I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.--Thomas Jefferson

Thursday, November 24, 2011

Why Your Doctor is Out of Date

First Published in the Journal of the Association of American Physicians and Surgeons, Fall 2011

In 1976, during medical school, the lecturer in biochemistry explained why the optimum dose of aspirin to prevent clotting in heart vessels was 82 mg, or one baby aspirin a day, not the two-aspirin-a-day regimen used up at that time.  Yet in 1996, when I was first in practice in Arizona I noticed that most patients were still taking two full aspirin for this purpose—a dose shown over twenty years before to work against the beneficial effect on platelets by turning off the anti-clotting mechanism of the arterial wall. 

I was shocked to think that doctors were practicing 20 year old medicine that was in direct conflict with basic biocehmistry.  Subsequently I have learned that this is not the exception, but the abysmal mode of practice in America.  There are at least three major factors which have contributed to this sad state of affairs--  state medical boards, clinical “group think”, and an ineffective approach to information gathering.  Sadly, even this current sluggish progress in medicine may come to a complete halt with the implementation of “evidenced based medicine” and “best practices”.

In any aspect of life, there have always been the herd and those who break out of the herd with new ideas.  Galileo broke from the pack to change our view of the solar system; George Eastman threw out wet plates in favor of dry photo plates and overnight changed photography. Joseph Lister revolutionized surgery with carbolic acid antisepsis.  These people became leaders by adopting different perspectives on old problems.  But if Joseph Lister were alive today, and proposed carbolic acid for asepsis, he would risk being sanctioned, even de-licensed, by his state medical board. Why?  Because state medical boards use the concept of “standard of care” in determining if a physician is right or wrong in his treatment.  If you are practicing the methods used by 90% of your peers you are “correct”, but if your treatment falls within that other 10% you are wrong by definition.  Never mind that within that 10% are the new improved ideas in any specialty.  This concept of  “standard of care”  is an absolutely guaranteed formula for mediocrity that would ruin any other industry.  Imagine if the electronic industry used this criteria. We would be using rotary phones and an abacus! Edison and Tesla would have been jailed in such a society.  Yet we accept this worldview as normal in medicine.

Few things in life is are as powerful as peer pressure.  Physicians--like football players, or stock brokers, and many others--tend to slap each other on the back (at least figuratively) and aspire to the “in-crowd”, reinforcing current beliefs at professional meetings and in publications while ignoring the unpopular guys—even though their ideas may ultimately prove correct.  Famous examples include the ridicule given the proposals (subsequently proven true) that stomach ulcers come from bacteria, that viruses can cause cancer, that germs cause disease.  Publication, while supposed to be peer reviewed without knowledge of the author, tends to favor those with connections to the reviewers or at least papers reinforcing the reviewers’ views.  I once tried to publish the result of performing a newly described surgical technique, which I had used successfully in over 70 patients, only to be told in the written denial, “Everyone knows you can’t do that.”  (The technique is now in fairly widespread use.)

Physicians and researchers holding contrarian views may be ostracized, criticized and actually humiliated, as in the case of Warren B. Warren who was rudely roasted at Princeton and whose funding was cut before ultimately his finding of anomalous MRI interactions was proven correct.  Improved MRI technology was the result.  

Recently, Andrew Wakefield, a university based British gastroenterologist, published a case report series concerning possible side effects of the MMR vaccine.  As a result, he has had his reputation impugned, his medical license revoked, and his book censored from publication in Britain.  Of course, a case report is only supposed to describe a clinician’s observations thereby giving others a chance to either confirm the findings or refute them.  But Wakefield has been charged with “falsification of data” (a charge he has reliably refuted in court), intent to defraud, and malpractice.  Why?  Because he made an observation outside the “group think”  belief that all vaccines are safe in all children.   In this case, the groupthink is reinforced by government self-protection and big pharmaceutical company money.  (It goes without much saying that government research funding is not generally given to the minority opinion, so again, the same ideas are reinforced.)   Whatever the truth is, history tends to uphold the beliefs of those whose writings were censored, not the agencies doing the censoring.  In cases such as Dr. Wakefield’s, the abusively bad treatment of the physician--simply for reporting his observations--has had a chilling effect on those who might come forward with supportive data.

Adding insult to injury is the creeping odium of consensus in science—the notion that truth is discovered by majority vote among investigators, not by careful application of testing and scientific method.  As Michael Crighton—a physician as well as author--said in 2003, in a speech at Cal Tech:
Let’s be clear: the work of science has nothing whatever to do with consensus. Consensus is the business of politics. Science, on the contrary, requires only one investigator who happens to be right, which means that he or she has results that are verifiable by reference to the real world. In science consensus is irrelevant. What are relevant are reproducible results. The greatest scientists in history are great precisely because they broke with the consensus. There is no such thing as consensus science. If it’s consensus, it isn’t science. If it's science, it isn't consensus. Period.

“Best practice”, is essentially consensus applied to medicine. University clinicians decide on the best way to treat something, then this is codified and disseminated to all practitioners.  What was first sold as a “suggestion”, now is becoming writ.  And this consensus is reinforced by government and insurance third party payers: fail to follow “best practice” and we will fail to pay you.  

Unfortunately such clinical dogma ignores the fact that people are individuals with individualized problems.  While the algorithmic approach may apply 90% of the time, and may be a useful learning tool or reference point, the good physician needs to be able to vary treatment when his patient’s problem varies from the norm.  In Orthopaedics, for example, we are told to “anticoagulate all hip fracture patients”, because statistically they are at risk of DVT.  But, if the patient’s fracture is fixed in a minimally invasive way within hours of the trauma and the patient mobilized the same day, does she really need Lovenox with its attendant risks?  Do we anticoagulate ourselves every time we go to sleep?  

Uniformity of thought leads to mediocrity of science and inappropriateness of care.

Evidence based medicine (EBM) only makes this problem worse.  It sounds good.  Evidence.  What’s not to like?  But EBM is an upside down approach to medical progress:  In the past, clinicians faced with novel problems were able to offer treatment they thought might be effective—based not only on the literature, but on their understanding of basic science, their clinical experience and their judgment—as long as the treatment would “first do no harm”.  With EBM, on the other hand, we are prohibited from offering treatment unless we can show, preferably with “high powered” long-term studies, that the treatment is effective.  

A clinician with good common sense and good ideas cannot act without a paper trail backup of some published study.  In spite of the acknowledged inadequacies (and actual falsification at times) of the medical literature, all emphasis is placed on these studies, and no credit given to clinical acumen.  This has led to incredible statistical gymnastics being applied to collections of studies generating meta-analysis papers that resemble numerology more than clinical medicine.  

Recently some British wags published a parody on this approach entitled, “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials.”  As they point out, tongue-in-British-cheek but quite convincingly, EBM really does not apply to everything.  Some things (such as appendectomies and parachute application) it is just common sense to do.  When considering EBM I am reminded of James Thurber’s quote “You might as well fall flat on your face as to lean too far over backwards.”

Finally, how do we learn new things?  It was said of Sir Isaac Newton, that, when at Cambridge, he had learned all the science there was to know at the time.   Today, it is difficult to stay abreast of even a small portion of available knowledge.  But we are particularly ill equipped in medicine to make best use of the knowledge at hand since we approach medical learning much like the Processional Caterpillar.  The Processional Caterpillar is named because of their habit of following a leader.  No one knows how the leader is chosen, but before slithering to or from feeding grounds the unchosen caterpillars form up in a line behind the leader.  If, however, such caterpillars are placed on the rim of a bucket, the leader will eventually catch the end of the line, conclude he has been replaced, and start to follow the caterpillar in front of him, until they are all going round and round the bucket rim following each other over the same ground again and again.  What a metaphor for resident education!  In 1976, while the biochemists were teaching us that one baby aspirin was optimal, generations of senior residents were teaching interns that they should prescribe two full aspirins—the lesson they had in turn been taught by their senior residents—and it would take years before level one studies would appear to countermand that dictum.  

Additionally, earlier and more rigid subspecialization has stovepiped learning into narrower and narrower brackets.  Specialists may solve a problem in their own realm without realizing the problems their treatments have created in another specialist’s area of expertise.  And, as fewer physicians see their own patients in the hospitals there is less and less face to face interaction with doctors in other disciplines—perhaps the best arena for cross pollination of ideas. 

I have often quipped that we need a “Journal of Good Ideas”—a non- peer reviewed publication where physicians can report their experience and ideas that might prove helpful to others, without the need for high-powered proof before publication.  For example, it has been my observation that many problems in postoperative in-patients can be averted by insuring that their caffeine levels are maintained.  I do not have the time nor the resources to do the kind of study which would be required to prove this, but it is a simple observation that can be tried by others.  (Trust me—less time for bowel recovery, less headache, less fatigue and better post operative mobilization!)  

Fortunately, a new forum for truly out of the box thinking has arisen.  The fastest growing subset of medicine today is in the field of “anti-aging”.  The title may be a misnomer, but this area of medical research and practice is dedicated to optimizing health throughout an extended lifespan.  In their journals and their meetings, anti-aging physicians of all specialties and interests discuss improving health, utilizing not only the published long term literature, but their experience and understanding of basic science—in short, they have gone back to the way it once was.  The anti-aging medical leaders scour the medical literature across all disciplines for ideas and evidence.   Then, instead of erecting barriers for the sharing of knowledge, they publish ideas with extensive documentation in non-peer reviewed magazines and let the discerning physician reach conclusions about the validity of the ideas presented. In essence, they have become the Google search engine for medical information, and have combined that knowledge in unique and useful ways.  

State Medical Boards, peer review, best practices and Evidenced Based Medicine are put forth to improve the quality of medicine and promote safety for the patient.  But how many patients die or are disabled due to lost opportunity, inability for ideas to be promulgated, and fear of being sanctioned for providing the avant guard, not just the standard care?  It is appropriate to remember the words of the late Hilton Terrell, former AAPS president, when he wrote, “Data does not rule.”  and also “Risk is basic to medical progress.”

Friday, April 22, 2011

Universal Health Care is Not the Solution


This article was first published in 2003 in the journal Orthopedics. It was written in response to a fellow Orthopedist's call for government single party payer.  Little did I know at the time how serious an attempt would be made within the next 7 years to "transform" medicine in America.

Lee D. Hieb, MD


Universal Healthcare Myths


Several superficially compelling reasons for universal healthcare are usually put forward. First, as the business of medicine becomes more complex, some physicians believe universal healthcare would be less of a hassle. Recently, a neurosurgeon commented, “I would be happy if the government would pay me $250,000 a year and took care of all running of the office so that I could see patients.” The second argument preys on physician ethics. It is often stated (and Dr Weiner discussed it in his article), that physicians under a capitalistic system fail to care for needy and sick patients. Presumably, universal healthcare, with the government looking after everyone, would somehow do charity better, and would “leave no patient behind.” The third myth is that the economy of scale would somehow cause medicine to cost less if run by a single-party payer. It is argued that the cost of the various insurance companies and government paperwork would be lessened if one unified form and one unified payer existed.

Universal Care Around the World


In the Soviet Union, medical care was free to all, but only the Polit Bureau (eg, high-ranking officials, their family, and friends) received any good care. When Boris Yeltsin required cardiac surgery, he went to a special hospital only for government officials, and was treated by American-trained surgeons. He even flew Dr Debakey from America to Russia to make judgements about his case. Why? Because he knew that he could not trust the physicians, nor the system he had helped create. As Ayn Rand wrote in Atlas Shrugged, “It is not safe to trust one’s life to a man whose life you have throttled.” According to Ann Ebeling (her husband, Dr Richard Ebeling, is President of the Foundation for Economic Education), who was raised in the Soviet Union, quality medical care was simply not available through state run medicine. To get help, patients would bribe doctors to come to their apartments and bring whatever equipment could be mobilized illegally from the hospital to perform lifesaving procedures. Black market private practice was the only effective medicine during the 70 years of economic decline and tyranny of Soviet Socialism.

Thursday, April 21, 2011

Immoral Medicine


The magician distracts the audience by doing meaningless but fascinating things with his right hand, while his left hand is doing the really meaningful activity unnoticed by the crowd.  The bigger the trick, the bigger the distraction required.

Democrats and President Obama should make David Copperfield proud.  With one hand they are distracting the American people with a nonstop barrage of bills and discussion:  What will happen to the budget? How many are really uninsured?  Is the Congressional Budget Office to be believed?

And for the ultimate distraction, Mr. Obama paraded a group of “doctors” in borrowed white coats for a great visual effect wholly devoid of  substance.  For all we knew, these guys could have been a group of actuaries at a DC convention bussed in as props for the day. (More likely they were doctors of the government paid variety, like Rahm Emanuels’s physician brother Ezekiel, sheltered in research institutions and teaching hospitals where they don’t have to run their own small businesses.)
While this diversion is going on, the real issues are hidden from the public -- the consequences of government funding of medical care on individual liberty and our moral compass.

Monday, April 11, 2011

Pay for Performance Treating the Well and Avoiding the Sick. (Letter to the Ft. Dodge Messenger)

Pay for Performance--Treating the Well and Avoiding the Sick.

On March 27th, a column in your paper appeared entitled “The one-word answer to health reform”.  For the most part I agreed with the sentiments and ideas expressed in the op ed, however I thought it ironic that under the heading of “Lowering Bureaucratic barriers”, the authors unwittingly touted a government program which will erect significant and immediate barriers that will affect the sickest among us.  Specifically they laud the idea that hospitals (and this will apply to individual physicians as well) will be paid for, as they put it, the “best care” not the “most care”. 

This program sounds good, as all government schemes do initially.  It is called P4P or Pay for Performance, and it seems reasonable that we should pay the better doctor and the better hospital more than we pay the bottom tier.  BUT, and this is a big but--how is this determined?  Government bureaucrats count what they can count, not what is ultimately important--very much like judging art by counting the brush strokes.  In the case of P4P, for example, doctors whose diabetic patients are under good control will be paid a higher fee than those with worse average monthly blood sugars.  The assumption is that the doctor totally controls the blood sugar.  The truth is that patients may choose to drink and eat bon bons, they may be too poor to get their medicine in a timely fashion, or may simply have very brittle diabetes that is difficult to control by even the best of doctors.  They may have learning deficits which make it difficult for them to be in perfect treatment compliance. What will happen to these people?  They will be discharged from the doctors’ “panels” because doctors have to run their offices and pay their increasing overhead, and they cannot afford non-compliant patients who will lower their “grade” and therefore their revenues.  Hospitals are already omitting the highest risk renal transplant candidates from the waiting lists because they will lower their “performance”.  In short, the people who least need a doctor will have one, and the sickest among us will be out in the cold. 

The other very bad aspect of P4P is its total lack of respect for the individual.  In an age when we have sequenced the human genome, and could deliver medicine tailored to the individual patient, government is enforcing a one size fits all program.  Under the rubric of “quality” we are forced into uniformity.  People become statistical ciphers.  As a surgeon, I am being told to treat patients by algorithms or face financial penalty, even when my individual patient may fall outside those guidelines.  (So far I have been able to dodge an out and out confrontation, but the shootout at the medical OK Corral looms large).

Ultimately, when you take the king’s dime, you take the king’s rules.  The only way to really give “Best Outcome to Every Patient Every Time” as written in the editorial, is to return the practice of medicine to patients and their doctors and hospitals.  Government medicine, wherever it has been applied increases cost, decreases quality, reduces patients options, and ultimately results in patients dying needlessly.  As Ronald Reagan said, “When government is the problem, more government is not the answer”.  For more information on medical economics please check out AAPSonline.org

Lee D. Hieb, MD

Sunday, March 6, 2011

Government Medicine, a Formula for Mediocrity.


First Published Nov 2010 in Orthopreneur

There are many reasons to avoid government medicine.  Cost is one.   Although cited as a reason in favor of government intervention, does anyone with at least an eighth grade education really think the government will save money by providing more efficiency and effectiveness than the free market?  Has it in any other area?  With all its regulation, the same government that brought you the $600 toilet seat brought you the $18 aspirin.  (I checked, and that is the going price in our facility which accepts Medicare).  And, then we could discuss the huge moral issues at stake here when doctors become agents of the state.  Few today remember the conclusion of the Nuremburg Doctor Trial wherein they hung the Nazi doctors responsible for the euthanasia program and experimentation on prisoners.   Allied prosecutors concluded that German doctors were not intrinsically evil, but rather, their fault lay in working for the government. Only 18 years before the implementation of Medicare, these prosecutors all agreed with the words of Leo Alexander of the American team when he opined  “We should never let doctors work for the government again.”

Another concern, and the one I wish to discuss today, is how government medicine-- by its very nature-- insures mediocrity in our profession.

In the big scheme of things government induced mediocrity is demonstrated easily.  Politicians and the elite may let the common folk get “average” care, but they themselves want EXCELLENT care.  Which is why two prime ministers of Canada snuck across the border in the dark of night to come to the USA for their own medical care.  If government medicine was so great why didn’t they stay home?  When Boris Yeltsin, needed heart surgery he employed American trained doctors, and even then flew over Dr. DeBakey to the Soviet Union to supervise, because he knew what Ayn Rand had written that, “It is not safe to trust your life to a man whose life you’ve throttled”.  

Saturday, March 5, 2011

Healthcare Bill Takes Away Our Liberty

by Lee D. Hieb, MD

Make no mistake. Every time the government offers you any form of safety or security, it takes away your ability to make choices about your own life. No matter how noble, every government safety imposition diminishes your individual liberty. This principle is no more obvious than in the current healthcare reform, which is why there are so many voices in chorus against this “transformation” of America.

When this law is in full force, individuals cannot choose to self insure, no matter how much they may be able to afford to do so. Now, you can be thrown into jail for not complying with the government’s plan for your own safety. This sounds like something out of a Stalinist show trial: “Comrade, you are guilty of “insufficient self protection”—five years in the gulag!”

Health Care: The Best Plan is to Have No Plan.

 In response to the Obamacare health plan, groups from doctors to union bosses to Republicans (not in any particular order) have put forth their alternative plans.  Today, there are more plans floating around D.C.  than those we used to win World War II.  (And at least the military readily admits that war plans don’t survive the first armed encounter.) No, we do not need any more plans.  The best plan, is to have no plan.  None.  Because plans require planners, and if the Twentieth Century should have taught us anything it is that central planning doesn’t work.

AMA Doesn't Speak for Most Doctors

 First Published at HumanEvents.com 1/5/2010

The American Medical Association officially endorsed the Democrats’ health reform bill.  An eager Barack Obama, of course, used this endorsement to claim that “doctors” support his healthcare takeover.  This misleading statement plays on the common misperception that the AMA represents some huge block of American  physicians.  Not true.  In fact, excepting membership given to students and residents in training, the AMA represents only 17-19% of physicians actually in practice.

Did Natasha Richardson Have to Die?


Liam Neeson, one of my favorite actors, experienced a great tragedy last week in the death of his wife, actress Natasha Richardson. I don’t usually pay too much attention to celebrity lives, but having two teenage boys similar in age to hers, I found Natasha Richardson’s death especially poignant.

As a mom, I must express my sorrow for the family’s misfortune. And as a physician, I have to ask: what can be learned in this case?

For the two or three Americans who haven’t read the details, Natasha’s death was the result of a head injury while skiing -- not a high speed Sonny Bono-type wipe out, but apparently a fairly innocent fall during a lesson. She developed an intracranial bleed, and by the time she was able to receive the necessary level of care in Canada, her intracranial pressure was excessive and ultimately fatal.

Medicine and the New Slavery


My father was a small town country doctor and dentist.  He made house calls,  He set his own hours and determined his own time off.  As he got older, he limited his practice hours, and the type of dentistry he did in order to maximize proift per time worked.  At the most, he made $25,000 a year -- enough to live comfortably, but not enough to completely pay his only child’s post graduate education.  He considered himself a free man.

I paid my way through a private Medical School by joining the Navy. After four years of college, four years of medical school, five years of Orthopaedic Residency and four years of payback time supporting the Marine Corps, I spent another year training to be a spinal specialist. That year, 1989, as a Board Certified Orthopaedic Surgeon, I grossed $15,000.

No, Barack, Medical Care is Not a 'Right'


At last night’s presidential debate, Barack Obama led the charge for government run health care by declaring in no uncertain terms that health care is a “right”. I suppose he thinks Tom and the boys accidentally left that one out of the Constitution. Or maybe it is an extension (in his mind) of the right to life.

But let’s think about this a minute. When our American form of government was created to form “a more perfect union” by insuring the “rights” of its citizens, it recognized only the “inalienable rights”. And to protect those rights, which I’m pretty sure only included life, liberty and the pursuit of happiness, the government was empowered to use force if necessary.

We created armed forces (and finally an adequate border patrol) to protect our people’s life and liberty from foreign invasion, and then police to protect our pursuit of happiness in the form of private property. So how will we insure medical care?

Atlas Is About to Shrug


Physicians are not generally thought of as businessmen, and many are not. But most of us are true cottage industries -- a one man or woman show with payroll to meet, buildings to purchase, books to balance. As a physician, I usually confine my comments to medical topics and let the political pundits weigh in on matters in their lane. But listening to the heavy hitters discuss the election outcome, I have not heard the real reason for the Democratic victory -- that we as a nation may have reached Ayn Rand’s tipping point.

I have heard too many explanations: McCain lost because people hate Bush. He lost because of Iraq, or the economy. He lost because conservatism is too strident, or because of Palin. Republicans haven’t enunciated their case. McCain was not a true conservative, Republicans have moved too far to the left, or maybe too far to the right.

How Will Doctors Handle Uncle Sam Health Care?


We can criticize socialized health care, citing statistics and chronicling the historical record of runaway costs and deterioration of quality.  But you have to deal directly with Medicare and Medicaid (or perhaps be a former Soviet citizen) to really appreciate the Twilight Zone nature of government-run programs.

Among federal Medicare regulations -- which are over 130,000 pages long -- there is more than ample room for confusion and some humor. After a long search for traction weights (those five pound blocks of metal used to pull fractures out to length) I found them propping open doors to patient rooms in the ER. It is a punishable offense under Medicare regs if the hospital is caught propping open these doors because they are fire doors.

Obama's $25,000 Error

 By Dr. Lee D. Hieb
Originally published at HumanEvents.com 8/24/09
I’ve been seriously underpaid.  According to President Obama, I get $30,000 “right away” for amputating a diabetic Medicare patient’s leg. So I checked the two inch thick book of procedure codes, then called the biller and found that instead of  $30,000, I actually get $554 or $857 depending on the level of amputation. Obama probably thinks that difference of $300 will incentivize me to take off more of the leg.

And does “right away” mean within two years?  Just ask the car dealers how easy it is to get the government to pay you even after you have spent hard cash rendering a service and have a “clean claim” as the Medicare bureaucrats call it.  Don’t feel bad, guys. After I bill the whopping $554, which covers the patient’s admission to the hospital, the surgery, and 90 days of follow on care, I will be paying out $15,000 in malpractice insurance before I get paid. And that’s only if it takes 90 days.

Fix American Health Care By Fixing the Market


American government policy has made a mess of medical care. But, predictably, the politicians -- and this is truly bipartisan -- do not blame themselves.

Governments never blame themselves. The Soviet government’s policies caused mass starvation and industrial collapse, but did they blame themselves? Hell no. They blamed the only people who knew how to make the farms and factories run. The engineers and specialists, so called “spetzi”, were labeled wreckers and class enemies of the people, imprisoned in the gulag or shot. That didn’t work out well for anyone.