October 16th, 2011

Is the Primary Care Doctor Obsolete?

During the Great Depression, we had a family doctor who was a general practitioner. He took care of adults, delivered babies, took care of them as well as their brothers and sisters, set bones, and did surgery. Today, family doctors are usually board-certified family or internal medicine specialists who do not deliver babies nor do surgery. They are regarded as “primary care doctors.”

Primary care doctors are the first ones the patient should consult regarding their medical concerns. That doctor is the first to assess their problems and manage their medical care.  For primary care doctors, the patient is at the center of care. This may seem obvious, but many doctors no longer do this. They focus on the disease and its treatment, often ignoring the personal needs of the patient.

Today, many regard medical care as the applied science of statistically derived, evidence-based medicine based upon practices shown to be effective for the majority of a group. They treat the individual as a statistical integer in a group or herd, and not as a person.

Medical care should be more than individual care. It should be personal care. Individual care defines a person in terms of measureable characteristics such as age, weight, height, blood pressure, blood tests for sugar, cholesterol, hemoglobin and many others tests such as genetic makeup, to name a few.

Personal care, on the other hand, includes not only measureable characteristics, but other factors that lend themselves less readily to measurement, such as cultural background, education, training, likes, dislikes, view of health and disease, and other biases. These factors have been proven to have a significant impact upon the effectiveness of disease management. They’re mostly ignored in herd care.

I want to emphasize that personal medical care should not be confused with personal-ized medical care, a term hijacked by geneticists and deceptively used starting 10 years ago. This genome-based care focuses on genetic markers to target diseases and care methods, such as susceptibility to certain drug treatments. This alone may help provide more precise individual care, but it is no more personal than a fingerprint.

Primary care physicians are the ones who traditionally focus on personal care.   Health systems that incorporate the primary care physician as a central part of treatment have better outcomes at lower cost than those systems without them.  

Despite the obvious advantages of using primary care doctors, they are in danger of becoming obsolete. They are the victims of a medical system that now largely focuses on costly technology in the treatment of disease.

The challenge today is to return the primary care doctor to the center of patient care.

Norman Makous, M.D.

[ Excerpted from the article, “Is the Primary Care Doctor Obsolete?” by Norman Makous, M.D. Follow this link to view the complete article. ]

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December 1st, 2009

Rationing in the Health Care Reform Bill

Most of the attention directed to the Affordable Health Care for America Act is concentrated on the provisions for the extension of health insurance coverage to a greater proportion of the population. Those provisions that reduce Medicare coverage for seniors are interpreted as “rationing” and pointed to with horror. The other significant aspects of rationing addressed in the bill are largely ignored.

Among these is the provision that health care benefits will be chosen by a Health Care Commissioner and by a government committee.  This will include benefit levels for private plans. How can this be done in order to be just and equitable and not based on cost savings alone? That’s the question on which public attention should be focused.

Instead of continuing to deny that we have had and still have rationing, and that it must continue, the necessity for rationing should be admitted.  The mechanisms must be closely scrutinized to help insure that they are just and subject to the least amount of lobbying and for-profit abuse.

The rationing system must not be left to politicians, bureaucrats and insurance company executives. Public values must control our methods of rationing.

Norman Makous, M.D.

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November 8th, 2009

What We Need Now Is True Medical Care Reform

The current health care reform legislation is, more precisely, health coverage reform. The intention is to cover more people through changes in the health insurance system. It will do little to control costs. In fact, the cost of the legislation will be much higher than touted.

The problem that has not been touched in the current legislation relates to how we provide medical services. The main driver of increases in medical costs is our technology-based medical service system. This causes an economic squeeze in health care that has already required rationing of medical services. Even with health insurance reform, the cost of medical care will continue to rise, and the need for rationing will increase. Read the rest of this entry »

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October 20th, 2009

Personal Care vs. Individual Care vs. Herd Care

The science of medicine can identify genetic, biochemical, physiological, and anatomic characteristics and measure how they are modified by disease in each individual. For example, the combination of hypertension, diabetes, and liver disease may be unique in one person and require treatment quite different from others with the same disease manifestation. Addressing these differences is the basis of individual medical care.

Many important differences that affect disease manifestations and responses to treatment, however, are difficult to quantify. Every person has his or her personal theory regarding the maintenance of good health and the nature of illness. These result from the combination of cultural background, education, vocation, standard of living, experience, and world view. As you can imagine, they are difficult to quantify.

These personal attitudes enhance or impair the responses to drugs and other treatments. A good example would be Read the rest of this entry »

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October 10th, 2009

The Assault on Medical Professionalism

Medical care is not a trade.  The professional commitment required is more than simply a calling to a discipline. It involves ethical conduct that recognizes the contract between the patient and the physician. The welfare of the patient always takes precedence over the doctor’s self interest.

Most people have turned their medical care purse over to third parties, who now negotiate with the doctor over care.  These insurers and managed care entities pressure the doctor to act as “gate keeper” and ration the patient’s care in ways that may not be in the patient’s best interest.  Doctors have a conflict of interest and are placed in an unethical position.

Doctors still interested in doing things in the best interest of their patients are concerned about the poor quality of care. The third parties blame the doctors.

Caveat Patiens.” Patient, beware. An increasing number of doctors have succumbed to turning medical care into a business for profit.

The third parties have wrested control of medical care from the physician community and turned medicine into a free market commodity. This is an assault on medical professionalism and independence.

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October 1st, 2009

The Rationing of Medical Care

Rationing of medical care has existed in the US for many years, and the denial of its existence has been around just as long.

Most people in the general public don’t recognize rationing when it happens, and many health professionals refuse to admit to its use or disingenuously deny that it exists.

In the past six months, nearly every politician has mentioned rationing in order to deny that it will ever happen under the new healthcare system.  The fact that it already exists in the current system is unaddressed.

Rationing is a normal part of our lives.  Everyone uses it on a daily basis.  What is actually meant by the word “rationing?” When resources like money or food are in limited supply, they require sparing and prudent use – in other words, rationing.

For individuals in a group to conduct rationing on a fair and equitable basis requires what is called, “the ethics of distributive justice.” The group must create the rules of rationing, and must agree on how these rules will be applied. This principle applies in the rationing of medical care, but it has not been followed.

In the US today, the decisions about who will receive funding for medical care and who will not are made by Read the rest of this entry »

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September 22nd, 2009

The Rationing of Healthcare for Profit

If medical care is an entitlement, our society cannot afford to pay for everything that is currently available. We need to set goals regarding who receives what care and for how long.

This requires rationing, by definition. In the US, rationing of medical care has always been with us. We are in denial, and we tend to avoid the term “rationing.” It’s perceived as un-American, so we refuse to acknowledge it.

One common method of rationing is by queue. People await their turn. Another method of rationing long in use in the US  is the limitation of  care through age discrimination. For example, organ transplants frequently are denied to those above a certain age.

Today in the US, rationing decisions are made by medical insurers based on profit motives. An individual’s healthcare needs are limited by the insurer’s financial goals. Read the rest of this entry »

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September 18th, 2009

Medicine’s Dirty Little Secret

The proportion of the GDP that we spend today on medical care is already high, but it is just a fraction of what will be required in the future. Consumer demand and the continuing advances in technology will exert unrelenting pressure on medical costs.

Within this context, there is a huge push by many people for universal care provided by the government. We are the only country in the world that is applying the capitalistic, free-market approach to the delivery of healthcare. This commercial approach has limited our access to care.

Key questions about universal care include: How much care should be guaranteed? Read the rest of this entry »

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September 14th, 2009

The Health Rights Amendment

To be perceived as fair in our egalitarian society, rights must be the same for everyone. Shouldn’t that apply to medical care as well?

Life is one of the inalienable rights set forth in our Declaration of Independence. But how healthy and how long a life is part of that inalienable right to life? The Constitution and Bill of Rights do not explicitly provide for health rights. Since this is not already covered as an American entitlement, maybe we need a Health Rights Amendment.

If everyone has the right to good health, this becomes a government fiscal responsibility. Our government, however, cannot possibly fund the good health to which everybody in the US may feel they are entitled today.

How should we define good health?  Read the rest of this entry »

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September 7th, 2009

Let’s First Define the Goals for US Medical Care

Healthcare reform is being widely discussed right now, but the goals of our healthcare system are undefined! What are our actual intended goals for medical care in the US?

Are the goals to improve the population’s health, relieve pain and suffering, and prevent immediate death? Or do the goals also include satisfying everybody’s self-perceived wants to prolong meaningful life as long as possible by all available means? These are very different goals with very different implications for our healthcare system.

Prolonging meaningful life by all available means includes not only treatment with all available drugs and surgical procedures, but also replacing and mimicking all sorts of body-part functions with transplanted organs and artificial devices. That’s a very expensive proposition.

Do our goals include the prevention of all disease? Read the rest of this entry »

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