In recent years, we have seen a magnificent increase in the accuracy of medical diagnoses. As the most compelling example, l propose the diagnosis provided by our country’s top clinicians with regard to what ails our health care system. Seasoned veterans of outpatient clinics, emergency rooms, intensive care units, hospital wards, and operating suites, they have focused their finely honed diagnostic acumen on themselves, their colleagues, and the system in which they practice. In this context, the dictum, “physician, heal thyself,” was never more profound. They have published their authoritative evaluations and recommendations for all to read.
In Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong, Dr. Robert Pearl, former CEO of The Permanente Medical Group and member of the faculties at the Stanford medical and business schools, draws upon his personal experiences and an array of highly pertinent scientific findings to expose the many serious flaws in the way we deliver health care to our citizens. In Uncaring: How the Culture of Medicine Kills Doctors and Patients, this perspicacious plastic surgeon explains how physicians’ intrinsically large reservoir of empathy is systematically drained by a culture that has lost sight of the critical importance of this one most valuable attribute.
In Broken, Bankrupt, and Dying: How to Solve the Great American Health Care Ripoff, Dr. Brad Spellberg, chief medical officer at the Los Angeles County-University of Southern California Medical Center, lays out the economics of health care in terms anyone can understand while seasoning his narrative with poignant vignettes culled from years of caring for the underprivileged. His assessment is unassailable: compared to citizens of other developed countries, Americans are getting fleeced by the profiteers of the medical-industrial complex.
In Doctored: The Disillusionment of an American Physician, Dr. Sandeep Jauhar, a cardiologist, explains how the fundamental cause of physician burnout is simply the realization that one is working in a broken, unjust, and impersonal system.
Like Dr. Jauhar, I have suffered the symptoms of burnout. Like Dr. Spellberg, I have worked in a large public hospital in California. During my almost 30 years of practicing neurology at Santa Clara Valley Medical Center, in the heart of Silicon Valley and just 20 minutes down the freeway from Stanford, I too have witnessed tragic and maddening consequences of losing one’s health insurance when it is most needed, or having inadequate access to proper preventative health care until an emergency arises. Like Dr. Pearl, I have seen what happens when doctors, despite being motivated by a desire to help, cause harm by falling under the spell of false hopes, promoted by a medical-industrial complex intent on maximizing profits, and eagerly embraced by an ingenuous public.
An ideal health care system would feature a resolute commitment to these three fundamental virtues: compassionate uninterrupted care for all, rigorous scientific standards, and cost-effectiveness. The cruel arbitrariness of a world where health care coverage for oneself and one’s family is subject to the vagaries of one’s employment status is incompatible with the first virtue. A fee-for-service payment model, embedded within a profit-seeking medical-industrial complex, is incompatible with the second and third virtues. Imagine a system comprising only non-profit health care organizations that employ a capitated payment (global budget) model, contracting with the government to serve all citizens at all times, regardless of their employment or health status.
As a prototype of the sort of health care delivery network found in an ideal national health care system, let me propose Kaiser Permanente, a highly successful non-profit health care organization operating 39 hospitals and over 700 medical offices in eight states and employing over 80,000 doctors and nurses. Kaiser Permanente’s capitation payment model allows it to put cost-effective, evidence-based medical care front and center as its highest priority. Among the many fruits borne from this model is an alignment of incentives to optimize the use of telemedicine, information technology, and an integrated electronic medical record, allowing Kaiser, in this regard, to leave its fee-for-service competitors in the dust.
The U.S. government, contracting with a number of Kaiser-like entities, competing with each other to provide the best care in the most efficient manner, while sharing best practices, would vault the American health care system to first place among developed countries, from its current position as an also-ran. Moreover, in the absence of such a transformation, American health care is destined to fall farther and farther behind countries that have adopted, or are in the process of adopting, an integrated, evidence-based health care system with universal coverage. The resistance to transformation is formidable, and therefore change must be led from within. Success depends on physician leaders convincing their colleagues and their patients that the path to wellness requires an elixir that, for many, has a bitter taste and is sometimes painful to swallow.
The diagnosis is well-established. A cure is within our reach, and the wisest among our practitioners of the healing arts are offering valuable counsel. When the U.S. government and science, in its most principled form, work together, insulated from a culture of insidious and invidious profiteering, they can put a man on the moon, and launch a helicopter on Mars. They can also deliver better health care in a much more equitable and cost-effective way. It is time for the patient to listen to her best doctors. They are giving it to her straight.
Jeffrey Fraser is a neurologist.
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