Friday, December 24, 2004

On Medicine

By all accounts we have a crisis in the medical world here in Maryland. This takes various aspects, but the most immediate is a sharp increase in the number of physicians who are either retiring early, leaving the State, or restricting their practice. All of this is principally due to a dramatic increase in the malpractice insurance premiums. Some obstetricians now have yearly costs of over $100,000 just for this malpractice insurance.

To be honest, this is just the tip of the iceberg. There is a myth that is circulating that if only the Governor (a Republican) and the chief legislature figures (Democrats) can agree on a "fix" that everything will be fine in medicine. It won't. And it won't for a number of reasons.

To understand what kind of a mess medicine is in at this time one needs to go back 30-40 years. Medicine was much different then. For instance, when I rotated as a student at D.C. General Hospital (since disappeared), I.V.'s were still started with hypodermic needles which were reused (after sterilization). There were no I.V. pumps and one regulated the flow by counting the "drips." Interns determined sugar levels themselves in the laboratory and we plated cultures of spinal fluid and blood. Blood counts were done by hand and a Coulter Counter was an experimental machine. Most dramatically, there was no CAT scanners and if one wanted to know if there was something in the brain, one had to do a pneumoencephalogram which involved injecting air into the spinal column giving the world's worst headache. Needless to say this was a last resort.

I encountered the same level of technology ten years ago when I visited a children's hospital in Siberia. While the level of expertise (book learning) was very high there, the instruments available for diagnosis and treatment, including pharmaceuticals, were dismal.

Fast forward to December, 2004. Medicine has entered an era of rocketing technology. It is said that knowledge doubles every ten years. I believe it. But it is hard to say whether technology "doubles" since the difference between a pneumoencephalogram and a CAT scan or MRI scan cannot be measured. Particularly with respect to patient comfort.

In spite of all this advancement (and we should probably talk about the pharmaceutical side of it at length), there are still certain areas that cannot be totally automated. One of this is childbirth. Although ultrasound has revolutionized the prenatal diagnosis of abnormalities, it can do nothing to fix them. Up to five percent of all births will have an abnormality.

Birth abnormalities are rarely the result of obstetrical error.

Let me repeat, birth abnormalities are very, very rarely the result of obstetrician error.

So, we have a heady mix. We have expotentially increasing levels of knowledge (a level in 1960; twice that in 1970; four times that in 1980; eight times that in 1990 and 16 times that in 2000), escalating technology, and a pharmacopeia that promises a cure for every little thing that afflicts you. (I am reminded by the availability in the South 20-30 years ago of a homeopathic remedy called Doan's pills. There were apparently 100 different pills. If you had a hangnail, you used pill number 46; forlorn love was pill 52; etc.).

Enter the mere human, which is all that a doctor is. There is absolutely no way that mere humans can encompass the full gamut of this knowledge and technology. But doctors are expected to know it all. And, to be truthful, we sometimes pretend that we do. What are we supposed to do? Say we don't know everything? Since everything is out there, we would soon be without patients. We have to hope that what we do know approximates the problem that we are facing.

With all of this technology out there, if something goes wrong, someone must be blamed. And that someone is a doctor. Since there are always going to be bad outcomes in certain pregnancies, there will always be disasters, no matter how advanced the knowledge and technology. And humans being what they are, they will always seek to attach blame for bad outcomes. Particularly when there is a million dollar reward for making it stick. Its the American way.

It is interesting that American society can be so hypotcritical about assigning blame. God knows that there have been mistakes made. Obstetricians invariably get sued for bad outcomes but Donald Rumsfeld hasn't been sued for screwing up Iraq. Kenny Boy Lay is still at large having bilked millions of dollars out of a lot of innocent people. Johnny Depp doesn't get sued for acting in "The Secret Window."

One of the differences is that the mechanism for suing a doctor has been honed to perfection. It costs the family nothing to sue an obstetrician for the birth of a child with cerebral palsy even though the overwhelming majority of times this is not the fault of the obstetrician (there are cases where it is; these are legitimate and there should be consequences). As the case goes forward, the physician is put under tremendous duress: his or her competence is questioned, citations go into a national data bank never to be erased, even if the suit is shown to be trivial. And, most importantly, lawyers and expert witnesses make a lot of money.

If the suit gets to the point of a jury trial (most never make it; many times the physician gives up and settles out of court just to avoid the hassle), you have 12 people who are not familiar with all that knowledge and technology trying to decide if a mistake was made. It is hard not to make that decision in favor of the plaintiff when presented with an unfortunate child who is physically and mentally handicapped. Your intuition tells you that somebody is to blame. The doctor is the only somebody available. The result is well known; multimillion dollar settlements with the plaintiff's lawyer taking his 40%.

That money has to come from somewhere. That somewhere is other physicians via the mechanism of increased fees for medical malpractice. As stated above, the current fee in Maryland for an obstetrician is over $100,000 a year. One doc told me he would have to work until August just to pay his malpractice.

I can assure you that doctors do not get a break on rent for their offices, cost of electricity, cost of equipment, and, most of all, cost of their employees (including their employees medical insurance if they pay it).

Thus the crisis.

All of this said, I have no solution whatsoever. To me it is as intractable of solution as gravitational relativity was for Einstein. I expect that it will get a lot worse before it gets better. But people should realize that physicians are human too. Furthermore, if you grind physicians into the dirt, if you strip them of their aura, if you do not respect them as healers, it will only come to rebound on yourself.

People shout out "Physician Heal Thyself!".

They will shortly be faced with healing themselves.

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