I hope readers take the time to read David Leonhardt’s terrific Sunday New York Times Magazine piece on Intermountain Healthcare. It is a great introduction to the changes that organized medicine must adopt to deliver team- and evidence-based care. (I wish we used the term evidence informed treatment, which brings fewer connotations of cookie-cutter care.)
This transition requires changes in the way doctors and hospitals are paid. It also requires changing medical professional culture to embrace a team approach. Many doctors have been socialized to believe in a model in which what matters most resides in the head of individual physicians. Jerome Groopman’s otherwise wonderful How Doctors Think expresses this mindset right in its title. Groopman provides a beautiful account of how doctors effectively diagnose conditions and how their heuristics can go astray. As Darshak Sanghavi notes in Slate, Groopman provides less guidance regarding how we could create systems that make patients less vulnerable to the mistakes or inattention of fallible human beings. (It’s too bad Groopman declined to be interviewed for Leonhardt’s piece, which has a nice little section on these issues.)
The change in medical culture will be tough, not least because there is so much to admire in the traditional medical model. Unfortunately, there is just too much evidence that it frequently produces bad care. More clinical intelligence and compassion reside in a well-deployed team of people than can reside with any single person, no matter how committed and well-trained that person might be.
Betsy McCaughey published a recent Wall Street Journal op-ed, in which she quoted 16 doctors she convened for an anti-reform discussion panel. If one reads the transcript, one finds the expected bias and exaggeration. One also finds more interesting genuine push-back against CER and team models of care. Here, for example, is heart specialist Mark Fields:
On February 25, 1994 Dr. Baruch Goldstein, a physician in the Israel Defense Forces living in the historically contested ancient city of Hebron, walked into the Ibrahimi Mosque, located in the Cave of the Patriarchs, and with his machine gun murdered 29 Muslim men at prayer. The tremor that ran through Israelis and Jews around the world was two-fold. The first tremor was that here was a massacre of innocents attributable to a madman. But this attribution could not stand by itself for long.
Earlier today, two key groups--the American Cancer Society and the American Association of Retired Persons--endorsed the House health care reform bill. On a conference call that's just wrapping up now, the American Medical Association (AMA) pledged its support, as well. But it did so with some crucial qualifications.
The AMA made clear that it was endorsing not one but two bills: H.R. 3962, the bill that would expand insurance coverage, reorient the delivery system, etc.; and H.R. 3961, the bill that would eliminate the planned reductions in Medicare physician payments to keep them in line with the Sustainable Growth Rate (SGR).
AMA President James J. Rohack explained the group's position thusly:
Congress is about to write a very big check to America's doctors, apparently without blinking. It may or may not be the right thing to do--more on that in a second. But it does make you wonder why they find it so hard to write a very big check to make sure everybody can get affordable health insurance.
The issue here is what's known as the Sustainable Growth Rate, or SGR. Under the terms of a law passed in 1998, Medicare is supposed to keep its payments in doctors in line with the SGR. In years when physician payments are below the SGR, Medicare is supposed to start paying the doctors more; in years when physician payments are above the SGR, Medicare is supposed to pay them less.
Predictably, physician payments tend to end up on the high side. And, perhaps just as predictably, physicians aren't too keen on that. They complain and, for the last few years, Congress has responded by "postponing" the reduction. It's become an annual ritual of sorts, although it sometimes features high drama. Or high farce, depending upon your perspective.
Nobody thinks this is a good situation.
Irving Kristol, who died on the eve of Rosh Hashana, will have many pages in every future intellectual history of the United States. Actually, also, in every intellectual history of the West. He was not actually a philosopher, certainly not in the strictest sense of the word or even merely in a strict sense. But he was a scholar in the meaning laid out by Ralph Waldo Emerson in his famous Harvard Phi Beta Kappa oration, "The America Scholar," of 1837.
On the advice of my physician, I do not watch or listen to Glenn Beck, preferring to follow his exploits via the serial bouts of hysteria he inspires in his fans. So it was news to me to learn that he spends a lot of time hawking the works of the late W. Cleon Skousen, an extremely sketchy right-wing character who lived on the far fringes of the conservative movement and of Mormonism.
In a fascinating piece on the subject in Salon today, Alexander Zaitchick explores Beck's near-apostolic advocacy of Skousen's work, which serves as a sort of intellectual framework for the highly paranoid worldview of the Tea Party movement that Beck has done so much to promote. In his very colorful career, which earned him a big fat "dangerous extremist" file with his former employers at the FBI, Skousen gained most notice in the early 60s as a fellow traveler and stout defender of the John Birch Society (after Birch founder Robert Welch had been read out of the conservative movement for contending that Dwight D. Eisenhower was a communist).
Today the New England Journal of Medicine released two articles exploring physicians' beliefs about health reform.
The first, by Salomeh Keyhani and Alex Federman, explored physician preferences about the broad policy options for expanding insurance coverage and Medicare. This April, a nationally representative sample of more than 5,000 physicians was asked which of three options they would most strongly support:
1. Public and Private Options: Provide people under age 65 the choice of enrolling in a new public health insurance plan (like Medicare) or in private plans.
2. Private Options Only: Provide people with tax credits or low-income subsidies to buy private insurance coverage (without creating a public plan option).
3. Public Option Only: Eliminate private insurance and cover everyone in a single public plan like Medicare.
Physicians being the pathetically unreliable respondents they are, only 43 percent returned the survey. That's not great. Yet the results and the response rate are consistent with prior surveys. Among responders, 63 percent favored option #1, the public plan option. 9.6 percent favored the public option only. The remaining 27.3 percent favored exclusively private options.
At around 2 p.m. on Wednesday, a few supporters and television cameras gathered near the Capitol to watch as two burly men unloaded 1.3 million signatures on 61,000 pages of paper from an ambulance onto a stretcher. The stretcher was wheeled over to a small stage stuffed with Republican congressmen and conservative talk radio hosts.
Want a hint about what the president will say tonight? Check out the guest list for the First Lady's box, which the White House just published. It's full of people who had trouble paying for their medical care--people who, though from different walks of life, all had to confront the same essential dilemmas. Whether or not Obama mentions them explicitly, it suggests the personal stakes Americans have in reform will be a major theme tonight--as it should be, but hasn't always in the last few months.
One other notable guest: Vietoria Kennedy, widow of Senator Ted.
Full list of guests follows:
As if you hadn’t heard, a gaggle of American conservatives is stridently charging that pending health care reform legislation will institute a mechanism for euthanizing selected members of the handicapped and elderly populations--that it would, in Sarah Palin’s formulation, establish “death panels.” It’s true that H.R. 3200, the bill that will eventually come before the House of Representatives, is still a work in progress.
Some progressive doctor friends have asked me to take Ezra Klein outside and knock him around a bit for a chat comment the other day. When asked in a chat session "why is it that so many doctors are opposed to Obama's plan?" Ezra attracted my friends' gentle wrath with the response:
Members of Congress who hold the balance of power, including Senate Finance Committee chair Max Baucus and the Blue Dogs in the House, have concluded that the health care proposals emerging from committee up to now would do too little to control costs. The next phase of deliberation and bargaining will revolve around strategies for reining in costs without reducing the quality of treatment or the pace of innovation in the health care sector.
In December 2003, Brent Cambron gave himself his first injection of morphine. Save for the fact that he was sticking the needle into his own skin, the motion was familiar--almost rote. Over the course of the previous 17 months, as an anesthesia resident at Boston's Beth Israel Deaconess Medical Center, Cambron had given hundreds of injections. He would stick a syringe into a glass ampule of fentanyl or morphine or Dilaudid, pulling up the plunger to draw his dose. Then he'd inject the dose into his patient.
More than a decade ago, Michael Kinsley, the journalist and former editor of this magazine, developed Parkinson's disease--a degenerative condition that impairs motor and speech control, producing tremors, rigidity, and eventually severe disability. While the standard regimen of medications helped, he knew that his symptoms were bound to get steadily worse with time. He needed something better--something innovative--before the disease really progressed. In 2006, he got it at the famed Cleveland Clinic in Ohio.
More than a decade ago, Michael Kinsley, the journalist and former editor of this magazine, developed Parkinson's disease--a degenerative condition that impairs motor and speech control, producing tremors, rigidity, and eventually severe disability. While the standard regimen of medications helped, he knew that his symptoms were bound to get steadily worse with time. He needed something better--something innovative--before the disease really progressed. In 2006, he got it at the famed Cleveland Clinic in Ohio.
A few hundred dollars a year. Maybe more than a thousand. Rex Delph really couldn't be certain how much larger his medical bills would be if his employer, the school board of Knox County, Tennessee, decided to swap health insurance plans. All Delph knew was that even a modest increase could end up financially overwhelming him.
I.
Why is it, in fact, that so many Jews have become doctors? Here follows a twice-told tale that bears telling once again.
More than any other Jewish thinker, Maimonides, who lived in the twelfth century, still has sway over the modern mind and not just the modern mind of Jews. He was also a physician, and wrote widely on medicine. Among his voluminous writings--on drugs, asthma, sex, poisons, almost everything but managed competition--is this short prayer: "Supreme God in Heaven: Give me the merit to regard every suffering person ... as a human being, without any distinction between rich and poor, friend and foe, good person and bad.
If these facts surprise you, it's because you haven't been given a straight story about the Clinton health bill. Take two examples: on November 4, Leon Panetta, the director of the Office of Management and Budget, testified to senators that the bill does not "set prices" and "draw up rules for allocating care"; a month later Hillary Rodham Clinton assured a Boston audience that the government will not limit what you can pay your doctor. The text of the bill proves these statements are untrue.
