Diagnosing And Curing Health Care System’s Ills

Driving home March 29, I heard Tom Ashbrook introduce Dr. Nortin Hadler, author of "By the Bedside of the Patient," on his radio program, "On Point."

The host quoted from the book, which describes "the evolution of the health care system from a cottage industry to a conglomerate of patient care assembly lines, turning caring professionals into time-clock providers marching to the tunes played by bloated overpaid administration wedded to a flawed approach to optimizing cash flow. The result is a nation peppered with self-serving, lumbering, costly institutions that play a small role in fostering the public welfare and a large role in rifling the public coffers. They are ethically bankrupt, highly leveraged houses of cards."

Whoa!

I loaded the book into my Kindle and have now read it twice, trying to absorb the author's perspective. It spoke to me as a surgeon with 36 years of experience in trying to understand where the profession I love is going as we attempt to address its shortcomings.

As the book details, this evolution predates the Affordable Care Act (aka "Obamacare"), which tries to achieve the triple aims of improved access (universal coverage?), improved quality and decreasing growth in expenditure. But many of the new regulations - particularly misguided quality metrics and "meaningful use" incentives - have exacerbated the headlong rush to a dystopian future.

The author is a Harvard-trained rheumatologist and molecular biologist who recently retired after a long career as a distinguished clinician and clinical educator on the faculty of the University of North Carolina, Chapel Hill. He has written seven books, including "Citizen Patient," "Worried Sick," "Stabbed in the Back" and "Rethinking Aging."

He may be guilty of romanticizing the doctor-patient relationship and his own training, steeped in a tradition that fostered dedication to a humanistic approach. But his primary message is that humanism is no longer valued in the brave new world of big data and evidence-based medicine, and this change is destroying the soul of health care.

This is a vitally important concern. Dr. Hadler has long been a critic of "overtreatment." He describes the evolution of the American health care system from individual practitioners and hospitals - that did little but allow patients to rest and escape the environment that quite possibly was responsible for their illness or, at the very least, was contributing to it - to the cathedrals of science and technology of today.

The institutions are now coalescing into megasystems involved in an ever-accelerating arms race to provide CT scans, MRIs, linear accelerators, gamma knives, cath labs and interventional units with stents for every artery from coronary to aorta, not to mention the latest generation surgical robot.

He questions the overuse of medications, antibiotics, proton pump inhibitors (Nexium, etc.) and statins as well as technology and procedures. With all this new technology and wonder drugs, and now with the dawning of genetic engineering and precision medicine, the spiral is accelerating. All this and the ever-increasing administrative costs are unsustainable.

"In By the Bedside of the Patient," Dr. Hadler is critical of the politicians, their policy-wonk advisers, hospital and insurance administrators and "reformers." I want to believe the latter are well-intentioned but I fear, and the author appears to be convinced, that they are motivated by profits. He paints "a dismal even lurid picture" of how more of our increasingly scarce resources - both capital and manpower - are wasted on increasing documentation, data collection and overpaid administration rather than spent on direct patient care.

He eloquently challenges the promise of big data and evidence-based medicine's ability to improve outcomes. He dissects the Libby Zion tragedy in New York Hospital that led to work-hour restrictions for residents and medical trainees, explaining why the restrictions did not have the desired effect of improving patient safety. He addresses the related issue of medical errors, recently in the news as the third-leading cause of death.

He also challenges the currently popular "systems" approach to address these very serious issues. He convincingly explains how these solutions have proved ineffective, if not counterproductive, and makes the case for the primacy of the individual doctor-patient relationship. "The entire effort is a pall over the clinical area. It is yet another layer of obstruction between a patient seeking rational care and a doctor who wants to provide it," he writes.

He is especially critical of electronic medical records whose focus on documentation of extraneous data and user-unfriendly interface make it more difficult for all providers - physicians, nurses, physician assistants - to spend the time necessary time to listen to and understand the whole patient, which is essential for good care. He calls implementation of the electronic privacy information center "theatre of the absurd," an "outrageous misguided exercise" and "the straw that may break the back of America's perverse health care system."

He acknowledges that health care system was unsustainable and in desperate need of overhaul. "It was clear that prior versions of American medicine had too many flaws to bemoan their passing. And it was clear that American realpolitik would not countenance a national health insurance scheme. ... The hope was in finding a way to re-establish the patient-physician relationship at the center of American medicine."

The challenge, as I see it, is for all health care professionals in cooperation with their patients, the population at large, to acknowledge these problems and demand they be addressed. It's a small, seemingly insignificant, but essential first step.

Edward T. Chory, M.D., is a general surgeon who feels blessed and privileged to have cared for so many patients in Lancaster over the last 25 years.