Medicine in a Changing World - Part 2
Medicine in a Changing World
Medicine is in a constant state of flux, but the radical changes we’ve witnessed in the past century have left us grappling with a crucial question: are these changes truly for the better?
Rockefeller and The Flexner Report
100 years ago, Rockefeller's influence on medicine was profound. He bought pharma companies and invested in medical schools, and his introduction of the Flexner Report led to the suppression of centuries-old natural remedies. This report, while improving the quality of life and treatment for diseases, also marked a shift towards a more pharmaceutical-based approach to healthcare. Despite these advances, we still grapple with major health issues such as cardiac disease, cancer, and suicide, which remain the biggest killers of humans each year.
United Health Care CEO
The recent assassination of United Health CEO, Brian Thompson highlights the frustration of trying to maintain health today. Thompson’s murder was a targeted attack on the way medicine is practiced in the US. Each bullet casing was engraved with “deny, defend, and depose,” which evoke a similar rallying cry among many upset with insurance companies. For someone to go through the effort of engraving each bullet casing goes beyond comprehension. The evidence and clues point to frustrations with healthcare companies and how they affect medicine. It’s no secret that healthcare insurers unfairly deny coverage to patients. Health insurance companies significantly influence medical practice by determining what treatments they will cover. Physicians and other healthcare providers must navigate complex approval processes, which detract from the holistic, individualized approach to patient care. Denial of healthcare has become commonplace and a major frustration in trying to maintain health. Prior authorization’s lead to serious adverse events, abandonment of treatment, delays in necessary care, and the prevention in preventative care. This event will undoubtedly change health insurance as we know it, especially with increased private security. No doubt, these costs will be passed down to the consumer.
A Changing of the Guard
Physicians are no longer in charge. Today, medicine is practiced not as an art but rather as a checklist of evidence-based measures and what health insurance companies will reimburse. Nurse practitioners, physician assistants, and other mid-level healthcare providers are replacing physicians for various reasons. The growing demand for healthcare has increased the demand due to an aging population and increasing chronic disease prevalence. Coupled with fewer physicians, the mid-levels are often placed inappropriately to fill these gaps. This also results in a decrease in the quality of healthcare delivered and adds to the frustration in the healthcare system and insurance companies, as we’ve seen with the recent murder of Brian Thompson.
Mid-Level Training and Scope of Practice
Physicians undergo extensive training, including residency, for which there’s no alternative. The rigorous training involves at least 12 years of rigorous education and dedication. This is why, for most physicians, it’s a calling or a vocation. If one aims to become independently wealthy from medicine, looking elsewhere is advisable. Nurse practitioners (NPs) and physician assistants (PAs) have different educational paths with less clinical training but offer advanced skills. The scope of practice for NPs and PAs varies by state, with some allowing full practice authority without physician oversight. Healthcare policy changes occur at the governmental level. The healthcare lobby is among the biggest in the world, and their policy initiatives often miss the mark. They aim to expand access to healthcare, like the Affordable Care Act, which helps meet healthcare initiatives more broadly. But in the end, it’s the patients who suffer the most due to the quality of care. Examples are:
Ten-minute psychiatric video visits.
Five-minute patient visits for family medicine.
Nearly zero minutes for preventative health care.
Simply put, we are practicing sick care, not health care.
As mid-level providers push for more autonomy and “scope creep,” i.e., being able to do more with less training — it causes many to practice medicine beyond their training and capabilities. This week, I was involved in a case where a mid-level provider in an urgent care diagnosed a swollen finger as inflammation and gave an “inflammation shot” to treat the condition. This patient, who has diabetes and had recent hand surgery only two weeks prior, was misdiagnosed. Any physician worth his or her salt and trained with hand surgeons knows this is a serious matter and an infection until proven otherwise. Indeed, the patient then presented herself to the Emergency department; laboratory findings confirmed an infection, and the patient received intravenous antibiotics and surgery the next day. If this infection had been left to linger, the patient easily could have lost their upper extremity to infection or, worse, their life from sepsis.
Evidence-Based Medicine (EBM)
The move towards evidence-based practices claims to ensure patient care is based on the best evidence. Yet the research claims on which these practices are based are, at best, flawed. The quality and bias of research exist with positive outcomes being published, large industries skew the evidence towards their financial goals, and fraudulent research is being published. If you want examples, look no further than the latest cancer, nutrition, and statin medication research.
Most Research Findings Are False
In his seminal 2005 paper, Ioannidis argued that for many research designs, the probability that a research claim is true is quite low due to factors like small sample sizes, the number of tested relationships, flexibility in designs, financial interests, and the bias towards publishing positive results. Research trials are not done in real-world settings, and the focus on statistical significance translates into misleading conclusions and less meaningful patient benefits. All these things take away the personal touch or “art” of medicine. While EBM improves outcomes and reduces variability in care, it is prescriptive and less personalized. The work of Emily and Greg Glassman from the Broken Science Institute brings problems with research statistics and EBM to the forefront.
Chronic Diseases
So, where does current medicine stand in the face of this enormous problem? Pain and chronic disease are the number one reasons people seek healthcare providers. The problem is that most patients prefer prescription analgesic medications to address their chronic pain. Likewise, healthcare providers prefer to prescribe these medications, which do nothing to cure the disease. Pain patients are the largest consumers of anti-inflammatories and anti-depressants. Why is this the case? Despite these medications, their pain is always present, and worse, they are chained in a vicious cycle of constantly taking medications.
One striking example of this issue is the modern medical system's failure to adequately address chronic diseases. Western physicians are well aware of the limitations in effectively treating chronic diseases. The initial response often involves prescribing medications while disregarding the role of emotions or the resulting depression from being unable to maintain an active life. Rarely do we ask about the person’s history of psychological trauma. One fundamental problem is that Western medicine primarily views chronic diseases as a biological problem when it embodies the mind, body, and spirit. A well-known physician, Dr. Gabor Mate, eloquently states that chronic illness is the body’s expression of experiences, beliefs, and lifelong patterns of relations to self and the world. The word healing means wholeness, and when we become whole, we can reconnect with ourselves and elevate our consciousness. Perhaps we should return to treating the body as a complex system rather than a “paint by numbers” checklist.