The Problem with Healthcare

I do not argue with my patients.  Rather, I teach, outline options and explain my point of view, as each person must choose their path.  However, the other day, Audrey and I got in a tiff when she was in the office to discuss her breast cancer.  We had an enthusiastic discussion not of chemotherapy, x-rays or surgical options.  Nope, we disagreed about what is wrong with healthcare.

It seems to me that the primary cause of dysfunctional medicine in this country is in my face every morning.  Big Pharma?  No. The United States Government? Nope. Insurers?  Not really.  How about capitalism verses humanism?  A distant second.  No, the major cause, the big problem, the central failure in healthcare is … doctors.

Nothing in medicine happens without a doctor’s order.  Nothing.  Directly or indirectly, every pill administered, test ordered, patient admitted, hospital built or insurance payment processed, was ordered by a physician. We have the ultimate power and can control or change medicine, if we wish. Therefore, everything good in medicine we created.  However, everything bad is also our fault.

If the pharmaceutical companies make too much money on copycat drugs, selling them at too high a price and pushing them on patients without adequate research or safety trials, physicians write the prescriptions.  If insurance companies put restrictions on over ordering of tests, so that the whole system bogs down in pre-certifications and denials, it is because doctors do not emphasize quality over quantity.

If hospitalizations are too long, it is the physician’s failure to discharge.  If antibiotic resistance and iatrogenic infections are sky rocking, it is physician’s failure to be conservative in antibiotic use. If there is too much emphasis on crisis medicine and fighting disease, and too little lifestyle prevention, this is the medicine doctors practice.

We have always controlled it all, but by failing to use that control to keep cost down, limit unneeded testing, police our own and by jumping on every shinny new technology, no matter the cost or the unknown side effect, we have failed to live up to the Hippocratic goal of the finest care. Moreover, the occasional rotten physician, who builds their practice on big bucks, taints the barrel.

Audrey says I am wrong.  She thinks that blaming doctors is a copout.  Audrey believes that there is only one person responsible for healthcare and the problems are all their fault.  That person is the patient. She believes that healthcare and healthy living are every person’s responsibility.  Patient’s demand excessive, expensive and ineffective care.  Patients fail to practice basic preventive medicine, such as exercise, good diet, rest and not smoking.  Patients, instead of working with their doctors, threaten them with malpractice humiliation, producing an adversarial relationship instead of a team.  It is patients that fail to understand their bodies and do not take the time to comprehend their medical problems, so that instead of leading in their own care, are lead blindly down the wrong path

Audrey believes that if patients did not always look for the newest, brightest and most exciting “cutting edge” therapy, that if they emphasized good basic care, that patients would avoid bizarre complications, confusing outcomes and out of control medical bills. If patients understood science and disease better, they would be more effective consumers and avoid quackery and confusion.

Finally, Audrey contends that patients must not see precious healthcare resources as a commodity over which to fight, but should work together to assure that every person has access to the medical treatment they need. Audrey said that if patients did not deny that bad things happen and that miracles are rare, and instead focus on achievable outcomes and on quality of life, that healthcare would be appropriate, available and affordable.

Of course, in the end, we are both wrong…and we are both right.  The future will only be one of quality, compassion, low cost and healthy living, if patients and doctors work together.  Whatever their good intentions, we cannot depend on any other player in the healthcare space to have a full understanding of the issues that each person experiences in achieving and keeping health.  The penultimate expression of the physician – patient relationship must be this; working together to build healthy lives for everyone.


  • Mary
    So similar to the chicken and egg argument . . . A patient can only work with her medical team if each member participates fully. A doctor can only work with a patient who is willing to go beyond the "fix me" mentality. Each must take responsibility for performing the acts that HELP and not performing acts that do not help. Easy to say but very difficult to achieve on all sides.
    • James Salwitz, MD
      Very difficult. But the alternative is a mess. jcs
      • Curtis Lilieholm IV P.A.,C.P.S.
        Life is a gift for all of us! Jim your words and passion, ethics, bedside manner, view of medicine, patients, colleagues is well deserved equally rare these challenging days in healthcare! After spending 25 years covering over 200 acute & sub-acute facilities, well you see and learn something new every day. I am no different than anyone else, "We all put our pants on one leg at a time". Health Care has not only been getting worse for our patient population but for our colleagues, abilities to treat patients adequately, with out interference from Insurance Companies who basically dictate what can and can't be done, Obama Care is not only making things worse, but will destroy health care as we know it? I am not that smart! I have three beautiful children, Sydney age 20 (Cancer free now), Ryan age 18, Marina age 15, they are all straight A students, appropriate, passionate, and smarter then dad, (they think so). At 3 1/2 yrs Sydney had multiple brain tumors, through 24/7 bedside care of her parents & being a bastard (Patient Advocate), making sure that her MD's, Nurses, Aids, provided the best possible patient care, medical expertise, or just what they were taught to do and take an oath, etc I always made time in my schedule to pick up my children from school, and mostly fed them dinner before i went back to work. In 2006 my best friend/wife (who also suffers from depression) choose to stop her medication and was on a path of self medicating herself. One day in May, i got a call that she had filed for divorce??? She got the house for a $1.00, (so our children could finish school in the 2nd best public schools in NJ). It's now 2013, I now take care of my 91 yr old dad & 85 yr old mom. Dad is in chronic pain, Nerve block testing today at 3:00pm. (Pray for us) Dad spent 10 days in the ICU for piss poor treatment from his primary G/P, I was stupid enough to listen to him for a while, thank god, he survived and is now home from the Hospital. One day at a time, i say! Once again i had to be the "Bastard" or patient advocate for his care. Their are great doctors and nurses and many that suck 80/20 rule. Yes everyone needs to be paid, but we did not get involved in healthcare to be rich, we did it because we wanted to make a difference one patient at a time! Times have changed for the worse, and will get much worse under "Obama Care", our patients will suffer, our colleagues will suffer, our children will suffer, and healthcare as we know it will go down the toilet. I am not smart enough to even begin to suggest how to fix it, What i am saying is we take life as a gift and live it to your fullest every day, treat every patient as a family member, with passion, respect & dignity, (ok so we get calls all the time no dinner, we signed up for this) If you don't like it resign! If you love it and can remember why your doing what you signed up to do with passion, etc, God Bless you! Curt L
        • James Salwitz, MD
          You have had a remarkable journey. You have so many lessons to teach. I salute your passion and you ability to see the beauty in life and in caring for others. jcs
  • alyce
    Ah yes it is a two way street. Patients and Doctors working towards healthier goals. We are all Responsible and I of course think maybe the patient has a bit more responsibility in their own health.
    • James Salwitz, MD
      Of course the most introspective physicians remember that they too, are "patients." jcs
  • Bill Wickart
    What I find most encouraging in this debate is that each of you is assuming a rightful burden: that you are responsible for your own decisions and actions. The people I've had the most trouble with are the ones who somehow expect Modern Medicine to provide the easy fix. "Just give me a pill for it" is a phrase at which I now cringe.
    • Mary
      And some of us fight taking in the pills much to our detriment. Modern medicine has much to offer but when a patient is living at the cutting edge of what is known, many things are thrown at the wall to see what will "stick" as we wait for research to catch up. A very hard lesson on both sides of the exam table but the doctor must be willing to admit when we are in that zone, and I must be willing to endure the effects AND the side effects as we continue the journey.
      • James Salwitz, MD
        This is a very tough area. What do we do when we need to do but have no knowledge of what to do? Ethicists have devoted whole theses to the educational role of the doctor in these times and to whether a patient whose life is threatened can even make an "informed decision." Indeed, very very hard on both sides of the table. It is simplistic to emphasize the importance of communication, compassion and team work ... but it is a start. jcs
        • Mary
          We don't want you in this position any more than we want to be here ourselves. It takes a strong and compassionate medical professional to avoid taking individual frustrations out on the patient and vice versa. I know the compliance lecture covers great concern just as my complaints and tears cover great fears. Sometimes I think the whole team needs to be in psych counseling together - too much stress on all parties.
          • James Salwitz, MD
            Too true. Thanks, jcs
    • James Salwitz, MD
      It seems to me that we often relinguish personal responsibility and in doing so harm ourselves. jcs
  • Ray Nolan
    When a patient confronted with a serious ailment he/she seeks advice and council from an 'expert', (Doctor). From there on the Doctor must take the lead and the patient must cooperate. Cooperation includes being responsible for living in a healthy way, following instructions and generally participating as a 'team' member. If it turns out the Doctor is not doing a good job a change is needed. In our open society Pharma advertisements often confuse the issue of who is the expert. Ray
    • Mary
      I must respectfully disagree a wee bit - I come to you not as an expert but as the best trained professional for my ailment. Perhaps it is semantics - but I prefer the collaboration of professionals as my model for the doctor patient relationship. We come to a consensus on treatment and then I have the responsibility to perform. It makes the experience a whole lot less paternalistic and gives me credit for being a highly trained professional myself.
      • James Salwitz, MD
        I definitely agree. I see the physician role as that of expert compassionate guide. I get anxious when they guide over too rocky a path. jcs
    • James Salwitz, MD
      Your thoughts are why I tend to take the "physician fault" of this argument. jcs
  • D Someya Reed
    I think there is something else that is at the root of the problem with healthcare that you haven’t exactly named…control. Everyone and everything you’ve mentioned in this post…doctors, big pharma, U.S. Gov’t, insurers, patients and even Capitalism…want control but for their own reasons and/or purposes. But even within any of these categories there is no consistency. Doctors actually have the ability to correct all the control issues, which supports your position. While, from Audrey’s perspective, the patients use their control as “enablers” to the doctors (and, thereby, all other categories) or too willingly/passively give up their control. Doctors do call all the shots and could institute change if/when they all get together and create a collective one-voice. Think of “Standards of Care” but not in the sense that those “Standards” are that which insurers will reimburse. For example, how long would big pharma offer a drug that had little testing, meager benefits, or horrific side-effects if all doctors refused to prescribe it? How many times have patients, as “enablers,” gone after doctors to prescribe those same drugs even when the poor testing, meager benefits, or side-effects are known (though usually minimized by big pharma)? All are symptoms of control. To think that any or all of these groups can come together and agree on something across the board is pretty much “pie-in-the-sky” but that’s really what’s wrong with healthcare. Doctors need to do and prescribe what works; patients need to expect the same. And, though some might say it, innovation need not be a casualty.
    • James Salwitz, MD
      I think you are absolutely right ... everyone want to be the big kahuna. Doctors need to set the tone of data driven, patient focused, ethically based and compassionately administered. They need to set a very high bar for all. They hold the bully pulpit and must use it. jcs
  • J. Williams, PhD
    It's not just the practicing doctors. Much of the "data-driven" advice (= education and clinical guidelines) coming from academic medicine is not geared toward patient care considerations. From sloppy science (doctors are not trained in how to do science, but in how to justify hasty decisions based on inadequate evidence) through pharma-influenced guidelines, all the way to convenient algorithms for the hurried doctor which are too simple to match the actual disease - I've seen it all. I am more disturbed by medical academicians manipulating the evidence and their colleagues and peer reviewers, than with practicing doctors who trustingly obey guidelines, and patients who trustingly obey their doctors.
    • James Salwitz, MD
      There can be remarkable gaps in theory from academia and the practical world of grunts practicing medicine in the streets. In response, front line docs often retreat into their silos and make the whole problem worse. jcs
  • A friend was marrying a Doctor, geneticist, who was studying brain tumors...oncology. She received a grant for her research. She was refused access to the tumor registry at a hospital and was filing a lawsuit. My question was why? I thought it through...risks of compromising the info, patient privacy, misdiagnosis, sloppy work.... Shortly after I was at a dentist who for some reason along with some of the other medical professionals I was seeing at the time..started mumbling..making awful statements of some kind or another..this particular time..I quote, "Doctors become jaded!!" delivered to me in an have to be one of the dumbest, unintelligent, simple minded women around. I do not believe that there are any absolutes when it comes to human behavior. All of this unnerved me. Still does. I am sure politics and cronyism come into play some times as well as nepotism.
    • James Salwitz, MD
      For an outside person or group to have access to a hospital tumor registry for research purposes the research must be approved by the hospital's Institutional Review Board (IRB) which is in charge of not only HIPAA, but of issues of informed consent and patient safety during research. I wonder if your friend's research could not get by the IRB. I have never heard of suing an IRB, but it must occassionally happen. jcs
      • Thank you for your reply. This was back in the late 80's. Before HIPAA. I was always curious because his agenda sometimes was very obvious to me. He was a curious sort too. Early on in HS I developed interest in human rights issues. He was born into it. I was too, actually, but never thought about things at more complex and personal levels. I think his agenda had something to do with gene manipulation. Not sure. Thanks again!
  • I really appreciate your well thought out opinion here Doctor, as well as your ability to clearly explain Audrey's. I see the value in both your arguments and agree with your wrapup that both entities simply need to work together to achieve the desired end result. When explained as eloquently as you have done, it really helps make the problem seem more digestible and fixable no matter where the burden lies. Thanks doc.

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