PHYSICIAN HEAL THYSELF

Hello again, and best wishes for a very happy and healthy 2025. As promised I will not dive into the snake pit of Donald of Orange until after the inauguration since we have no way to fathom which of his daily mouthings actually represent ideas of policy (if such exists in his vocabulary) and which will fall by the wayside once he moves -- perhaps alone? -- back to 1600 Pennsylvania Avenue. Before moving on, while enjoying a cruise along the Mexico coast, I will share one experience: in conversation with a very VERY conservative Trump-loving Russian-born physician, I asked if she truly believed 20% tariffs were a good policy proposal, and she opined this was just a "negotiating tool" -- like I would call a gun a negotiating tool, perhaps. But on the subject of U.S. medical care, much to my surprise we found common ground. Which leads me into today's discussion: the deplorable state of the American health care system.

I was recently struck by a blurb for "New Amsterdam", a five-season Netflix series which has gone off-line this month: "This NBC medical drama . . . presents a protagonist whose good intentions and can-do attitude can, for at least an hour, assure viewers that the health-care industry is working in their best interests. The central character is Dr. Max Goodwin . . , the new director of a New York public hospital who embarks on an idealistic mission: to put patients before profits and to help people no matter what the cost. . . . ." I'm reminded of all the tv doctor (sometimes just a resident or maybe even a nurse) who overrules all the attending MDs and spots the correct, often very obscure ailment troubling the patient at death's door and in a flash restores a happy human to full function. Would that any of this were true.

I suspect almost every reader in our little circle within the past year has experienced some frustration accessing or using the American health care system, whether getting an appointment without an interminable delay, insurance approval issues, finding the right physician or ending up with one whose idea of communication is ten seconds in the examination room and no more than fifty spoken words (and us thinking of a dozen questions as soon as we're back in the waiting room -- too late), or getting a referral onward when the initial visit fails to provide any answers, or eye-watering prescription prices, perhaps a huge co-pay after a medical treatment . . . and obviously I can go on enumerating the frequent frustrations in our system. Not to mention that from a macro view, health care in this country just doesn't do the job; doctors are treating patients with what I call "large number medicine" rather than individualizing care. As but one example (with which I confess I have personal experience): consider the PSA measurement, a simple test formerly routinely included in men's annual blood work but is now disapproved. Why? And I quote,

“The U.S. Preventive Services Task Force (USPSTF) recommends that men ages 55 to 69 discuss the potential benefits and harms of prostate-specific antigen (PSA) screening with their doctor and make an individual decision about whether to get screened:

“Benefits

“PSA screening may slightly lower the chance of death from prostate cancer in some men.

“Harms

“Screening can lead to:

“False-positive test results that require additional testing and possible prostate biopsy

“Overdiagnosis and overtreatment

“Treatment complications, such as incontinence and erectile dysfunction

“The USPSTF recommends against PSA-based screening for men age 70 and older because the potential benefits do not outweigh the harms.”

While it may be true that a few proud men would prefer death over a risk of erectile dysfunction, some anonymous agency decided based on large numbers that early detection of prostate cancer was a bad idea and trumped the idea of individual choice because -- since in the very elderly, prostate cancer tends to progress so slowly that death arrives from other causes -- early diagnosis didn't seem to have a majority effect on life-expectancy of large numbers of elderly men but caused lots of men to undergo relatively simple (if embarasing and frankly only slightly — for me -- uncomfortable) prostate biopsies; evidently some aggressive physicians then recommended unnecessary surgery rather than CT or MRI scans to determine a course of surgical or non-surgical medical treatment or not. The patently obvious flaw in this thinking -- now being re-considered in many medical circles -- is that this ignores individual survival and quality of life potential after developing prostate cancer for many vigorous healthy older men, treating all as frail and near death, and deprives the individual patient of the opportunity to make his own care decisions after medical consultation. It in fact has condemned too many men to painful bone metastises, disability and untimely death.

Sadly, even though affecting millions of patients in this country, the PSA scandal by far isn't even the greatest flaw in our health care system. The third leading cause of death in the United States is medical error -- 250,000 people per year! The lower-middle income families have little access to health care while, varying wildly state-by-state, the very lowest income families may have greater access to public health services. Our infant mortality rates are an embarassment, and life expectancy has not kept pace nearly as in Europe or Japan. Cure rates for most cancers are lower here than elsewhere. Administrative obstacles can make getting care a nightmare. Yet we pay more for health care per person than in any other country in the world, and we just don't have enough health care providers and yet have a system which blocks new entrants, wilfully limiting the number of medical schools and physician graduates. Talk about the supposed vices of the union shop!

We have an extremely compartmentalized health care system. Fewer and fewer family doctors are actually equipped to make more complex diagnoses and arrange prompt referrals to the correct specialist. And when you do arrive at the new doctor's office, does that MD have all of your records at hand? Of course not. While the federal government is gradually requiring that all medical records be available electronically, there is no mandatory intercommunicability of the systems. One facility may use Elation, another MyChart, or yet one of many proprietary record storage systems. In Denmark, Estonia, Finland, Singapore, Australia or France (and probably many other countries as well), by contrast, all records are stored in a single system and available to any MD you might need to consult. This obviously increases efficiency in diagnosis and treatment and avoids major medical errors. But sadly not here.

So that is step one in you having to be your own health care supervisor, no matter if you have any medical or science training or background. But it gets worse. Selection of tests to perform or scans to order require awareness of the variety of choices for different ailments plus willingness of your particular insurance provider to spring for the best pick. And while we are legally entitled to obtain a so-called second opinion, good luck making such an arrangement or finding a qualified and willing opinion provider.

So how might we fix this -- from a liberal perspective, meaning providing more accessible and better care to more people? Let's start with the private insurance system. Some countries (Germany, for example) keep a private insurance system in conjunction with the national health care programs but regulate it strictly as to rates and coverages. It should not be necessary -- although might be advisable -- to abolish the private health insurance industry, but we most definitely need to move to MediCare-for-All at the very least. Now MediCare is nominally part of the social security system, so an incredibly easy way to fund the program would be to remove the cap on social security deductions from earned income, presently at $168,000 per annum which annually would generate an additional $200 BILLION in yearly federal funding. Actually more will be needed to finance a national health care system and keep social security solvent, but imagine how little impact it would have on personal income if virtually ALL health insurance and health care expenses were removed from your annual payouts and covered by national insurance, justifying an easily absorbed indexed tax increase. (I'm guessing each of you might be seeing personal savings of $12,000 - 20,000 per year for health insurance, medical co-pay and prescriptions so could afford -- say -- half that in a tax increase!)

For my next number, I'd abolish state licensure of physicians in favor of a national licensing system -- except allowing individual states to set higher standards for licensure in medical specialties; I'd do this for the same reason we have allowed some states like California to set higher air quality standards for cars so we avoid the race to the bottom in regulation. Doctors attend the rather few existing medical schools, less than 200 in the entire country, serving four hundred million people; Alaska, Montana and Wyoming have zero medical schools but still license physicians. Go figure. Is medical science really so different in New York than in Honolulu such that a different examination and license or a so-called but limited multi-state examination is needed for each? This is not only a needless multiplication of beaurocracy but also an obstruction to quality care; in many states is is illegal for a physician in one state to provide telemedical assistance to a patient in another unless licensed in that second state as well! Stupid (and fortunately often ignored). Most doctors also graduate with huge school debts. Let's build many more medical schools and make them state funded and free (as all higher education ought to be as it is in so many other countries).

It should go without saying that we will require all electronic medical records system to be readable by each other so when you are referred to a specialist she will have all of your records before her and will not have to rely upon your memory for your medical history, possible dangerous drug interaction issues, and previous diagnostic tests and examinations. Each of your physicians will then see a complete rather than fragmented picture of your health.

With a national health system should go a national prescription drug registry with prices government negotiated in every case, not just the dozen currently covered by the MediCare system under the Biden health care expansion laws. All prescription drugs should be included in the health care system so no $1000/month co-pay for obesity management or cancer drugs to keep wealthy patients alive. For people living in currently under-served areas where certain medical specialties just don't exist, transportation to and from the health care center must be government funded, and the telemedicine system greatly expanded so at least initial consultations are expedited and you can be directed to the doctor most likely suited to your problem.

I'll stop here for now, although there are many other ways to improve our health system. These few affordable changes would have a vast impact -- and still might not resolve the PSA-or-not dispute. Please chime in and pile on with your ideas, and maybe we can get a Senator to pay attention for the next time we have a more liberal unified national government. In the meantime, see you next month or sooner with initial observations of the neo-Trump era. Until then, please invite a friend or five to join or discussion circle and spread the word. And please comment freely -- don't be shy.