The Blind Men and the Elephant

Posted on | January 9, 2008 | Comments Off on The Blind Men and the Elephant

Everyone’s talking about reform, but who is capturing the true scope of our problems?

A most endearing Indian parable, written into poetic form by John Godfrey Saxe, describes how six blind men, each touching a different part of the elephant’s anatomy, vehemently argued about who was right.

The moral as penned by Saxe concludes:

“So oft in theologic wars,
The disputants, I ween,
Rail on in utter ignorance
Of what each other mean,
And prate about an Elephant
Not one of them has seen!”¹

One can easily replace “theologic” with “health care” and not alter the message of this parable. In this election year, we will hear 30 second sound bites from all of the presidential candidates discussing her or his framework for reforming a broken and now second rate health care sector.² Magazines, newspapers and electronic media will continue to report on the personal tragedies of those infirmed citizens who ‘fall through the cracks’ and die because of some ‘snag’ in the approval process or due to lack of health care insurance. Commentators will interview experts who will discuss a particular facet of the broken health care sector, addressing one small piece in a large puzzle. Just like the blind men in the parable, everyone will touch on specific problems to reform, but no one will capture the entire scope or magnitude of the crisis.

Although health care reform solutions abound, one needs to appreciate that the perspectives of the authors may be heavily biased by their locations and local health care experiences. Consider that some locales in the U.S. have more than 100 doctors practicing in a square mile while other regions may not have one doctor in 100 square miles. Moreover, there are 50 states with very diverse laws that can affect the practice of medicine – medical resources, malpractice issues, insurance regulations, presence of a medical school, HMO penetration, state Medicare/Medicaid policies, and the relative age of the population.

Dr. Mike Magee has reported on mega-trends that are driving health care in America which includes aging, consumerism and technology.³ He makes a compelling argument for following the development of these trends in order to determine where health care restructuring is headed.

I would also suggest that we separately consider (1) the expansion of non-physician professionals providing traditional medical care, (2) the expanding role of complementary and alternative medicine (CAM), and (3) the restructuring of the centuries-old model of primary care physician-delivered general health care, as trends that will also significantly impact the delivery of medical care in the U.S.

Non-Physician Professionals
Non-physician professionals (or the more politically correct health care professionals) are the most rapidly expanding occupations in health care. As voids in health care provision are created because of poor access to physician care, due to physicians engaging in the more technical aspects of their practices, and because of the rapidly expanding demand of care by seniors, more masters’ level practitioners and non-MD/DO doctors are stepping up to provide the basic and essential health care. Often, they compete with physicians in the form of ‘turf wars’ where issues of training levels, patient safety and quality of care are always debated. It’s interesting to note that medical care has been improving for 3500 years, and historically what once was a ‘doctor only’ procedure may now be a task seldom performed by the MD/DO. At the end of the 19th century (circa 1900), it was inconceivable for anyone but a physician to auscultate, take a blood pressure or start an intravenous line. Today, doctors have replaced these routine medical tasks with more technologic interventions – scoping, minor surgery, radiologic and sonographic procedures – leaving the vital signs and venipuncture to others. Will the next evolution of health care provision assign the first few iterations of general preventative medical care exclusively to non-physician professionals assisted by computer algorithms? Will the new health care system help to stratify medical procedures so as to avoid unnecessary disputes over who should do what and to whom?

Complementary and Alternative Medicine (CAM)
Many reasons are offered for the meteoric rise in CAM. The most persuasive explanations include the un/underinsured must seek other means of care, distrust in the established health care sector, the mystique of ancient and natural remedies, recent findings supporting certain homeopathic therapies, and of course, slick marketing like the Sunday morning/late night infomercials. One must also consider that this largely ‘caveat emptor’ sector of health care is estimated to be a ten billion dollar industry and will certainly attract the profiteers.⁴ How will the CAM movement impact on future health care delivery? Will it simply be a Darwinian principle whereby those who could otherwise benefit from established therapies will be lured by the entrapments of ‘magical cures’ without the suffering? It is possible that this movement will increase health care costs by those who failed early CAM therapies now entering the health care market at an advanced stage in their disease? Will it reduce costs by allowing people to self-diagnose and treat minor medical conditions and avoid unnecessary ER visits? CAM will surely continue to attract more Americans as the access problems and payment nightmares intensify.

Primary Care Physicians
Primary care medicine physicians appear to be at a crossroad with respect to the direction in which their respective specialties should evolve. Consider that the current cost of a medical education is between $38,000 – 55,000 per year.⁵ The average graduating medical student carries a debt of $130,000 into practice with repayment costs of about $1900 per month for 10 years. Internists, family physicians, and pediatricians earn, on average, about $135,000 – 150,000 per year, up from about $130,000 in 1997.⁶ Congress and the Centers for Medicare and Medicaid Services (CMS) threaten to cut physicians’ payments each year by 10%, only to restore payments at the same funding level in the eleventh hour. Meanwhile, the cost of running a primary care practice steadily rises by about 3% annually – thereby reducing doctors’ profit margins by that amount. Many physicians in private practice are forced to retire or close up their practices because they can’t earn a living.

Internal medicine has spawned a number of sub-specialties in the last 50 years, the newest being emergency medicine, hospitalists, palliative care, and even interventionalists. What is the likelihood that primary care medicine can sustain itself in its traditional gatekeeper role as it continues to experience flattened salaries, rising office costs, challenges from non-physician practitioners, the threat of ‘skimming’ from in-store clinics, and the spawning of more “specialists” that all reduce the numbers entering in general practice?

Final Thoughts
Identifying the different drivers of health care delivery regionally, nationally, and globally seem to be the best approach for addressing the multivariate equations of how to provide the best possible cost-effective health care to the greatest number (all?) of Americans with little regional variation. No one person or candidate is likely to solve this conundrum. In fact, no campaign strategy team is capable to delivering the product. The provision of health care in America is becoming an international embarrassment and necessitates that a concerted effort by all involved parties address its redesign. The government needs to take a bipartisan lead much like the efforts leading to the formation of the WPA in the Roosevelt era to end the Great Depression. The Institute of Medicine in 2001 had already started to address the health cost/delivery dichotomy and published a monograph recommending what conceptual changes are needed to fix health care in America.⁷ They concluded by saying:

“The committee believes a sizable commitment, on the order of $1 billion over 3 to 5 years, is needed to strongly communicate the need for rapid and significant change in the health care system and to help initiate the transition.”

It is obvious that 30 second sound bites delivered from campaign podiums over the next 10 months are akin to the six blind men touching part of the elephant and describing what they sense. All players in health care must work in collaboration and all playing fields need to be examined and scrutinized before any intelligible solutions can be publicly vetted. Like ending the Great Depression, all of America needs to get behind health care reform in order for meaningful, beneficial and cost-effective change to occur.

References

1. Linton’s Poetry of America (1878), pp.150-152

2. Davis, et al., The Commonwealth Fund, 2004

3. Picker, L.A. The Future of Medicine, Unique Opportunities® The Physician’s Resource, Nov/Dec 2006, pp.14-22.

4. Barnes, P.M. et al. Complementary and Alternative Medicine Use Among Adults: United States, 2002. Adv Data. 2004 May 27; (343): 1-19.

5. AAMC Medical School Tuition and Young Physician Indebtedness: An Update to the 2004 Report, October 2007

6. Woo B. N Engl J Med 2006;355:864-866.

7. Institute Of Medicine, Committee on Quality of Health Care in America,
CROSSING THE QUALITY CHASM: A New Health System for the 21st Century, 2001, National Academy Press

(Mark Lema, MD, is Professor and Chair of Anesthesiology at the University at Buffalo, Roswell Park Cancer Institute and past president of the American Society of Anesthesiologists. He can be reached at [email protected]. Opinions expressed by Health Commentary guest bloggers do not necessarily represent the views of Health Commentary.)