It is advantageous for a patient working with a trusted physician to understand the necessity to control blood pressure, control diabetes, control weight and eliminate harmful habits (tobacco, alcohol, illegal drugs, violence, etc.). Every literate American has access to abundant sources of information regarding health issues. Unfortunately, because of dysfunctional reimbursement policies, driven by Medicare as the nation’s largest insurer, for many patients there is little quality time between physician and patient. It then becomes difficult to develop the healing relationship so important for good health care. Frequently patient education develops into unrealistic beliefs in the power of medicine with inappropriate expectations leading to consumerism. In complex situations in patients with multiple health issues there is no substitute for medical judgment. This can only be obtained with formal training and years of experience.
Indeed it takes more training to take care of seriously ill patients than to fly a jet liner. Yet it is inconceivable that a jet pilot when facing a problem, instead of using his experience and judgment, would have the passengers vote on what to do. However, unlike the pilot, in today’s medical practice it is common for physicians to place the task of medical judgment on the patient/family frequently resulting in irrational care. This often leads to patient suffering and the wasting of valuable resources.
This exaggerated sense of patient autonomy along with the fear of legal action has augmented medical consumerism. This problem has been enhanced by drug and device advertisements directly to the public and by the medical profession’s undue reliance on the legal system to decide what are, in effect, medical questions. Instead of our various medical societies forming referral mechanisms to help decide difficult issues, hospitals and doctors have abdicated this responsibility to the courts with the result being an ever-present fear of legal action.
As long ago as October 16, 1975 Dr. Franz Ingelfinger, then editor of the New England Journal of Medicine, wrote about physicians allowing the legal community to be the referee in difficult medical issues. He wrote:
“Serious questions may also be raised concerning the propriety or usefulness of legal proceedings when essentially medical questions are at issue…..dependence on the lawyer in reaching essentially medical decisions will continue, however, unless organized medicine can develop its own effective system of in-house arbitration…..”
It should be noted that till this day our medical societies have not answered this challenge. Again, in May, 1994 (New England Journal of Medicine) while discussing the Baby K court case, an encephalic baby with no chance of recovery, George J. Annas had a similar message. He commented that for medicine to avoid becoming a consumer commodity and thus unbearably expensive requiring control by payers, physicians will have to set standards and follow them. Again organized medicine did not and has not responded.
A few weeks ago (November 2009) a talented second year resident told me that, in his opinion, American medicine is no longer about treating patients’ problems. It has become a hospitality industry focused on customer satisfaction regardless of the appropriateness of the medical plan.
For health care reform to be successful we have to insist that our medical societies set up procedures so that patients are treated as individuals, each with unique needs. At the same time mechanisms must be established so that we uniformly practice high quality medicine with evidence-based use of resources. We must have expanded peer review so that difficult situations and overuse can be quickly resolved using medical experts.