Over at “Ohio Surgery” Buckeye Surgeon is not at all happy with the commencement speech that fellow-surgeon Atul Gawande recently delivered to Harvard Medical School’s graduating class. Today, Buckeye (a.k.a Jeffrey Parks, a general surgeon on the East Side of Cleveland, Ohio), summed up what he called  Gawande’s “essential message”:

“Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms. . . Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) . . . All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew.” 

No surprise, Gawande, who is a regular contributor to The New Yorker, makes his case in somewhat more eloquent terms: “The distance medicine has travelled in the [last] couple of generations is almost unfathomable,” he writes, comparing that span to the “vast quantum leap” his father made when he traveled “from his rural farming village of five thousand people [in India] to Nagpur, a city of millions where he was admitted to medical school, three hundred kilometers away. Both communities were impoverished. But the structure of life, the values, and the ideas were so different as to be unrecognizable. Visiting back home, he found that one generation couldn’t even grasp the other’s challenges. Here is where we seem to find ourselves, as well.” 

Medical culture has been roiled by change, leaving some doctors who remain attached to the past dismayed. This was inevitable, Gawande says.  In the past, physicians had only a handful of remedies. “Now we have treatments for nearly all of the tens of thousands of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures, and you, the clinicians graduating today, will be legally permitted to provide them. . .

“We in medicine, however, have been slow to grasp . . .  how the volume of discovery has changed our work and responsibilities . . .” he added, “The rapid growth in medicine’s capacities is not just a difference in degree but a difference in kind . . . the reality is that medicine’s complexity has exceeded our individual capabilities as doctors.”

He told the graduates that In earlier decades, “The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. . .  We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.”             '

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In the post below, “Can Empathy Be Taught?” Dr.  Chris Johnson reflects on how and why, so many medical students seem to lose that compassion for others that is “innate in all of us,” and causes many students to choose the profession in the first place. Johnson writes: “We need to prevent medical training from driving [compassion] into the background, belittling it, or even snuffing it out.”

For nearly thirty years Johnson has been practicing medicine in an area that makes great demands on both the heart and the mind—pediatric critical care. It is a field that, in the words of 19th century medical ethicist Thomas Percival requires that the physician “unite” great “tenderness with steadiness.” Johnson is a blogger and the author of  How Your Child Heals, How to Talk to Your Child’s Doctor, and Your Critically Ill Child.

Throughout most of his career, he has taught medical students, residents, and fellows. “I also served on a medical school admissions committee for some years,” he notes “and interviewed many prospective students, so I have had the opportunity to see and speak with them before the medical education system got hold of them.”

Before reading Johnson’s post, you should know what inspired it.

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By Chris Johnson, M.D. 

We want competent physicians, but we also want compassionate ones. How do we get them? Is it nature or is it nurture? Is it more important to search out more compassionate students, or should we instill compassion somehow in the ones we start along the training pipeline? I think the answer lies in nurturing what nature has already put there.

Throughout most of my career in pediatric critical care I have taught medical students, residents, and fellows. So I have seen young physicians as they made their way as best they could through the long training process.

After reading Doctor Treadway’s essay, I think my overall perspective on the question is similar to hers – the main principle to keep before us is not so much that we need to figure out a way to teach compassion, but rather to devise ways such that the training process does not reduce, or even extinguish, the innate compassion all humans have toward one another. Unfortunately, our current way of doing things does not do a very good job at that task. We are hobbled by our success. Some historical background is helpful, I think, to explain what I mean.

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Trustees’ Report Much Less Gloomy than Advertised        
      
Summary: Below, Part 2 of the May 13  post headlined “Medicare Trustees Report that Reform Legislation Cuts Medicare Costs by 25 Percent.”

Conservatives continue to use the annual report recently released by Medicare’s Trustees as evidence that Medicare needs what one conservative pundit calls a “sweeping overhaul.”  In theory, House Budget Chairman Paul Ryan’s plan to privatize Medicare is dead, but somehow, it’s still in the news. Yesterday Newt Gingrich announced that he’s with Ryan, and today Senator John Kerry is calling a press conference to denounce Ryan’s voucher plan.

What has been lost in the debate is the fact that the Trustee’s report is not nearly as gloomy as advertised. Anyone who reads the entire report will find a major disconnect between the headlines and what the trustees actually say. In this post, I quote the Trustees as they express their optimism that Medicare’s challenges can be solved by “building on” the Affordable Care Act (ACA). They also recognize that the ACA calls for structural changes “in how health care is financed and delivered” that could yield substantial savings. Meanwhile, Medicare Actuary Richard Foster has issued a dissenting opinion to the Trustees’ report, arguing that their predictions are based upon unrealistic spending cuts. Foster doesn’t believe that hospitals can become more efficient. In this post I explain that a fair number of hospitals already have proven him wrong, and research by the non-partisan  Medicare Payment Advisory Commission (MedPac) reveals that there is plenty of hazardous waste to be squeezed out of our hospital system.(I call the excess “hazardous” because it includes so many preventable medical errors.)  Finally, at the end of the post, I itemize exactly how and where the ACA saves money and raises new revenues, which, according to the Congressional Budget Office, will total $950 billion over the course of the decade.

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Today, S&P released data tracking the growth of health care costs which showed that over the year ending March 2011, Medicare spending rose at an annual rate of 2.78%—the lowest rate posted for the Medicare Index in its six-year history. (Hat-tip to Kent Bottles for calling attention to this report on Twitter. This news is, as Bottles says, “very important”, not to mention timely, given the deficit debate in Washington.)

By contrast, over the same 12 months, health care costs covered by commercial insurers rose by 7.57%.  Still, as the chart below shows, even these costs (tracked by the “commercial index”) have been falling, down from a peak inflation rate of nearly 10 percent in the 12 months ending in July 2010 to 7.5% in the 12 months ending March 2011.

Why is health care inflation decelerating?  In the commercial sector, the recession no doubt plays a major role.  Insured patients often have high deductibles that must be paid before they receive care. As a result, hospitals report that patients are putting off elective surgery.  Thus, commercial insurers are paying out a lower share of premiums. (See for example, Cigna’s most recent financial report which shows patients’ “relatively moderate use of medical services”.)

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Below, a guest post by Dr. Clifton Meador. Over the years, Meador has practiced as a family doctor, an epidemiologist, a health care administrator and Dean of the University of Alabama Medical School. He also has published many books and articles including a tale set in the not too distant future called The Last Well Person, which uses satire to comment on the folly of our obsessive drive to test and screen every well person in America—until we find something wrong with each and every one of them.  If you have seen the film version of Money-Driven Medicine, you will remember Meador as the doctor who takes the viewer on a wonderful tour of Nashville. Thanks to Dr. George Lundberg for sending me this essay.

I would add only that I don’t think that Meador is saying that “the worried well” caused the overtreatment that has become so prevalent in our health care system. Rather, they responded to the advertising and the hype as hospitals, drug-makers and others began to persuade us that there is a cure for everything—if you can just detect it early enough.

Meador quotes Lewis Thomas on “the general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health care professionals.”  This, I think, is key.

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Today, the Trustees who keep an eye on Social Security and Medicare trust funds issued a summary of their 2011 Annual Report. Predictably, headline writers rushed to announce that Medicare will be “going broke” in 2024. This isn’t true. 

What the report actually says is that in 2024, money flowing into the Medicare Hospital Insurance (HI) Trust will “be sufficient to pay [just] 90 percent of the trust fund’s costs.” In other words the money flowing into the Medicare fund that covers hospital stays will be 10 percent less than money flowing out.

Looking ahead another sixty years, the Trustees project that the Trust fund’s ability to pay all of its bills with revenues dedicated to HI is projected “to decline slowly to 75 percent in 2045, and then to rise slowly, reaching 88 percent in 2085.”  In other words, in 2085 Medicare still will be able to cover 88 percent of hospital costs–which means that, in theory, the other 12 percent would come out of general revenues. But that is not likely to happen.

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Today, I stumbled onto a new blog,“Deeper Tweets–Sometimes 140 Isn't Enough.” There, “Medskep” has just reprinted a comment that I made on The Health Care Blog a year ago, turning it into a stand-alone post. At the time, I was responding to an essay by Dr. Nortin Hadler professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and Dr. Robert McNutt, a professor of Medicine at Rush Medical College in Chicago titled “The Evidentiary Basis for a Clearly Meaningful Benefit.”  (Hadler is the author of Worried Sick: A Prescription for Health in an Overtreated America, The Last Well Person, and Stabbed in the Back).

As I re-read my comment, I decided that I would like to share it with HealthBeat readers. But since it is only a response, first let me offer some excerpts from their provocative post :

“We entered the 21st century awash in “evidence” and determined to anchor the practice of medicine [in that evidence]. There is the sense of triumph; in one generation we had displaced the dominance of theory, conviction and hubris at the bedside. The task now is to make certain that evidence serves no agenda other than the best interests of the patient.

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Below, a guest-post by Harold Pollack on Osama bin Laden’s death.  (Pollack is Helen Ross Professor at the School of Social Service Administration, and faculty chair of the Center for Health Administration Studies at the University of Chicago. He recently joined The Century Foundation as an adjunct fellow focusing on issues of Economics and Inequality. This post originally appeared on the Foundation’s blog, www.tcf.org )

Pollack suggests that bin Laden’s death signals a time for reflection, not celebration.  I totally agree.  I found the televised spectacle of college students, high-fiving and cheering, as if their team had just won a football game, unsettling.  War is not a sport.

 I fully understand why anyone who lost a loved one on 9/11, along with families of soldiers killed in the Middle East, would feel a great sense of relief, as well as a certain grim satisfaction upon hearing that bin Laden had left this planet.  His death will not fill the holes in their hearts, but it is something.

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“I diagnosed ‘abdominal pain’ when the real problem was hunger,” admits Dr. Laura Gottlieb in a wonderfully candid Op-ed that explains why physicians so often fail to recognize poverty as the true cause of what appears to be a physical disease.

“I confused social issues with medical problems in other patients, too. I mislabeled the hopelessness of long-term unemployment as depression, and the poverty that causes patients to miss pills or appointments as noncompliance. In one older patient, I mistook the inability to read for dementia,” writes Gottlieb who is a Robert Wood Johnson Health and Society Scholar at the University of California, Berkeley, and the University of California, San Francisco. 

“My medical training had not prepared me for this ambush of social circumstance,” Gottlieb adds. “Real-life obstacles had an enormous impact on my patients’ lives, but because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether.” (Many thanks to HealthBeat reader Dr. Rick Lippin, who called my attention to Gottlieb’s superb Op-ed.)

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