The commercialization of the practice of medicine is driving up the cost of health care in America. While many drugs, devices, and procedures available are truly miraculous, study after study has shown that commonsense approaches increase quality and length of life to a greater degree than do expensive technologies. These commonsense approaches are not new: regular exercise, not smoking, getting enough sleep, stress management, and an unprocessed diet that is rich in beneficial fats. These modifications increase healthy life expectancy by many, many years by preventing the onset of chronic illnesses. The Chinese have advocated similar strategies for thousands of years: inexpensive lifestyle changes are the cornerstone of Eastern medicine.
Such simple actions cost very little, yet they would save the country billions and billions of dollars. First, millions of Americans would not suffer from chronic diseases such as diabetes or heart disease; money would be saved by decreasing the incidence of these conditions. Second, with each intervention, such as cardiac catheterization or arterial bypass surgery, complications inevitably occur. Without these millions of interventions, even more money would be saved by avoiding the necessity of treating the complications. It is estimated that complications from adverse drug events alone cost $200 billion each year. That is not including the cost of complications from medical procedures.
So, who is responsible for our lack of common sense? We all are.
From the pharmaceutical and medical-device companies to the FDA, from processed-food manufacturers to physicians, from medical schools, political lobbyists, and health insurance companies down to each of us as individuals, we are all responsible for this predicament.
Of course, each of these entities is responsible in its own way, for its own reasons. Various factions promote our reliance on expensive technology predominantly because of one of two things: either the desire to reap financial rewards or the misguided notion that high-tech treatment yields superior long-term results.
In addition to the belief that more technology delivers better results, doctors overuse expensive diagnostic technologies for three other reasons. The first is the fear of litigation. In a 1993 survey, 60 percent of physicians who responded admitted to ordering more diagnostic tests than truly needed because they worried about being sued. In 2008, the American Medical Association conducted a survey and found that that number had greatly increased, with 93 percent of responding physicians admitting they have practiced this sort of defensive medicine. Even if they are virtually certain of the diagnosis based on the patient's history of the presenting illness and their physical exam, there is a strong tendency for doctors to order extra tests to rule out uncommon diseases. They do this to avoid being sued for missing a rare diagnosis. It is unusual these days for a physician to treat a patient based on the clinical evaluation alone. Before, if a patient did not improve as expected, then the doctor would go on to order tests. Many physicians are unwilling to use this approach, as it carries a small risk of failing to diagnose an esoteric disease; however, the cost of these extra tests is estimated at almost $230 billion annually.
The second reason that doctors order excessive tests has to do with the way they are trained. It has been said that more than 90 percent of a diagnosis will be discerned from the patient's history and physical exam. The emphasis that has been placed on these skills has diminished as availability of diagnostic modalities has increased. In places and time periods in which these advanced technologies were in short supply, physicians had to rely almost completely on their diagnostic acumen.
The third reason that physicians order unnecessary tests is the strong urge to "do something." It is very difficult for doctors, particularly those in the United States, to allow enough time for a condition to either declare itself or resolve. There is an undeniable tendency to order more tests, prescribe more drugs, or perform more procedures than may be necessary. Sometimes this behavior is driven by the patients, and their expectation that they will walk out of their doctor's office with "something" in hand, either a prescription or test order. The recent trend of drug and medical-device companies directing their advertising toward the public has reinforced this behavior. It becomes very hard for American doctors and patients alike to accept that "watching and waiting" is not "doing nothing." It is allowing the body to undergo the normal process of healing. In these circumstances, the physician can best serve the patient by making recommendations that support this natural process. It may not be in the patient's best interest to take more pills or undergo an expensive battery of tests and procedures. It will, however, certainly drive up the cost of health care.
Disproportionate Number of Specialists
Another way medical education in America drives up the cost of care is in the number of specialists that are trained in relation to the number of family practitioners. Over the years, there has been a steady increase in the number of specialists and subspecialists and a corresponding decrease in the number of family physicians.
In his book Overdosed America, Dr. John Abramson states that "comparisons both within the U.S. and between countries show that access to comprehensive, family-centered, primary care service is the distinguishing characteristic of health-care systems that are both effective at producing good health and efficient at controlling costs." Generally, in America, the higher proportion of specialists has led to increased costs to the system. The greater the number of specialists, the greater the cost. This is because specialists' fees are higher, and specialists are more inclined to performed procedures. After all, that is what they are trained to do. The problem is that, in many areas, more procedures may not improve health outcomes.
It has been determined that an efficient proportion of primary care doctors to specialists should be 50 percent, but in 2002, it was found that only 21 percent of physicians in the United States were primary care doctors. That number fell by more than 25 percent between 2002 and 2007. The Wall Street Journal reported in April of 2010 that, in spite of a push to boost the numbers of family physicians, there could be a shortage of 150,000 primary care doctors by 2025.
There are several reasons for this disparity. During a doctor's training there is a perception, whether true or not, that there is more prestige attached to being a specialist than a family doctor. From a financial perspective, specialists command higher salaries and fees than do their generalist colleagues.
Finally, to a young doctor embarking on a specialist training, there can be some comfort in having a narrower field of study, with the hope that they can learn everything about one area of study. Family doctors have a more daunting task: they are expected to know almost everything about everything! They must have a firm foundation in all aspects of medicine—cardiology, dermatology, gynecology, pediatrics, psychiatry, and infectious disease, to name but a few. They must also get their patients to lose weight, quit smoking, and wear their seat belts. For all this, in spite of their equally staggering debt from medical school, family doctors get paid, on average, only half of a specialist's salary. Is it any wonder that fewer new doctors are choosing to become family physicians?
While the disproportionately high number of specialists is understandable, it is driving up the cost of our medical care. The more troubling issue, as we have seen, is that the quality of our health as a nation is considerably lower than in other countries where specialists are fewer and where the majority of the population is treated by primary care doctors.
The above is an excerpt from True Wellness: How to Combine the Best of Western and Eastern Medicine for Optimal Health by Catherine Kurosu, MD, Lac and Aihan Kuhn, CMD, OBT, publishing date September 2018 by YMAA Publication Center ISBN: 9781594396304