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Let’s not steer our medical students toward cynicism


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Dear Students of America’s Medical Schools:

You may have noticed a recent viewpoint article from Senators John Barrasso and Tom Coburn regarding their opinions regarding the Patient Protection and Affordable Care Act (ACA).

If you take away only one insight from this article, let it be this: the Senators are ignoring or simply do not see the very serious problems facing our health care system, and the potential solutions to our problems. They still persist in the provably false assumption that America has the best healthcare system in the world. No amount of studies, no amount of data, no amount of reasoned argument will dissuade them from this. Major international studies have shown that we routinely do poorly in virtually every measure of health care available to us, including life expectancy, survival from preventable deaths, infant mortality, chronic disease management, and on and on. Our system is wildly inefficient, fragmented, inconsistent, and rationed – often cruelly and severely – based on income and insurance status. As Don Berwick has said, you cannot claim that high quality, efficient health care cannot be delivered at low cost – for it is being done around the world, year in, year out.

This does not mean that America does not have the best healthcare in the world much of the time. America has the best system of “rescue care” in the world, but I think it is safe to say that most Americans would prefer to have the best overall health care system in the world, wherein illness is either prevented or caught early and managed effectively and continuously so that we have the best chance of living long and healthy lives. We have incredibly intelligent and dedicated professionals working in our health care system, and make no mistake – they are in many ways the best in the world. However, relying on expensive treatments and procedures to get the horse back in the barn, when other countries focus their efforts on keeping horses in the barn in the first place is why America spends about twice as much on health care as any other country in the world and gets results that are mediocre, at best.

Fortunately for America, you know better. Medical students are not training in wealthy practices, comforting the comfortable. America’s medical students are serving in underserved areas, learning about the plight of rural and urban patients, with and without insurance, and you can see the difference.  You have probably already seen tragedies like I have, of cancers diagnosed too late, medications not taken due to cost, illnesses not addressed because of insurance concerns, leading to untimely deaths and illness requiring hospitalization and intensive care. Consequences like these are a direct result of the system being so ardently defended.

As best I can tell, the Senators’ arguments boil down to this: most American doctors are doing just great, except for that darn government insurance, so why do we want to rock the boat?

It seems that their greatest fear may be of the independent payment advisory committee created in the new law. Not to put too fine a point on it, but if you are an orthopedic surgeon or an obstetrician making three or four or five or six times more than a primary care physician, you may have reason for concern from an independent payment advisory committee. Reimbursements, up to now, have been largely determined by a specialist dominated board that emphasizes and rewards specialty and procedural care at the expense of primary care. So if you’re a medical student who wishes to practice primary care and not be treated as a fourth class citizen in the world of medicine, and have student loans that you wish to have paid off before your children go to college, you may welcome it.

We physicians are in the top 2% of all American wage earners, and this will not change as a result of the PPACA. In spite of the insinuation from the Senators that we will all be made paupers, we will all continue to do very well for ourselves and our families.

We have the added privilege of being considered healers, and patients confide in us their deepest secrets and trust us with their lives.  No amount of money can replace the satisfaction I derive from being a positive influence in my patients well being.

Another interesting concern the express is for “cookbook medicine.” Now, I am as old a dog as these gentlemen, but I have been paying attention to the patient safety movement and the patient centered care movement and the evidence-based medicine movement, and I know that what they call “cookbook medicine” is actually rational, evidence-based, safe care. The obverse of cookbook medicine is mindless variation in the practice of medicine, where physicians order whatever they want whenever they want based on their training, regional practice variation, or whim. This is bad medicine. They fret about protocols and standards of care when we know that the rationalization and regimentation of care is one of the true breakthroughs taking place in American medicine this century. A recent article in Health Affairs found that over 60 percent of Americans supported the use of comparative effectiveness research to provide information about whether a given treatment works better than alternative ways of treating a patient for the same condition, and believe that there should be warning labels on treatments that are not supported by scientific evidence.

They also fret about the pilot programs in the new Affordable Care Act. And yet, if it weren’t for “pilot programs”, how would anything in medicine be advanced? A pilot program is simply another name for an experimental protocol. Perhaps the Senators believe they have all the answers and know exactly what will work in the future, I don’t think the rest of us claim this. As Atul Gawande pointed out in a New Yorker article last year, the process by which medicine will advance will probably be quite analogous to the way agriculture advanced at the beginning of the last century. Pilot programs were implemented, those that worked were propagated around the country, and those that failed were allowed to die off.

It is also interesting that the Senators are so greatly concerned about Medicaid. Medicaid has been woefully underfunded and unable to provide the aggressive preventive and chronic care needed to effectively manage patients’ needs. The fact that half of physicians are not willing to take Medicaid patients has little to do with the Medicaid patients themselves, rather it has to do with the unconscionable underfunding of the program. When, in many of the largest states, reimbursement for Medicaid is only about 30 cents on the dollar compared to Medicare, there is a problem. And yet, including a robust public option in the ACA may have provided a vehicle to remedy some of this, and both Senators opposed it. Certainly, allowing the states to underfund at will and even further degrade the access to care of Medicaid patients would be a tragedy. Medicaid is a tremendously important pillar of American health care, and a vital component of our health care safety net.

We do agree on one thing, however, and that is the vital importance of the physician-patient relationship. This will not be impaired by PPACA, but enhanced. The doctors worry about government interference in this relationship. Those of us in practice know that the real danger to the relationship is private health insurance companies. The PPACA does not go far enough, as far as I am concerned, in addressing this, but the inherent conflict of interest between making a profit in direct proportion to how little is spent on actual patient care is unacceptable. Virtually every country in the world has looked at this relationship and declared it unacceptable. We have not yet done this, and so individual insurance companies continue to harass physicians with paperwork, phone calls, and a hassle factor unmatched anywhere else in the world. Two Health Affairs articles last year looked at this and found nearly 14% of physicians income is drained by dealing with private insurers, along with requiring 35 minutes PER DAY of doctor time and 2/3 of a full time employee PER PHYSICIAN!. We become physicians so we can care for our patients, not to waste our time struggling with unnecessary red tape and fragmented care.

Perhaps the most important enhancement to the special relationship is the PPACA’s promotion of primary care. Enhancing primary care through increased reimbursement, emphasis on patient centered care and promoting medical homes will all improve the physician patient relationship. Focusing on outcomes and communication in primary and specialty care are all to the good.

So, in summary, the Senators are hoping to convince you that healthcare is under attack. Far from it, unless you count those seeking repeal of the law. For only the second time in my lifetime, the first being with the introduction of Medicare, Americans have taken a bold step to improve the health care of all Americans. Let us strengthen it together.

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