Stanley Feld M.D., FACP, MACE Menu


It Is All About How You View The Elephant


Stanley Feld M.D.,FACP,MACE

 I received the following comment from a reader. The comment is sincere, honest and heart felt. The dysfunction in the healthcare system affected his mother and father.   

 In the past, I have pointed out the sources of waste in the healthcare system. All the stakeholders are at fault. I have included physicians in creating waste. I have not included physicians as a primary source of the waste. Their waste is secondary cause to other dysfunctions.

“Dr. Feld,

 This is a blind spot for you and a blog that comes across as defensive versus simply acknowledging the role the Physician must play in reducing excess utilization. “

 There is no question that physicians’ delivery of medical care can be ineffective and dysfunctional creating waste.

 It does not follow that physicians are the primary source of waste. Physicians are convenient targets for causing the majority of the waste in the healthcare system because the medical interface is between physicians and patients.

 Sometimes patients have a horrible experience interacting with the healthcare system.

Most people (80%) are not sick at any given time. They are not interested in understanding the dysfunction in the healthcare system because they are well.

It is difficult for a sick person to navigate the healthcare system. When a person is sick they realize how inefficient the system is.  

 I have tried to emphasize how all the stakeholders’ incentives are misaligned. The results is this dysfunction. Physicians’ incentives are created by government, healthcare insurance industry and hospital systems rules and regulations.

 I am not interested in making excuses for some physicians’ poor behavior. I am more interested in making the public aware of every stakeholder’s role in our dysfunctional healthcare system.  

 “Either you have never had someone in your family who’s been referred around the system with no significant benefit or your Endo experience is what you apply to the rest of healthcare delivery.”

 Unfortunately, I have had that experience and have had to intervene on behalf of a family member with some logical medical decision- making.

“Either way, you accept no responsibility for Physician intervention to reduce consumption of healthcare and all the data says you’re not being objective.  There are many reasons Physicians don’t intervene to reduce consumption but to imply it’s only a small amount of $ isn’t being honest.”

 I have tried to point out some of the major reasons for physician dysfunction.


  1. Lack of tort reform results in between $300 billion and $700 billion dollars in wasted defensive medicine costs.
  2.  Most physicians do not benefit from the defensive medicine procedure fees. Hospital systems do the procedures and bill independently.   
  3. The Healthcare insurance industry benefits because it is  able to raise premiums.
  4. The legal system does because it benefits from settlement fees because of the lack of tort reform..  

         e.  Inefficiency in communication as a result of the lack of functional electronic medical records.       

         f.   Inability of patients to make timely appointments and move through the system effectively and                efficiently due to lack of the use of information technology and effective scheduling programs.

         g. There is $150 billion dollars of administrative waste.

         h. Decrease in effectiveness in reproducible laboratory results and procedure results lead to                retesting to make the correct diagnosis.

 What can seem like piling on of procedures to a patient and his family might not be a quest for dollars but a quest for a correct diagnosis.

In most cases the dollars do not go into the ordering physician’s pocket.

This is the reason the healthcare system must be consumer driven. It would incentivize patients to challenge physicians who are spending the the consumers money. The system should not be government or healthcare insurance industry driven. Patients must own their healthcare dollars. Patients must be involved in understanding the physician’s thinking.

 “My mom was referred around the system for tests, specialist visits etc. for 6 years with a very clear set of symptoms until my sister diagnosed her through web based research with a Histamine allergy/reaction.  Why in the world with classic symptoms that are available on the web would she simply be handed off Dr. to Dr. to duplicate tests over and over again yielding no care plan or plan to narrow the diagnoses?” 

 “ The answer is EVERY activity, every visit, every test, every procedure generated revenue for the providers.  My sister is a real estate broker not a Dr.”

I cannot address this problem with the data provided. Maybe your mother went to the wrong physicians.

A Histamine reaction is are usually an epiphenomenon. The reactions are usually secondary to an underlying stimulant. Sometimes the underlying stimulant is a disease that can be deadly. If diagnosed the underlying diseases can be cured. Many time the cause is benign.  Perhaps this could explain her physicians difficulty in diagnosis.

My Dad was diagnosed with lung cancer in 1995.  He had a lobe removed and recovered for a great year in 1996.  In Nov 1996 he was diagnosed with brain mets (what were his chances for survival at that point?  No one ever talked to the family.) 

At the beginning of your Dad’s illness your parents and the family could have stepped in and demanded being involved in the treatment decisions. The family could have made the decision to not try for a cure at any time. 

 “They did brain surgery, radiation and rehab and 6 weeks later the cancer was back in the same location in the brain.  Now what were my Dad’s chances for survival?  No one ever mentioned palliative care or that my Dad was going to die barring a miracle.  Instead, another brain surgery was scheduled by the surgeon, then more radiation until my Dad’s brain was fried and he stroked.” 


 “Now, if you think that surgeon isn’t part of the problem, that generating revenue with activity isn’t rampant in our healthcare system, then I simply don’t give your blog much credibility because clearly it is and it must be addressed not by outsiders, but by Physicians.” 

You have described the reason Primary Care Physicians are demanding that they be the captain of the healthcare team.

I disagree with the PCPs. Patients and their families should be the captain of the healthcare team. The Primary Care Physicians should coordinate care and follow the will of patients and their family. Primary care physicians should be the coach of the healthcare team.  .

Your father’s case is an excellent example of defensive medicine on the part of the brain surgeon. He was probably doing everything he knew to save your father and cover himself defensively. It does not sound as if the family demanded being involved in the decision making process. The family must demand involvement.

 “These aren’t isolated cases of excess utilization, they are the norm.  If Dr.’s aren’t proactively part of fixing it, then care will be rationed.  If consumers get control of their own healthcare dollars it would be the single biggest hit to revenue for all providers that could possibly take place (I support consumers armed with info making decisions).”

 I do not think it would decrease physician revenue significantly. I think it would decrease waiting times to see a physician and decrease delays in treatment.

 The major cause of excess utilization is the lack of tort reform and the resulting defensive medicine. Consumers must drive physicians to communicate effectively or move on to another physician.

President Obama has refused to recognize tort reform as an issue.

Communication could be solved utilizing my concept of the Ideal Electronic Medical Record.

The healthcare insurance industry’s control of the healthcare dollar would vanish utilizing my concept of the Ideal Medical Saving Account. It would reduce costs by the 30-60% the healthcare insurance industry takes off the top for first dollar coverage. It would make consumers wise spenders.

 “In the meantime, the fee for activity system we have now doesn’t work for anyone except industry, insurance companies and providers who do expensive things.  The patients and doctors whose expertise requires cognitive time with patients have all been shortchanged on this journey to where we are today”.

This is precisely why we have to have a consumer driven healthcare system. Consumers must control their healthcare dollars and be individually responsible for their treatment decisions.

“Sorry, you’ve touched a nerve.” Sincerely your

The same blog hit a nerve in another reader.  He wrote:

“This piece made me think of an old verse that states the case of the physicians pretty well:”

I'm not allowed to run the train
The whistle I can't blow…
I'm not allowed to say how far
The railroad cars can go.
I'm not allowed to shoot off steam,
Nor even clang the bell…
But let the damn train jump the track
And see who catches Hell!

 It is easy to see the elephant from one point of view. Incentives have to be aligned. The healthcare system must be realigned to the patients’ point of view.

 President Obama and Dr. Don Berwick think they are seeing the problems from the patients’ point of view. They feel the government has to dictate care.

They are creating a system so bureaucratic and complex that they will blow up the healthcare system. They will make the system more dysfunctional and more costly. 

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







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