What Are the "Top 3" Changes Needed to Improve US Healthcare?

Robert M. Centor, MD; Pennie Marchetti, MD; R.W. Donnell, MD; Roy M. Poses, MD

Disclosures

November 13, 2006

In This Article

Robert W. Donnell, MD

I make no pretense at being able to fix or identify the top 3 problems in healthcare. However, here are 3 that have recently grabbed my attention:

Primary Care: State of Emergency

A burgeoning population of elderly patients with multiple complex medical problems is making demands on a shrinking pool of primary care doctors in the United States. The number of Internal Medicine residents choosing a career in primary care decreased from 54% in 1998 to 20% in 2005.[6] Moreover, many general internists are leaving primary care to retire early or to become hospitalists. These trends may contribute to fragmentation and inefficiency of healthcare.

Many factors are driving doctors away from primary care, one of which is poor compensation. Doctors who care for patients with complex chronic medical problems, typically general internists, do not get paid in a way that rewards the unique dimensions they bring to the patient encounter: time and intense cognitive effort in solving complex problems and coordinating care. Although the Current Procedural Terminology (CPT) codes nominally compensate complex decision making, in the real clinical world, they reward the physician who can see the largest number of patients in the least time. Reforms are needed to provide incentives for doctors to assume comprehensive care of medically complicated patients. The American College of Physicians, which warns of the impending collapse of primary care, has some suggestions.[7]

The Liability Crisis

The rising threat of malpractice liability has contributed to a brand of costly "defensive medicine" that may not be in the best interest of patients.[8] In fact, rising insurance rates in some regions have been linked to shortages in high-risk specialties.[9] With the exception of trial lawyers, who stand to gain from the system now in place, most agree that the present medical tort system is seriously flawed.

The question of what is the best remedy is a subject of vigorous debate. Many physician leaders and politicians are urging tort reform that centers around caps on punitive damage awards. Opponents of such reforms claim that damage caps do not address the root causes of the malpractice crisis. Although health courts, no-fault compensation, and panels of unpaid expert witnesses might be more effective in addressing the problem at its core, there is evidence that recent tort reform efforts have paid off. In Texas, for example, reforms seem to have caused a decline in insurance premiums and a repopulation of underserved areas with high-risk specialists.[10] Damage caps can provide needed relief while we await more fundamental reforms.

The Invasion of Pseudoscience Into Mainstream Medicine

Increasing numbers of patients are turning to unscientific health methods under the rubric of "complementary and alternative medicine." Strangely enough, society seems more tolerant of pseudoscience and quackery now than ever before. Franz Mesmer, who was thoroughly debunked for his magnetic "energy healing" claims in the 18th century,[11] likely would find a niche in mainstream medicine today. Similarly, fabled snake oil salesman John R. Brinkley, virtually chased out of the United States and stripped of his medical and broadcasting licenses in the 1930s,[12] would fare well in today's medical climate. The Flexner Report[13] spurred reforms that essentially banished the teaching and promotion of quackery that was rampant in US and Canadian medical schools a century ago. You would hardly know it today, as the uncritical promotion of pseudoscience is once again pervasive in medical schools.[14]

Despite the rising popularity of alternative medicine, patients who come to us expect treatment based on science, not an eclectic world view. Although patients increasingly seek out information for themselves, most realize that they lack the expertise to evaluate their healthcare critically and must therefore trust us in the "mainstream" to possess and apply such scientific expertise. It is a violation of fiduciary duty to betray patients' expectations by offering or promoting scientifically unsound treatments.[15]

Medicine has devolved away from rigorous standards of science. Although there are many reasons for this trend, it starts in medical school. Alongside the promotion of quackery in the curriculum of many medical schools[14] is a groundswell of student activism in the promotion of the eclectic healing arts. A large and influential medical student organization distributes the Complementary Therapies Primer,[16] which teaches the Ayurvedic methods of "purification" via vomiting and enemas (p 3), large doses of vitamin E to "support the immune system" (p 15), and chelation therapy to improve memory and treat scleroderma (p. 20).

What should we do to address this problem? Congress must take a critical look at the funding of dubious complementary and alternative medicine "research."[17] Medical student and faculty activism against promotion of quackery is needed. Finally, we need another Abraham Flexner to do some house cleaning in our medical schools.

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