Stanley Feld M.D.,FACP, MACE

Trust is confidence in the honesty or integrity of a person or thing. An example of trust is the belief that someone is being truthful.

 The world is complex. As individuals we cannot know and do everything. We must assign surrogates to express and carry out our will.                                                           

We must trust those surrogates. When those surrogate seem to deceive us we distrust them.

In the past six years Americans’ trust in their leaders has been eroded.

It seems that our government surrogates have tried to deceive us over and over again. I have discussed almost all the instances the Obama administration has deceived the American people with respect to Obamacare i.e “If you like your doctor you can keep you doctor” to name one.

The State Department has deceived us about Benghasi and with the outlines of the nuclear agreement. The Clintons have deceived us with their Clinton Foundation donations and the perception of undu pedaling of influence.

The result is public distrust of our institutions and each other. They have promoted distrust and  media is the message.

Atul Gawande M.D., a surgeon and public-health researcher, became a New Yorker staff writer in 1998. He contributed greatly in the public healthcare arena in 2007 making surgery safer by creating a pre-op, inter-op and post-op surgical checklist.

He has also created a checklist for delivery of babies in under-developed countries. These checklists have decreased morbidity and mortality.

I am a Gawande fan. He is a good thinker. However, in my view, he has a few blind spots. These blind spots showed up in his most recent article “Overkill.”  

Dr. Gawande’s problem is that even if his observations are somewhat correct they are not universally valid. He proves that his observations are not totally correct as he describes his approach to clinical practice.

His approach to clinical practice is to do less, not more. However, he does not consider the potential unintended consequences of doing less.

Most of his writings in the New Yorker criticize physicians and their practice of medicine.

 The articles could be interpreted as an attack of practicing physicians’ care. It could erode consumers’ confidence in their physicians causing them to mistrust all physicians and their clinical judgment and advice.

 Dr. Gawande should reexamine some of his premises. He should focus on educating both consumers and physicians as he did with his surgical checklist.

 Yellow journalism does not solve the healthcare system’s problems. It creates greater problems.

 In this New Yorker article his blind spot is well illustrated. He initially quotes Kenneth Arrow an economist who in 1963 won a Noble Prize in Economics for describing a vital problem economic call “information asymmetry.”

“There is a severe disadvantages that buyers have when they know less about a good than the seller does.”

Kenneth Arrow pointed out that the prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting.”

Kenneth Arrow is absolutely right. Since 1963 many industries have worked to solve this problem of information asymmetry using the Internet to make consumers Prosumers.

Physician leaders knew Arrow was absolutely correct. Some have tried to correct the situation through patient education and the developed System of Care through the use of Chronic Disease Treatment Teams.

To me this represents a constructive approach to information asymmetry in the healthcare system rather than the approach of stimulating consumers to mistrust their physicians.

There is a simple solution. Patients must be empowered to understand their disease and the options they have for treatment. They must also take responsibility for their care.

The American Association of Clinical Endocrinologists initiated the team approach for the treatment of Diabetes Mellitus in the 1990’s. It was called “A System of Intensive Self-Management of Type II Diabetes Mellitus.”

Teaching patients to intensively control their own blood sugars and helping patients become the “professor of their disease” can decrease the complication rate by at least 50%.

The complications of diabetes result in 80% of the cost of diabetes to the healthcare system. Managing Diabetes Mellitus correctly also decreases the pain and suffering resulting from this devastating disease.

It took twenty years for the government and the healthcare insurance industry to support this notion of chronic disease management.

AACE wrote guidelines outlining the development of Diabetes Education Centers wherein patients with diabetes were the center of the Diabetes team with physicians being the coach of the team and nurse educators, dieticians, exercise therapists, psychiatrists or psychologists being the assistant coaches and an extension of the physician’s care. 

“A System of Intensive Self-Management of Type II Diabetes Mellitus.”

It is critical patients take responsibility for their diabetes care.  They must not be passive about their treatment. They must judge the quality of their treatment. If it is not excellent they need to move on. The problem might be that the patients’ healthcare plan will not permit the patient to choose those physicians and care provders in Obamacare.

Consumers have abrogated their responsibility for their treatment and the cost of their treatment to a third party. This problem originated when they were able to buy first dollar healthcare insurance coverage. Consumers were not and are still not at financial risk even though their health is at risk.

This system of disease management demands that patients become responsible for the management of their disease.

Our health is our most valuable asset. We must be responsible for our health.

Obamacare’s health insurance exchanges continue promote the same defect in our healthcare system.  It does not encourage patients to be careful about healthcare dollars or the responsibility for their healthcare.

“Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”

Please note that Gawande indicts physicians in his second sentence for recommending care of little or no value because it enhances income.

In fact ordering a CAT scan, MRI or lab work does not enhance physicians’ income unless the physicians own the machinery. Hospitals and independent testing centers own the machinery to do these tests and make the profit. Therefore his reason for “Overkill” is not primary.

Dr. Gawande goes on to expand Professor Arrow’s argument about over-testing in a system of “information asymmetry.”

“Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body.”

“The United States is a country of three hundred million people who annually undergo around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests.”

New technologies have ben a boom to the practice of good medical care. It could be argued that someone getting hit in the head and developing a long lasting headache should get a CAT scan or MRI of the brain rather than pre MRI, CAT scan era, a skull x-ray that would tell us almost nothing.

Perhaps the unnecessary care is not so unnecessary. Perhaps it is important to know the baseline study results of tests to understand the progression of an illness and controlthrough blood testing.  

There does seem to be too much testing. What might be the cause?

Dr. Gawande overlooks a very important cause of over-testing.

It is defensive medicine. Physicians are afraid of getting sued in our litigious society if they miss something. The Massachusetts Medical Society study brought out this very important point. Physicians by their own admission over-test to avoid missing an underlying disease.

A rough estimate of the cost of over-testing in America is between $200 billion to $750 billion dollars a year as a result of defensive medicine.

Dr. Ezekiel Emanual, an advisor to President Obama, has stated that the healthcare system does not need malpractice reform because defensive medicine only cost the system $25 billion dollars a year. The cost is insignificant. He is dead wrong. He is also immune to law suits because of institutional protection. He does not appreciate the wear and tear on the physicians being sued.

As Obamacare makes the healthcare system more dysfunctional consumers have less responsibility for their healthcare. A system of socialized medicine is evolving as a result of Obamacare. The government takes care of us. We all know that Medicare is unsustainable. Intelligent well-respected folks like Antul Gawade use questionable logic to unintentionally erode peoples’ trust in physicians and their judgment.

Meanwhile taxes continue to rise and America is digging itself into a deeper financial hole.

The question should be how do we do things in a constructive  rather than a destructive way.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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