Report Card: Sexual Behavior of High Schoolers and Overall Health of Children in the U.S.
Federal Consortium Issues Comprehensive Annual Report on Health and Behavior of Children
In case you were paying attention to other things this weekend (like the Tour de France), a report was issued Friday that is basically a report card on several parameters of children’s health in the U.S. The report, America’s Children: Key National Indicators of Well Being, issued by a consortium of federal agencies, has some good news and some bad news. Of surprise to no one who has watched Bush slash every program related to children’s health and education:
• The percentage of children covered by health insurance decreased from 2004 to 2005;
• The percentage of low birth weight infants increased;
• Sixty percent of children live in counties with air pollutants above maximum federal levels.
On the good news side of things, the birth rate among teens 15-17 went down and immunizations of children are improving. For conservatives, the biggest news of “success” was that fewer high school students are having sex. The improvement, however, is less than stellar: Forty seven percent of high school students in 2005 report having intercourse, down from fifty four percent in 1991. While that’s encouraging, that’s still about half of all high school students, and this includes 10% of high school girls and 4% of high school boys forced to have sex.
What's the Definition of Sex?
Also, it only gives the statistic for sexual intercourse, not sexual activity. Traditionally, it has been noted that children who delay sexual intercourse have fewer lifetime partners, lower rates of STDs, and do better overall. However, with the pornification of the U.S., sexual activity as opposed to just intercourse, appears to be practically ubiquitous among teenagers. It would be interesting to see a study that surveyed all sexual activity among teens, since many of these activities are at least as effective at spreading STDs as intercourse.
If the popular media is to be believed, the “girls gone wild” phenomenon has become an intractable rite of passage for young women and, optimistic national reports notwithstanding, shows no sign of abatement. The question remains, then, when will the current sexual revolution end?
The End of Girls Gone Wild?
For an answer, we need only look at the history of the last sexual revolution and its demise. The baby boomers’ sexual revolution, the “free love” phenomenon, fueled by hippie morals, widely available contraception, and the assurance that antibiotics could fix any disease, ran into a brick wall in the 1980s.
Hippies Gone Straight
The former-hippie baby boomers were by that point living in the suburbs and voting republican, and the generation reaching adolescence was caught up in a perfect storm combining the rise of the Reagan Youth and the appearance of AIDS. With lots of pompous morality posturing in the media to keep up appearances coupled with a horrific disease to ensure compliance, the sexual revolution of the sixties and seventies was dead and gone. If you were carving a headstone for the absolute final demise of the FL revolution you could pinpoint November 7, 1991, the day that basketball legend Magic Johnson announced he was HIV positive.
Six More Years
What replaced FL, of course, was the era of “hooking up,” with emphasis on oral sex, nontraditional sex, and complete removal of all pubic hair to facilitate the aforementioned. The result, from a disease standpoint, has been the rise of HPV, to the point that some estimates have HPV as pandemic among adolescents, teens and twentysomethings. While not nearly as deadly as HIV, it can lead to unsightly genital warts and cancer, which has at least gotten the attention of many young people.
But don’t look for an increased virulence of HPV to be the death knell of the GGW sexual revolution. Like Magic’s announcement, the end will come via the media, although this time not by a single celebrity’s press conference. And it’s still a few years away: It will occur July 1st, 2013, via the internet.
The date of the final demise is just an estimate, of course, but we will probably be seeing the beginnings of the end soon, and here’s why: The first of the GGW videos came out in 1998. Since the videos are mostly college and spring break related, assume an average age of 20. The average age of having a first child for women in this country is 25. Assuming a normal distribution of birthdays across the calendar, the “average” child born to the “average” woman displaying herself in video format for all to see would be about four years old as of now.
Mom Did What? That is so Gross
One trait of adolescence that has been absolutely invariable across generations is a complete disgust at the thought of their parents doing anything physical. Today’s children are internet savvy. Assuming the normal curiosity of preteens, it will be at about age 10 when these children of the GGW will stumble across the internet videos of mommy being taken doggie style by an entire frat house. Their disgust, coupled with the natural desire at that age to be very different from one’s parents, will be the doom of the GGW revolution.
The Next Revolution
What will replace it is anybody’s guess. Since hormones will always be there to stir young people into some kind of sexual experimentation, something will certainly come along. Given their love of computers, maybe it will be some type of virtual reality. Or maybe, if they really want to try something different, it will be the SWL (sex with love) revolution. How’s that for a far out idea?
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VIP Syndrome: A Prescription For Poor Health
Want great care in the hospital? Don’t try to pull rank!
True story: A man, let’s refer to him as Junior VIP, comes into a major hospital in the wee hours of the morning with abdominal pain, mostly located to the right and downward from the belly button. His lab values indicate he has some type of infection, and he has been running a slight fever. Appendicitis is suspected. A CT scan is obtained, which neither rules in nor rules out appendicitis. At this point, about two hours after presenting to the ER, Junior VIP has been seen by the ER physician, ER nurse, senior surgical resident and chief surgical resident. The attending physician now examines the patient and agrees that appendicitis cannot be ruled out and admits Junior VIP to the hospital, explaining to JVIP that we don’t want to miss anything but we also don’t want to do an unnecessary surgery for what may turn out to be a viral illness. Therefore, we will admit, obtain further labs, give fluids, keep him from eating, and observe his condition during the day. If he improves, there will be no need for surgery. If he gets worse, we will take him immediately to the operating room. JVIP agrees to this plan, but soon becomes agitated in the ER. “When am I going to get my room,” he complains to the ER nurse, followed by “It smells in here. Did someone crap their pants?” followed by “There are drunks in here, get me out of here right now!” The ER nurse, then the ER physician, as well as the residents, explain that the hospital is very full but they are working as fast as they can to obtain an available bed as soon as possible. JVIP tells them to hurry, and make sure it’s a private room. But after one more hour of being in the ER, JVIP decides he can’t stand it any more, and checks out Against Medical Advice.
Being a (Junior) VIP, he is incensed at his “shabby” treatment, and uses his connections to contact the local newspaper outlet, the local television news outlet, the mayor’s office, and several prominent friends who are tight with the hospital board members. The attending surgeon, who saw the patient two hours ago, and is now in the OR where he plans to finish his first case of the day and then check on JVIP to see how he is doing, gets a phone call from the CEO of the hospital, demanding that he break scrub to discuss this “unacceptable” matter. This, within five minutes of receiving a phone call from the surgical resident explaining that the patient has checked out AMA, another phone call from the local television news asking for a comment on a story they are doing about Delays In Diagnosis For Severe Medical Conditions, another phone call from a physician colleague in the hospital who wants to know what happened with her friend JVIP and why he didn’t get treated, and a phone call from JVIP’s lawyer. Two more phone calls from the Chair of Surgery—all this while the attending surgeon is trying to operate—and it is established that JVIP will be returning to the hospital, will go directly to preop and be taken immediately to surgery. No more tests, no observation, no more “flimflam” is the word from above.
Eight hours after checking out AMA the patient is seen by the attending surgeon in preop, advised that his problem may have nothing to do with his appendix and that this surgery may be unnecessarily exposing him to risks of infection, bleeding, and further surgery in the future, to which JVIP answers: “Get on with it!” He is taken to the OR, a diagnostic laparoscopy is performed, no intra-abdominal pathology is noted, and per protocol the appendix, although it does not appear inflamed, is removed. The patient is discharged home the following day. Final pathology on the appendix shows a normal appendix with no infection.
Not only is this story true, it is repeated every day in hospitals across the country. It even has its own name: VIP Syndrome. The VIP Syndrome has been a recognized phenomenon in medicine since at least 1964. It is described as generally poorer care that is given to a patient of particular influence—due to money, fame, political power, or connections to powerful community members—because of deviation from the standard of care. The changes made to the standard of care can be too much of something, too little, or things totally inappropriate. These decisions are made because of fear of causing discomfort, or embarrassment or lack of privacy to the VIP, the VIP’s own demands, and the feelings of caregivers that they must do something different for the special patient.
As a surgical resident, I spent many months on trauma rotation at a very busy "Level One" trauma hospital. As there were dozens of traumas every day, we got very good exposure to trauma care, and consequently became very competent at it. The Chief of Trauma used to admonish us often that he hoped if his wife was ever the victim of a motor vehicle crash and brought in as a trauma patient that we would treat her exactly like a Saturday Night Drunk. Starting at about 11 p.m. Saturday and continuing until dawn Sunday, the SNDs would crash their cars, sustain various injuries, and be brought to us by ambulance. They would he bloody, messy, smelly, often screaming and cursing, and reeking of alcohol. We followed the same procedure on everyone: Primary Exam, with a quick look at airway, breathing, major circulatory problems and immediate threat to life, with life-saving interventions as needed; Secondary Exam, head to toe, every body part inspected; standard labs; standard set of X-rays called a trauma series; a decision made to proceed to the OR or obtain further testing; followed by a series of CT scans determined by the findings of the xrays, usually including head, cervical spine, chest, abdomen and pelvic CT scans; then admission to the appropriate ward of the hospital, followed by another complete head to toe exam several hours later, to ensure nothing was missed. To accomplish this took at least two ER nurses, two surgical residents, an attending trauma surgeon, an anesthesia attending, a nurse anesthetist, two OR nurses, an ER technician, a radiologist, as well as consults from many specialists, depending on their injuries (eg, orthopedics, head and neck surgery, neurosurgery). The process took hours to get through, often with the SND screaming and puking all over us, all in the middle of a busy, noisy, smelly ER, all of which we ignored and carried on with what we knew was the right thing to do. Yes, they were drunk and annoying, and many of them were repeat customers, but they were also very at risk for severe injury. Yelling and cursing, for example, might be due to the alcohol, or it might be a sign or severe pain or a head injury. We knew the protocol and we knew if we followed it we were not going to miss anything.
Now imagine a scenario in which the Trauma Chief’s wife comes in to the trauma bay, with the following results: We can’t cut her clothes off, it might embarrass her, meanwhile missing a major injury. Or: We can’t put this cervical collar on, because it might be uncomfortable, and then it turns out she has a c-spine injury and is paralyzed because of our “niceness”. Or: Don’t put such a big IV into her, it might hurt, meanwhile having no way to resuscitate her when it turns out she has a major bleed. Or: Let’s not get so many CT scans, it’s too scary for her to be in there all alone, meanwhile missing any number of internal injuries. Examples abound, but the bottom line is VIP = substandard care. In the end, the SNDs were getting the best care, which is what the Trauma Chief wanted for everyone, including his wife.
I had many opportunities to witness this phenomenon as a resident. Many patients have the idea that residents are not “real" doctors and therefore provide a lower level of care, and insist that the attending physician is the only one who they will talk to. What these people never realized is that they are hurting their own health. The general practitioner “one doctor for everything” phenomenon works fine when all the GP has to do is prescribe physics and pull teeth, but that concept has no place in modern medicine. Medicine today is a team sport, involving, in a typical hospital stay, 50-100 professionals—attending physicians, consultants, residents, nurses, technicians, physician assistants, pathologists, lab assistants, radiologists and a host of other hospital personnel. It’s expensive but comprehensive. Removing integral parts of that team is like trying to fly an airplane that's missing several of its components, or having a patient tell me to operate blindfold and with one hand tied behind my back. Both can be done, but with similarly disastrous results.
The greatest irony in the case of Junior VIP is that the reason the hospital was full on that particular day and he didn’t get a room right away—beyond the bed shortages that are now endemic to hospitals that must operate at 100% occupancy or go bankrupt—is that another VIP, let’s call him “Super VIP,” had given the hospital a substantial donation so that he could have an entire wing to himself for recovery after an elective surgery. The wing was needed to accommodate all his guards and gofers and general hangers-on, all of whom provided a blockade to his health care providers. Which meant that nurses and residents and fellows and lab techs were sent away, which added up to care way below the standard for Super VIP. A homeless drunken man who trips and falls in front of the hospital will receive better care than either Junior or Super VIP, because Mr. Homeless Guy will get the standard of care with no deviations, while the VIPs use their power to hurt themselves.
The most annoying part of all this is that Junior VIP is probably going to sue. For what? It doesn’t matter. Lawyers know that juries often hand out large cash awards, not because the doctor did anything wrong, but because they feel sorry for the patient. After all, it’s only insurance money, those insurance companies have plenty of money, and who cares if the doctor’s career is trashed. And who writes the laws that allow this foolishness? Other lawyers, of course. So JVIP will sue for Delay of Care (even though that was his own fault) or Pain and Suffering (never mind that he caused way more of that to the people around him than he suffered himself) or Unnecessary Surgery (even though he demanded it). And caught in the middle of all this is the surgeon, who just wants to do his job, treat his patients, make them well, and send them home healthy.
Even for those rich enough or connected enough to have a personal physician follow them around the world, that’s not going to help with anything except little stuff. For anything major, someone needing medical help is going to end up having to talk to a specialist, a surgeon for example, or a neurologist or whatever, and then have to be seen by that doctor either in a clinic, if it can wait a few days, or in an ER, if it’s an emergency. And on any given day in any ER in this country, even to foo-foo private ones that cater to the rich and powerful (like the Frist family’s Hospital Corp.), there are going to be drunks, and nasty smells, and noise, and lots of chaos. And bed shortages. Screaming and complaining and calling your congressman won’t change that.
This is not to say that patients shouldn’t be advocates for their own health, of course they should. They should ask questions, and read all about their diseases, and get second opinions (or third and fourth opinions if they're not satisfied). But anyone who thinks that pulling rank is going to improve care should conduct the following experiment: The next time you get on an airplane, first go to the air traffic control tower and fire everyone in there, since you know so much; then fire the aircraft mechanics and service the plane yourself; then fire the pilot and fly the plane yourself. And afterwards, if you survive the crash, consider not making those same mistakes when you get sick.
We may not be as well-connected as politicians, or as famous as celebrities, or as rich as lawyers, but we do know about health, and we do try to do our best for our patients' health, even those patients who do everything they can to prevent us from helping.
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HPV Vaccine: A Life Saver, If You Can Find It
Want your daughters to be protected against cervical cancer? Get them immunized against HPV. But good luck finding the vaccine, thanks to high costs and political roadblocks.
The term "sexually transmitted disease" is a term charged with emotion. The effects of STDs range from gross, like the draining sores of herpes simplex, to lethal, such as AIDS from HIV. For most STDs there is treatment but no cure or prevention. Recently, a vaccine was found that prevents a potentially lethal STD—human papilloma virus. But the HPV vaccine, which has the potential to save hundreds of thousands of lives, has run into serious political and legal roadblocks.
HPV is an STD nearly endemic in our society, the low estimates being tens of millions of affected Americans. As one medical school professor once described it to our class during a lecture on STDs: "If you have ever had unprotected sex with a partner who has had unprotected sex with anyone else, you have been exposed to HPV." Because a person can be infected but show no symptoms it is easily passed from partner to partner. Also, it can take weeks to months for symptoms to appear. To further complicate the issue, HPV has multiple strains, each of which has a different effect. To date, more than 100 strains have been identified, with more than 30 of the strains being sexually transmitted. Some of them are cleared from the body without any symptoms ever presenting, others cause genital warts, and some cause cancer. By age 50, according to the Centers for Disease Control estimates, at least 80% of women will have acquired genital HPV infection.
While HPV can lead to several types of cancer in men or women, including cancer of the penis, vaginal area or anus, the concern about HPV has always focused on cervical cancer, because it is a silent killer, typically without symptoms until it is very late stage and too late to do anything about it. Until the development of a vaccine, prevention of cervical cancer has relied entirely on women getting regular pap smears, which can detect changes in the cervix, leading to early treatment. In 2004, according to the American Cancer Society, over 10,000 women contracted cervical cancer and nearly 4,000 women died of it. Almost all of the deaths occurred in women who had not had regular pap smears.
The FDA approval in 2006 of Gardasil, an HPV vaccine that targets four HPV strains that together account for 70% of the cervical cancer and 90% of the genital warts caused by HPV, was a huge leap forward in the fight against cervical cancer. It is recommended by the FDA for women age 9 to 26 who have never been exposed to HPV, with immunity provided for close to five years. But even before it appeared on the market it met with strong opposition. Among the first to fire preemptive sorties against the vaccine was the group Concerned Women of America, a Right Wing Christian Conservative organization that seeks to “bring Bible principles into all levels of public policy.” Prior to the vaccine’s FDA approval, CWA Executive Vice President Wendy Wright said her organization was against immunizing preteens against HPV. “It would seem to send a message that we’re expecting the girls to be sexually active,” she said. The ferociously conservative Family Research Council, initially vocal in its opposition to the vaccine, has softened its tone, if only a little. FRC Vice President for Policy Peter Sprigg, in a July 15, 2006 opinion piece for WashingtonPost.com, shied away from opposing the vaccine outright, but opposed states making it a mandatory vaccine. In other words, the great defender of states’ rights while the Democrats held the presidency now wants to take power away from the states, so that the vaccine will remain out of the public eye and most girls won’t be immunized.
But even with FDA approval and CDC support, the HPV vaccine has slammed into another wall: cost. Merck, the company that owns Gardasil, charges $120 per dose, with three doses required to provide immunity. But insurers are barely willing to pay for each dose, much less the costs of administering it. CNN.com reports in a Feb. 2, 2007 article that doctors are expected to stock thousands of dollars in inventory, store the vaccine in highly specialized refrigerators, pay for any broken or damaged vials at $120 each, provide syringes, administer the vaccine and pay for disposal of the sharps all for as little as $2 over the cost of each dose administered. Thus, being forced to lose money by providing the vaccine, many pediatricians and family practitioners have stopped providing it. With the public spotlight on the vaccine, some insurers have relented and are raising their reimbursement. But for those without insurance, or insurance that doesn’t provide coverage, or only partial coverage, the vaccine remains out of reach.
There’s an old saying in the pharmaceuticals business: The first pill costs you half a billion dollars, everything after that is profit. Merck says that it will provide the vaccine for free to those who can’t afford it, but the big drug companies say this about all their expensive products, and as any patient who has tried to apply for such fee waivers or any physician who has tried to help their patients apply for the waivers can tell you, cutting through the red tape involved in actually getting a waiver requires a bulldozer. In fact, Merck gave away only about 800 doses in the last three months of 2006. To have an idea of how expensive $120 per vaccine is, consider the following CDC list of vaccine costs, per dose, in 2007: Diptheria/Tetanus/Pertussis: $12.25; Hepatitis B: $26.25; Hepatitis A: $35.57; Mumps/Measles/Rubella: $17.28; Varicella (chickenpox): $56.90.
It is expected that the overall cost will decline over time, but given the prevalence of HPV, the high cost of the vaccine, the reluctance of the insurance industry to pay that cost, vocal opposition from politically connected Right Wing organizations who think money is better spent telling youngsters to wait until marriage, and tepid support from a presidential administration that sees eye to eye with the Conservative Christians, it is likely that cervical cancer will continue to be a killer for a long time. For parents who would like their daughters immunized and young women who would like to be immunized against HPV, and thus drastically reduce their chances of contracting cervical cancer, the struggle continues.
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Oh Those Darn Money-Grubbing Doctors!
Boston Physician Goes After Other Docs. Author and Physician Jerome Groopman goes after physicians' "flawed thinking." But Groopman himself is guilty of flawed logic.
Boston Physician Admonishes Doctors
Professor Jerome Groopman, oncologist at the Beth Israel Deaconess Medical Center, is a man of much accomplishment: author, scientist, professor. His books The Measure of Our Days and Second Opinions were the inspiration for television’s Gideon’s Crossing. He has a new book due this spring, How Doctors Think. But based on excerpts printed in a January 28, 2007 Boston Globe article, I think the title should be How Doctors’ Thought Processes Are Flawed.
Let me start with the premises of the book, as presented in the Globe article, that I agree with:
• Some doctors are arrogant. True.
• Some doctors some of the time rush to judgment and make an incorrect diagnosis as a result. True.
• Doctors are human and can make mistakes. Very true.
• An emphasis on teaching medical students to think rather than regurgitate memorized facts will produce better doctors. True, true, true.
Where I differ from Dr. Groopman, and I hope his book turns out not to be as one sided as it appears to be in the Globe article, is the notion that everything wrong with medicine today is the fault of doctors. Quoting from the article, Groopman details a diagnostic failure: “Groopman tells of a woman who saw close to 30 doctors for a constellation of ailments that gradually sapped the life out of her. She endured excruciating pain and was down to 85 pounds. Her immune system was failing and she had developed severe osteoporosis. All of them missed what was ailing her.” Her disease was celiac sprue, a notoriously difficult to diagnose autoimmune disease. He gives other similar examples, including one that happened to his own son. What all of these anecdotes have in common is the theme that if only the doctor had probed more, had questioned more, had ordered one more test, all would have been well. Only once does Groopman concede: “There is no generic best treatment to a serious problem.” Indeed.
Setting aside the fact that we have no idea what the woman with celiac sprue was telling her doctors about her symptoms, it is rather disingenuous of a physician to speculate, with 20-20 hindsight, on how easy a particular diagnosis was to make. Good medical care, which is of course founded on sound diagnosis, is a process that requires participation and cooperation among many specialist physicians (who must work together in a coordinated fashion), insurance companies (who must be willing to finance the test, procedure or office visit), hospitals, and especially patients. To attack an already fragile patient-physician bond, thanks to our hyperlitigious system of anything-other-than-perfection-and-you-owe-me-big-time, only serves to further shatter the necessary trust that patients must have with their doctors.
We already have an extremely unfair and harmful system of torts in this country, in which any doctor can be sued by any patient for any reason, spurred on by usurious lawyers, with the case to decided by juries that are notorious for handing out gratuitous awards in absolute opposition to facts. Large awards given to patients who have suffered a bad outcome that is not the fault of the doctor because the jury felt sorry for the patient are the bread and butter of the malpractice industry. There are entire legal journals dedicated to informing lawyers how to successfully sue for individual medical procedures, because of a missing or misplaced word in the chart. And now we have a doctor who is going to saturate this fire with jet fuel? To state, or imply, that most medical errors and bad outcomes are the result of shoddy thinking, if not outright laziness on the part of doctors, is not only incorrect, it makes a difficult situation nearly impossible.
I do not wish to impose a Cosa Nostra style Code of Silence among doctors. Open and honest debate is the lifeblood of the science of medicine. But self-serving attacks on the intellect and ethics of the medical profession only serve to further erode trust and make doctors’ jobs even harder. I believe there is no profession comprised of harder-working, more committed professionals. Of course we have our shoddy members, those money-grubbers who care more about dollars than disease. They’re called plastic surgeons. But aside from a few Hollywood-type “doctors to the stars,” in what other profession would you find a group of people willing to endure four years of college, followed by another four years of intense study and training, incurring an average debt of $130,000, followed by three to ten years of bone-crushing servitude, at a wage below the federal minimum wage, to be allowed to enter practice, take call, work all night, carry a pager that anyone can call at all hours of the night for the least of reasons, have a career savaged by lawyers, judges and juries that have never spent a single day in a hospital, for a salary that works out to be about $20 per hour. Sound like a good deal? Don’t all rush up at once.
Just about the most depressing thing a doctor can do is get out a calculator and determine what else he might have done with that $130,000, added to the money he could have amassed working the same hours as he did in residency but at a living wage. The amounts are staggering. No one except a fool does this job for money, so for the overwhelming majority it has to be a personal passion and commitment to patient care. All doctors know this. But unless you have rock-star status as a physician, the popular press is not inclined to listen. If Sam Allis’s Globe article was fawning and at no point challenged the best-selling Groopman’s assertions, surely, you think, the academic press is not prey to such misty-eyed philandering? Think again. Consider an editorial from January 1, 1998, by the normally clear-eyed New England Journal of Medicine, in which Groopman’s book The Measure of Our Days is compared to the Bible!
I don’t argue with Groopman’s assertion that doctors can make mistakes, or that we should do everything in our power to eliminate mistakes. But to hold us to a standard of anything less than perfection is failure will absolutely guarantee failure. Doctors carry a great deal of responsibility in caring for our patients. No argument there. But it cannot be denied that operating with hands tied by the whims of (mostly non-medical) politicians, profiteering by millionaire-CEO-led insurance companies, savage attacks by soulless lawyers, and ever increasing demands of non-compliant patients, the heavy burden of responsibility for improvement of health care does not rest solely on the shoulders of physicians. I hope that Dr. Groopman’s forthcoming book reflects the challenges doctors face more accurately than is seen in his interview with the Boston Sunday Globe.
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What's the minimum wage for lawyers? Half a million, according to Chief Justice Roberts.
It will be very interesting to see what the media and the public make of Chief Justice John Roberts assertion that $160,000 a year is slaves’ wages and that anybody with any sense could make much more than that in academia or the corporate world. In medicine, the massive rewards to be had by ceasing to actually work with people and become a corporate shill are not seen as a major cause of brain drain. Any doctor can multiply by a factor of 10 his or her salary by becoming an “adviser” to the drug companies, product manufacturers, congressional lobbyists, or trial lawyers suing other doctors. But only a few choose this route, because we do what we do not for the money but because it’s who we are. (See Millionaire Doctors? for more on that sore subject.) I would have thought the same thing would be true for lawyers, that the chance to have such a tremendous influence over the way this country operates as to be a federal judge would outweight any monetary concerns. So far, the public has reacted with a big yawn, which works heavily in Roberts’s favor: no complaints=no controversy=easy amendment to massive spending bill=big raise for him and his cohort. Prediction for 2007: Lawyers’ pay will rise, doctors’ pay will fall.
Doctor or Waiter?
Ask any doctor, especially those who have been practicing since before the insurance giants ruled the land, what the biggest loss to his practice has been, and the answer is likely to surprise you. The predicted answer is dramatic salary reduction, but actually that is far less troublesome than the loss of autonomy. First it was the HMOs that said, You must prescribe this not that, or No this patient is not a candidate for surgery. (If you ever wonder why doctors are sometimes seen as icebergs, imagine the emotional stamina that it takes to have spent 16 years, working 80-100 hours a week, to become an expert in subspecialty surgery, and after examining a patient, reviewingthe chart, discussing the case with colleagues, and consulting current literature, all in agreement that the patient needs surgery, only to be told by a 23-year-old MBA who just fell off the beer float that the patient is NOT a candidate for surgery.) Next, hospitals, which having much more bargaining power (dollars, lawyers, congressional lobbyists), get a very large chunk of cash for its services, turned around and said that as a cost-cutting measure doctors must ONLY use certain drugs, products, or devices. Never mind that other devices, drugs, products work much better. And to complete this Sisyphean triad, doctors are now being told how to practice medicine by their patients. Thanks to direct advertising and our short-sighted Entitlement Society, patients now come in and demand certain drugs, procedures, tests, or equipment: Don’t bother with the physical exam and I don’t care that you went to medical school thank you very much, this is my body and your job is to do as you’re told. “It’s just like the waitress job I had in college,” says one Denver pediatrician who asked not to be identified. “I used to go from table to table, ask them what they want, hint at a few suggestions but never contradict them act like I knew more than they did, and then make it happen just the way they ask. Now I go from room to room and do the same thing with my patients.”
Case Files
Fine, except that waitstaff are not asked to make life or death decisions about their patrons. Case in point: A patient comes to my clinic with abdominal pain. I perform an exam and order tests. The result is that the patient’s pain is caused by a stomach condition, but one that will heal with medicine not surgery. A prescription is given to the patient for the appropriate medicine (after checking with the patient’s insurance company, to make sure the medicine is covered, of course). Additionally, the patient is given a prescription for a narcotic pain medicine, and advised that the narcotic is just a temporary stopgap, that if the pain persists, it means the insurance-approved stomach medicine is not working and we will have to discuss other options. A followup appointment is made for three weeks later, with the standard admonition that if things get worse to call or come to the ER. Two weeks later this patient, having not communicated any problem since the office visit, shows up unannounced in clinic and demands of my secretary that she page me out of the OR to write a refill prescription for the narcotic pain medicine, because the patient still has some pain and is going away on vacation the next morning and has no time to be seen in clinic or the ER.
Nevermind what we talked about at the first visit about the possibility of needing other treatment. Never mind that the patient is quite capable or reading a calendar and knowing about her vacation ahead of time. Never mind that the patient is quite capable of counting pills in a bottle and noticing when they are running out before reaching the very last one. I should mention that this was not a drug-seeking patient, as in, someone who is addicted to pain medicine trying anything and everything to get more pain medicine. Those patients are not that hard to spot and referred to addiction specialists. This was rather the more common entitled patient who figured she knew better than her doctor and just wanted me to do as I was told. Let me also mention that I bend over backwards for my patients, seeing them between cases in the OR, early mornings, in the middle of the night in the ER, wherever, and my pager is always on. I get pages at three in the morning from patients wanting to know if they can reschedule an appointment that is still three weeks away. But I draw the line at them sacrificing their own health through ignorance.
No more Mr. Nice Guy
The end result for this patient was a stern lecture, a change in medicine, and close followup by phone while she is away on vacation. To some degree I am lucky, in that I can get away with this. As a surgeon, I already have fewer patients than an internist or pediatrician, since I have to spend a lot of time actually doing the operations, and with a smaller pool of patients, the number of headache-causing patients is smaller. Plus, as a subspecialist in a tertiary-care center, I’m the last stop. If they don’t like what I have to say, there aren’t a whole lot of other options. Which is not the case for most physicians. For most docs, patients see things they like on television or in a glossy mag, they show up for their 15-minute appointment and demand it. So now the doc has a draconian choice: Give them what they want and speed them on their way, or spend 30 to 60 minutes arguing with and educating the patient. The textbook answer is that the ethical thing to do is educate the patient. Except that there are forty more patients to see, and every hour spent on a “problem” patient makes everyone else that much more late, and adds another hour to what is already going to be a 60 to 70 hour workweek. And even if you opt for spending that extra hour with each and everyone of these “problem” patients (and there are many of them, believe me), they will then just go to another doctor, and another and another, until they get what they want, adding additional burden to an already overwhelmed medical system. And they will call their insurance company and complain about that “insensitive” doctor and you will get a snarling phone call from the MBA frat boy, telling you that if you’re going to continue to irritate “his” patients, he will remove you from “his” group.
An impossible task
I watched this scenario play itself out many times as a medical student, and fought this uphill battle many times myself as a resident before conceding the inevitable. (Sissyphus had the advantage that when he rolled the rock up the hill, at least he was able to get out of the way when it ran back down the hill. Every boulder I tried to strongarm out of the valley just ended up rolling over me and crushing me like a bug.) This had a lot to do with my chosen career, in that being the “last stop” I had a little (a very little) more freedom to fight back against this grim trend away from medical practice and into “service excellence.” Emphasis on service.
What can be done to stop the assualt on health care? Patients can try to see their physicians as equal partners. If the aura of “doctor knows best” is long-gone, at least trust that your physician, with decades of very arduous training, might know something worth listening to. Would you try to tell your plumber how to fix your pipes? You might try, knowing that the worst result will be a wet floor. But are you likely to ignore your electrician’s advice and wire things any which way? Not likely, because the results could be deadly. Same thing with your health.
As for what physicians can do to stop the erosion of good healthcare by the tsunami of know-nothing CEOs, we will continue to fight Big Insurance and Big Pharmacy and Big Government, so that we can always get you the best medicine, product, treatment or device. And we’ll do it with a smile, and for a lot less money than your average lawyer.
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