What Shall We Do With Healthcare?

04/15/2008 12:35 pm 12:35:34 | Updated May 25, 2011

Imagine you are a doctor walking down the street. You come upon a woman lying on the sidewalk possibly unconscious. Surrounding this woman are four people each loudly suggesting a different way to help. One is urging a candy bar, while another is promoting his unique, patented guaranteed cure for today only: $19.95 plus tax. A third is trying to resuscitate the woman, and the fourth is threatening her with a charge of public drunkenness.

This scene looks like something straight out of The Three Stooges. You approach the self-styled helpers and ask if they know what the woman's problem is. They all start speaking at once, suggesting diabetes, low self-esteem, a heart attack, and vagrancy. No one has examined the woman or even tried to talk to her. You shake your head, wondering how anyone could even think of treating a patient without first understanding why the person is sick. As a doctor you know that treating symptoms never cures anything, it just masks the problem.

The woman down on the sidewalk is Healthcare. Those offering to help - in essence doctors-without-licenses - are legislators, insurance executives, expert consultants, and regulators. You are the doctor - the person responsible for making the patient (healthcare) better. What should you do?

This blog is devoted to answering to that question. One message will be repeated over and over. The Lone Ranger had silver bullets. Harry Potter has magic potions. In our real world, these do not exist. Anyone who offers you a simple, quick, painless solution to a complex issue like healthcare, that person is selling snake oil. If the Public demands a simple solution, someone will sell us one - for money or votes. It just won't work.

Among the myriad problems in healthcare, one is relatively simple: semantic confusion. Words such as cost and quality have different or ambiguous meanings in healthcare versus general conversation. For instance: healthcare or health care? The answer is both. Health care (two words) refers to what a patient receives and what nurses and doctors offer. It is a service. Healthcare (one word) refers to a process or system for providing health care services.

Making good decisions is part of "practicing good medicine," for both doctor and patient. A key element in any decision-making process is evidence. In order to avoid a charge of saying one thing but doing another, I will defend myself in advance. While everything I write is by definition opinion, the assertions are based on hard evidence, not just personal bias. I will gladly share the references with any interested reader.

To start the discussion, consider what "practicing good medicine" means. How would you - the doctor - care for a sick individual? First, you take a history and do a physical exam. Then you do various tests. You study the results and review the literature to compare your patient to previous reported experience. Eventually, you figure out WHY the patient is having the symptoms: what doctors call the etiologic (or causal) diagnosis.

If the patient is obese; goes to the bathroom frequently; has a high blood glucose as well as foot ulcers; and experiences chest pains, this might point to an etiologic diagnosis of diabetes. If confirmed, the doctor and patient then understand that the body is not handling sugar properly. A medical and dietary regimen will aim at restoring proper control of sugar metabolism by treating the cause - insulin production - of illness.

Is that how we treat healthcare? (That was a rhetorical question.) The answer is an emphatic no! The Public experiences and loudly complains about certain symptoms. Rising costs; errors and bad outcomes: not always the same; insufficient access; and shortages of nurses or doctors: these are four of the most obvious. How do we handle these? Do we discuss and uncover WHY they occur? That was another rhetorical question.

What we actually do is the following. For rising costs, the treatment is to reduce payments. For errors and bad outcomes, we punish the perp. For limited access, the government mandates that care must be provided. For nursing shortages, we offer signing bonuses. All these "treatments" are symptomatic. As we all know, none has worked: the problems - symptoms as well as causes - remain and the patient is no better.

What we need to do is uncover, discuss and agree on the reasons for healthcare dysfunction. The "we" in that sentence is the general populace, not leaving it to the self-styled experts, our political leaders, or hospital administrators. Before we can cure healthcare, we must first understand the WHY of healthcare sickness, and then develop a consensus of what we want healthcare to accomplish. Neither answer is simple or easy (I told you I would write that several times) but here online, is where we can make a good start. We need to discuss: Price-based costing; Casting stones; the Dangers of risk-free medicine; and Cost reduction that does not reduce costs. Topics to consider include: Bad apples; Name, blame and shame; Efficiency kills; and our Continuing, never-ending healthcare crisis.

Comments are not just welcome: they are eagerly sought. Let the discussions begin!