Dr.  Kenneth Cohn, a surgeon and blogger, offered a particularly thoughtful response to my post “Surgeons and Other Physicians: The Cultural Divide.” First, let me introduce him.

On his blog, Cohn describes himself as a “board-certified general surgeon currently splitting time between providing locum tenens surgical coverage in New Hampshire and Vermont and working as a consultant at Cambridge Management Group, which specializes in physician-physician and physician-administrator communication issues. I am a recovering academic surgeon who is passionate about helping physicians, nurses, hospital leaders, and board members work together.”

Let me add that I’m impressed by his blog, Collaborative Confession, and that we’re adding it to our blogroll.

In his comment here on Health Beat, Cohn explained that his training was very different from the surgical training I described in the post:

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Over at TPM Café (www.tpmcafe.com) I’ve posted a review of James Galbraith’s witty, insightful book, The Predator State, which some readers may find of interest.

What is delightful about James Galbraith’s The Predator State is that he says things that are, at once, outrageous– and completely true. Because he shows so little concern for what one "can" and one "cannot" say in a polite capitalist society, one might call him an idealist. But Galbraith is not tilting at windmills; he is simply toppling the conventional wisdom of the past 28 years.

Begin with "the market." When you come down to it, Galbraith explains, "the market" is a fiction. In theory, "it is the broker, the means of detached and dispassionate interaction between parties with opposed interests…Buyers want a low price, sellers wants a high price. The market works out the price that exactly balances these desires, a price that is fair because it is the market price." Even liberals believe in this mythical "market"–a higher intelligence that hovers over transactions ensuring that, as long as you let "the market" work its magic, everything will work out for the best…

To read the whole review, click here.

In a 2006 New York Times article, Dr. Amit Shah, a physician at Johns Hopkins, recalled how other doctors looked down on him during his residency because of his chosen field. “The most memorable discouragement came during his residency, from a pulmonologist,” notes the Times. ‘When I passed him in the hall, [the pulmonologist] would shake his head and mutter, ‘waste of a mind,’” Shah said.

Dr. Shah’s sin? He had chosen to become a geriatrician.

You’d think that Shah would be applauded by his colleagues for choosing geriatrics, given that the U.S. is in the throes of a major geriatrician shortage: Since 2000, the number of geriatricians in the U.S. has fallen by a whopping 22 percent to a mere 7,100. According to a May Institutes of Medicine report, the outlook for the future isn’t much better: by 2030, there will be just 8,000 geriatricians, despite the fact that the U.S. will need about 36,000 to cover the workload as the number of Americans 65 years and older mushrooms.

Clearly, the U.S. needs more geriatricians. Yet the reason we don’t have more stems from the mindset of the pulmonolgist that scoffed at Dr. Shah: both our health care system and our medical schools devalue the kind of care that geriatricians provide.

Geriatricians are family or internal medicine physicians who have taken extra training in the area of aging and the special needs of seniors. In the words of Cheryl Phillips MD, a Sacramento geriatrician, “the particular focus of geriatrics training is the care of frail elders—where understanding how to assess and determine the individual’s ability to function is oftentimes every bit as important as understanding their diseases.” Thus geriatrics deals with coordinating long-term care for chronic conditions or helping seniors to manage their day-to-day life. Geriatricians tackle issues like confusion, dementia, incontinence, falls, depression, and the special effects that medications can have on the elderly. As the New York Times explains, “caring for frail older people is about managing, not curing, a collection of overlapping chronic conditions, like osteoporosis, diabetes and dementia. It is about balancing the risks and benefits of multiple medications, which often cause more problems than they solve. And it is about trying non-medical solutions, like timed trips to the bathroom to improve bladder control.”

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Are there intrinsic differences between how surgeons and physicians who are not surgeons see the medical world?  A pediatrician who reads this blog thinks so, and he e-mailed me to suggest that “The distinction matters because the dichotomy between doctors who perform procedures and those who practice ‘cognitive medicine’ [listening to and talking to the patient] is a major culprit in driving up the cost of American medicine.”

His grandfather was a physician and his father was a surgeon, which puts him in a unique position to muse over “the cultural divide between surgeons and non-surgeons.” I’ll call him Dr. Y

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It’s no secret that the pharmaceutical industry trades in junk science. We’ve talked about how prescription drug companies distort research many times here on Health Beat, focusing on how companies fudge measures of drug effectiveness and generally control our knowledge of what works in medication. Big Pharma’s track record of shady science is a serious problem, especially considering the fact that recent discussions about creating a Comparative-Effectiveness Research Institute currently hold a place for prescription drug companies on the organization’s board.

The obvious problem is that, to the pharmaceutical industry, “research” is just a code-word for “smart-sounding marketing.” If you really want a sense of how deep this deception runs, consider the fact that the prescription drug industry relies on so-called “research” not just to shill its drugs, but also to argue that it has a vital role to play in shaping the doctor-patient relationship for the better.

This dubious claim comes in the June 2008 issue of PharmaVoice where Meaghan Onofrey from CommonHealth, a pharma marketing consulting firm, pens a piece arguing that coaching from the prescription drug industry can make sure that “physicians and patients speak the same language” so that “everyone wins.” According to Onofrey, “one case study illustrates [how marketers can help physicians improve their communication]: by videotaping primary-care physicians, who were struggling to assess migraine prevention candidacy with their migraine patients.” According to Onofrey, it turned out that the doctors were actually asking the wrong questions of their patients. In working with key opinion leaders and advocacy groups, a simple solution was formulated to address the issue. These same physicians were taught to ask a single question to help them more simply and clearly identify the patients’ candidacy for migraine prevention.”

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In 1970,  a Fortune magazine cover story warned the nation: “Much of U.S. medical care, particularly the everyday business of  preventing and treating routine illnesses , is inferior in quality, wastefully dispensed, and inequitably financed.” That year, a Fortune editorial declared: “The time has come for radical change…The management of medical care is too important to leave to doctors who are, after all, not managers to begin with.”

This was the beginning of the revolution Paul Starr described in his Pulitzer-prize -winning 1982 book,  The Social Transformation of American Medicine.  In his final chapter, “The Coming of the Corporation,” Starr expressed his concern that “those who talked about ‘health care planning’ in the 1970s now talk about ‘health care marketing. Everywhere one sees the growth of a kind of marketing mentality in health care. And, indeed, business school graduates are displacing graduates of public health schools, hospital administrators and even doctors in the top echelons of medical care organizations.

“The organizational culture of medicine used to be dominated by the ideals of professionalism and voluntarism which softened the underlying acquisitive activity,” Starr wrote. “The restraints exercised by those ideals now grows weaker. The ‘health center’ of one era is the  ‘profit center’ of the next.”
In this brave new world of the 1980s, corporate executives would become both the  wealthiest and the most powerful actors on the new cultural stage.  Hospital CEOs would haul home salaries that made neurosurgeons look like pikers.  In health care, as in other industries, CEOs, not physicians, make the decisions, and their goal, Starr suggested, would no longer be better health, but rather, “the rate of return on investments.”

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The Kaiser Daily Health Policy Report below announces that the Chairs of the Senate Finance and Senate Budget Committees have introduced a bill to create a Comparative Effectiveness Institute.

The question: Would its decisions guide Medicare’s decisions about what it covers?  Clearly Congressional Budget Office Director Peter Orszag thinks the Institute would have some real power: He estimates it “could save up to $700 billion annually in health care spending by identifying treatments that do not produce the best medical outcomes.”

That’s the $1 out of $3 health care dollars that we now waste on unnecessary, unproven, ineffective and often over-priced treatments.

Of course, we wouldn’t save anything close to that amount at the beginning. It will take years to wring the waste out of the system. But putting U.S. healthcare on an evidence-based footing would be a giant step toward the national health reform we need.

I am also encouraged by the fact that the 18 members of the Institute’s panel would be appointed by the Comptroller General. The Comptroller General appoints the members of the Medicare Payment Advisory Commission (MedPac), and they have been producing extremely intelligent reports. They are also widely perceived as apolitical.

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Last month I wrote a post highlighting a truly boneheaded development in the Department of Defense (DoD): the introduction of AHLTA, a new system of electronic medical records for the military. Usually I’m a big fan of electronic medical records (EMRs), but not in this case  AHLTA is an entirely new system built by military contractors and funded by taxpayer dollars. Its mere existence is wasteful, because the military has long had a high-quality health care IT system in place called VistA, the Veteran Administration’s (VA) EMR system. And VistA  could have served as a very efficient foundation for modernize military health records. 

As I’ve mentioned in the past, VistA has quite a lot going for it: the VA has improved productivity by 6 percent a year since it was implemented in VA hospitals nation-wide; VistA has helped the VA cut its health care costs by 32 percent since 1996; and the VistA computerized prescription system is incredibly accurate, correctly matching patients and medication 99.997 percent of the time. It makes little sense to ignore this homegrown asset when setting out to build a broader DoD EMR system. Worse still, AHLTA can’t even communicate with VistA, adding a new layer of dysfunction to the military’s IT development.

This is all incredibly foolish, but maybe the real kicker is that AHLTA is proving a total failure. Not only is it a waste from an IT development stand-point, but it’s also proven to be a hindrance to the very military clinicians whom it’s supposed to be helping.

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Over at Kevin M.D.’s excellent website, The Happy Hospitalist recently posted a “Reader’s Take” on Medicare that sparked  a fierce debate.

The Happy Hospitalist began by pointing out, rightly, that Medicare is approaching a financial crisis:  “On March 25, 2008 the Boards of Trustees released their Annual Report of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. In this 43rd edition, the Trustees note [Medicare is] a government program covering just over 44 million people at an expense of $425 billion dollars during 2007. That equates to approximately $10,000 per beneficiary.

“Ten thousand bucks. A cost accelerating at an unsustainable rate”

This is entirely true.  If we continue in our profligate ways, Medicare will break the bank. But then Happy Hospitalist explained his solution:

“The appropriate course of action should be a radically new approach to the Medicare entitlement program…A restructuring of the program towards a transparent means based qualification system is necessary. Having Uncle Sam pay for an elective cataract surgery so grandma can go on an African safari is inexcusable in a time of financial collapse.”

Often I agree with The Happy Hospitalist. But on this point, I cannot.

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In a post originally published on The Health Care Blog  and reprinted on Bob Laszewski’s Health Care Policy and Marketplace Review, health care analyst Brian Klepper asks: “Is Meaningful Health Care (Or Any Other Kind Of) Reform Possible?”

His answer: “I’d be surprised. Delighted! But surprised.”

I decided to answer him.

Klepper believes that the lobbyists are just too strong. Always incisive, he pulls no punches: “In a policy-making environment that is so clearly and openly influenced by money,” it’s just not likely that “Congress will be able to achieve health care reforms that are in the public interest.”

I disagree. I believe economic pressures are pushing us toward a political turning point. (If you want to understand what is happening in history or in politics, follow the money.) The Bush administration has been thoroughly discredited. Americans are ready for change. Healthcare reform will not happen tomorrow; it will require a bare-knuckled political fight. But it will happen, and this is why: Although lobbyists are powerful, so are voters. And they realize that we are approaching a flashpoint.

You’ll find the rest of the post here.

To comment, come back here.