THE BOND BETWEEN PATIENTS AND PHYSICIANS IS IN JEOPARDY
The good physician treats the disease; the great physician treats the patient who has the disease.
— SIR WILLIAM OSLER, MD
REMEMBER YOUR PERSONAL PHYSICIAN? He or she may not be yours much longer. And even if you keep your doctor, the odds are he or she is not really working for you. Soon most doctors will have abandoned their private practices and become employees of hospitals, multihospital affiliations, or the government. Only 35 percent of doctors currently describe themselves as independent, compared with 62 percent in 2008. This trend will undoubtedly continue; a medical student starting training today has virtually no chance of starting his or her own solo practice.
How did this happen, and why is it a threat to patients? The main culprits are the government and the insurance companies. As a result of the payment provisions under the Affordable Care Act (ACA), the government essentially encouraged hospitals to "own" doctors, and it is likely these provisions will remain in any modifications of the ACA. With inscrutable logic, the government pays more for the exact same medical procedure or doctor's visit if it is done in a hospital clinic rather than in an independent doctor's office. This is a strong incentive for hospitals to buy physicians and their practices. Doctors may have little alternative but to take salaried hospital positions if their practices disband. Combine this with federal rules and regulations regarding electronic records and medical partnerships that make it prohibitively expensive for all but the largest physician partnerships to compete.
Over the past several years, more than a quarter of a million doctors have been informed their Medicare and Medicaid payments would be reduced because they have not sufficiently implemented electronic medical records. Small physician practices unable to afford the capital investment are hurt the worst — just another nail in their coffin.
The government's willing partner in the dismantling of private practice is the insurance industry. Even before the Affordable Care Act, insurance companies advocated "narrow networks" — business speak for deciding which doctors patients could choose — as the means to control costs, offer reduced premiums, and broaden coverage (without mentioning the opportunity to realize higher company profits).
Put simply: one way for insurance companies to control premiums is by limiting patients' choices of doctors. These networks could change every few years; every time they do, some doctors will be shown the door. None of this bodes well for either American medicine or patients, no matter how the insurance industry and the federal bureaucracy spin it with corporate jargon like "consolidated health systems," "coordinated care delivery," or "pooled financial risk." These large consolidated health systems eliminate any possible benefit derived from local competition. Consider that when Wal-Mart comes into a community and forces out the corner mom-and-pop grocery store, the locals may be opposed, but at least everyone generally benefits from greater product selection and lower prices. In today's brave new health care world, as corporatization increases there is less selection and prices do not drop.
But there is a far more ominous implication. The centuries-old bond between patient and physician, described by Hippocrates twenty-five hundred years ago, is in jeopardy. The mutual-trust relationship is frayed when physicians become corporate (or government) employees; their loyalties are divided between their employer and their patient. How does the doctor determine how to advise or treat a patient? Is it what is in the patient's best interests, or is it adhering to performance goals and satisfaction surveys, which are increasingly being used as rewards or penalties that factor into the doctor's salary?
Fortunately, in most cases, there is no conflict, and when there is, most doctors still act in their patients' best interests. But now there is an ever- present threat the doctor will defer to a "quality improvement initiative" designed by a faceless manager in some distant corporate headquarters.
This new disconnect between patient and physician is typified by the electronic medical record. Despite never being adequately tested for actual utility, the computerized record was introduced to medicine over the last two decades at a cost of billions of dollars. In 2009 the government provided even more billions of dollars in bonuses if providers implemented the electronic medical record. The electronic record is admittedly easier to read and transmits information off-site better than paper records. But it has introduced an invisible barrier between patient and physician. Doctors now stare at a computer screen while they talk to patients and then spend an inordinate amount of time completing electronic records, time that would be better spent talking to patients. Cut-and-paste and poorly designed software templates create bad habits when doctors question and examine patients. And the records are anything but secure: millions of electronic medical records have been hacked or stolen; the information in millions more is routinely sold to third parties. Hardly a technology that engenders trust.
There has always been a love-hate relationship between doctors and society. Some physicians are lampooned as imperious jerks, and others are accused of doing too many tests and procedures. (President Obama famously made that assertion early in his presidency.) However valid these charges, one thing has always been true: with rare exception, even the most arrogant or venal physician has had the patient's best interests at heart. Can the same be said of the new business mandarins in charge of health care? With physicians becoming pawns in a much larger game, who will look out for patients? We may never again be completely sure.CHAPTER 2
IS IT SMART TO SKIP YOUR ANNUAL PHYSICAL?
Well, first of all, let me say that I might have made a tactical error in not going to a physician for 20 years. It was one of those phobias that really didn't pay off.
— WARREN ZEVON
THE POORLY TOLD TRUTH may be the most misleading falsehood. Ezekiel Emanuel, a leading American physician, provoked national debate in 2014 by suggesting that most people should not live past age seventy-five. Later he sparked further controversy, advising healthy people to forgo annual physical exams. He wrote in the New York Times, "Not having my annual physical is one small way I can help reduce health care costs — and save myself time, worry and a worthless exam. ... Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial. If they cannot, join me and make a new resolution: My medical routine won't include an annual exam."
The medical community has debated this issue for decades. Emanuel, displaying great assurance, relied on an analysis that pooled data from fourteen studies. He wrote, "In 2012, the Cochrane Collaboration, an international group of medical researchers who systematically review the world's biomedical research, analyzed 14 randomized controlled trials with over 182,000 people followed for a median of nine years that sought to evaluate the benefits of routine, general health checkups. ... The unequivocal conclusion: The appointments are unlikely to be beneficial."
This is strong stuff, especially coming from an éminence grise like Dr. Emanuel when he cites the Cochrane Collaboration, a respected not-for-profit network of health experts. Unfortunately, a careful reading of the report on general health checkups reveals surprising limitations in the data of Emanuel's source — which question whether Emanuel's conclusions are applicable today. Some limitations in the Cochrane report, and the studies comprising it, include:
Six of the fourteen studies were done in the 1960s. Nine were done more than forty years ago.
Not a single study was initiated in the twenty-first century.
No study included patients over age sixty-five or under eighteen.
Five studies excluded women.
The actual median follow-up time for the patients was closer to six years rather than nine, insufficient time to prove or disprove the value of annual checkups for patients in whom chronic diseases are identified. The only studies that followed patients for more than ten years all began before 1971. Five studies did not track mortality in the patients. The nine that did all began before 1993.
An entire generation of medicine has elapsed since these studies were clinically relevant; for some studies, two generations. Is this credible evidence that routine doctor visits are worthless? Consider heart disease. Virtually all the Cochrane patients were studied when cardiac catheterization was in its infancy, when many effective blood pressure medicines had not yet been discovered, and before statin drugs became routine treatment for high cholesterol. Today asymptomatic patients found by their doctors to have hypertension or hyperlipidemia are far more likely to receive effective therapy than was possible during the study period.
For children and the elderly, excluded from this report, vaccination is more effective today than when these studies were performed. In terms of cancer treatment, most current chemotherapy had not yet been developed, and screening colonoscopy was not yet the standard for detecting colon cancer. More than half the Cochrane studies were done before CT scans, an invaluable tool in cancer management, were available. None of this demonstrates the benefit of annual doctor visits. A narrow interpretation of Emanuel's point may be valid. In healthy patients with no complaints, detailed physical examination is unlikely to detect lifesaving findings. Assuming one is healthy and asymptomatic, many doctor visits result in excessive blood testing and X-rays, merely provoking concern, leading to more testing and driving up costs.
Yet the absence of value in a comprehensive physical exam does not mean people should avoid doctor visits. Most people, even the healthy, should visit the doctor at reasonable intervals for personalized evaluation and age-specific testing and intervention. Young people should have vaccinations, developmental evaluation, and counseling. The elderly, more prone to developing chronic conditions, should be screened and also counseled about safety issues (e.g., driving difficulties, falls), memory problems, and medication evaluation. (The elderly are on more medications than ever before.)
For everyone else, routine visits to the doctor should be a serious consideration. Yearly intervals are a decent target and easy to remember. Visit frequency should be based on individual health history, family history, personal habits, occupation, and personal concerns. A complete physical exam may only be necessary if you have specific symptoms, but weight and blood pressure checks are essential, especially if you have a family history of hypertension or are African American, where hypertension occurs more commonly and at an earlier age. Cancer screenings — mammography, Pap smear, and colonoscopy — are not annual tests but should be benchmarked at regular intervals. Skin screening for cancer is important when someone has significant sun exposure, and the doctor should inquire about smoking, drinking, drug use, occupation-related conditions (e.g., repetitive stress injury), and excessive stress. All these are important to your ongoing health history.
There is no hard-and-fast rule regarding bloodwork and X-rays, other than to ask your doctor whether you need specific tests and why he or she is ordering them. The medical community continues to research appropriate indications for testing; different doctors take different approaches. Just be informed as to the whys and wherefores of the tests. Younger patients, especially, should have ongoing records of their radiation exposure history from X-rays and CT scans. We may not know for decades whether we will confront an epidemic of medically related radiation cancers.
A final word on the routine doctor visit. Just talking with your doctor, so you know he or she cares, is a good way to spend a couple of minutes once a year. Yes, time spent thumbing through outdated magazines in the waiting rooms may be tiresome (doctors have to work on that), but getting to know your physician is a good idea. It might be old-school, but trust in your doctor is a vital element of your health, and that wasn't mentioned in the studies cited by Dr. Emanuel.CHAPTER 3
HOW OLD IS TOO OLD?
Old age has its pleasures, which, though different, are not less than the pleasures of youth.
— W. SOMERSET MAUGHAM
IN A CONTROVERSIAL ARTICLE in a 2014 issue of the Atlantic, Dr. Ezekiel Emanuel wrote, "Seventy-five. That's how long I want to live: 75 years." The controversy is not strictly because of the sentiment he expresses; many people feel the same way he does about growing old. Even Psalm 90 in the Bible describes a similar life span for man: "The days of our years are threescore years and ten ; and if by reason of strength they be fourscore years , yet is their strength labor and sorrow; for it is soon cut off, and we fly away."
Nor, to his credit, does Emanuel draw cheap attention to himself by advocating for legalizing euthanasia and physician-assisted suicide. He has always been against those movements and in favor of improving hospice and end-of-life care. But his remarks are provocative because he is one of the most influential doctors in America — a key health adviser to President Barack Obama, as well as a brother of Chicago mayor Rahm Emanuel. When he advocates life past seventy-five is not worth living, at some point there may be public policy implications.
In the article, he wrote, "The fact is that by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us. ... It is true, people can continue to be productive past 75 — to write and publish, to draw, carve, and sculpt, to compose. But there is no getting around the data. By definition, few of us can be exceptions."
Before consigning everyone over seventy-five to the fate of Soylent Green (if you're under fifty, google that reference), Emanuel should be reminded what his world might look like were it not for those exceptional people over seventy-five. When he was over seventy-five, President Ronald Reagan gave his famous speech challenging Soviet leader Mikhail Gorbachev to tear down the Berlin Wall. No speech was more crucial to ending twentieth- century European Communism.
While Emanuel, a Democrat, may hold no special fondness for Reagan, in terms of political balance he need only look at Edward Kennedy, the longtime Democratic senator from Massachusetts. In 2008 when Kennedy was over seventy-five, he compared his brother, President John F. Kennedy, to Barack Obama. The senator then made the momentous decision to endorse Obama for the Democratic nomination for president at the expense of Hillary Rodham Clinton. Without the Kennedy endorsement, Obama might not have won the nomination and become president.
In his eighties, British leader Winston Churchill completed one of the twentieth century's greatest historical works, A History of the English- Speaking Peoples. Astronaut John Glenn, the first American to orbit the Earth, became the oldest person, at the age of seventy-seven, to fly in space. In a remarkable and underreported life, adventurer Barbara Hillary, having survived cancer, at the age of seventy-five became the first African American woman to reach the North Pole. Four years later, she made it to the South Pole, becoming the first African American woman to visit both poles.
In the Atlantic, Emanuel despaired of the declining contributions of elderly scientists. Yet when he was eighty-eight, Dr. Michael DeBakey, America's greatest heart surgeon, supervised Russian cardiac surgeons who performed bypass surgery on Russian president Boris Yeltsin. DeBakey practiced medicine, lectured, and wrote well into his nineties. His medical career alone spanned Emanuel's natural life span of seventy-five years. Barbara McClintock won the Nobel Prize in Physiology or Medicine when she was in her eighties for her groundbreaking work in genetics.
If any group has the right to take issue with Emanuel, it is attorneys. When he was seventy-eight, Supreme Court justice Oliver Wendell Holmes Jr. issued an opinion, familiar to every law student, that outlined the limits of free speech: he wrote that the First Amendment "would not protect a man falsely shouting fire in a theater and causing a panic." His colleague, Louis Brandeis, served on the court for twenty-three years, well into his eighties. Three of the nine current Supreme Court justices are over seventy-five. Great authors including George Bernard Shaw and Johann Wolfgang von Goethe did some of their best writing after they were seventy-five, and two of the immortal artists of the Renaissance, Michelangelo and Titian, worked prolifically until they were nearly ninety.