Diagnosis: malformation of a health care system [PODCAST]

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“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.

He shares his story and discusses his KevinMD article, “Diagnosis: malformation of a health care system.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Jeffrey Fraser. He’s a neurologist, and he wrote the KevinMD article “Diagnosis: malformation of a health care system.” Jeffrey, welcome to the show.

Jeffrey Fraser: Thanks, Kevin. I really appreciate an opportunity to be here and chat with you.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Jeffrey Fraser: Yeah, sure, I’d be happy to. I finished my neurology residency at UC San Francisco back in 1991, and I moved south to start my journey into neurology in that year. I moved down to the South Bay, and I joined a small neurology group at Santa Clara Valley Medical Center, which is the public hospital, the county hospital for Santa Clara County, right there in the heart of Silicon Valley. I had the good fortune to work there in the capacity not only as a practicing neurologist but as someone involved in the teaching of Stanford medical students and Stanford neurology residents. So I enjoyed both of those roles very much.

Kevin Pho: Over your decades-long career as a neurologist, how has the field changed over those years?

Jeffrey Fraser: Well, obviously MRI scanning was a huge advance in the field of neurology, and that was coming into clinical utility right around the time of my residency. Once that came around, of course, the saying became, “One MRI scan is worth a room full of neurologists.” There’s some truth to that, but that’s also an exaggeration, of course. We discovered that MRI doesn’t always have the answers, but it’s obviously a very, very useful tool, and it really revolutionized the field of neurology. Especially with advances in imaging to detect early stroke, it really revolutionized the care of acute stroke.

Kevin Pho: And going forward, what do you see are the major challenges facing the field of neurology?

Jeffrey Fraser: Well, the other part of my journey has to recognize the fact that the 1990s were labeled the decade of the brain. There was a lot of hope about these advances that we talked about, MRI scanning, the treatment of chronic pain. We were told that we had the answers for the treatment of chronic pain with the advent of these newer opiates, and those great hopes in the 1990s have to be qualified now. Certainly, we’ve made a lot of advances in the treatment of stroke, but chronic pain remains a very difficult problem, and we have had to backtrack, haven’t we, with regard to a more liberal use of opiates.

And the chronic diseases that we take care of, Alzheimer’s disease, Parkinson’s disease, etc., etc., there was great hope that we were making a lot of progress, but we seem to have kind of reached a plateau, in spite of the fact that every few years some new treatment comes out that seems to hold a lot of promise. But the disappointments have been somewhat greater than the expectations.

Kevin Pho: All right, let’s transition into the KevinMD article that you wrote. It’s titled “Diagnosis: malformation of a health care system.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Jeffrey Fraser: First of all, again, part of my journey did involve periods of burnout, just full disclosure. I became curious as to why I and some of my colleagues were facing these challenges: How do we really practice medicine in a way that’s truly satisfying? What are the barriers to satisfaction? So along my journey, as I was busy with my usual duties, I did start to read here and there about health care policy issues and how other countries provide health care. Obviously, I became aware that the burnout rate among physicians is quite high, sometimes as high as 50 percent for primary care, and neurology also ranks very high up there in terms of the proportion of neurologists that are burned out. So I became curious about that issue.

Right around that time, I found that book by Sandeep Jauhar, a cardiologist who was writing about the same issues. He came out of residency and training as a cardiologist very optimistic but found himself disillusioned with the for-profit world of medicine in America. That really resonated with me, and so these ideas kind of percolated. Then, when I started to approach retirement in 2020, I said, “You know what? I’ve kind of picked up a little bit of information here and there through osmosis about what might make a medical system work better, and I have my own personal experiences to share.” So as I was kind of backing off from full time into part time, I said, “I’m going to write a book. And you know what? I’m not going to do a lot of research. I don’t have the credentials that a lot of authors have, but I’m still just going to write it based on what I’ve learned over the years from personal experience and from watching what happens.”

The one thing, for example, that’s always stuck in my mind is we would continually see patients who lost their job who had previously had health care insurance. It might be Kaiser, it might be some other form of insurance. They would lose their job, they would lose their insurance, and they would bounce into the county hospital system. Many times, and this was just around the time that the EMR was coming out, we would have a hard time getting their records. It was a very disjointed, very fragmented system of care, and many times we’d have to struggle to get records or we’d have to repeat tests. Then, just around the time we got to know the patient, oftentimes they’d get a job back and they’d bounce out of the system. I would just say to myself, “This just doesn’t make sense. It’s so inefficient.” I think that’s just one example of the waste in our system, the inefficiencies, just one example.

So I wrote my book. I’m going to plug my book now. I wrote it in 2020. It’s called “Blueprint for a Gold Medal Health Care System,” and it’s self-published. It’s short; that’s one of its redeeming features. If somebody wants a quick introduction to one neurologist’s point of view, it’s an easy read, and I’m donating all of the proceeds to the National Association for Free and Charitable Clinics.

So I wrote that book, and I said, “OK, now that I’ve written my book, let me see what contemporary authors are writing.” That’s when I came across Robert Pearl’s two books, and I came across Brad Spellberg’s book, and with both of those authors, again, I really felt a connection. First of all, Brad Spellberg is the chief medical officer at USC LA County Hospital, one of the biggest county hospitals in the country, and he had a very similar point of view. He saw the same thing I did working in an emergency room: people coming into the emergency room at USC LA County because they lost their insurance.

And then Robert Pearl was, as you may know, the CEO of Kaiser for almost 20 years. He also remains a Stanford professor of plastic surgery and a lecturer at their business school, so he’s right up the road at Stanford. I’ve exchanged some emails with him. He pointed out that he spent time during residency in our burn unit at Santa Clara Valley Medical Center. I’ve also been a fan of the Kaiser system, because I think their model of capitated payment and getting away from fee-for-service is really a necessary step if we’re going to hold down costs.

So those books resonated with me, and I said, “Hey, these guys actually have the credentials. They’ve got the street cred. Let me write an article about them and showcase what they’re saying.” That’s how the article came about.

Kevin Pho: So we’ve had Dr. Pearl several times on this podcast, certainly very insightful from his perspective, both as a physician and as a former CEO of a major health care system. If you were in charge of our health care system, and we can take this any number of different ways, what would you think is the single most important thing that you would change?

Jeffrey Fraser: Well, as I said in the article, I think there are three principles, or three features, that you would find in an ideal health care system. Number one, citizens of the nation would have uninterrupted health care, compassionate health care, where they don’t have to worry about losing it. That gives them a whole lot more job security. They would be less fearful about taking chances in trying a different job, maybe moving into something that ultimately holds more promise for their future, and not have to be held back because of concerns about, “Oh, I’m going to lose my health care.” You can imagine all kinds of other scenarios where that fear of losing their health care is a burden. It’s a cause of anxiety.

So that’s number one, and the way to do that is to have universal single-payer coverage. So full disclosure, now you can see where I’m going with this. I really believe that that’s necessary if we’re going to have a society that thrives in the future, because health care is going to continue to evolve in other ways, and if people are constantly fearful of losing their insurance, it’s just going to raise anxiety all through the country, and anxiety leads to poor health outcomes. So I’d like to see a nation that looks to the future and builds a healthier, happier society.

Number two, we have to get back to really embracing science. I think our scientific standards have become too relaxed, and I think the best example this year is the advent of this drug Aduhelm. I’m not sure I’m pronouncing that right, but I’m sure you’re familiar with it. The FDA approves this drug for Alzheimer’s disease in spite of the fact that their independent panel of experts almost unanimously said, “Hey, the data just isn’t there yet to support this.” Now we’re seeing the struggle in the real world, where health care facilities struggle to decide whether to actually offer this infusion service. It creates a lot of, again, uncertainty, and it also sends a message to the public, like, “Who do you trust? What’s going on here?”

I think we have to do a better job of educating the public about how science really works, and just because something, again, even this drug did not even reach statistical significance in their primary endpoints. But even when a drug does reach statistical significance, that doesn’t mean it’s clinically significant, and we’ve done a poor job of drawing that distinction, because American health care is in the business of making money, and the way to make money is to keep promising new treatments, better treatments.

Now, both of my in-laws had Alzheimer’s disease. My wife’s parents both had Alzheimer’s disease. I understand the struggles that families go through in caring for people with Alzheimer’s disease. We have to find a better way as a society of adjusting to the fact that we have an aging society and we’re going to have to take care of patients with Alzheimer’s disease. But Aduhelm is not going to solve that problem. And yes, I know families are desperate, but as a society, we have to say sometimes, “We just don’t have a good treatment yet. Let’s find other ways to help you.”

But as a taxpayer, I don’t want to pay for drugs that don’t work, or if I have private insurance and the premiums keep going up because of drugs like Aduhelm. Remember, Aduhelm is not only expensive, but now you have to do MRI scans before you start treatment and after you start treatment. As a society, we don’t want health care premiums to keep going up, but they will unless we start to say, “Hey, you’re not always going to get what you want, but you’ll get what you need.” But we’re kind of in the business of just giving people what they want, regardless of whether it’s cost-effective.

Kevin Pho: One of the points that you mentioned was decoupling our health insurance system from employment, and you mentioned single-payer as one way to do that. Now, would you be open to other ways? Because other countries in the world, of course, don’t necessarily have a single-payer system, right? In Germany, you just have highly regulated private insurers, and you have countries like the Netherlands, for instance, that have a similar system. And of course, with the Affordable Care Act, we’re looking to regulate our private insurers. What are your thoughts about those other ways of decoupling our health insurance from an employment-based system?

Jeffrey Fraser: Well, that’s a fair question. And again, I’m a bit of an idealist. I like to simplify things when I don’t understand them very well, and I’m not an expert. But if you read Brad Spellberg’s book, here’s a frontline clinician who took a year off to study health care systems in other countries, and his book is an excellent introduction to a comparison of how different countries structure their health care systems. I think the takeaway for me is nobody’s really cracked the code and found the perfect system. That’s why I chose to sort of idealize it.

But yes, I’m open to other solutions, and I think one step there is to allow the states to become laboratories. I think the states, as I understand it, are somewhat handcuffed in terms of what they’re allowed to do in experimenting with new ways of providing health care. I think if you let the states have a little bit more freedom, we could have 50 different laboratories and figure out which one works best. And I think there’s a cliche: The United States will eventually find the right solution after trying every other option first. Probably true.

Kevin Pho: We’re talking to Jeffrey Fraser. He is a neurologist. He wrote the KevinMD article “Diagnosis: malformation of a health care system.” Jeffrey, what are some of your take-home messages that you want to leave with the KevinMD audience?

Jeffrey Fraser: Well, here’s another thing that I come back to time and time again: Why did doctors burn out? Here’s what I see. Number one, at some level, they realize they’re working in a broken system, and they see the frustrated patients. They feel their own frustration.

Here’s my point of view as a neurologist. I know what the guidelines say. I know that we don’t need to do an MRI scan for everyone who has back pain. I know we don’t need to do an MRI scan for everyone who has a headache. And yet that’s what the patients have come to expect and sometimes demand, and they don’t trust the system, because they see it’s fragmented. So if you say, “Well, you know, here’s the data. I don’t think you really need an MRI scan,” they’re not hearing you, because they don’t know whether to trust you or not, especially when you don’t have that continuity of care where you actually get to know a patient, because they’re bouncing around between different health care systems. So it’s very hard to say no to those patients who come to expect or even demand, who get angry.

I’ve had many patients who are very grateful for the care we provided at Valley Medical Center, but many patients were also angry, because they don’t trust the system. So even where I work, where my income is not dependent on keeping everybody happy, certainly I want to keep people happy if I can, but I find it very hard to say no. There’s just no incentive, and there’s no support for saying, “No, you don’t need an MRI scan.” There’s just no support. And imagine you’re working in the private sector or an academic center, where the expectations are even higher. There’s no incentive to talk to the patient about, “Well, this is not really cost-effective care.” Absolutely no incentive to do that, and that causes burnout.

Not to mention, now you not only often find yourself in an adversarial position with your patient, having trouble connecting; you’ve got employers looking over your shoulder, looking at your RVUs, and you’ve got to keep the people moving through your clinic. And then you have to argue with insurance companies, because sometimes you do think, or many times you do think, a patient needs this or that, and now the insurance company is arguing with you. So the doctors find themselves in the crossfire from three different directions: patients, employers, insurance companies. That’s a recipe for burnout.

If you change the system and try to align the incentives and help everybody understand, “Hey, this is about providing compassionate, continuous, cost-effective care, let’s all get on the same page,” now you have restored your job satisfaction, I feel. And so I would tell people, doctors, takeaway message: If you feel the way I do, advocate for some of these things we’re talking about. You have some disagreements about how to achieve that, but talk to your national specialty association, talk to the AMA, express your point of view, and let’s, as doctors, take some control over our future.

Kevin Pho: Jeffrey, thank you so much for sharing your time and insight, and thanks again for being on the show.

Jeffrey Fraser: Thanks, Kevin.

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