KNOW-HOW ŰBER ALLES

The April 30 edition of the New Yorker features an article about Stanford University’s brilliant success in its support of technological innovation, a strategy that’s earned it $1.3 billion in royalties. Stanford and/or its graduates had a hand in developing almost every household-word e-success, including Hewlett-Packard, Yahoo, Cisco Systems, Sun Microsystems, eBay, Netflix, Intuit, Fairchild Semiconductor, Agilent Technologies, Silicon Graphics, LinkedIn, and Facebook.

It’d be hard to argue that this hasn’t contributed significantly to our culture, yet it has its detractors, however polite and circumspect. In obliquely criticising Stanford’s outsized focus on technology, one of its ex-presidents described the United States as having two types of college education that are in conflict with each other: the classic liberal-arts model and explicit job preparation.

The classic approach is designed to explore the human condition. We’ll navigate more wisely, effectively and kindly through our lives, its rationale goes, if we know something about history, psychology, anthropology, music, and art. High-level job preparation, on the other hand, aims toward lush Silicone Valley employment, or, on the east coast, Wall Street.

During the past generation, the latter model has predominated, not only at Stanford, but in American education in general, from high school up. We’ve heeded the pundits who warned relentlessly that unless we prioritize science in our schools, China or the Eurozone or even India will leave us in the financial dust. We've followed that advice successfully, but at significant cost. A friend from Mumbai commented, "You Americans excel at know-how. What you're not so good at is know-why."

Thus a New Yorker cover in October, 2010, depicted kids trick-or-treating while their chaperoning parents uniformly stared at their cell phones. Our gadget prowess now dwarfs the community skills—nuanced communication, civics, esthetics, sense of place, humility—that we might have learned in humanities courses.

Healthcare exhibits exactly this shift. We apply costly, hi-tech, often invasive and hazardous technologies where compassionate counseling would often suffice. This approach would work if the bulk of medical visits were for strictly physical derangements, but they’re not. Most current illness, from obesity to type two diabetes to hypertension to much of heart disease and cancer results from pathogenic behavior, including toxic exposure. We physicians, able to transplant organs and tweak genes but uneducated in the human condition, can only respond with our routine hi-tech hammers.

Medical educators saw this coming decades ago. When I trained in the mid-1960s, we were offered humanities tidbits, like the opportunity to discuss Tolstoy’s Death of Ivan Illich, or a course in Spanish. It was a decent try, but amounted to water off the backs of ducks anxious to get onto the wards and perform spinal taps. We simply didn’t see the relevancy, nor did the faculty provide a convincing explanation.

Today there are numerous experiments around the country designed to implement humanities more meaningfully in the medical curriculum. They’re up against a culture that continues to value know-how over know-why, but thanks to elucidations such as the New Yorker’s provided, we can afford optimism.

GLORIOUS FOOD

Ah, food, my second favorite fantasy subject. We’re talking about it more these days, possibly because we know more about the association between food and health, especially in the face of endemic obesity and type two diabetes.

Yet doctors get minimal to zero training in nutrition. So Dr. David Eisenberg, an associate professor at the Harvard Medical School and the Harvard School of Public Health, is teaching it to his colleagues—not in some dry, windowless classroom, but at the Culinary Institute of America (the other CIA), in Napa Valley, Calfornia. Read about it at http://www.nytimes.com/2012/04/11/dining/doctors-learn-to-cook-healthy-crave-able-foods.html?_r=1&pagewanted=all&utm_source=mQ+Health+Weekly&utm_campaign=5cd4035972-Health+Apr+13+2012&utm_medium=email.

He offers hands-on experience, teaching them how to cook. Many, having spent their entire adult lives in either intensive trainings or rushed practices, have existed on vending machine cuisine or take-out, and have never hefted a whisk. The idea, of course, is that when they converse with patients about nutrition, they’ll have experiential access to flavors, aromas, and texture in addition to data about protein, cholesterol, and sodium.

After cooking, these docs dine and wine together. Said one chef-instructor of his medical pupils, “Many doctors treat food as a clinical procedure rather than the sensual act it ought to be.” They’re learning what we could all use as a refresher, the opportunity to eat well, which is more than filling the mouth. It means leaving care and responsibility temporarily, communing with friends, and enjoying the world of the senses. One doesn’t have to pay for a Napa Valley workshop to do this. You can do it anywhere, with just about anyone. My mantra is rapidly becoming, “The best medicine is living well.”

IT'S NOT ONLY DEFENSIVE MEDICINE

It's plausible and popular to conclude that unnecessary testing and treatment comes largely from "defensive medicine," but that's not the whole story. Much of it comes from physicians' almost exclusive loyalty to medical science.

This came home to me recently when a friend told me her story. She'd been caring for her frail and aged mom, two hours from her own home, for weeks. At last things settled down. Driving home, she noticed pain in her back. She realized she might have expected something like that, "…as I'd been carrying a heavy burden." By the time she reached home, the pain was severe enough that she called her physician and requested strong pain medication. He suggested he see her first.

He examined her, agreed that her pain was probably secondary to stress, but--just to be sure--recommended a CT scan. When she took the order slip to radiology, the receptionist said, "Fine, but are you aware this will cost you about a thousand dollars?" My friend hit the ceiling. She tore up the note, called her physician, and said, "We both know I don't need a scan. How about just giving me a prescription?" The doc said, "Fine."

Okay, we can say that was an example of defensive medicine. When I related it to another doctor friend, though, he had a different take. "How old is she?" he asked. "Has she had a bone density test? How do we know this isn't a pathologic fracture, or a bony cancer metastasis?"

"My God," I answered, "those are such zebras." That's actually a medical term, deriving from a time-honored axiom in this biz, "When you hear hoofbeats outside, think of a horse before a zebra."

"Sure," my friend said, "but zebras do show up sometimes."

Thinking about that, I realized that's a standard medical rejoinder. Mention zebras and horses to doctors, and they'll focus on zebras because pulling the strange and rare diagnosis out of the hat is one of medicine's holy grails. We all want to be the diagnostic hero. With no connection to the woman with back pain, my doctor friend wasn't practicing defensive medicine. He was on rounds, demonstrating his allegiance to exhaustive science.

The doc who finally wrote the painkiller prescription (the pain, by the way, is now history) was jarred from his scientific perch by his patient simply reminding him of common sense. Of course, both approaches are valid, and precise circumstances ought to dictate the eventual strategy. That must depend, then, on a full conversation between doctor and patient. I'm gratified that an increasing number of studies are concluding that this crucial relationship--which our obsession with high-tech interventions has steadily eroded--seems to be reviving.

SENSIBLE USE VERSUS "RATIONING"

In a comment on my last posting, Anne asked me to respond to an article in today's NY Times (http://www.nytimes.com/2012/04/04/health/doctor-panels-urge-fewer-routine-tests.html?ref=todayspaper), in which a slew of doctor panels recommended fewer routine tests.

Thanks for asking, Anne. Another friend forwarded the same article to me, and I've been anxious to comment on it.

I've bellyached for years that Americans overuse expensive healthcare technology. We take too many tests, too many drugs, and undergo too many surgical procedures where less intervention might actually lead to better outcomes. In other words, we're in thrall to the presumed wonders of medical science. Some of us behind the scenes, though, are aware that many costly, invasive, and often hazardous interventions do not at all lead to better health…yet some do, and that's our dilemma. The point isn't to do everything for everyone versus nothing for everyone, but to weigh each decision thoughtfully.

We need to get a handle on healthcare costs, after all. While I favor a national single-payer healthcare plan, it will bankrupt us no less than our current non-system will UNLESS we buy it more reasonably.

I suspect at first we'll resist today's pronouncement, for a couple of reasons. First, people in general believe that high-tech diagnostic tests are somehow therapeutic in themselves. This is a common, worldwide misperception. Take radiation, for example. If you travel in Mexico, you'll find signs on medical offices advertising "rayos equis," x-rays. Ask the patients about them, and many say they get them because they feel better afterward. In Hungary, I spent an afternoon swimming in a lake reputed to be radioactive from radon beneath its floor. Fellow bathers uniformly emerged from it refreshed, swearing to radiation's restorative qualities. In the same way, glamorous medical technology exerts a placebo effect on us Americans--not a bad reason to continue its use, but not good enough to spend on it what we do.

Second, today's suggestions will inevitably be met by objections of "Rationing!" from the hard-of-thinking. Look: healthcare, like all services, has always been rationed and always will be. If there were no such thing as insurance, we'd have to weigh the value of anything we buy against its cost; that same principle resides in any financing mechanism. Intent on offering everyone everything, we're spending twice as much on healthcare per capita as any other country, and receiving tangibly less for it. This is an abysmal strategy. It's about time we smartened up.

The article quotes Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, who puts it more kindly than I do: “In fact, rationing is not necessary if you just don’t do the things that don’t help.”

I salute the medical associations that are stepping in and recommending less intervention. This needs to go hand-in-hand with taking more responsibility for our own health instead of asking docs to clean up behind our careless lifestyles.

WHAT KIND OF BIZ BILLS TEN THOUSAND DOLLARS AND ACCEPTS EIGHT HUNDRED?

A couple of months ago, I made my first visit as a patient to an emergency department. To my delight, I received terrific, humane care, and two hours later went home. No problem. 

Then I received the bill: ten thousand dollars. I’m on Medicare, so I wound up paying only seventeen dollars. According to the paperwork, the ED settled for eight hundred. 

I phoned the hospital’s congenial VP for financial matters and said, “I’m not calling to complain about my care. That was great. I’m just curious about a business in which the seller asks ten thousand dollars and accepts eight hundred.” He told me he didn’t quite understand the discrepancy, either, but what the hey, that’s the current state of the art.

An article in the March 31 edition of the L.A. Times (http://www.latimes.com/health/la-me-lopez-erfollowup-20120401,0,6799675.column) tackles this very issue. It mentions Debbie Cassettari, who had outpatient foot surgery to remove a bone spur. She arrived at the surgery center at 8AM, left just after noon, and the bill came to $37,000, not counting doctor fees. Another patient, Gary Larson, has a $5,000 deductible insurance plan, but found his medical bills are cheaper if he claims he's uninsured and pays cash. Using that strategy, an MRI scan of his shoulder cost him $350. His brother-in-law went to a nearby clinic for an MRI scan of his shoulder, was billed $13,000, and had to come up with $2,500. Those of us who’ve encountered similar quirks scratch our heads, wondering first, why does this cost so much, and second, why do healthcare outfits bill so surreally and ultimately accept so little?


Certainly some of the expense derives from defensive medicine, testing meant only to minimize litigation potential. In my case, for example, ED staff gave me an EKG, an inappropriate test considering my history and physical, not to mention the definitive diagnosis delivered by a CT scan. Still, I can imagine a lawyer smirking to the ED doctor, in court, “I see you didn’t order an EKG for this patient, who expired from a massive coronary on the way home. I’m sure you had a good reason, doctor…if indeed you are a bona fide physician, a subject I’ll soon address…” I knew I didn’t need an EKG, but like almost all patients, was in too much pain and too distraught to contest it. Besides, I knew I wouldn’t need to pay for it anyway.


Some of an ED’s gross expense comes from needing to maintain a full-service, life-and-death establishment even though most patients present with minor problems. EDs are predictable loss leaders for hospitals, so administrators routinely bill upwards.


I’ve mentioned here that healthcare’s cost, both absolutely and relatively, has been skyrocketing for a half-century. When I was in training, Americans spent about six dollars on healthcare out of every hundred they spent on anything. Now its share is eighteen dollars, and the punch line is that we’re not any healthier for it. According to experts who look at such things, we’re thirty-seventh in outcome quality, nested in with Slovenia and Cuba.


The gross discrepancies between billings and payments are just one expression of the insanity that results from healthcare’s steady devolution from a civic service—like police and fire protection and public education—into hugely profitable commerce. However the three branches of the federal government bat this issue around, they'll succeed only in rearranging the Titanic’s deck chairs. As it’s now conducted, American healthcare is frankly unsustainable. 


The only effective repair will be a national single-payer plan, and even that will work only in the short run, since no proposal I know of addresses our rabid penchant for overusing medical technology. Ultimately, we’ll need to conduct town-hall meetings nationally to discuss healthcare’s basics, including enhanced personal responsibility for health, and what we own one another when health fails.