The Sick State of Healthcare: Part I
"Practice two things in your dealings with disease: either help or do not harm." From the Hippocratic School, Book I, Epidemics
The industrial complex is a socioeconomic concept wherein businesses become entwined in social or political systems or institutions, creating or bolstering a profit economy from these systems. Such a complex is said to pursue its own financial interests regardless of, and often at the expense of, the best interests of society and individuals. (Wikipedia wikipedia.org)
I have become increasingly discouraged that the profession of medicine will not survive the business of healthcare. Healthcare has been co-opted by governmental and international agencies, the insurance industry, pharmaceutical companies, consolidated health care systems, technocrats and even the media to become an industrial complex in its own right. Most physicians, as well as other healthcare providers, and patients have become lost within that “complex” and are no longer the primary drivers of healthcare decisions. The following three examples help to illustrate this point.
A good friend of mine was scheduled to undergo a surgical procedure to manage an abnormality noted by her gynecologist on a pelvic ultrasound. She has known and been cared for by this physician for over 20 years. She respects and trusts him. My friend had to plan time off from work and just as importantly had to prepare herself mentally to undergo surgery. Giving up control to another is not easy for most people, and when someone has to undergo a general anesthetic for surgery they are relinquishing control. It is a part of the process and it is stressful.
Imagine her dismay when she was contacted by her doctor’s office late on Friday afternoon and was informed that the insurance company had refused to “okay the procedure”, which had been scheduled for Monday morning. Let that sink in. The insurance company refused; refused, and were unavailable over the weekend, thereby ending any possibility of an appeal to proceed as planned. Their protocols required that further testing needed to be performed before they would “give their blessing”. The details of her story are not mine to tell, but as a physician I understand the indications for the proposed surgery, that it was medically appropriate, and that sufficient information had already been provided to the insurance company. The interference of the insurance company into the care of this individual ended up costing more money for the system by requiring further clinically unnecessary testing, greater disruption to not only three businesses (hers, the physician’s and that of the independent surgical assistant), but also to the hospital operating room schedule and staffing, as well as unnecessary stress and delay in receiving the care indicated. Protocol based healthcare is now the norm where check boxes need to be clicked off in the “right sequence”; the experience of the physician and the wishes of the individual patient no longer matter.
A colleague sent me the attached photocopy of a section front page from the Denver Post from October 20, 2022.
Attention grabbing headlines aimed at the vilification of a profession are misleading and disingenuous. The article was written by Gina Kolata, a science and medicine reporter at the New York Times (NYT). Ms. Kolata’s story is about a professor of medicine at Harvard, Dr. Lisa Iezzoni and the study she co-authored. The purpose of the study was to evaluate how physician attitudes contribute to disparities in access to healthcare experienced by persons with disabilities. Their study abstract states:
People with disabilities face barriers when attempting to gain access to health care settings. Using qualitative analysis of three physician focus groups, we identified physical, communication, knowledge, structural, and attitudinal barriers to care for people with disabilities. Physicians reported feeling overwhelmed by the demands of practicing medicine in general and the requirements of the Americans with Disabilities Act of 1990 specifically; in particular, they felt that they were inadequately reimbursed for accommodations. Some physicians reported that because of these concerns, they attempted to discharge people with disabilities from their practices. Increasing health care access for people with disabilities will require increasing the accessibility of space and the availability of proper equipment, improving the education of clinicians about the care of people with disabilities, and removing structural barriers in the health care delivery system. Our findings also suggest that physicians’ bias and general reluctance to care for people with disabilities play a role in perpetuating the health care disparities they experience.
The study aimed to interview 3 groups of 8-10 physicians (22 physicians participated) by video conference. The physicians were either primary care physicians (PCPs) or specialists practicing in urban or rural settings. The groups were asked questions about their experiences caring for patients with disabilities, and people with disabilities were separately interviewed regarding their experiences. Details regarding the issues, difficulties and hurdles that often exist in caring for patients with disabilities were brought up by the physicians during the interviews. The authors concluded that physician bias and reluctance to care for patients with disabilities was a significant element in perpetuating the discrepancies. The study had numerous limitations, many of which were acknowledged within the report itself: the small number of participants, as well as the process used to recruit the participants, and the survey methodology. The study recognized these issues, and also noted that there are significant barriers to care not physician specific. Those parts of the study were certainly deemphasized within Ms. Kolata’s piece in the NYT. As for the headline, it was purely inflammatory.
Barriers to accessing optimal care for people with disabilities do exist. The truth of the matter is that challenges exist in providing care for most patients. The healthcare industrial complex does not like to recognize the differences in people. The “complex” rarely accounts for space, time or resource differences required for various patients let alone those with disabilities.
Exam rooms, as an example, are generally all the same size with the same equipment. If you are of the “standard size and weight”, the exam tables are easily accessible, although still not comfortable. For some patients with disabilities, or those of advanced age, getting up onto the standard exam table is not even an option. When planning and building clinic space, conformity is the norm. Physicians frequently ask for different types of exam tables, larger rooms or specialized rooms to accommodate patients. These requests are generally ignored unless the modification supports the growth of a well reimbursed practice type which is profitable to the system, such as a bariatric surgery practice tailored specifically to the needs of obese patients.
Beyond the physical barriers, more and more physicians, and other healthcare providers, are constrained by set schedule times and productivity targets. The number of patients seen during a physician’s day becomes the metric. Disruptions to a tightly managed schedule are not tolerated by the “complex” as profit trumps care. Quality and compassion, once goals of the profession of medicine, are given lip service by the industry. Sadly, physicians learn that the main incentive is now productivity.
Serious solutions will require acknowledging that barriers exist, identifying those barriers for both the patients and physicians and then instituting the required modifications for success. These solutions may vary by practice type, community, etc., but they all require that the voices of the participants, both patients and physicians, are not only at the table but actually heard. Rather than acknowledging these points, the headline and Ms. Kolata’s piece are more interested in generating clicks and views; what better way to achieve their metrics than by maligning physicians as the problem. The NYT’s “all the news that’s fit to print” has sadly become “all the rhetoric fit to inflame”.
The initial Covid-19 response by healthcare workers, along with other frontline workers, was selfless and inspiring. However, as the pandemic lingered the humanity of some became too easily lost to the drumbeats of the healthcare industrial complex.
It was easy to understand in the first months that extreme caution was warranted. By the fall of 2020, however, data from around the world was available for analysis; the high mortality from the disease primarily affected the elderly and those with co-morbidities. The Great Barrington Declaration (GBD) was authored by Dr. Martin Kulldorff, Dr. Sunetra Gupta, and Dr. Jay Bhattacharya and signed on October 4, 2020. These three physicians worked at Harvard, the Karolinska Institute in Sweden and Stanford respectively. All three have a focus on infectious disease, and are respected experts in epidemiology (a cornerstone of public health). They noted at that time that the data from around the world showed the risk of death was a thousand-fold higher in the elderly and those with significant other illnesses compared to the young.
In Sweden, where day-care and schools were kept open even through the height of the pandemic, there were zero deaths from Covid-19 amongst the children. The recommendation of the authors of the GBD, one that was supported and signed by many physicians and scientists from around the world, was to allow the young and the healthy to return to normal activities and to protect those that were most vulnerable: the elderly and those with other health issues. Theirs was a focused approach, rather than a blanket policy; one based upon historical experience with current data to support. They warned about the negative physical, mental, educational and economic consequences of lockdowns. Instead of allowing dialogue and robust evaluation of data, and possible changes in policy as appropriate, these three respected physicians were shut down. Literally, shut down. Four days later, on October 8, 2020, an email from then Director of the NIH, Dr. Francis Collins, to Dr. Anthony Fauci, Director of NIAID (National Institute of Allergy and Infectious Diseases) reveals this black listing:
Hi Tony and Cliff,
See https://gbdeclaration.org/. This proposal from the three fringe epidemiologist who met with the Secretary seems to be getting a lot of attention-and even a co-signature from Nobel Prize winner Mike Leavitt at Stanford. There needs to be a quick and devastating published take down of its premises. I don’t see anything like that on line yet-is it underway?
Francis
Fauci responded with an email that referenced a piece from Wired that he stated “debunked this theory”. Follow-up comments from Collins and Fauci in interviews over the next several days to weeks, along with suppression of the GBD on social media and in the press effectively removed the topic from debate and the lockdowns continued.
Example #3 is troubling because although cloaked in “follow the science” chants and yard signs, the approach did exactly the opposite. It ignored and suppressed data and therefore science was not allowed to be science. It is a problem when the approach to management of disease becomes primarily political and/or controlled by the interests of the healthcare industrial complex. Sweeping declarations and policy decisions, some of which placed the most vulnerable into higher risk situations, were misplaced, often tyrannical in nature and rarely based in actual science.
The prolonged lockdowns had very real consequences for individuals and the population as a whole as warned by the authors of the GBD. Consequences which included delays in diagnosis and treatment of other medical conditions, and people being separated from their loved ones during vulnerable and precious times. Whether unable to be at the death bed of a spouse or parent or to provide comfort to a loved one, or to have grandchildren visit their grandparents responsibly; sacrifices were mandated. Stories abound of losing precious moments with family and friends. Time lost and experiences missed are heart breaking for many reasons and ultimately those experiences are part of what forms our humanity.
Too many physicians and healthcare providers were too willing to follow the mantra from the “complex”. Signs of professional acquiescence could be seen in various topics including:
The significance of natural immunity.
The potential role of oral medications such as Hydroxychloroquin or Ivermectin.
When to mask or not.
The essential nature of liquor stores and pot shops.
Rather than the usual scientific rigor analyzing data and encouraging open dialogue, a cornerstone of science, too many in the medical community accepted the proclamations from “on-high” without questioning the scientific validity. What happened to the once normal curiosity of the physician mind?
Also troubling was the increasing censorship of physicians that did speak contrary to the message of the “complex”. The concept of protective benefits of natural immunity acquired from infection with Covid or discussion of referenced studies that showed a positive benefit to the use of off-label medications, such as hydroxychloroquine and ivermectin in the out-patient setting, were ridiculed rather than discussed in earnest. The inconsistent messaging from the “complex” regarding when to mask, who should mask and what type of mask added to the fear and misunderstanding. The idea promoted that masking to enter a restaurant was necessary but that it was safe to remove the mask to eat in that same setting was ludicrous and needed to be called out as such. Similarly, why pot shops and liquor stores were deemed essential but other small businesses were not defies medical reasoning.
Rather than being encouraged to search for answers, physicians were threatened, and still are, with the possibility of losing their hospital privileges or suspension of their state license. Most recently California Governor, Gavin Newsom, actually signed a bill into law which could result in a physician being suspended if a regulatory agency believes they are not adhering to consensus opinion and are therefore “spreading misinformation” regarding Covid-19. As the recent past has shown us, opinion is just that and may be in error. The travesty that follows this suppression of inquiry and disparate opinions is the loss of learning and future dialogue. Shockingly, the California Medical Association was supportive of this bill. It is a sad day for the profession of medicine when “oversight” is now wielded like a weapon, not for the purpose of better outcomes for patients or a stronger foundation for the profession, but to control the desired narrative from the “complex”.
The first two examples are indicative of how disruptive and detrimental the healthcare complex has become to the patient-physician relationship. The changes that have occurred over the last 100 years have taken what was once a special connection of empathy and mutual respect between patient and physician to a system increasingly devoid of relationships. Neither patients nor physicians are well served by this alteration and both feel as if they have become merely cogs in a wheel.
The third example exposes the willingness of some members of the profession to yield and be easily managed by the “complex”, and highlights what happens if physician leaders become key participants within the healthcare industrial complex and no longer represent the core values of the profession: compassion, excellence, collaboration, integrity, accountability, diversity and respect. Instead they have chosen control and profits over the health of people and the tenents of medicine.
How did we get here?