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The Medical Crisis That Nobody Knows (November 09, 2000)*

I wish to sound an alarm about your medical care. Our Medical System has been dismantled piece by piece, under federal legislation, regulation and rules, reimbursement schemes, intimidation, slight of hand, lies and deceit, legal actions, until what exists now is unrecognizable. No one has announced it at a news conference, or put it to a vote. They just did it. And we allowed it.

MEDICAL CARE: To practice medicine is (1):

To diagnose, treat, prescribe for, palliate, or prevent any human disease, ailment, injury, deformity, or physical or mental condition, whether by the use of drugs, surgery, manipulation, electricity, or any physical, mechanical, or other means whatsoever;

Suggesting, recommending, prescribing, or administering any form of treatment, operation, or healing for the intended palliation, relief or cure of any physical or mental disease, ailment, injury, condition, or defect of any person with the intention of receiving, either directly or indirectly, any fee, gift or compensation whatsoever;

The maintenance of an office or other place to meet persons for the purpose of examining or treating persons afflicted with disease, injury or defect of body or mind.

Doctors practice medicine, right? Not anymore. Practitioners practice medicine. Practitioners are not doctors. There has been a shift in philosophy about the training needed to care for patients. Medicine has adopted the corporate model. Activities are broken down into parts that can be learned in a short time, and then workers are organized into a fast food, factory model to deliver it. No need for superfluous "specialist" knowledge. More knowledge is wasteful, dangerous, hard to control, expensive. And it must be safe, because the practitioner's work is guaranteed by some doctor’s medical insurance.

The Old Medicine, as a profession, required each individual to train for very long periods under intense scrutiny and certification. This culminated with independent authority vested in that one individual. It was an earned authority over life and death. The right to make the mistake.

AUTHORITY: We view authority differently now. We demand perfect care, viewing inevitable human error as purposeful harm. We magnify the mistakes of those who are accessible to us. Those we can scrutinize up close become responsible, those at a distance from us remain infallible.

We expect government, and now private companies to make our decisions for us in return for this perfection. Obviously, only such anointed groups can weigh important decisions. We are led to "re-engineer" into systems that control workers and root out errors. We trust in these systems. We assume they provide protection from mistakes and corruption. When we get less than we expect, we grab anyone we can hold accountable, often our most knowledgeable personal advocates. Executives are at a distance, safe from our scrutiny as long as they bury the inadequacies and appease our fears. We even excuse their purposeful harm as inevitable human error. They certainly cant be sued for it.

In the New Medicine authority is bestowed. Corporate organizations grant and restrict authority by decree, by virtue of title and position. One learns what to do by copying everyone else, by protocol. Crucial decisions in corporate medicine are made by those who have never known the burden of years of medical study, nor the personal responsibility for the failure to meet a patient's needs.

We have moved from a time with clear, appropriate delineation of authority (although with fierce turff wars), into a morass. Medicine is spinning out of control. No one is in charge. And EVERYONE takes advantage of that to grab a share of the money and power. This system is not set up to improve quality, but rather to feign improvement of profit and loss. Don't look, don't tell.

MERGER MANIA: One devastating result of this is merger mania. Investors raid medical corporations, sell off the assets and extract them as one-time profit. Experienced nurses, physicians, and staffs are downsized or retired early. Hospitals and equipment are auctioned. Specialty units are closed. After all, there are too many specialists (translated as "doctors know too much and cost too much"). We have moved from a time when doctors are professionals who do the right thing, to one when they are executive managers who fix or camouflage mistakes. Eventually, even these physicians are replaced by non-physicians.

WHO IS SUPPOSED TO FIX IT? Who decides what to value? Many groups try. Federal Government. State Legislatures. Governors. Medical Societies. Nursing Boards. Data Banks. Hospitals. Medicare Administrators. Political groups. Community activists. Religious leaders. Task forces. Non-profit companies. Employees. Insurance companies. Banks. Taxpayers. Polls. Courts. Lawyers. Lobbyists. Drug companies. CFO's. Sometimes even Patients. Which of these should have such authority? Which of these should pay the price?

State Legislatures now empower Nursing Boards to license less trained, non-physicians to practice medicine. The Medical Boards are then bypassed entirely. It is a political and economic process. We are propagating "communal wisdom", without demanding that practitioners can meaningfully examine that wisdom, much less advance it.

A doctor who has completed a 3 year residency may do procedures (upper G.I. endoscopy, vaginal delivery, pediatric emergency care, vasectomy, infertility treatment, colposcopy, breast biopsy). So might a Physician Specialist with an additional 2 to 5 years training. A Nurse Practitioner might perform many as well. The proliferation of practice titles is maddening. FNP (Family Nurse Practitioner) after a name looks very much like the initials which indicate a physician specialty, FMP (Family Medicine Physician). ID badges are little help, even when used.

How can anyone tell who can do what? Who is to decide who does what? Who credentials them? Who disciplines them? How unwieldy that process has become, bloated with bureaucracy, and paralyzed to the point of absurdity.

LOWER STANDARD OF CARE: We thus accept a lower standard of medical care. Anyone who has been in medicine more than 15 years will tell you that clinical training is less rigorous. One medical school wanted to dissolve the department of anatomy because it could not attract grants. New Nurses get their training after graduation on the job in hospitals. Extenders get clinical experience in doctors offices, with scant reimbursement to their physician teachers. There is superficial oversight, little supervision, and no correction. Mediocrity has become the standard, with interference with and even financial or professional penalties for excellence. Being mediocre (not worse than anyone else) maximizes profit. What is the incentive to give good care?

Lower standards are mostly invisible to patients, partly because there is such variation in training, skill, certification and titles. All are all now called "provider". One substitutes for another, gaining authority based on appearance, implication, or association. Patients assume that the someone caring for them is trained at the level of a specialist doctor. Maybe they are too afraid to consider otherwise?

A study in the May 30, 2002 New England Journal of Medicine documents how replacing Registered Nurses with less trained Licensed Practical Nurses and Nurse Assistants increases patient deaths. Is there any doubt that replacing Physician Specialists with less trained Practitioners is any less damaging?

NEW TECHNOLOGIES: An explosion of new technologies adds to the confusion. Technical advances are improving our abilities. But many physicians have retreated into niches of technological expertise to survive. As extensions of our skills, technology has always been an asset. I suspect, however that technological revolutions can not replace comprehensively trained and broadly experienced physicians, who are given authority and self-determination commensurate with their training, and interact in a meaningful way with their patients.

HOW MUCH DOES IT COST? It is clear that medicine shouldn't stay as it was. It actually has never stood still. Yet, dramatic changes are too often imposed from the outside. We have been hypnotized to believe that "the problem" is the high cost of medicine, and these changes will address that. A cost is visible when you get a hospital bill or when your pocketbook is empty. It's so easy to believe that services rendered are overpriced. But how do you accurately measure the worth of years of training and uncertainty which go into making an important correct diagnosis or treatment? The cost of a life totally put right because of the actions of someone with that knowledge? The cost of losing that knowledge because there is no longer any place to keep it? How can you tell until after it is gone? We will see that throwing it all away has actually saved us nothing.

QUALITY: The American Association of Academic Health Centers addressed the issue of quality at a Symposium in 1993. They concluded that, "A responsible individual whose performance is continuously reviewed and judged by peers is a more reliable guarantor of performance than an administrative system relying on credentials, rules, regulations." (2)

Professions encourage this when they:

•define their areas of expected knowledge and skills
•train and test in those areas of knowledge
•evaluate using peer review
•don't perform activities outside of those areas

NEW MEDICAL MODEL: Government and Business have ignored this understanding by forcing the technologies and blatantly corrupt practices of corporate business into the practice of medicine. This neutralized the authority of individual physicians, and gave the profit of their labors to others.

We have lost focus. An individual must be rewarded more from doing it right, then from taking advantage of allowing it to be done wrong. Surrogacy in medicine has always been a dangerous game, and the use of providers who know less is cutting one corner too many. The game fix is in.

Timothy D. Bilash M.D., M.S.
Diplomate, American Board of Obstetrics and Gynecology

(1) The State of Arkansas Medical Practices Act
(2) The Roles of Physicians Assistants and Nurse Practitioners in Primary Care, D. Kay Clawson and Marian Osterweis, Eds, 1993

essay history:

submitted The Los Angeles Times 06/01/2003*
submitted The Los Angeles Times 06/03/2002
submitted Bangor Daily News 05/10/2002
submitted The New York Times 03/26/2002
submitted The Los Angeles Times 03/31/2002
first submitted Journal of The Society of Laparoendosopic Surgeons 11/09/2000

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