The practice of medicine has been significantly enhanced by advancing technology. However, even with four years of medical school and an MD degree, this only provides the foundation for what is needed to be a good doctor. A critically important skill is the ability to make sound medical decisions.
This is why there is a hierarchy in training that begins after medical school, progressing through internship, residency, fellowship, and eventually leading to becoming a staff physician. At each level, individuals learn, implement, and then teach the necessary decision-making processes to improve their proficiency in effective medical decision-making.
Today, one of the most significant challenges that doctors face is the intervention of those who seek to take control of medical decision-making away from experienced and evidence-based physicians. These intervening parties include insurance companies, hospital administrators, medical groups (including HMOs), and pharmaceutical companies. These entities often prioritize profit over patient care, even contradicting the Hippocratic oath that physicians have taken.
Many of us have likely experienced denials or limited insurance coverage when dealing with situations like car accidents or home fires. In the realm of medicine, I have personally witnessed stacks of “prior authorization” requests being improperly discarded by profit-driven HMO personnel, jeopardizing the health care of their patients.
In the present day, obtaining approval for special radiology tests such as CT scans, MRIs, or PET scans may be denied by your insurance company. Getting a referral to a specialist can be challenging, and even a necessary surgical procedure for evaluating cancer could end up being denied.
Typically, insurance company physicians or their other health care providers are making these decisions, even when they lack the necessary background in the specific area requiring expertise. Doctors frequently complain about “peer-to-peer” prior authorization discussions with insurance gatekeepers who have no understanding of the medical knowledge needed to make appropriate evaluations. They often rely on algorithms to justify blocking the medical necessity of your doctor’s request. Most of the time, the credentials and background of these individuals are unknown, and we may not even know if they have taken the Hippocratic Oath.
Often, time is of the essence for a physician to make a diagnosis, but the additional paperwork often creates obstacles in your doctor’s efforts.
Unfortunately, this is the health care system that American citizens now face, as it is clearly profit-driven. I believe that there are many countries around the world that provide quality health care to their citizens. Available U.S. data now reveals that life expectancy and maternity health care reflect a failing health care system.
One of the crucial factors in this situation is medical decision-making, which must be returned to the hands of well-educated and experienced health care physicians to ensure quality care. If not, our system will continue to deteriorate, ending up in the health care trash bin.
Gene Uzawa Dorio is an internal medicine physician who blogs at SCV Physician Report.
