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

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”.  

This month, my hospital, and maybe yours, was prohibited from performing Doppler ultrasound testing to check for DVT.  This test has been performed successfully even in the smallest of hospitals for over 15 years.  But the government, via Medicare CMS regulatory body (those unelected officials who have churned out over 160,000 pages of regulations which carry the force of law) says we mustn’t do the test unless our technician is certified.  Certified by whom?  We have a board certified Radiologist who reads these studies and can certainly vouch for the quality, or reject them if need be.  What possible certification can add to that?  In the real world, this prohibition means that an Orthopaedic patient after a hip fixation, suspected of a DVT must be placed in an ambulance, driven 30 miles to the nearest “certified facility” tested and then returned.  It means grossly magnified costs, and delay of care. This is not quality.  This is enforced mediocrity.

In Orthopaedics, as you are probably aware, we can no longer put Velcro wrist splints on our Medicare patients unless we are “certified”. I can surgically fix forearm fractures, apply external fixation and casts, but am not qualified to apply a simple Velcro splint.   To do that, I would need to be certified by an Orthotist with vastly less education than I.  According to my billing service, I do not put on enough splints in a two-year period to justify the  $3000 certification fee.  So rather than me putting on a splint immediately and competently in my office for roughly $30, the patient must go to the Orthotist where the least trained person in the office will apply one for $90.   We can only hope the Orthotist office is open.

A major guarantor of mediocrity is the licensing board in your state.  According to the current general principle of “standard of care” employed by boards today, when judging your clinical behavior, board members decide if 90% of physicians in your specialty in the community would have acted as you did in the clinical case in question.  If I am in the 10% I am by their definition outside the standards of care, i.e. wrong.  Imagine if any other industry functioned thus.  Instead of hand held i-phones we would still be dialing on rotaries hard wired to the switchboards downtown.  We would be driving a team of horses not Porsches.  There will always be the tail draggers in any profession, but in that 10% (and I would opine most of these) are our leaders. And licensing boards declare them to be wrong. 

Finally, lets look at Evidence Based Medicine.  Under Obamacare, the Institute of Medicine will be given millions of dollars to research efficacy, and will advise the government as to which treatments will be paid for and which will not.  Now, it sounds good on the surface to use “evidence” and not to throw taxpayer dollars on treatments that are unproven.  But look deeper and you will discover that this stands medical progress on its head.  Since Hippocrates, the maxim “Primum Non Nocere” meant that doctors could use their judgment, knowledge, and experience and offer treatments that might help if they were convinced that they would not make the problem worse.  This has allowed everything from the first use of antibiotics to new techniques for fracture fixation and complex spinal surgery.  Under the new paradigm, however, you cannot move forward.  You can only do the treatments that have shown efficacy in large long-term studies.   Value is given to long-term studies but none given to clinicians’ judgment and experience and insight—those factors most responsible for scientific progress.  This literature only approach comes at a time when we have found significant failings in the body of medical literature, from statistical inaccuracies to outright fraud.   And how many physicians have had their papers rejected for publication because they ran counter to the conventional wisdom?   As a university colleague of mine reported to me, when I complained of this very thing, “Don’t feel like the lone ranger.  We couldn’t get our papers published until we got someone we knew on the review board.”  In short “Evidence Based Medicine” as it is being implemented is not only a formula for, but a mandate for mediocrity and professional stagnation.

The tragedy in all this is the lost opportunity.  In an age when we have sequenced the human genome and can offer individualized treatments to each patient, the government is pushing for one size fits all.  Of course in medicine that means one size fits none.  It means we will anticoagulate hip fracture patients who are fixed and mobilized within hours of their fracture. (Do we anticoagulate ourselves just to sleep at night?) It means all inpatients will be given Pneumovax or the flu vaccine—although a reaction to this will be difficult to distinguish from postoperative fever.  As predicted by many of us, the so-called government “recommendations” for care have become unthinking treatment algorithms. It means we will be licensed more and more by non-medical technocrats supporting a cottage licensing industry.  Even our own Orthopaedic recertification requirements do nothing to improve care but do everything to support the ABOS, and AAOS.  I spent hours away from my practice, paid out a lot of bucks and studied total joint replacement concepts,-- and as a spine surgeon I haven’t done a total joint since residency training in 1987.  That improves care?

Medicine is a noble calling.  It is still the best profession.  But we are approaching the point where we will be forced to choose between the best interest of our patients and the government dictum.  Which will

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