Map of life expectancy at birth from Global Education Project.

Thursday, March 03, 2011

Just do it?

My old friend (really) Dr. Sean Palfrey wants doctors to go lower tech and higher wisdom. He sees his colleagues ordering up too many tests, and treating too aggressively, because they don't trust their clinical judgment and they fear doing too little more than they fear doing too much. The wasted resources make medicine much too expensive, which means that lots of children (Sean is a pediatrician so that's where he's looking) don't have continuity with a primary care provider. Which means we're hurting the most vulnerable when we waste resources on the more fortunate -- and we aren't actually making them better off either.

All this is true, as anyone who has been reading your humble and obedient servant for any time knows I would say. However, the situation isn't going to get any better just because Sean's editorial hits some doctors like a diamond bullet, right between the eyes.* It's going to require policy changes, not just exhortation.

That begins with medical training. Unfortunately, right now, it is almost impossible to reshape the way physicians learn how to be physicians. The four years of medical school is just an introduction, heavy on the basic sciences and light on clinical practice. Even so, nobody is really in charge. The dean is just a mediator among departments that jealously guard their "contact time" (the class hours they essentially own within the curriculum) and traditions. Physicians learn the trade through an apprenticeship system after they graduate, and essentially, what they learn depends on the luck of the preceptors who they draw. Nobody is shaping what their role models do so nobody has any real leverage to control the experience.

Then, they go forth into a world tightly constrained by financial and career incentives, and the organization of medical practice. They will likely become sub-specialists because there's more prestige, more money, and less demand on their time than going into primary care. If they resist all that and do enter primary care, they will have heavy caseloads, long hours, and lots of paperwork and administrative crap to deal with. They will get paid for throughput and doing procedures, and paid very little to talk with patients and families, counsel them, and urge restraint. If their patients are depressed, or anxious, or have behavioral problems, just about all they can do is push pills. They will be heavily influenced by the culture around them and the allure of shiny, magical machines.

In order to really get control over this mess, we need universal, comprehensive, single payer national health care. In the meantime, the Patient Protection and Affordable Care Act does offer some openings to get started. The Republican campaign to thwart it, and leave us stuck with the present disaster, is a crime against humanity.

* Yes, it's from Apocalypse Now. I intended that you recognize it.


kathy a. said...

we need more primary care doctors. and for lots and lots of situations, "wait and see" is a perfectly appropriate answer. or, let's try this low-tech thing, and wait and see.

what patients need to know is what to look for in terms of bad changes -- when to call back, when to look into some testing.

robin andrea said...

While we were waiting in line yesterday at the local pharmacy in a box store, I was struck by how non-health oriented this entire health care situation had become. I felt like a cog in a Big Pharma machine.

And in another show of infinite medical wisdom, my mother's doctor prescribed anti-depressants for her without considering that her sudden onset of lethargy and confusion might have been a side effect of the Percocet she's been taking for three weeks. How he could have missed that obvious connection is beyond me.


davidknz said...

Here in NZ we have universal, comprehensive, single payer national health care, and workable Primary Health organisations. They provides excellent results and there are private insurers for those who want softer beds or green leafy surroundings. Pharmac is the sole agency for competitive tenders for medicines to the health system. So yes, it can be done. And yes, the american pharmecutical industry want Pharmac removed as 'an impediment to market forces' Nothing new here

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