions. Care is being pushed out of hospitals, which are expensive, and into homes and clinics”

Gerard Klesterlee, CEO of Royal Philips Electronics NV, as quoted in “Electronics Giant Seeks A Cure in Health Care: Fleeing Chips and TVs, Philips Makes Big Bet on Aging Consumers,” Wall Street Journal, July 11, 2007

“The economic borderlines of our world will be drawn between countries, but around Economic Domains. Along the twin paths of globalization and decentralization, the economic pieces of the future will be assembled in a new way. Not what is produced by a country or in a country will be important, but the production within global Economic Domains, measured by Gross Domain products. The global market demands a global sharing of talent. The consequence is Mass Customization of Talent and education as the number one economic priority of all countries.”

John Naisbitt, chapter “Economics: From Nation-States to Economic Domains,” in Mind Set, Collins, 2006

When we think about health care, we focus on how each nation-state organizes its health system. We compare national costs and outcomes, but we ignore international business opportunities posed by aging populations worldwide. The health care paradigm may be shifting from care by nation-states to care assisted by international businesses.

Royal Philips Electronics NV, the Netherlands based electronic giant with $37 billion in 2006 revenues has shifted its attention from electronics and TV sets to business opportunities posed by aging populations across the globe. Since 2001, Philips’ annual revenues have shrunk from $44 billion to $37 billion, a drop of 16%, but its medical systems division has increased revenues from $7.0 billion to $9.2 billion, a jump of 31%.

In a 2006 move, Philips paid $750 million to buy Massachusetts-based Lifeline, a medical alert system company. The company makes devices allowing home-bound patients to push a button on a bracelet and connect to a call center. Operators, armed with health profiles, are on hand to help. Lifeline, founded in 1974, has 670,000 customers and strong relationships with 2500 hospitals, community organizations, and home health agencies.

Philips CEO, Gerard Klesterlee, noticed Philips professional medical division had grown 40% from 2003 to 2004. One of its products was HeartStart Home Defibrillator, which it sold to drugstores, on Amazon.com, and to hotels and shopping malls. The defibrillator success became a “trigger point,” and the company began to look for gaps in consumer health care not being addressed by competitors.

Philips created a new consumer health care division with one simple mission: look for opportunities outside of hospitals. Focus groups were organized in Madrid, Frankfurt, San Francisco, and Boston to find out what the elderly and their children wanted most in health care outside of hospitals. Philips sought a “A Senior Solutions Hot Spot.” They found people cherished self-reliance, staying connected to family and friends, and technologies and human help to address failing vision and trouble walking.

I believe Philips is on the right track. Companies like American Telecare in Eden Prairie, Minnesota, have remarkable results reducing hospitalizations and ER visits by placing audio-visual devices next to home-bound patients bedsides. Re-admission rates for patients with congestive heart failure dropped to near zero. Patients control the devices over ordinary telephone lines, communicate openly with doctors and nurses, and have proved to be highly educable and knowledgeable about complications.

Another company, Enhanced Care Initiatives, or ICI, located in rural Connecticut, has similar success with “hands-on” care of the elderly by nurses bearing laptops. Through contracts with managed care organizations, such as Tufts Health Plan and HealthSpring, Inc., a small managed care firm in Nashville, ICI provides and organizes care for frail and elderly patients, mostly over 80 and mostly with multiple chronic diseases. ICI has succeeded in reducing hospitalizations by 33% and ER visits by 25%.

More than anything else, aging patients seek self-reliance, independence, dignity, and technological and human support at home – away from hospitals. It may take a while for nation-states to recognize these desires are powerful drivers for better health for the elderly and for multinational corporations seeking new markets.

Costs, Only Consumers can Reduce Costs, Why Selling of Innovations and Consumer-Driven Care as Reform Measures is So Hard

I support innovations and consumer-driven care as effective measures to cut costs and reform care. For in the end, only cost-conscious consumers can contain costs. As long as third parties promise comprehensive care with hidden or unknown costs to the consumer, health inflation will roar. Consumer-driven care is beginning to have an impact (there are now nearly 300 consumer-driven organizations, and employers offering nearly 700 different high deductible plan premiums), but that impact is marginal in the larger scheme of coverage.

The political voice of consumer advocates is small. Proponents of universal coverage have a strong emotional argument combining pleas for compassion and equity. Unfortunately, as every reform minded politician and crusader for universal coverage now knows – from presidential candidates to governors of Massachusetts, California, Illinois, and Pennsylvania - you can’t reform care unless you first bring down costs, or you will overwhelm the Federal and State budgets. Superimposing single-payer on the present system will not work without first cutting costs.

No Quick Fix

There is, in short, no quick fix, at either the State or national level.(1) Because of their diversities and variation in the number of uninsured, and lack of resources, State-based universal coverage plans may not be the “laboratories of democracy” that will serve as models for national reform (2) In the reform process, reform experiences everywhere indicate you will alienate hospital, physician, health plan, business communities, and even those who are uninsured and don’t want to be obligated to pay for insurance. Participation of these parties is necessary for reform to succeed. When stakeholders’ oxen get gored, health reform may end up stillborn.

Innovation and Consumer-Participation Needed

Proposals to cut costs need innovation and consumer participation.. Some proposals to cut costs involve innovation and consumer-participation, some do not.

•Ban on smoking in public places

This is something government can do, but it isn’t innovative. Those 20% of consumers who still smoke have their own form of innovation. They smoke outside. Human behavior is like a balloon. Push it down from the top, and it will pop out elsewhere down below.

•Reduction in rates of hospitalization for controllable chronic diseases, such as diabetes, asthma, heart disease.

Innovations like telemedicine with home monitoring markedly reduce ER visits and hospital admissions. Home monitoring requires active patient participation, and chronically ill patients have shown they are up to the challenge.

•Expansion in nurses’ roles in disease management, telephonic and personal follow-up, and retail clinics.

These roles require innovative restructuring and decentralization of delivery systems. Consumers have responded positively to increased attention to their needs. Hands-on home care works especially well.


•Taxing revenues of hospitals, doctors, and small businesses to cover costs of universal coverage.

It doesn’t strike me as innovative to raise costs to cut costs In fact, this may be counterproductive. The response seems to be, “Not on my back and not in my business backyard.” Gore someone’s ox, and they will gore back.

•Reducing hospital infections and medical errors.

This is often innovative and takes the form of systematic, hospital-based educational and monitoring programs.


•Stopping health plans from excluding people with pre-existing coverage.

To health plans, this is punitive, not innovative.

•Expanding IT systems to cut costs by promoting efficiencies and including only those high-performance physicians and hospitals that are cost-effective.

So far these ideas, which have existed for at least five years, have mixed results.

Innovation Not Highlighted

Politicians behind government–sponsored, cost cutting measures are reluctant to highlight the role of innovators and consumers, perhaps because innovation distracts from politicians as the movers and shakers of reform. Besides, innovators are businessmen who do not have roots in government sector. Government officials tend to think of themselves of protectors of the sick, the elderly, and the poor from the private sector and do not believe consumers are capable of making intelligent health care decisions and prudently spending their own money.

Hard Sells – Hard Steps to Create Ecology of Innovation

Innovation and consumer-driven care are hard sells when it comes to reforming the system. This is true even though a culture of innovation is absolutely indispensable for the progress of the U, S in the global economy. (3) According to William Wulf, president of the National Academy of Engineering, America must step back and encourage innovation by

•Adjusting patent processes for quicker and more flexible acceptance of patents relating to information software, snippets of DNA, medical devices, and business processes. In health care, government rules and regulations are strangling the business processes needed to advance care.

•Changing intellectual property and copyright laws to accommodate the ubiquity needed to speed the spread of digital technologies by allowing copying of web pages, A web page "would have zero value if it hadn't been copied," Wulf said. "If it was just stuck on the hard drive of the server, it would have no utility whatsoever." The power of the Internet and search engines like Google are their ubiquity.

•Change tax policy to remove the "idiocy" of reviewing and renewing the credit on a year-to-year basis, Innovation requires systematic long term investment in research and brain power, not diversion of monies into non-innovative government policies.

•Change manufacturing policy to promote manufacturing in the U,S, .The United States has effectively "ceded manufacturing to low-wage countries," but that's "both dangerous and unnecessary,” Wulf says "I have real trouble with the notion of a robust economy that doesn't produce something, even if the something produced is ephemeral, like software. I just don't see an all-service economy."

Innovation Turn-Offs

A friend of mine, who works with corporate benefit officers, tells me minds automatically shut down when health care consumers hear the words “$ 2000 deductible.” Subsequent language about tax deferred income, more portable choices, free preventive services; savings for the employer simply falls on deaf words. Convincing health consumers to be responsible for their own care isn’t easy.

Regina Herzlinger, professor of business administration at Harvard Business School and godmother of consumer-driven care has written that health care innovation may be turned off because of these forces (4)

1.Friends and foes, often competitors, who help or destroy innovations through passive or active resistance.

2.Difficulties finding funding, the raising of which differs from other industries.

3.Policies and regulations, e.g., the Stark Laws and Certificate of Need, HIPPA regulations, and anti-trust lawyers which handicap and sometimes make impossible innovations.


4.The slow adoption of technologies, e.g. EMRs that make other industries more efficient and offer more convenience to customers but in health care are sometime blocked because of concerns about privacy and costs to doctors.

5. The slowness and inertia of consumers in transitioning to market-based care requiring their active participation and even partnerships with physicians.

5.The often unreasonable demands of health plans, consumers, and government that every innovation must be proven absolutely safe, cost-effective, and accountable.

Public Difficulties in Understanding Innovation

There is another factor as well – difficulty of the public in understanding how incremental innovations, – be they in the realms of technology, service, new delivery models, new types of practitioners, new forms of financing – or how an innovative economy can reform the overall system.

The public wants a universal “fix” to bring down costs, not piece-meal innovations – not matter how good, no matter if these innovations help the U.S. maintain its reputation as the “best” urgent system in the world. Innovations simply do not fit the mindset of those who yearn for an instant government mandated fix...

The concept of a market-driven system is simply much harder to grasp. It doesn’t lend itself to political sound bites. It is perceived to reward entrepreneurs, innovators, and businessmen rather than the public at large, the chief benefactors of innovation. By the way, I define a health care innovation as doing something quicker, better, more conveniently at a lower cost – whether or not government or the private sector initiates the innovation.

Add to these various obstacles the image, fostered by some, that the U.S. has a cruel health system. It is a system, they say, that drives people into bankruptcy while letting them bleed, even die in the streets. It is a system, driven by HMO denial of services in pursuit for profits that punishes the sick and rewards the greedy. It is capitalism at its worst, so say the progressives.

Universal care advocates believe all people everywhere are morally entitled to “free care.” These beliefs pose political, psychological, and financial barriers to market-based entrepreneurship and innovation because there are only so many resources to around in the public and private sectors, a fact which may account for a general lack of entrepreneurial and innovative activities in single-payer nations.

Market-based care, and consumer-driven care, depends on consumers making their own decisions, spending their money, and it depends on innovators and entrepreneurs coming up with ideas that save money, expand choices, and provide convenience.

But as with all things human and non-governmental, such care depends on persuasion not force. As such, it may fail to protect all, may let a few people fall through the cracks, and may provide an incomplete safety net.

It is an illusion, of course, that government systems provide a complete safety net, particularly for the costly sick. A seldom mentioned truth is that single-payer systems are politically potent because they protect the healthy (95% of the voting population), but ration care for the sick (only 5% of voters).

It would be great, of course, for all health care participants, government technocrats, and consumers would join together for the common good, not their own self-interests, but that would require repealing the laws of human nature and of Adam Smith.

References

1.Sack, Kevin, “A States Finds No Easy Fixes on Health Care,” New York Times, July 10, 2007.

2.Klein, Ezra, “Over States: Why The ‘Laboratories of Democracy’ Can’t Achieve Universal Health Care,” Washington Monthly, July 10, 2007


3.Dean, Cornelia, “Determined to Reinspire a Culture of Innovation,” New York Times, July 10, 2007.

4.Herzlinger, R.E., “Why Innovations is Health Care is So Hard, “Harvard Business Review, volume 84, pages 58 to 66, 2006.

Limits ot Technology - Limits of Government Intervention in Technological Assessment

The Case of Catheter Ablation for Atrial Fibrillation

In 1976 Dr. Howard Hiatt, dean of the Harvard School of Public Health, give a speech advocating a U.S. technological assessment center before any medical product went to market.

Joseph Califano, secretary of Health and Human Services, chimed in. He whined more CAT scanners existed in Los Angeles than in Canada, as if that was a bad thing.

The rest is history. Neurosurgeons recognized CAT scans as a superior technology. Immediately they deployed CAT scans to spot brain tumors. MRIs followed CAT scans. The scans received the same warm reception as CAT scans among physicians. In 2001 a survey of 225 general internists published in Health Affairs ranked the top 30 major medical innovations, and MRI and CAT scans came out number one.

Government can’t control technology markets once doctors and patients spot a superior device, even if the device costs more than government thinks it can afford and even studies of safety and effectiveness have yet to be published..

Take the case of catheter ablation of heart atria sites that spark fibrillation. Atrial fibrillation afflicts 2.2 million Americans. It’s a leading cause of strokes and heart failure. Doctors think ablation is more effective than open heart surgery and multiple drug treatments. Consequently, thousands of ablations have been performed since 2000 – even though federal regulators haven’t approved the procedure and don’t pay for it.

Where there’s a will, there’s a way. Catheter ablation is moving faster than the federal approval process. Doctors and patients are saying, in effect, “To hell with the clinical trials. This ablation procedure works.” And “We” the patients, will demand it, and you, the doctor, had better provide it, or we’ll go elsewhere.

Doctors and hospitals are inventive. They know they can bill Medicare and insurers by using codes for similar cardiac procedures to partially pay for atrial ablations. Doctors perform ablations in major hospitals or teaching centers, where doctors are on salary and not compensated for procedures, but who wish to distinguish and differentiate themselves from the competition. The American Heart Association and the American College of Cardiology have recommended the procedure, and many established and start-companies are marketing ablation devices. Major ablation centers are trumpeting ablation success stories and marketing services to atrial fibrillation victims..

When patients want something done, and doctors and hospitals want to do it, and mounting anecdotal evidence shows it works, it will be done, and there is little government can do to stop it.

Market forces often move so fast they overwhelm government assessment and resistance. There are limits to federal intervention in health care, and catheter-ablation to remove or neutralize the cause of atrial fibrillation is the latest, but not the last example of those limits.

Doctor Shortage, Needed: A Documentary on “The Doctor in America”

Q: What’s on your mind these days?

A: A television documentary or a movie documentary on the “Doctor in America.”

Q: Why?

A: American doctors need to respond to Michael Moore’s “Sicko, ” to comment on Muslim physicians’ involvement in British terrorist attacks, and to state their positions on health reform. The public needs to know how doctors feel about these issues.

We need to counter “Sicko.” The major media admit Moore is slanted and polemic. But most agree with him the American health system is unfair, it’s the HMOs’ fault, and we need a “free” government-run system to straighten it out.

Q: What’s wrong with that?

A: Every issue has two sides. The American system is a product of our culture –dependence on market forces, thirst for innovation, desires for choice, and access to American medical technologies.

Moore doesn’t mention problems of single-payer systems. People are suffering or dying while waiting to receive treatment for serious illnesses, single-payer systems ration services to control costs, and most don’t offcr quick access to MRIs, CAT Scans, cancer drugs, coronary stents or bypasses, kidney dialysis, treatment for terminal disease like brain cancer. In most, you may wait for months to specialists. Furthermore, foreign trained doctors are flooding into America to practice.

Have you ever heard of Americans going to Canada, the United Kingdom, or France for treatment? I haven’t.

Q: What’s wrong with foreign-trained doctors coming to America?

A: Nothing. The AMA says foreign citizens or Americans graduates of foreign medical schools (about 20% of the total) account for 229,000 of the 902,000 physicians practicing in the U.S. That’s 25% compared to 42% of foreign-graduates practicing in the U.K.

Q: So what’s your problem?

A: The problem with physicians linked to terrorism is psychological. It paints Muslim physicians with a broad brush as potential terrorists, as persons to be treated with suspicion among fellow workers and patients.

I believe Khaled Hamid, a St.Louis-based asthma and allergy specialist, who said of physician-links to terrorism,” We’re hurt as Muslims and as physicians who believe life is sacred and must be protected.”

Q: Are foreign physicians practicing in America potential terrorists?

A: I see absolutely no evidence of that. But I do know that two of the eight British physician terrorists did apply for U.S. entry. Look, he U.S. gets the cream of the foreign medical school crop, many of these doctors become physician leaders in America, and they are more rapidly assimilated than in other countries..

Q: Any other problems?

A: Yes, the public needs to know the U.S. has a tremendous doctor shortage – 50,000 by 2010 and 200,000 by 2020.

Q: Any other beefs?

A: Yes. Through HMOs restrictions, government regulation, and systematic lowering of reimbursement rates, we’re making the profession of medicine unattractive to bright Americans. We need at least 12 more medical schools to produce the requisite number of American-born doctors; and we can’t make up the deficit through physician assistants, nurse practitioners, or retail clinics.

Q: I still don’t see the need for a documentary.

A: The American people need to know from doctors their opinions about the physician shortage, the need for foreign-trained doctors to fill the gap, the cost of third-party intervention, and doctors’ stands on reforms and who and what contributes to the so-called “health care crisis.” The AMA is about the launch a campaign on reform issues, but we need other voices too.

Q: What would the documentary contain? What would it explain?

A: It would contain interviews with various representatives of the American medical community: academics, leaders of big multispecialty groups, high tech specialists, but most of all, primary care physicians in the trenches, many of whom are dying on the vine, retiring, failing economically, quitting independent practice, and going to work for hospitals and HMOs. It would explain most Americans are satisfied with their care and most of its urgent care facilities and those who staff them are first-rate.

Q: And what would the American people learn from such a documentary?

A: They would learn there’s a doctor morale crisis bordering on despair, that doctors aren’t happy with the status quo; that doctors have good ideas on how to make the system better, and that they have the patients’ best interests at heart. The problem with the current political debate – whether we ought to have a government-run or consumer-driven system – is that the politicians rarely present doctors’ points of view. For God’s sake, doctors are a big part of what health care is all about. Let’s hear from them.

Obstacles to Health Reform -What’s Standing in the Way of A Perfect Health System?

To hear the presidential candidates tell it, the only things standing in the way of a perfect health system are improved quality, more prevention, better information systems, lower costs, and universal access.

There may be another reason – lack of patient compliance and better health habits. I pointed out these factors in the following July 6 letter to the editor of the New York Times.


To the Editor:

In her superb piece “2008 Candidates Vow to Overhaul U.S. Health Care, “ reporter Robin Toner gets it exactly right. The debate is about the role of government versus the private market in providing affordable and available care.

What she didn’t address were three realities: 1) In 42 years of existence, Medicare and Medicaid cost inflation rates have paralleled those of the private sector; 2) government already pays for nearly 50 % of health care; 3) the health of nations depends more on a nation’s culture than its health system. About 85% of health outcomes depend on the culture and 15% of the health system (Sagan L , 1987, The Health of Nations, The Cause of Sickness and Well-Being, Basic Books, and Satcher, D, and Pamies, R ,2006, Multicultural Medicine and Health Differences, McGraw-Hill).

In other words, in a multicultural nation like the U.S., neither a government-run or market-driven system is likely to reduce costs or influence outcomes. Government may relieve financial anxiety about costs, and the market may produce more choices, but neither is likely to dramatically improve our health, which is more a function of bad diets, lack of exercise, inactivity, obesity, stress management, self-care, accidents, and domestic violence and mayhem in the streets.

A recent survey of physician executives reinforces my point.

Obstacles, Percent of Physician Executives Feeling the Following Obstacles Are Major Issues

Patient compliance and awareness of healthy habits, 93%

Lack of resources or money, 90%

Clinician communications and culture, 88%

Physician resistance to evidence-based care, 87%

Insurance company practices, 80%

Federal government policies, 80%

Source: 2007Quality of Care Survey, American College of Physician Executives

And as far as electronic information systems guaranteeing quality, it isn’t necessarily so. In a survey of 50 family physician practices – 13 with EMRs, 37 without, these were the results

Measure, Percent of Practices with Favorable Quality Outcomes

• Processes of Care (3 of 5 guidelines met), with EMRs , 35.0%, without EMRs 53.8%

• Treatment (all guidelines met), with EMRs, 35.3%, without EMRs, 46.6%

• Outcome targets (2 of 3 guidelines met), with EMRs, 29.0%, without EMRs, 43.7%

• Outcome targets (all guidelines met), with EMRs, 3.9%, without EMRs, 10.7%

Source: “Electronic Medical Records and Diabetes Quality of Care, Annals of Family Medicine, May/June, 2007

Oh, well, everybody has some bad habits, nobody’s perfect, even when they are fully wired.