Oleg I. Reznik - The Secrets of Medical Decision Making: How to Avoid Becoming a Victim of the Health Care Machine

Where has Marcus Welby, MD, gonethat prime-time hero of the 1969 TV medical drama starring actor Robert Young? We really need him now. Sadly, this image of a gentle friend and neighbor to his patients, who relied more on his caring and belonging to his community than upon bioengineered pharmaceuticals and high-resolution computerized imaging techniques, is nowhere to be found in the early 21st century. This is disappointing, even to physicians, many of whom entered the non-specialized area of primary care with this gratifying model very fresh in their minds. What happened to the home town physicians who based their diagnoses and treatments on personal knowledge of patients and their context? They have quietly disappeared through retirement or disillusion with the social changes (of which there are manymanaged care, malpractice crises, federal regulation, etc.) that have transformed medicine. They have not been replaced.

Everything in medicine has changed. The social and cultural context in which patients live has changed dramaticallywith less job security, higher unemployment, less insurance coverage, higher deductibles, and a pervasive mistrust of civic leaders. US society now tolerates a clear and widespread social division between the medical haves (those with good health insurance) and the have nots (those without medical insurance). Both groups have profound medical problems, but they are very different. Medical education now limits the vision of family doctors by recruiting mostly those who are destined to be specialists wielding high-technology diagnostic devices or state-of-the-art intrusions into the body for various repairs. The content of medical education has become highly research-based, specialist-oriented, and focuses almost exclusively on secondary prevention (what to do after a disease has already become manifest, and directed only towards those with good health insurance), rather than on the truly life-saving, life-prolonging strategies that comprise primary prevention (steps to avoid the disease in the first place). Conveniently forgotten is the fact that improvements in sanitary conditions are responsible for most of the longevity we have achieved, and that the most impressive, cost-effective, and high-yield medical interventions are still simple things like diet, exercise, vitamins, and aspirin.

The landscape for physicians to find opportunities to practice has been radically altered by governmental and legal constraints. The only physicians who will be financially rewarded are those who seek to deliver high-margin services to the well-to-do (meaning at a minimum those with good health insurance), in popular living centers where new physicians are least needed. They will generally work for large, impersonal organizations that are rich enough to manage legal risk, monitor compliance with all applicable local, state, and federal regulatory constraints, insure aggressive risk management practices and maintain adequate malpractice coverage in order to insure the ability of the enterprise to continue participating in the potential profits of medical practice. Patients have to turn to relatively soulless, mega-corporate enterprises, being conducted by warring behemothslarge insurance companies (Aetna, US Health, United, etc.), pharmaceutical drug companies (Pfizer, Merck, Lilly, etc.), medical and biotechnology engineering companies (GE, Johnson & Johnson, Hewlet Packard, Genentech, Medtronic, Guidant, etc.), and very successful political lobbies for all these groups plus additional special interest groups like AARP and the Trial Lawyers Association. This landscape should be readily recognizable to all of us; some part of it gets a new headline everyday. Conspicuously absent from the widespread media coverage of the modern American health miracle is a concern for the average citizen's healthcare experience or the patient outcome that really mattersthe number of preventable years-of-life-lost. We should urgently be asking, Where do we fit in? as both patients and physicians. Survival is not particularly easy in this world, but it can be graceful.