The Doctor's Corner

THE ELEPHANT IN THE EXAM ROOM

Dr. Connie CatellaniI, who graduated in1977 from the University of Illinois at Chicago Medical School, completed both her internship and residency at Michael Reese Hospital. Board Certified in both Internal Medicine and Emergency Medicine, Dr. Catellani spent several years at Rush Presbyterian St. Luke's HospitalL as an emergency room teaching physician. From 1993 to 1995, she practiced at the Chicago Holistic Center, the forerunner of American Holistic Center. Along with several partners, she established The Miro Center for Integrative Medicine in Evanston in 1995, and later joined Wellspring Integrative Medicine in Evanston. Dr. Catellani now has a private practice in Skokie.


Connie Catellani, M.D.

Since seeing "Sicko" recently, I have been pondering the truly sad state of healthcare in the U.S. Perhaps the most upsetting realization after watching the film was that there were no surprises in the long series of revelations about the flaws in the way medical care is delivered, or not, in this country, or the often shoddy methods that are routinely practiced (e.g., the mentally-ill homeless woman who was sent to a shelter instead of more appropriate care.) The only surprises were how much better the care and methods of delivery were in other countries.

. . . what about the increasingly tangled web that exists between healthcare providers, the public, and the pharmaceutical industry? What about the statistics that show that approximately half of bankruptcies in the U.S. are a result of a healthcare crisis? And that the majority of those bankrupted for health reasons had health insurance?

When I did my medical training in the mid- to late-seventies, there were certainly many political and ethical controversies and dilemmas, but the underlying motivation for all of us was always "the best interests of the patient." I realize that my view of that past may have been colored at the time by my youth and naiveté, but I am absolutely certain that we never questioned patients about their insurance policies or other financial issues in order to make a treatment decision. Now, I have that conversation with patients every single day in one form or another, knowing that if I do not the consequences could be disastrous.

Also, in those long-ago days of training, I never would have imagined that I would make a serious career decision, or have one made for me, based on the restrictions imposed on me by the malpractice insurance industry. Yet, despite the fact that I have never been named in a malpractice lawsuit, let alone sued (as of the writing of this article), both types of events have occurred in my career.

And what about the increasingly tangled web that exists between healthcare providers, the public, and the pharmaceutical industry? What about the statistics that show that approximately half of bankruptcies in the U.S. are a result of a healthcare crisis? And that the majority of those bankrupted for health reasons had health insurance?


The Case for Disabling Dysfunction in the U.S.'s Healthcare System

Webster's defines dysfunction as "abnormal or impaired functioning, especially in a bodily system or social group." A healthcare system could be judged as functional if it fulfills its stated purpose most of the time. If we define the basic purpose of U.S. healthcare as a system designed to improve or preserve the health of the population of the U.S., then there are really two fundamental components of an optimally functional system: 1) Does it improve or preserve the health of most individuals who interact with the system to an acceptable degree? And, 2) Is this healthcare available to a large percentage of the population?

We can also expand this definition of optimal function to include other factors such as ethical criteria, cost-benefit analyses, or independence from outside influence.
Let's examine these criteria:

#1 Does the U.S. healthcare system improve or preserve the health of most individuals who interact with the system to an acceptable degree?
This is a very broad question, and hard to measure directly. If we look at more easily measured, smaller criteria, we might at least approach the larger question indirectly. Two commonly used criteria for comparison of the effectiveness of a country's health care are infant mortality and life expectancy. The Central Intelligence Agency (C.I.A.) compiles these statistics on a frequent basis, omitting countries for which data are not available. For infant mortality (deaths/1000 live births within the first year of life), the U.S. ranks 42nd of 221 countries listed, with 6.37 deaths/1000 live births, as of August 16, 2007. For life expectancy at birth, the U.S. ranks 45th of 222 countries listed, (78.0 years) as of the same date. (See the C.I.A.'s website, www.cia.gov) Closer scrutiny of both lists reveals that we rank behind most of the world's developed or industrialized nations, and behind more than a few non-industrialized nations as well.

Two commonly used criteria for comparison of the effectiveness of a country's health care are infant mortality and life expectancy. . . . For infant mortality (deaths/1000 live births within the first year of life), the U.S. ranks 42nd of 221 countries listed, with 6.37 deaths/1000 live births, as of August 16, 2007. For life expectancy at birth, the U.S. ranks 45th of 222 countries listed, (78.0 years) as of the same date.

Another way to examine this broad question is to examine it from the converse aspect, i.e. "How harmful is it to interact with the U.S. healthcare system?" Again, the data is not encouraging. The F.D.A., or Federal Drug Administration, estimates on its website (www.fda.gov/CDER/drug/drugReactions) that adverse drug reactions (ADRs) in hospitalized patients occur at a rate of over 2 million per year, and that they account for 100,000 deaths yearly. This makes ADRs the fourth leading cause of death in the U.S., ahead of pulmonary disease, diabetes, AIDS, pneumonia, accidents and automobile deaths (detailed in an article in JAMA.1998;279:1200-1205). This statistic does not include ADRs in non-hospitalized patients - ambulatory and nursing home patients, for example. The FDA estimates ADRs in nursing home patients to occur 350,000 times yearly.

#2 Is healthcare in the U.S. available to a large percentage of the population?
This is an easier question to answer concretely, and the answer is a clear "NO."A recent Consumer Reports survey, published in August 2007, states that approximately 16% of Americans had no health insurance, and approximately 24% are "underinsured," meaning that two or more of the following conditions apply to their policies: inadequate coverage of prescription drugs, and/or doctor visits, and/or medical tests, and/or surgery or other medical procedures, and/or catastrophic medical conditions, or the deductible is too high. Clearly healthcare in the U.S. is not readily available in an optimal or at least adequate form for a very large portion of Americans.

A recent Consumer Reports survey, published in August 2007, states that approximately 16% of Americans had no health insurance, and approximately 24% are "underinsured," [meaning] inadequate coverage of prescription drugs, and/or doctor visits, and/or medical tests, and/or surgery or other medical procedures, and/or catastrophic medical conditions, or the deductible is too high.

Some consequences of this situation are that uninsured/underinsured people often delay routine care, or minor sick visits, which sometimes results in more difficult-to-treat illnesses, or more expensive treatment when finally addressed; or that people who are uninsured/underinsured for financial reasons become uninsurable or insurable only with "exemptions" (i.e., major loopholes for the insurance company, never for the insured) because they develop "preexisting conditions" while they are uninsured, and then cannot afford health insurance except, possibly, of the "underinsured" variety.

So, by our two major criteria, the U.S. healthcare system is in major trouble. But let's not stop there. Let's look at how the dysfunction manifests in the interface between healthcare and other related industries.


The Case for Dysfunction in U.S. Healthcare's Relationship with Related Industries

How do we define dysfunction in a relationship? Again, if the goals, or functions of one party become distorted or less well executed because of the relationship between the parties, we could call that a dysfunctional relationship.

Healthcare and Big Pharma
A recent episode related to me by a patient brought home how the lines between the pharmaceutical industry and the medical profession have become more and more blurred.
Louis (not his real name) was given a new prescription by a specialist for symptoms of prostatism. When he picked up the drug at his pharmacy, he stopped to read the patient information sheet in the store. After reading the potential side effects, he decided to not take the drug and returned it to the pharmacist. A short time later, he received a letter at his home address asking him why he had declined the prescription—from a representative of the drug's manufacturer! Not the prescribing M.D., not even the pharmacist, but the pharmaceutical company! How they even knew that he had declined the prescription, and where to send the letter, are both legal issues in my opinion.

[A patient] was given a new prescription. . . . After reading the potential side effects, he decided to not take the drug and returned it to the pharmacist. A short time later, he received a letter at his home address asking him why he had declined the prescription—from a representative of the drug's manufacturer!

Carl Elliott, in "The Drug Pushers" (The Atlantic Monthly of April 2006), describes in very accurate detail how the boundaries between salespeople representing Big Pharma and physicians have become more and more blurred, with a resultant compromise in the ethics of the prescribing role of the physician, and therefore the physician-patient relationship. He also explains how pharmaceutical reps are able to track the prescribing habits of individual physicians, so that they can profitably zero in on their best potential high-volume prescribers. (Now I know why the drug reps never visit my office.)

Healthcare and the Malpractice Insurance Industry
This is a gigantic topic, and we can only touch on the superficial bullet points. But as we discussed earlier, adverse drug reactions (remember, these are when the drugs are appropriately used, not when errors are made) are one of the leading causes of death in the U.S., and medical malpractice (when errors occur) are another huge, often undocumented, cause of death and disability. Tom Baker, a lawyer and professor at University of Chicago, in the opening pages of his book, The Medical Malpractice Myth, gives an excellent summary of the situation in this country. His premise is that the current crisis is, in fact, a myth designed to divert attention from the high incidence of medical malpractice, or medical mistakes. He points out that the vast majority of the costs of medical mistakes in practice are born by the victims and their health insurance (if they have it!) because only about 10% of medical malpractice ever comes to litigation.

. . . 82% of doctors have never had a malpractice payment (meaning they have never been found responsible in a lawsuit or out-of-court settlement) since 1990. And, 5.9% of all doctors have been responsible for 57.8% of all malpractice payments since 1991. But are these doctors appropriately censured, or forced to change their ways?

Again, another gigantic topic is the medical profession's failure to monitor the performance of its members. A fascinating website article, Public Citizen Publications—The Great Medical Hoax (www.citizen.org/publications) summarizes some of the key indicators of this failure. For example, 82% of doctors have never had a malpractice payment (meaning they have never been found responsible in a lawsuit or out-of-court settlement) since 1990. And, 5.9% of all doctors have been responsible for 57.8% of all malpractice payments since 1991. But are these doctors appropriately censured, or forced to change their ways? Unfortunately, doctors at all levels of fault were barely given a slap on the hand. To quote their data, "Only 33.26% of doctors who made 10 or more malpractice payments were disciplined by their state board - meaning two-thirds of doctors in this group of egregious repeat offenders were not disciplined at all."

Certainly, this looks like egregious dysfunction to me!


Healthcare and the Health Insurance Industry
As mentioned before, only 60% of the American populace has adequate health insurance. Michael Moore, in "Sicko," showed excellent examples of how even the care of people with health insurance is dictated by the health insurance industry. For example, length of stay in the hospital is determined by what the insurance company involved in a case thinks is adequate for certain diagnoses. It remains very difficult to obtain extra time in the hospital after surgery, for example, unless the circumstances are extreme. Post-op patients are routinely sent home in accordance with health insurance deadlines, rather than individually assessed by their surgeon. Are health insurance representatives adequately trained to make these sorts of decisions? Even if they are, are they free of conflict of interest?

The Elephant in the Exam Room

It is for the reasons outlined above that I would say that the healthcare system in the U.S. is dysfunctional in a major way, both internally within its own functions, and externally as it interacts with other related systems. When an individual or family is entangled in a similar web of denial, malfunction, and abdication of responsibility, it is often said in the recovery/rehab community that there is "an elephant in the living room" meaning that there is a big obvious problem that no one wants to talk about directly. Rather, they talk about it indirectly, like "It's so hard to get anything done around here. Everything I do fails." But they don't talk about the real issue that is the obstruction.

I would say that there is a similar large elephant in the exam room, and we in the healthcare profession are refusing to talk about the real issues at hand. Until the medical profession assumes responsibility for the quality of care delivered by all its members, and ensures that health insurance is available to all members of the public, the dysfunction cannot truly be addressed in a meaningful way. Likewise our twisted relationships with the pharmaceutical, malpractice, and health insurance industries need major rehabilitation.

When an individual or family is entangled in a similar web of denial, malfunction, and abdication of responsibility, it is often said in the recovery/rehab community that there is "an elephant in the living room" meaning that there is a big obvious problem that no one wants to talk about directly. . . . I would say that there is a similar large elephant in the exam room, and we in the healthcare profession are refusing to talk about the real issues at hand.

We might make a good start by simply seeing what the forty-plus countries getting better results on infant mortality and life expectancy are doing differently than us, and adopting some of those measures. That might require rethinking many of our cultural biases about the countries involved, like France and Cuba, for example. A pleasant side effect of this institutional rehabilitation process might even be that we save some money, or at least increase the value obtained for each dollar spent.

Only when the fundamental aspects of the healthcare dysfunction are recognized and addressed, can the secondary issues of cost, delivery methods, emphasis on prevention vs. early detection vs. remedial care, and our willingness to integrate other philosophies ("alternative" or "complementary" -- which are often older methods, or mainstream approaches in other cultures) be tackled.