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The Top Ten Things Wrong with Medicine


Someone outside the medical industry recently asked Jeff Brown, MD, "What's wrong with medicine?" He came up with a whole list of interrelated issues that have contributed to the mess health care is currently in.

A civilian (non-medical) asked me recently "What's wrong with medicine?"

Aside from his apparently living under a rock, I was temporarily at a loss because there is such a long, complex list. But after giving it some thought, I decided it might be useful to utilize a long list to help me get my head around the interrelationship of issues involved.

See if you agree, disagree, have any additions or modifications and a different rationale for the order I have chosen.

The first strike on my list, because it has forced the on-going discussion and because it is the most directly relevant to PMD, is the high cost of health care in America. One can argue that there is no better use of a society's resources than the health of its citizens, but every person in America is a skilled shopper and you don't have to have an MBA to realize that health care is a poor "value proposition," as the jargon goes.

There is poor transparency, poor accountability, inadequate outcome information and "shopping around," the great American sport, is an exercise in apples and oranges when it comes to healthcare.

The next nexus of dysfunction is in communication in all directions, even in this internet age. Overtaxed docs can't keep up with new and established best practices. Also, docs do not talk to docs nearly as well as patients think they do, or certainly should.

Everyone knows that docs are, even today, still relatively deficient in communicating with our patients ("Hey, not me!" you say. Hah!). And lest we forget, patients are generally terrible at communicating with their doctors. There is plenty to chew on here.

Of course American health care in its many iterations was never a planned exercise, like Topsy in "Uncle Tom's Cabin," "It just growed." It grew to the unintended and grossly inefficient monster that it has become today. For you younger docs, Google "Rube Goldberg Machines.”

The fact that employers get between patients, insurers and docs is another unplanned nightmare, historically resulting from the temporary labor shortage and wage freeze of WWII. This time was then followed by the rapid growth of the burgeoning middle class, which piled on more and more coverage when it was cheap.

Now business can't politically get out from being between the patient and health care services, but every single business, big and small, Obamacare or not, would love, love to do it immediately. Profits would soar.

Part of this structural problem is the concomitant explosion in the wealth and power of the insurance companies who took advantage of the aforementioned developments to grow exponentially.

To top off and accelerate the whole jury-rigged mess is the tax deduction for health insurance. This alone pretty much ensures that there will be minimal customer scrutiny of costs. And these last two factors alone have unintentionally, and geometrically, expanded the original, casual and local fee-for-service system to the bloated monster that is driving costs along like tumbleweeds in front of a storm.

As economists would say, the incentives in our modern high-tech medical world are all wrong. We end up paying for more and more, because we can, with too-little self-regulation or self-restraint. Fee for service is a big part of the cost and complexity problem to be solved.

In part because of the poor transparency and accountability ("The insurance will pay for it!") in the health care arena, a systemic lack of emphasis on personal responsibility has allowed it to wane. Patients are more uninformed and less personally responsible than they could be. If you guesstimate that half of what makes us sick and kills us is our own doing, you can readily see we could drastically cut morbidity and death rates by living in healthier ways. To be fair, docs, too, have individually and collectively, in many of our organizations, abrogated our implied leadership in responsibility for the flow of health care dollars that come out of our pens.

We are now at, or past, the standard 10. But I still have a longish list of other failings in health care in America, so I will carry the theme along to next week's rant. If this is all too loud and too fast to be completely rational, keep in mind that we are immersed in these issues every day and it really does help to stop once in a while and try to sort it all out. There's just so much.

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Victor J. Dzau, MD, gives expert advice
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