“We need a revolution and we need it now” ended my last posting. There I discussed our biological and technical orientation towards “disease” driven by dollars leading to a catastrophic collapse from cost shifting. We need to look at psycho/social and environmental factors and expand the role of public health. I feel the current legislative draft is another patch to the current system only to keep it going a little longer and fails to address the underlying issues. I referenced prevention, lifestyle, and the need for all individuals, institutions, and others to acknowledge their role in our current crisis.
Now it is time to address the paradigm shifts we all need to make. Until now, everyone has simply been responding to events in the short term to maintain their position in a 50 year old health care system that does not work. Some have done it better than others. The “patient” as the purpose of the system and the smallest voice has suffered the most.
As I considered the paradigm, I wondered if we all agree on what is “health”. I would suggest health is both a goal and a process of one’s living successfully within his own internal and external environment. This requires autonomy, freedom and love. This statement ventures into greater societal issues such as loneliness, alienation, hunger, poverty, etc, which I will leave to others to address. I will try to focus only on mainstream health functions as they exist today. The goals I will advocate are greater patient autonomy, involvement, education and revitalizing the patient physician relationship. We need access and universal health care for all.
As we discuss health
we must discuss disease and consider the role of physicians in disease. Most physicians know the 500 year old French expression
restated again about 150 years ago:
To cure sometimes
To relieve often
To comfort always
Francis Bacon suggested in the Cartesian era that we “cure always, comfort sometimes and extend life”. This emphasis on science probably encouraged our biological orientation and took us away from faith healers, spirituality and a holistic approach.
Public health has done much to extend the life expectancy of one hundred years ago from 50 to now seventy years and beyond. Modern medicine has contributed too, and few now die in childbirth or from appendicitis, etc. Most people now expect to live into old age. We haven’t extended the life expectancy of the human organism, but we now spend enormous dollars on end of life care. We also pour large amounts of money into incurable illness. We remain focused on illness instead of health. Doctors keep problem lists with illnesses. If you don’t have an illness, more tests need to be done. Recently I had a 104 year old patient who was active and happily living with her 80 year old daughter. She died peacefully and I signed her cause of death “old age”. The State of Oregon refused to accept this cause.
The Paradigm, the
Following are a list of people, institutions, etc in the current system. My list of participants may be incomplete and I certainly haven’t thought of all of the paradigms. Please contribute freely. It is not my goal to defend anyone but rather, examine how we arrived here. Also, it is time to stop criticizing everyone else. It is time to think critically in the long term to achieve optimal health for EVERYONE..
Often the most maligned. Thirty years ago they were just check writers. Now they lead in data collection and analysis. Demands are increasing and money tighter, and they are responding for the moment to survive. Telephone voices with protocols handle prior authorizations. Some days I feel as if I am simply a “warden” at the outpost following rules, watching money and trying to explain to patients why they can’t have something. PacifiCare wrote me a letter recently to thank me for helping them with THEIR patients.
The new paradigm for insurance companies is to look long term and partner better and more closely with physicians and patients. Also when insurance companies really look long term, prevention becomes more desirable. It can be hard to pour money into smoking cessation when the benefits are realized in two years and in one year the employer changes companies.
The old paradigm is “make money for our stockholders”. Through corporate P.R. they convince people of the magic of medicine, research and development, etc. It is very easy to criticize the drug cartels. I suggest assailing them is like blaming the mafia for illegal drug use. We need to consider other ways to health via lifestyle, diet, exercise, rest, etc, instead of a pill for this or that. I would also suggest the entire pharmaceutical industry be subject to greater scrutiny and restraints. My fear is that just as the drug cartels in Colombia control the government, the drug companies have control of our government.
Hospitals are becoming larger and monopolistic. They have been a major factor in the medicalization of life. We are usually born there and frequently die there. In between we go in to have our lung cancer cared for. Hospitals are the leaders in spending and charging for high tech. Do we really need the best hospital in every community over 10,000 people. If you live near a hospital which performs heart surgery, you have a greater chance of having heart surgery. I would suggest it is okay to have a ruptured aneurysm and die with family at home. If you lived next door to a hospital or were life flighted somewhere you would have less than a 10% chance of survival.
The new paradigm requires hospitals to collaborate with the entire community. Collaborate not just on the terms of the hospital. Hospital finances in their entirety should be completely available and transparent. Hospitals must use their “tax exempt” status to collaborate and benefit the community much more than they do. They must join in the care for those without access or otherwise disenfranchised. They must reorganize and respond to cultural differences.
Doctors are practicing within a conservative system that selected and trained them. They complete training with large debts. Specialty practice is more attractive as this has the potential of ten times the income over primary care. Specialties often focus more on the biological model. Doctors are often entrepreneurial scientists. In the new paradigm more FP’s and primary care providers are needed. We should examine medical school admissions, debt and post graduate opportunities for “payback” opportunities such as rural service, etc. We need collaboration more with patients and all people in the health field. I suggest doctors stop compromising with insurance companies and do not sign contracts that are not good for the patient or physician. Doctors should be humanitarian scientists. Consider the physician role to educate, collaborate, prevent, comfort, control, and maybe cure.
Patients need to realize “you are not in good hands with Allstate”. Take matters in your own hands. Assume responsibility. Exercise, maintain weight, rest, eat well, enjoy hobbies and friends, etc. Partner in a knowledgeable way with your physician.
Premedical programs generally do well to encourage rounded education. Premed students might be required to work for six months as CNA’s in nursing homes. Medical schools should teach collaboration with all providers, and deemphasize the hierarchy. We need more family physicians.
In the current paradigm, the media focuses often on what sells, popular belief systems of health, and health misconceptions, and preconceived concepts. I suggest the media should educate itself, and assume more role in educating patients. Also, people need to understand “cost shifting”.
Currently many people think “public health” helps with family planning, venereal disease, communicable disease, etc. The Public Health sector should take charge in communities, address the issues, collaborate with the other community members, and be involved with environmental, educational and other elements of health care.
Focus on what is right for the entire population and ignore special interest groups.
Many other participants whom I did not mention have roles also. These include employers, lawyers, etc. The discussion is not simple.
I finalize my thoughts I offer them a starting point in a paradigm shift. Pogo said “we have met the enemy and he is
us”. We all must acknowledge and assess our roles.
Once we acknowledge the inadequacies of our system and our roles and our potential for change, we have CHOICES.
We need a revolution and we need it NOW.
Norm Castillo, D.O.