How Government Killed the Medical Profession

[natasa778]

Long article, well worth a read

http://www.cato.org/publications/commentary/how-government-killed-medical-profession

few highlights:

I am a general surgeon with more than three decades in private clinical practice. And I am fed up. Since the late 1970s, I have witnessed remarkable technological revolutions in medicine, from CT scans to robot-assisted surgery. But I have also watched as medicine slowly evolved into the domain of technicians, bookkeepers, and clerks...

At first, the decay was subtle. ...

...
Twenty years after the fall of the Iron Curtain, protocols and regimentation were imposed on America’s physicians through a centralized bureaucracy. Using so-called “evidence-based medicine,” algorithms and protocols were based on statistically generalized, rather than individualized, outcomes in large population groups.

While all physicians appreciate the development of general approaches to the work-up and treatment of various illnesses and disorders, we also realize that everyone is an individual—that every protocol or algorithm is based on the average, typical case. We want to be able to use our knowledge, years of experience, and sometimes even our intuition to deal with each patient as a unique person while bearing in mind what the data and research reveal.

Being pressured into following a pre-determined set of protocols inhibits clinical judgment, especially when it comes to atypical problems. Some medical educators are concerned that excessive reliance on these protocols could make students less likely to recognize and deal with complicated clinical presentations that don’t follow standard patterns. It is easy to standardize treatment protocols. But it is difficult to standardize patients.

What began as guidelines eventually grew into requirements. In order for hospitals to maintain their Medicare certification, the Centers for Medicare and Medicaid Services began to require their medical staff to follow these protocols or face financial retribution...

...
These requirements have consequences. On more than one occasion I have seen patients develop dramatic postoperative bruising and bleeding because of protocol-mandated therapies aimed at preventing the development of blood clots in the legs after surgery. Had these therapies been left up to the clinical judgment of the surgeon, many of these patients might not have had the complication.

Operating room and endoscopy suites now must follow protocols developed by the global World Health Organization—an even more remote agency.There are protocols for cardiac catheterization, stenting, and respirator management, just to name a few.

Patients should worry about doctors trying to make symptoms fit into a standardized clinical model and ignoring the vital nuances of their complaints. Even more, they should be alarmed that the protocols being used don’t provide any measurable health benefits. Most were designed and implemented before any objective evidence existed as to their effectiveness.


"evidence-based’ means you are not interested in listening to anyone.”

 

[xchocoholic]

I'm confused about how having protocols for procedures is bad.

Or is it that the protocols given aren't taking each patient's medical history or current status into account ? If so basing a protocol on more data seems like an obvious answer. That's what the doctor is doing when he/she evaluates a patient.

The manufacturing facility I used to work at until I became ill in 1990, had explicit protocols in place for every single step in the manufacturing process. We're talking every screw, bolt, etc. Employees scanned bar codes into bar code readers at each step. I'm assuming it's the same in other manufacturing plants. I wonder if this is where they got the idea. I understand our bodies are more fluid than say airplanes.

This could actually work to the patients advantage if certain parameters are entered. Your doctor may forget you have drug intolerances, diabetes, low blood pressure, allergies, etc etc etc but the computer won't. Or the computer may recognize patterns in our blood work that medical professionals missed. Computer systems could be set up to recommend further testing if certain parameters were met.

I'm pro electronic records and don't understand his beef with this. Getting medical records is much faster this way. Most of my doctors use computers instead of paper folders.

Computer coding for diagnoses and procedures and electronic medical records was inevitable once computers were accessible to everyone and have helped me several times when seeing different doctors within the same group. I forgot my allergies, previous surgeries, ailments, etc but the computer didn't.

It would be handy if I downloaded my med recs to my smart phone. Actually I have my latest dental records / xrays on my phone thanks to my dentist. How cool is that ?

Tc .. x

 

[natasa778]

I'm pro electronic records and don't understand his beef with this. Getting medical records is much faster this way. Most of my doctors use computers instead of paper folders.

Computer coding for diagnoses and procedures and electronic medical records was inevitable once computers were accessible to everyone and have helped me several times when seeing different doctors within the same group. I forgot my allergies, previous surgeries, ailments, etc but the computer didn't.

It would be handy if I downloaded my med recs to my smart phone. Actually I have my latest dental records / xrays on my phone thanks to my dentist. How cool is that ?

Tc .. x

This is not what the article is about. Apples and oranges.

 

[xchocoholic]

This is not what the article is about. Apples and oranges.

This was referenced in the section titled "Electronic records and financial burdens".

It's an interesting article. I see a private pay integrative doctor who has opted out of insurance but never really understood why. I still don't ...

 

[WillowJ]

I'm confused about how having protocols for procedures is bad.

...

The manufacturing facility I used to work at until I became ill in 1990, had explicit protocols in place for every single step in the manufacturing process. We're talking every screw, bolt, etc. Employees scanned bar codes into bar code readers at each step. I'm assuming it's the same in other manufacturing plants. I wonder if this is where they got the idea. I understand our bodies are more fluid than say airplanes.

...

I'm pro electronic records and don't understand his beef with this. Getting medical records is much faster this way. Most of my doctors use computers.

There are some advantages to it, as you said. The problems are:

1) doctors did not design or provide design input into (nor, for the most part, have they tried to redesign) the EMR systems. They find them awkward, and they do not provide the framework to record what the doctor wants to know.

EMR is for the express purpose of itemizing items which lead to payment by insurance companies, and items which document compliance with standards of care according to neatly ordered flowcharts. It was not developed to help doctors personalize patient care. (And most patient cases do not conform to neatly ordered flowcharts.)

2) A wingnut is always a wingnut, and a crescent wrench is always a crescent wrench. It is not that hard in manufacturing. In medicine, you're right, it's a lot different from airplanes. We are not always sure of the diagnosis. Even when we have a diagnosis, it could mean any one of 16 (number pulled out of a hat) different things (not just ME, but cancer and pneumonia and other things).

The patient may be intolerant of the recommended treatment, or it might just plain not work. There might be complications from other conditions, which lead to things other than the recommended protocol being needed.

This could actually work to the patients advantage if certain parameters are entered. Your doctor may forget you have drug intolerances, diabetes, low blood pressure, allergies, etc etc etc but the computer won't. Or the computer may recognize patterns in our blood work that medical professionals missed. Computer systems could be set up to recommend further testing if certain parameters were met.

There is a role for that, I agree.

I think what the article is complaining about is the computer helping the doctor to not think about your case, or to be bullied into choosing a form of care thought to be less optimal in some particular case.

Let's see, what's wrong with this patient[typing]

The patient has Chronic Fatigue Syndrome. Standard treatment is Cognitive Behaviour Therapy and Graded Exercise. TCA could be also used, as this can help with depression, pain, and sleep all with one medicine, which limits iatrogenic harm. Further testing should be limited to avoid reinforcing possible belief in an incurable organic illness to improve hope and therefore improve prognosis, and to avoid iatrogenic harm.

I hadn't really thought of them as a head case, but if you say so.

That's why I would kind of rather I didn't have EMR following me around, just at the moment. I can use a paper list for allergies.

Never mind that TCA is used in different doses for depression and for pain. I never did understand that recommendation.

Patients should worry about doctors trying to make symptoms fit into a standardized clinical model and ignoring the vital nuances of their complaints. Even more, they should be alarmed that the protocols being used don’t provide any measurable health benefits. Most were designed and implemented before any objective evidence existed as to their effectiveness.

Seems like we aren't the only ones with unsuitable guidelines.

 

[xchocoholic]

Thanks @WillowJ. I appreciate your effort to help me understand this.

I didn't know doctors input wasn't part of the design and how the guidelines given can be inappropriate. I can't imagine designing a computer system without the users input.

Do you know who comes up with the guidelines for medical care in this system ? Medicare doctors maybe ? Can we see these ? This seems like the biggest problem.

I see what you mean about this system's purpose being for payments too. The author mentioned that some medical professionals use "creative" coding for payments. I'm all for doctors being paid for their services and feel bad about being on Medicare.

Most of my doctors who are using EMRs seem happy with them. Another upside is they don't have to try to read their own writing. Lol.

Oh and lab results are downloaded to each patients file so you get the results faster. I like the automatic prescription service to my pharmacy too. And the way the pharmacy texts or calls me when it's ready.

My background as a programmer analyst makes me look at this different too. I like the idea of using codes for diagnoses and protocols. It's less cumbersome. And I like having medical records that aren't scribbled on a page so I can read them. If I had a brain, I'd love to get a closer look at these.

 

[WillowJ]

Do you know who comes up with the guidelines for medical care in this system ? Medicare doctors maybe ? Can we see these ? This seems like the biggest problem.

I agree. I think guidelines are made mostly by bureaucrats, even if some are technically doctors/researchers as well, as I understand it.

You can see a lot of them, but maybe not all (and not necessarily for free). Just do a search for guideline for heart disease, or liver cancer, or MRI dyes, or whatever you want to know about.

Hospitals (and health plans) get scores by how well they conform to guidelines for certain selected diseases and conditions (is everyone with high blood pressure getting x class of drug? did everyone of x age get y screening? everyone of x age get y vaccination?). The problem is, a lot of these guidelines are based on outdated or inaccurate information.


Guideline says to use cholesterol-lowering medication when cholesterol is high, but we know that lowering cholesterol does not, by itself, reduce the risk of adverse events. Cholesterol-lowering medications do not reduce poor outcomes unless they also lower inflammation. But the guidelines do not get updated, because things are very, very slow to change in the medical world. So ticking a box that the guideline was followed doesn't necessarily do anything to improve patient care. It would in some cases (hand washing protocols for instance).

Most of my doctors who are using EMRs seem happy with them.

Do they say? My docs either don't say (in which case I have no information), or they complain that it's awkwardly set up and they cannot find things, or they are happy that they can look things up particularly from other clinics which are now linked (but they still have trouble finding things, and complain that the system is finicky).

I read articles saying other doctors I haven't met say they are designed awkwardly and do not collect the most valuable information (but are optimized for collecting information needed by insurance companies, not information needed to practice medicine), except two or three systems not widely distributed.

I think codes are useful, and e-charts and things (although I don't find my pharmacy-to-clinic communication to be flawless). I am not arguing for paper charts.

Just that the current EMRs are not set up well, and that compliance to guidelines should not be set in stone, nor should the guidelines themselves. We learn new things. Patients rarely have a textbook case of something and often have complications. Diagnostic and treatment guidelines should be meant as a suggestion of something to consider as a first attempt, not something that should be rigidly or uniformly followed (whether this is overt policy or the downstream effect of other policies). (Safety guidelines might need closer conformity.)

 

[taniaaust1]

We have a fairly new EMR system here in which one can get ones whole medical record on a system in which any doctor or oneself can access. Ive avoided it thou as Ive seen too often how one doctor may diagnose something wrongly and it go onto ones records and then it can be a nightmare to get off.. everyone else then has it on their records for you too. If its something "unpopular" it can biased others who one is going to see before they even see you.

(I dont know if our system is self correctable if one doesnt agree with a doctor but Im not going to give it a go to find out in case it isnt).
....

I think doctors have generally lost the ability to truely think for themselves due to a reliance on common protocols. Hence anything a little out of the normal eg complicated ME cases.. becomes then "too hard" for them to deal with.

 

[xchocoholic]

Thanks @WillowJ . So far I found the US preventative service task force referenced for pap smear guidelines. But that got confusing because it said the FDA was looking at changing these guidelines. So are they connected ?

I was surprised to see the uspstf was made up of 16 volunteers with different backgrounds. Why volunteers ?

The uspstf is part of the Agency for Healthcare Research and Quality (AHRQ) who reports directly to Congress. I've never heard of AHRQ. I got this from the uspstf website.

And I found the American Heart Association referenced for heart failure guidelines.

I've seen P2P referenced here as setting guidelines for me/cfs. I've heard the American Pediatric Association and the American Medical Association quoted as giving guidelines on tv.

Geesh. And I thought I was doing well to know who the FDA, NIH, and CDC were. Is there a heirarchy I'm missing here ?

On a slightly different note, I noticed that two of the healthcare workers who had been exposed to ebola refused to listen to the CDC guidelines about being quarantined for 21 days. Do you know why ? Dr. Nancy Snyderman was confined to her house after ignoring the cdc guideline and going out for food.

Tx .. x

 

[alex3619]

I think the article refers to new doctors being trained to think less and comply more. That is turning doctors into medical technicians, not thinkers. This might, in some cases, mean doctors become unnecessary and nurse practitioners etc. are sufficient, since they only have to follow the rules.

This is all bound up in the EBM movement. Evidence based medicine is a good idea in general, though what is really needed is evidence based practice. The difference is that EBM is about standardizing, and EBP is about doctors learning how to navigate through information. EBM has however been adopted by the insurance industry and government watchdogs over much of the world. Its an economic management tool, only vaguely like the scientific medical tool it should be.

People with anything unusual wrong with them will have incentives or disincentives to force doctors to comply. Its people who become bureaucratic cases. Individual issues with patients will be lost in the "evidence base", even though EBM typically only deals with simple non-complicated medical cases. Disease A is treated, but not A+B, and definitely not A+B-C-D where C and D are treatments that are not tolerated.

Many of these points were made by @WillowJ. Its important to realize that this is about economically efficient medicine, according to statistics, not effective medicine. Doctors have lost control of their own profession. This all started in the UK, and in the US is complicated by different insurance companies having different variations on how they want things done. In one review about two years ago a medium size hospital needed 400 admin staff, and a comparable one in Canada needed one or two for the same job. Its bureaucracy gone mad, and is a factor in increasing the cost of medicine.

The other thing is this. The US is on the way to getting standardized nationalized medicine but at private medicine cost. In other words, the worst of both worlds.

I largely agree with the article, but I think the scope is very narrow.

 

[chipmunk1]

EBM has become a tool of power because everyone believes if it is EBM it must be correct no matter what which means doctors and patients have to obey EBM.

If there is no protocol for what you have then it is all in your head. Problem solved.

 

[alex3619]

The problem isn't the government, it is the lobbyists and the corporations. Welcome to the oligarchy.

No, I think its much deeper, and deeply entrenched with economists, economic advisers, bureaucracy and political ideology in most parties, left or right. What the corporations and lobbyists do is reinforce it, just as the government reinforces what the corporations do.

 

[PeterPositive]

The question about so called "Evidence Based Medicine" is where's the evidence for it being a superior modality for treating disease?

While the core idea of gathering evidence for therapies and healing modalities makes perfect sense, there are several outstanding issues with EBM which have been criticized, sometimes hardly, by a good portion of physicians. One of the main criticism being that it would lead to a mechanized delivery of medications with little or no room for physicians to use their clinical experience and for individualized therapies.

A couple of interesting articles:

A categorization and analysis of the criticisms of Evidence-Based Medicine.

The major criticisms and limitations of Evidence-Based Medicine (EBM) appearing in the literature over the past decade can be summarized and categorized into five recurring themes. The themes include:

• • reliance on empiricism,
  • narrow definition of evidence,
  • lack of evidence of efficacy,
  • limited usefulness for individual patients,
  • and threats to the autonomy of the doctor/patient relationship.

Analysis of EBM according to these themes leads to the conclusion that EBM can be a useful tool, but has severe drawbacks when used in isolation in the practice of individual patient care. Modern medicine must strive to balance an extremely complex set of priorities. To be an effective aid in achieving this balance, the theory and practice of EBM must expand to include new methods of study design and integration, and must adapt to the needs of both patients and the health care system in order to provide patients with the best care at the lowest cost.

http://www.ncbi.nlm.nih.gov/pubmed/15036077

Full version:
http://skynet.ohsu.edu/~hersh/ijmi-04-ebm.pdf

Evidence based medicine is broken

Today EBM is a loaded gun at clinicians’ heads. “You better do as the evidence says,” it hisses, leaving no room for discretion or judgment. EBM is now the problem, fueling overdiagnosis and overtreatment.

http://www.bmj.com/content/348/bmj.g22

 

[xrunner]

"evidence-based’' actually means cost control unless we believe the fairytales of "effective healthcare" or "best practice".

"What began as guidelines eventually grew into requirements."
You bet. It's been an effective tool for protecting profit margins by capping costs of insurers and health care providers, including governments providing "free" healthcare to anybody and where public spending is virtually out of control.

 

[JAM]

No, I think its much deeper, and deeply entrenched with economists, economic advisers, bureaucracy and political ideology in most parties, left or right. What the corporations and lobbyists do is reinforce it, just as the government reinforces what the corporations do.

May I suggest the book "Gangs of America"? It does a good job of outlining how corporations caused all of the above. http://www.amazon.com/Gangs-America-Corporate-Disabling-Democracy/dp/1576752607/ref=sr_1_1?s=books&ie=UTF8&qid=1417470424&sr=1-1&keywords=Gangs of America

Of course, it has gotten even worse since the book was published in 2003, but it all follows the pattern.

Another good book, if you are as interested in this stuff as I am, is "The Great Transformation" http://www.amazon.com/Great-Transfo...eywords=the+great+transformation+karl+polanyi

 

[natasa778]

May I suggest the book "Gangs of America"? It does a good job of outlining how corporations caused all of the above. http://www.amazon.com/Gangs-America-Corporate-Disabling-Democracy/dp/1576752607/ref=sr_1_1?s=books&ie=UTF8&qid=1417470424&sr=1-1&keywords=Gangs of America

Of course, it has gotten even worse since the book was published in 2003, but it all follows the pattern.

Another good book, if you are as interested in this stuff as I am, is "The Great Transformation" http://www.amazon.com/Great-Transformation-Political-Economic-Origins/dp/080705643X/ref=sr_1_1?s=books&ie=UTF8&qid=1417470610&sr=1-1&keywords=the great transformation karl polanyi

Putting these on my Santa wish list, thank you

 

[Mary]

If you want an explanation of why the modern medical profession does not operate under the assumption that health is the natural condition of the human body, and instead hands out drugs instead of learning what actually creates health (most notably proper nutrition, among other things), see World Without Cancer, the Story of Vitamin B17. The book does talk a lot about laetrile and Sloan Kettering's mission to squash all positive test results -- but the later sections of the book go into the history of the unholy alliance between international chemical/pharmaceutical companies, the Rockefellers, and how they glommed onto control of medical school curriculum, the AMA, American Cancer Society etc. It is not an accident that doctors know almost nothing about nutrition and real health. Follow the drug money. http://www.amazon.com/World-Without...17476623&sr=1-1&keywords=World+Without+Cancer

I don't agree with everything the author says - e.g., he opposes almost all forms of government control, including minimum wage laws - (it seems that most people who oppose a minimum wage law don't have to try to live at the poverty level or below.)

But the book in general seems to be very well-documented. For the most part he is not just throwing out opinion but backs up almost everything with incredible detail. It's a fascinating read. (I got it from my library!)

 

[barbc56]

There is no vitamin B17. The term is inaccurately applied to laetrile, a discredited cancer drug, and amygdalin, the natural substance from which laetrile is made. Amygdalin occurs in the seeds of apricot, peaches, and almonds. Despite the lack of proof that laetrile/amygdalin works, promoters have continued to make unwarranted claims for it, referring to it as vitamin B17 and selling it as a dietary supplement to prevent, as well as treat, cancer. I've also seen promotions that claim these compounds can prevent and treat high blood pressure and arthritis

.

http://www.drweil.com/drw/u/QAA400624/Do-You-Need-Vitamin-B17.html

I just read a more recent article but the site has been down the last several hours. Basically they said the same as Dr. Weil.

Barb

 

[barbc56]

There are several clinics where I live and each has a dietician on site..

BTW, the person who wrote the above article is associated with the Cato institute which has an "iffy" reputation.

Too tired to post more about the article. Hopfully, tomorrow.

Barb

 

[alex3619]

Story of Vitamin B17

Laetrile, which is related to cyanide, made world history when a clinic in Israel announced loads of cured cancer patients. It was published all over Europe. A year later a journalist went back to do a follow up story. All the patients were dead ... of cancer. This also made the headlines.

Now it might be the media made it all up, but then it might also be the authors of the book supporting laetrile made it all up. There were no formal clinical trials that I was aware of.

People have gone to prison for prescribing laetrile, in Texas I think. For murder.