"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.
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.