Embracing science but reliquishing the soul

Jerome Groopman writes in the New York Review of Books that our fascination with technology and the commodifying of the practice of medicine may be stripping it of its human element:

At the conference, an animated discussion followed, and I heard how changes in the culture of medicine were altering the ways that the young doctors interacted with their patients. One woman said that she spent less and less time conversing with her patients. Instead, she felt glued to a computer screen, checking off boxes on an electronic medical record to document a voluminous set of required "quality of care" measures, many of them not clearly relevant to her patient's problems. Another resident talked about how so-called "work rounds" were frequently conducted in a closed conference room with a computer rather than at the patient's bedside.

During my training three decades ago, the team of interns and residents would move from bedside to bedside, engaging the sick person in discussion, looking for new symptoms; the medical chart was available to review the progress to date and new tests were often ordered in search of the diagnosis. By contrast, each patient now had his or her relevant data on the screen, and the team sat around clicking the computer keyboard. It took concerted effort for the group to leave the conference room and visit the actual people in need.

Still another trainee talked about the work schedule. Because chronic sleep deprivation can lead to medical mistakes, strict regulations have been implemented across the country to limit the amount of time any one resident can attend to patient care. While well intentioned and clearly addressing an important problem with patient safety, the unintended consequence was that care became more fragmented; patients now were "handed off" in shifts, and with such handoffs the trainee often failed to learn how an illness evolved over time, and important information was sometimes lost in the transition.

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But only recently has medical care been recast in our society as if it took place in a factory, with doctors and nurses as shift workers, laboring on an assembly line of the ill. The new people in charge, many with degrees in management economics, believe that care should be configured as a commodity, its contents reduced to equations, all of its dimensions measured and priced, all patient choices formulated as retail purchases. The experience of illness is being stripped of its symbolism and meaning, emptied of feeling and conflict. The new era rightly embraces science but wrongly relinquishes the soul.

More here. Indeed, the "management economics" people that Groopman mentions are the operations researchers I wrote about in my last post -- these practitioners continuously focus on "costs", "throughput", "bottom line". They are trained that way, and sometimes the constant use of a particular type of language -- despite the best of intentions -- can in fact change one's worldview.

Other healthcare pieces: Reforming Healthcare in the United States; Healthcare Costs: The Atul Gawande New Yorker essay. And Pauline Chen writes about mindfulness in medicine.

Reforming healthcare in the United States

I've reproduced the content below from a page that I recently created on my website. Some of the links here have been discussed in earlier posts. Feel free to voice your opinion.

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By all accounts, the United States healthcare system is in crisis. We hear this every day: some 45 million people are uninsured; hundreds of thousands go bankrupt every year because of medical bills. Everybody agrees the current system is dysfunctional. But the solutions are contentious and divisive. Should government play a greater role by introducing a public insurance option in addition to Medicare and Medicaid to cover the uninsured? If everyone is going to be insured, where will the money come from? These questions elicit shrill noises from both extremes of the political spectrum. And there's the question of culture, culture of the nation -- that ambiguous but all-too-influential presence in the background. Mention 'government' in connection with US healthcare and the term 'socialized medicine' will follow like a stigma.

My intent in creating this page was to aggregate content from the internet pertaining to policy issues in US healthcare. This is a daunting task of course, and I am no expert. But in the process of teaching a healthcare class last spring, I came across essays, documentaries, radio clips that I'd like to share. Email me if you think there is material that should be added.

I.

The PBS Frontline documentary Sick Around the World compares the health systems of developed countries -- Britain, Japan, Germany, Taiwan, Switzerland -- and reveals the glaring flaws in the US healthcare system. Three key shortcomings emerge. In the countries listed above 1) No one with a pre-existing condition is denied insurance 2) Everyone is covered one way or another 3) Pricing mechanisms are transparent and nobody goes bankrupt because of medical bills. Are these basic things too much to ask in the United States? Sick Around America, another PBS Frontline documentary, focuses on the shortcomings of the American health insurance industry.

II.

It is true that European nations have a much better universal care record. But history played an important role in shaping the insurance structure of these countries. The national health systems of Britain and France emerged as a result of the devastation wrecked by the Second World War. Switzerland, because of its wartime neutrality, took the private insurance route before opting for reform in the last decade. Surgeon and writer Atul Gawande says in Getting There From Here that the experience of the United States is different and that difference must be acknowledged. Hence piece wise reform of healthcare, by building on what currently exists currently in the US, is better than a radical overhaul based on models elsewhere.

III.

Healthcare insurance reform is not healthcare reform, although the two are related of course. True healthcare reform is possible only if costs are brought under control. Atul Gawande explains why healthcare costs are ridiculously high in the United States. Technology can collude with strange monetary incentives to increase health care costs and reduce the quality of care. Physicians are leaning towards more tests, more scans, more surgeries -- all of which generate revenue -- when simpler wait-and-watch alternatives would have been preferable. And there is no conspiracy here: the system in the United States seems to have subconsciously evolved this way because of the incentives in place. Gawande travels to the city of McAllen, Texas and finds that the over utilization of medical resources has sent costs skyrocketing. Only by trimming the fat from the system will Obama be able to finance healthcare reform.

IV.

David Ignautius argues that Denise Cortese, CEO of the famous Mayo Clinic, should be made "medical commander" of Obama's health reform initiative. Cortese's message is similar to Atul Gawande's: Health insurance reform is necessary, but true reform is possible only if medical practices are paid for value (outcomes, safety and service) rather than for the number of services provided. Peter Ubel, a primary care physician, says yes, we must change how we pay physicians, but we must also change how much they are paid in the United States. Certain types of specialty physicians have disproportionately high incomes. Unfortunately, this is an issue no one is willing to tackle politically.

V.

Princeton economist Uwe Reinhardt talks with Terry Gross (NPR) about the lack of transparency in healthcare pricing. Each hospital may negotiate a different rate with a different insurance company for the same service; and the prices are kept secret. Indeed, there may be a tenfold difference in prices because of this secrecy. Hospitals have to hire an army of hagglers to negotiate and keep track of prices. This hikes up administrative costs. In other developed countries, pricing is not this opaque.

Reinhardt also discusses the feasibility of a public, Medicare-like insurance option for the uninsured. The private insurance companies don't like this, because they fear they will no longer be able to complete with a government run option that enrolls millions and sets its own prices. Paul Starr, author of the famous 1984 book, The Social Transformation of American Medicine, weighs in with pieces in the American Prospect: Sacrificing the Public Option and Perils of the Public Plan. Finally, this essay in The New York Review of Books discusses the messy political process underlying healthcare reform; and Bill Moyers of PBS interviews scholars and policy experts on various aspects of reform.

Healthcare costs: the Atul Gawande New Yorker essay

Do expensive state of the art medical facilities correlate with better health outcomes? In this superb essay, surgeon and writer Atul Gawande tells us how, in certain places in the United States, technology can collude with strange monetary incentives to increase health care costs and reduce the quality of care. Physicians are leaning towards more tests, more scans, more surgeries -- all of which generate revenue -- when simpler wait-and-watch alternatives would have been preferable. And there is no conspiracy here: the system in the United States seems to have subconsciouly evolved this way because of the incentives in place. Atul Gawande travels to the city of McAllen, Texas and makes the argument that the overutilization of medical resources has sent costs skyrocketing. And he tells us that only by trimming the fat from the system will Obama be able to finance healthcare reform.