An important lesson that has emerged from the experience of several countries is that when profit motive is dominant in health systems, good care of patients and desirable heath objectives are difficult to achieve. This remains true even when a lot of money is spent on health. Profits of private hospitals as well as costs of drugs, equipment and insurance companies may increase, but doctors who want to be true to their profession can feel trapped in an excessively commercialised system.
This is brought out very effectively in the context of the USA in a recent book ‘Doctored – The Disillusionment of an American Physician’ written by Dr. Sandeep Jauhar (and published by Farrar, Straus and Giroux, New York). Dr. Jauhar is the Director of the Heart Failure Program at a leading US hospital and he also writes regularly for the New York Times.
In this book, Dr. Jauhar has portrayed a highly commercialised system in which doctors who want to be honest to their profession feel helpless and hence are exposed to high levels of depression. In a survey of 12,000 physicians, only 6 percent described their morale as positive. A majority of them said they did not have enough time to spend with their patients because of paperwork. In the USA, among professionals, physicians have the highest suicide rate. One American doctor kills himself (or herself) every day.
One doctor said on Sermo, the online community of more than 1,25,000 physicians, “Working up patients in the ER these days involves shot-gunning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them and becoming aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a money-making game for hospital administrators.”
Another doctor quoted in this book says, “You’re doing things, and you’re doing them because you’ve got to be them, but you’ve thinking, why the hell am I doing this?”
One doctor regrets, “We allowed the insurance companies to come between us and our patients.”
Dr. Jauhar says, “Year after year, health care spending grew faster than the economy as a whole. Premiums for insurers like Blue Cross, whose reimbursement rates were determined by doctors, increased 25 to 50 percent annually. Meanwhile, reports of waste and fraud were rampant.”
A Congressional investigation found that surgeons performed 2.4 million unnecessary operations resulting in nearly 12,000 deaths.
The Institute of Medicine estimated that wasteful health spreading (that does not improve health outcomes) costs $750 billion in the USA every year.
A study published in the New England Journal of Medicine found that one in five Medicare patients discharged from the hospital was readmitted within a month. One in three was re-admitted within three months.
Dr. Donald Berwick and Dr. Allan Detsky wrote in the Journal of American Medical Association that inpatient care at teaching hospitals has become a relay race for physicians and consultants, and patients are the batons.
Researchers have found that a doctor who owns a nuclear scanner is seven times as likely as other doctors to call for a scan. Between 1987 and 2006 the exposure of Americans to radiation increased by seven times, primarily because of CT scans. The number of CT scans in the USA in one year is around 70 million.
Patients are overexposed to a battery of specialists, several of whom they do not need, while the doctor who knows a patient best is often not involved in her or his care at the time of hospitalisation. Dr. Jauhar gives one example, “A fifty-year old patient of Oni’s was admitted to the hospital with shortness of breath. During his month-long stay, which probably cost upward of $200,000, he was seen by a hematologist; an endocrinologist; a kidney specialist; a podiatrist; two cardiologists, a cardiac electrophysiologist; an infectious-diseases specialist; a pulmonologist; an ear, nose and throat specialist; a urologist; a gastroenterologist; a neurologist, a nutritionist; a general surgeon; a thoracic surgeon and a pain specialist. The man underwent twelve procedures, including cardiac catheterisation, a pacemaker implant, and a bone marrow biopsy (to work up mild chronic anemia). … When he was discharged (with only minimal improvement in his shortness of breath), follow-up visits were scheduled for him with seven specialists.”
Dr. Jauhar comments, “Patients don’t always require specialists. Patients often have ‘overlap syndromes’ (we used to call it aging), which cannot be compartmentalised into individual problems and are probably best managed by a good general physician. When specialists are called in, they are opt to view each problem through the lens of their specific organ expertise. Patients generally end up worse- …….. I have seen it over and over again.”
Medicare imposed a requirement that antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital. Doctors often cannot diagnose pneumonia so quickly, but because of Medicare requirement antibiotics were given despite all-too-evident dangers to patients.
Introduction of surgical report cards which rewarded lower mortality led to a strong tendency to avoid more serious patients. As a research report stated, “Mandatory reporting mechanism inevitably gives providers the incentive to decline to treat more difficult and complicated patients. …Observed mortality declined as a result of a shift in incidence of surgeries towards healthier patients.”
In New York state 63 per cent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery. Fifty-nine per cent of cardiologists said it had become harder to find a surgeon to operate on their most severely ill patients.
Despite very high spending on health the USA lags behind in health achievements.
According to the Commonwealth Fund, a health care research group, the US ranks forty-fifth in life expectancy (behind Bosnia and Jordan). Among developed countries, it is almost at the bottom of the list when it comes to reducing infant mortality. Similarly, it is near the last place in terms of health care quality access and efficiency.
What is more, as Dr. Jauhar tells us, “…within the USA, regions that spend the most on health care appear to have higher mortality rates than regions that spend the less, perhaps because of increasing hospitalisation rates that result in more life-threatening errors and infections.”
Dr. Jauhar concludes, “I am convinced of one thing; the vast majority of doctors aren’t bad. It is the system that makes us bad, makes us make mistakes.” He says that more doctors are willing to stay till late and provide good care, but “they are struggling to do so in a system that is diseased.” The most disturbing part of what Dr. Jauhar says is that most doctors realise that the system is forcing them into a situation in which they cannot be honest to their profession yet feel so trapped by the system that they can’t resist it enough to find the honest way out.
(The writer is a freelance journalist who has been involved with various social movements and initiatives.)