America’s HealthCare Crisis: Part IV.  Physician, heal thy profession.

One bright sunny day two decades ago, I stood rather nervously in an examination room, taking an oral examination in order to graduate from medical school.  The examiner stood a few feet from me and with a curtly nod summoned a patient.  The patient shuffled in and the examiner observed his watch.  After thirty seconds, he nodded again, and the patient shuffled out.  The examiner turned towards me.  “Your diagnosis, doctor?”

That was a different era, an era where physicians were scientists, trained observers and good listeners.  It was an era when physicians spent time with patients.  How times have changed.

In thirty seconds, I observed that the patient’s right shoulder drooped, he took shallow quick breaths, and that he was rather emaciated.  Pulmonary insufficiency afflicting the right lung, secondary to either tuberculosis or cancer was my diagnosis and I passed.  I was able to make that diagnosis because I had been taught the importance of taking a good history and performing a thorough physical examination.  By the time of graduation, those skills had been mastered.  Though the two can be time consuming, they are a lot more cost effective than modern tests.  But more importantly, they establish a rapport between physician and patient that is priceless. 

These days, physicians spend less than 5 minutes with a patient and move on after ordering myriad laboratory or radiology tests.  The art of a differential diagnosis that required options to be carefully vetted has been lost to batteries of expensive tests.  How many patients can attest to their physicians having spent time with them, and lent a sympathetic ear?  Sadly, centuries old sacrosanct trust that existed between patients and physicians has been relegated to history books.  A physician is not looked upon as a knowledgeable family friend but as a glorified laboratory technician out to make a bundle. 

The mentality of conducting tests rather than dealing with patients directly contributes to the health care crisis.  In my last op-ed, I had mentioned that it took a CAT scan to identify my neighbor’s neck mass, something that any physician worth his/her salt should have identified from across the room.  If such tests are to replace the eye, is it any wonder that medical expenses have sky rocketed?  A gastroenterologist I know brags that he does not even touch a patient any more.  He sends them straight for radiological imaging or endoscopy.  Since he spends less time per patient, he can see many more patients a day, enhancing his income considerably.  Unfortunately patients fall for this, assuming that more and expensive tests are better.  While directed tests to prove a diagnosis are very understandable, testing simply to replace the process of physical diagnosis process is very wasteful.

Physicians argue that the legal atmosphere or patient pressure forces them to perform myriad tests.  While both arguments are true to some degree, physicians must ask themselves who ultimately dictates standard of care.  Lawyers do not establish standard of care – physicians do. 

A big issue for practicing physicians is insurance coverage.  Filling out paperwork, arguing or petitioning insurance companies can eat up 40 – 50% of the practice income in administrative costs.  In fact, Medicare and Medicaid are cause so much angst that some physicians do not take it at all.  They either ask patients to pay cash, or see them for free.  This is indeed a laudable trend and if all physicians were to follow this practice, insurance companies would have their wings clipped.  Since physicians cannot form unions (so much for following the constitution of the US), this would have to be a spontaneous mass movement.  In contrast to the Obama administration and Congresses penchant for a government run insurance or ‘heath exchange’, which I think will create just more government jobs but not much else, the profession may be better off with less insurance mandates, not more.

Another aspect of medical care is related to therapy – after all, the increase in life expectancy over the past five decades is due largely to life saving drugs developed by the pharmaceutical industry.  However, despite our appreciation for the pharmaceutical / biotechnology companies and their products, we should also keep in mind that they are in part responsible for the increase in health care costs.  In this area, physicians can do a lot to curtail runaway prices.  An example would be prescribing generic drugs instead of brand name ones.  It is wrongly assumed that generic drugs are somehow inferior to brand name drugs, at least when it comes to chemical entities (the situation with biologics is more complex).  Generics have to prove their safety and equivalence to branded drugs before the FDA approves them and there is no reason to prescribe expensive brand names while cheaper alternatives are available.

My last comment is to exhort physicians to take back the practice of medicine.  To take it back to an era where physicians were respected and the profession was an honored one.  To take it back from bureaucrats, lawyers, and insurance company executives whose short term vision is dangerous to patients and the field of medicine.  In short, physician, heal thy profession.