when health care becomes personal by

When Health Care Becomes Personal

By Arnold Kling

"Despite a rapidly growing elderly population, the number of

certified geriatricians fell by a third between 1998 and 2004.

Applications to training programs in adult primary-care medicine

are plummeting, while fields like plastic surgery and radiology

receive applications in record numbers. Partly, this has to do with

money-incomes in geriatrics and adult primary care are among the

lowest in medicine. And partly, whether we admit it or not, most

doctors don't like taking care of the elderly."

--Atul Gawande

Over the past eight weeks, I have been spending a lot of time with my

father, who has developed some acute medical problems. For the most

part, my focus is day-to-day (or hour-to-hour) on the issues and

stresses that arise.

But I have also come around to some different points of view about our

health care system. I no longer think of Medicare and health care

regulation as inefficient. I now think of them as pure evil.

My Father's Case

My father has benefited from America's health care innovations and

research. He had heart bypass surgery 17 years ago. His use of diet

and medications to control blood pressure and an irregular heartbeat

have enabled him to live to almost ninety, whereas his own father died

of heart problems in his fifties. When told eight weeks ago that he

had terminal cancer, thinking back on his heart issues my father said,

"I'm lucky I've lasted this long."

In late November, my father started having episodes where he could not

eat without throwing up in the middle of a meal. His doctor sent him

for an endoscopy, which found an advanced malignant tumor in his

esophagus. The survival rate for esophageal cancer tends to be

extremely low, because it is rarely diagnosed early enough. In my

father's case, the cancer is viewed as inoperable. Instead, he

underwent a course of radiation.

On the evening of January 10, my father experienced severe pains near

his right ankle. The next day, he went to see his internist, who

diagnosed the problem as cellulitis, meaning an infection. He

prescribed antibiotics, and also sent my father for a precautionary

X-ray.

While standing near the entrance to the building for the X-ray, my

father slipped and fell, fracturing his hip. He was taken nearby to

the emergency room of BJC hospital in St. Louis, admitted to the

hospital, and operated on that Monday. His hip required a

reinforcement (screws) rather than replacement.

From an orthopedic perspective, he was supposed to begin

rehabilitation the day after surgery. However, the operation had

required stopping his heart medication, and his heart rate rose above

safe levels. He spent more than a week as a cardiology patient,

getting no rehab. Finally, he was transferred to the nearby St. Louis

Rehabilitation Institute. I believe that he has the strength to

eventually be mobile with a walker. However, statistically when people

his age suffer hip fractures, 25 percent of them never make it out of

the hospital, and with his cancer and heart problems he is probably

not above average for his age in terms of overall health.

Health Care Complaints

I do not expect health care to be perfect. I do not expect someone

with cancer to have an enjoyable experience. I am not threatening to

sue anyone, or even to suggest that the care my father received was

anything other than far above average. But I do think that there were

serious flaws, and that these flaws are systemic.

When Atul Gawande says that "most doctors don't like taking care of

the elderly," I think he is including my father's internist and

virtually every other doctor that he saw at BJC. None of the doctors

touched my father with their hands. Many of them used a stethoscope.

The internist looked at the cellulitis. Otherwise, they never examined

him. And each specialist was only concerned with his or her particular

area--the heart doctors only worried about his heart, the orthopedists

only cared that the screws were in correctly, the internist only

worried about the cellulitis. Nobody noticed problems with my father's

veins or his skin that were caused by having too many IV's and

spending too much time on his back.

I do not blame my father's internist for failing to detect the

esophogeal cancer earlier. However, it is a fact that for years my

father had been coughing after meals, and he had asked the internist

about this symptom. The internist treated it as an allergy.

I probably should not blame the internist for sending my father for an

unnecessary X-ray, on the way to which he broke his hip. But the X-ray

was unnecessary, because the internist already had made his diagnosis.

A Better Way

However, having seen the doctors at the Rehabilitation Institute, I

know that there is a better way to practice geriactric medicine. The

doctors there were hands-on. They changed dressings themselves. They

looked at his entire body. They took their time. They found a number

of problems that had slipped through the cracks of the specialists at

BJC. And they figured out why my father has difficulty with balance.

It really was quite simple. The doctor at the Institute held each of

my father's feet and asked him to make some specific motions. It was

obvious to me just watching that my father has some neuromuscular

deficits, which he has clearly had for at least a year. For example,

he cannot feel his feet well enough to control whether his toes point

up or down. These are issues that can be dealt with--but only if

someone knows about them. And doctors who do not like to touch old

people are not going to know.

The real key to preventing my father from falling and breaking his hip

would have been to identify and treat his deficits. But it takes a

hands-on doctor to do that.

Integrated Medicine

Our health care system is widely criticized for its fragmentation,

specialization, and lack of incentives for quality. For example,

Shannon Brownlee's highly-regarded book Overtreated makes a strong

case that specialist-driven health care is more expensive and less

effective than the best-of-breed integrated care systems. My guess is

that the Saint Louis Rehabilitation Institute comes closer to this

integrated care ideal than does its bigger BJC brother.

Atul Gawande points out the key issues with geriatrics. The elderly

are particularly ill-served by narrow specialists who deal with issues

piecemeal and in haste.

The Saint Louis Rehabilitation Institute offers a glimpse of a better

way to care for the elderly. There, more of the care is driven by the

needs of the patient than by the habits of specialists. However, best

practices, whether at that Institute or elsewhere, are not going to

spread to the medical profession as a whole. That is because our main

policy objective in health care is to insulate people from having to

pay for it.

Government is the Customer

When consumers are in the driver's seat, best practices tend to

spread. In a market economy, if you fail your customers, you go out of

business. BJC, which is regarded as one of the best hospitals in the

country, should go out of business. It should be driven out by

hospitals that function more like its subsidiary, the Rehabilitation

Institute.

Internists and specialists who do not like to touch old people should

be driven out of business. They should be driven out by hands-on

doctors and by gerontologists who take a more holistic view of

patients.

The reason that medical care works the way it does is that government

is the customer. Government pays health care providers for time and

materials. Shannon Brownlee and others believe that government could

come up with better compensation schemes that would help promote

quality. I doubt this.

Trying to influence medical care from a government bureaucracy sets up

a game between bureaucrats and doctors. The object of Medicare

Administrators will be to get the largest change in behavior with the

least increase in compensation to health care providers. The object of

the health care providers will be to get the biggest increase in

compensation for the least change in behavior. The health care

providers are bound to win. They control the information flows ("you

want to see reports that demonstrate quality? we'll give you reports

that demonstrate quality.") More importantly, they have the most

organized lobbyists, so that any "pay-for-performance" schemes that do

not work in doctors' favor will be shut down.

Medicare is wonderful for relieving the elderly from the burden of

worrying about health care expenses. By the same token, it is

wonderful for relieving doctors of the burden of worrying about the

elderly as customers. You get paid for understanding the billing

system, not for understanding your patients.

State and local governments do their part to harm our health care

system. Licensing regulations serve to entrench and protect the

specialist system and fragmented health care. In other industries,

business owners decide how to train their employees to do their jobs.

Competition leads firms to adopt training methods that foster customer

satisfaction. In health care, training methods are dictated by

government licensing boards, and they foster high prices and

inefficient staffing. A recent story tells you which side the

regulators are on.

Mayor Thomas M. Menino embarked on a highly public campaign

yesterday to block CVS Corp. and other retailers from opening

medical clinics inside their stores, an effort that exposed a rift

between Menino and the state's public health commissioner, a

longtime ally.

...The decision by the state Public Health Council, "jeopardizes

patient safety," Menino said in a written statement. "Limited

service medical clinics run by merchants in for-profit corporations

will seriously compromise quality of care and hygiene. Allowing

retailers to make money off of sick people is wrong."

In a separate letter, Menino urged members of the city's Public

Health Commission to consider barring the clinics from Boston.

I believe that our health care system could be a lot better.

Unfortunately, the politicians who claim to be our friends are in fact

our worst enemies.

Source

# posted by JR @ 12:25 AM

Comments:

Arnold,

I'm disheartened to hear your father is getting such sketchy care, but

not surprised. I hope you are able to find ensure that his doctors do

touch him, both physically and emotionally, and that they see his

ailments as part of the whole person. The geriatricians sound like a

great start. A palliative care doctor would also be a boon. These

doctors are trained to relieve pain, to coordinate care, and above all

to comfort.

I'm not sure that the difference between government and private

industry is the issue here. It's more a matter of the incentives for

physicians and hospitals, and how you measure their performance.

SOmetimes patients and their families can do the measuring, as you are

now, with your father's care. Sometimes not.

All best wishes for getting good care for him in the coming weeks or

months.

Shannon Brownlee

# posted by Anonymous Anonymous : 1:14 PM