The Secrets of Medical Decision Making E-Book

Oleg I. Reznik

• Herausgeber: Loving Healing Press
• Kategorie: Ratgeber
• Sprache: Englisch
• Veröffentlichungsjahr: 2006

Seitenzahl: 318

Beschreibung

We are all patients at some time. Is the medical industry giving us the best treatment possible, at the best price? We all know that it isn't. This new book shows what goes on behind the scenes of the current medical care and how it impacts the patient. Dr. Reznik describes actual cases from his clinical practice showing the most common paths that lead to increased patient suffering. This book offers possible solutions for outpatient, inpatient, preventive, and end-of-life care settings. Learn about: The Medical Box and how it affects the care you receive When to avoid risky and uncomfortable tests Hazards of under-treatment, over-treatment, and mistreatment How to make an informed medical decision in your best interests Cancer and how to approach your treatment Planning for quality of life during end-of-life issues
Foreword by Colin P. Kopes-Kerr, MD, JD, MPH, Vice-Chairman of the Department of Family Medicine, and Program Director of the Family Medicine Residency Program, at University Hospital and SUNY Stony Brook School of Medicine, Stony Brook, NY.
"The Secrets of Medical Decision Making should be read by everyone, because all of us are sometimes in need of medical care. It is an eye-opener, a call to arms and a guide." -Robert Rich, Ph.D., author of Cancer: A Personal Challenge
"Dr. Reznik candidly exposes the conflicting interests inherent in contemporary medical practice. This empowering and insightful book is a must read for healthcare professionals and the patients they treat."
-Beth Maureen Gray, R.N., B.S.
"The Secrets of Medical Decision Making awakens the reader rather quickly with startling revelations about the lack of seriousness the health care industry has towards a society of wellness. If this book at least motivates its readers to become more involved in medical decision making when seeking treatment, it will have succeeded as a critically needed public service."
- James W. Clifton, Ph.D., LCSW
"As a Canadian and a health care provider this book frightens me. This book lays out what our country is headed for if we privatize health care in Canada. A must read for everyone working, or accessing, health care in North America and for anyone who has any doubts that we must take drastic action to preserve Universal Health Care in Canada."
- Ian Landry, MA, MSW, RSW

Leseprobe

The Secrets of Medical Decision Making:

How to Avoid Becoming aVictim of the Health Care Machine

ByOleg I. Reznik, M.D.

Foreword byColin P. Kopes-Kerr, MD, JD, MPH

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

Copyright© 2006 Oleg I. Reznik. All Rights Reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

First Edition: January 2006

Library of Congress Cataloging-in-Publication Data

Reznik, Oleg I.

   The secrets of medical decision making : how to avoid becoming a victim of the health care machine / by Oleg I. Reznik; foreword by Colin P. Kopes-Kerr.-- 1st ed.

      p. cm.

   Includes bibliographical references and index.

   ISBN-13: 978-1-932690-16-3 (case laminate : alk. paper)

   ISBN-10: 1-932690-16-6 (case laminate : alk. paper)

   ISBN-13: 978-1-932690-17-0 (trade paper : alk. paper)

   ISBN-10: 1-932690-17-4 (trade paper : alk. paper)

  1. Patient participation. 2. Medical care--Decision making. 3. Physician and patient. I. Title.

R727.42.R49 2006

610.69'6--dc22

2005019931

Distributed by:Baker & Taylor, Ingram Book Group

Published by:Loving Healing Press5145 Pontiac TrailAnn Arbor, MI 48105USA

http://www.LovingHealing.com [email protected] [phone]

Loving Healing Press

To Mathilde.

About the Author

Oleg I. Reznik, M.D is a Board Certified Family Physician working at the Willamette Family Medical Center and in private practice, on staff at Salem Memorial Hospital, Salem, OR.

Family Medicine Residency Program at State University of New York (SUNY) Stony Brook, Stony Brook, NY 2000-2003;

MD degree cum laude at SUNY Downstate, Brooklyn, NY 1996-2000;

Bachelor’s degree in Neuroscience cum laude at New York University, New York, NY 1991-1995;

Pre-publication Praise for Secrets…

“The Secrets of Medical Decision Making is an important book. It should be read by everyone, because all of us are sometimes in need of medical care. It is an eye-opener, a call to arms and a guide.”

—Robert Rich, Ph.D., MAPS, AASH, author of Cancer: A Personal Challenge

“Dr. Reznik candidly exposes the conflicting interests inherent in contemporary medical practice. He encourages patients and their family members to be knowledgeable and pro-active healthcare consumers by asking questions, evaluating research, trusting personal preferences, and understanding the limitations of modern medicine. This empowering and insightful book is a must read for healthcare professionals and the patients they treat.”

—Beth Maureen Gray, R.N., B.S.

“The Secrets of Medical Decision Making awakens the reader rather quickly with startling revelations about the lack of seriousness the health care industry has towards a society of wellness. Patients in today's society resemble an assembly line as they are pushed through a healthcare system that seeks to serve and protect the medical industry at the expense of the patient's health, safety, and welfare. If this book at least motivates its readers to become more involved in medical decision making when seeking treatment, it will have succeeded as a critically needed public service.”

—Rev. James W. Clifton, Ph.D., LCSW

“This is a profound book for the layman. Many times a doctor never levels with their patients because the doctor wants to spare us the pain of dealing with the illness or disease. I know, from personal experience, I'm more hurt and suspicious of my doctor when they behave this way rather than telling me plainly. I recommend The Secrets of Medical Decision Making to all patients interested in their health and keeping healthy.”

          —Lillian Cauldwell

Table of Contents

Table of Figures

Acknowledgments

Foreword by Colin P Kopes-Kerr, MD, JD, MPH

I. Introduction.

II. The Medical Box.

III. The Case of a Man with Chest Pains.

IV. The Case of Threatening the Doctor.

V. The Case of a Sinking Ship.

VI. The Case of Death in the Emergency Room.

VII. The Case of C-section for Breech.

VIII. The Case of Truth—a Conference on Defensive Medicine.

IX. The Case of a Quiet Rebel.

X. The Cases of a Compliant and Not So Compliant Surrender.

XI. Ulysses Syndrome and the Case of the Endless Search for Reassurance.

XII. The Case of Insurance Casualty and a Sense of Entitlement.

XIII. The Medical Model

XIV. The Medical Industry and Medicalization.

ATP III Update 2004: Financial Disclosure.

XV. It is OK to Hurt Many a Little in Order to Prevent One From Getting Hurt a Lot.

XVI. Illusions of Medical Omnipotence.

A Simple Example: Pharmacologic Omnipotence and the Search for the Perfect Drug

A More Complex Example: Very Modest Effectiveness of Most Cancer Treatments

Other Examples

Conclusion: What Should a Patient with Cancer Do?

XVII. Patient Expectations and the Standard of Care.

XVIII. The Case of Unreasonable Expectations, Family Guilt and Blame.

XIX. The Case of Letting Go.

XX. Freedom in Living and in Dying.

XXI. Putting It All Together—How To Get What You Want And Know What You Need.

XXII. Afterword

References

Index

Table of Figures

Fig. 7-1: Pre-printed physician's orders for Congestive Heart Failure

Fig. 7-2: Invitation to a CME Program

Fig. 7-3: Invitation to a CME Program.

Fig. 7-4: A letter from a drug representative, addressed to me.

Fig. 7-5: An “expert” lecture sponsored by a pharmaceutical company.

Fig. 7-6: A lecture by another expert sponsored by the company that manufactures product.

Fig. 7-7: An invitation for a CME dinner

Table 16-1 Number of Deaths from the Most Common Cancers

Table 16-2: Five-Year Relative Cancer Survival for Lung Cancer by Year of Diagnosis, Race, and Gender

Table 16-3: Risk of Death From Breast Cancer

Table 16-4: Comparison of Total Survival with Cancer-Specific Survival in Stage III-IV Breast Cancer

Table 16-5: Five-Year Relative Cancer Survival Change from 1974-1976 to 1983-1990

Fig. 19-1: Percent of Medicare Deaths Occurring in Hospitals (1995-96)

Fig. 19-2: Percent of Medicare Enrollees Who Spent 7 or More Days in Intensive Care During Their Last 6 Months of Life (1995-96)

Table 19-1: Top Ten Causes Of Death In The US

Acknowledgments

I would like to express my appreciation to Dr. Kopes-Kerr for his brilliant professional newsletters, which were the source of a great deal of the supporting material used in this book; for his inspiring character, and for writing a foreword to this book.

I would like to thank Dr. Bob Rich for his invaluable help in editing this book. During this journey together I had the privilege of contributing to his book CANCER: A Personal Challenge, which is an invaluable resource for cancer sufferers and their families.

I would like to thank the Trustees of Dartmouth College, who have given their permission to use the wealth of information concentrated in The Dartmouth Atlas of Health Care, with excerpts and diagrams, free of charge.

Forewordby Colin P Kopes-Kerr, MD, JD, MPH

Where has Marcus Welby, MD, gone—that 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 many—managed 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 dramatically—with 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 behemoths—large 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 matters—the 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.

This is the starting point for Dr. Oleg Reznik's new book, The Secrets of Medical Decision Making: How to Avoid Becoming a Victim of the Health Care Machine. Dr. Reznik is a recently trained (at a prestigious northeastern university hospital) physician, now in the small-town practice of Family Medicine in the US Northwest; he has had previous careers as a nurse and as a patient. He knows what he is talking about. While there are numerous recent books that critique various parts of the current health care in the US; they focus on the major external forces coming to bear on the system— pharmaceutical industry, the malpractice crisis, the regulatory environment, the biotechnology revolution, the failure of health insurance, and many more. Dr. Reznik's book is different. He elucidates the interior psychodynamic processes that go on in both physicians and patients that have made these outside forces so incredibly and regrettably successful. He tries to demonstrate that the only way to get effective health care is to get inside the heads of the individuals who operate the system, the doctors and the patients, and find out how they think, and, in fact, how they make the decisions they do. This is both a challenging and a hugely rewarding process. It turns out that neither group is making logical decisions, if you define “logical” as meaning rationally related to their best outcome. It is worth spending some time with an exploration of “Why not?”

On the physician side you find the paradoxical result that the elaborately specialized, research-based, system of educating physicians is actually inimical to original, creative, and individualized problem solving. Medical students are being taught that some technical marvel or pending drug development is the answer to all medical problems, they are led to believe that the root of all problems is a biochemical or anatomical problem amenable to biotechnology or surgery. They are taught that “good medicine” does not involve creativity, or relationship-oriented compromises with technical standards, but that it consists merely of following rules, guidelines, “care maps,” and “standards of care.” All of these plunge the patient into ever-increasing medical testing and medical interventions. The role of the generalist physician is only to refer the patient to the appropriate technician (i.e., specialist). Of course, no status-conscious student wants to go into the generalist field; the few Marcus-Welby-minded exceptions are usually relatively quickly disillusioned by low-status, low-income, or mere boredom. All of this represents a derangement. The history of medicine, starting with Hippocrates, has taught that it is the person who has the illness, who defines what is needed for care and how a “successful” treatment should evolve. The modern limited, technological vision of medicine is a temporary aberration, and an enormous act of hubris by corporate, governmental, and medical leaders.

This book is not just for patients. It is appropriately dedicated to physicians as well. It reminds them of the contemporary medical training process and how it acts on common patient examples. It will not take much self-reflection for most physicians to recognize how confined they are within the modern “medical box” that Dr. Reznik describes—confined by the financial and time pressure of modern organization of heath care delivery, the prevailing, mechanistic model of human illness and disease, the technology- and pharmaceutical-oriented bias of most contemporary medical “expert” guidelines for care, and finally by the feeling of devastating financial vulnerability for a bad outcome, should they practice anything but main-stream care. How else to explain why our national healthcare expert and consensus guidelines are so much stricter, and our costs so much greater than any other industrialized country, without anything better in the way of results to show for it? Physicians need to acknowledge, even though they are not responsible for the system, that they do, in fact, as Dr. Reznik points out, have “a vested interest in patients undergoing all of the recommended screening procedures [and that] fear and convenience drive doctors to try to impose the guidelines upon their patients, without verifying whether the recommendations are really good for those patients.” The traditional elements associated with our vision of a ‘family doctor‘ have taken a remote back seat to these forces. Gone are the most valuable aspects of real caring, as Dr. Reznik puts it—”genuine compassion, a desire to do what is in the patient's absolute best interest, and the courage to take necessary risks.” For most physicians, the question of why don't they slow down, perform fewer tests, and spend more time with their patients presents a persistent, painful dilemma. How do we get back to what we were after in the first place? Dr. Reznik offers some answers. The first element required is simply courage—the courage to stand apart and just to be willing to think for oneself about what a patient needs, because we know all the social, financial, emotional, and spiritual forces acting upon her better than any other expert in the whole medical system. “It is far more comfortable for a general practitioner to send a patient for multiple studies and to multiple specialists than trying to shoulder the responsibility alone.” The answer to this dilemma is a frank discussion with patients, acknowledging the limits of both the research base of modern medicine and the way in which it has been implemented in practice, and honest education about our very limited ability to produce spectacular results. We must first disclose to patients that we are not omnipotent in the realm of health and that the “health care machine” lacks any real cure for most disease, despite the glamour and much publicized stories of a few exceptions. This is a very humbling role for physicians. It requires a great deal of courage.

In trying to get into the mind of patients, Dr. Reznik's only assumption is: “When we enter the system as patients, we are simply hoping that a physician will take good care of us.” What he shows us, in some harrowing detail, are the steps by which this simple, basic human motive gets betrayed by the very same system of healthcare that we are so proud of in the U.S.—the fabled heart-lung transplants, cancer cures, and the unparalleled array of advanced technology to throw at any problem, i.e., “the health care machine.” It is a system that all of the players—both patients and physicians—desperately want to believe in. They all need to take note and listen to Dr. Reznik's description of how and why it is not working. He vividly supports his hard-earned conclusion with poignant and persuasive examples from real patients’ lives. He also professes his other major assumption, that “emotional, mental, social, moral, and spiritual aspects of a human being may be fundamental in developing and maintaining health.”

Dr. Reznik's account is so specially valuable because it reveals the inner workings of a physician's mind, not only to the physician who is capable of self-reflection, but to the patient as well, so that he or she can remove the halo from their personal physician and allow him or her to be a mere human, much like oneself, again. He cites numerous examples of how patients and families make their medical decisions, and, specifically, of how they often lose track of their original goal of the longest life possible with the greatest degree of comfort, and become constrained by the four corners of the physician's ‘medical box’ and by their own need to impute “omnipotence” either to their doctor, or even where there is obvious contrary evidence to this, to the “health care machine.” The critical impact of Dr. Reznik's work will lie in enabling both sides of the ordinary medical encounter to see and understand how their routine, well-intended, very human behaviors conspire together to produce a result that achieves neither quality life nor quality healthcare. Change can only come from enlightened joint participation in the process. The case examples that Dr. Reznik provides are real, timely, typical, and should in their broad outlines be familiar to everyone. Their message is coherent, and compelling. Blind or automatic deference to the “health care machine” is only the pursuit of an illusion, which directly results in more suffering, not less. Achievable health lies far more in consciously living one's own life, pursuant to one's own values, and in partnering with a supportive advisor, who has no bias other than to see that you get as much of your self-defined healthcare needs met as possible. “Be your own authority, or be someone else's agenda”—is as true for the physician as it is for the patient. For both more courage and more autonomy is prescribed.

Dr. Reznik has the uncommon wisdom not to label various persons and pressures as merely “evil.” In every case they represent what started off as a good intention, but which has, through very understandable human failings, gone wrong. The process is always rational, understandable, and sympathetic; it is just flawed. He reminds us that each of us have numerous instances of similar failings in our own history. We need to start out in empathy and compassion and respond to the system in ways that foster respect and civility. But the key is to start with a staunch and immutable respect for yourself and confidence in your ability to determine your own needs.

In addition to painting a detailed portrait of the current health care delivery interface, Dr. Reznik has a rich supply of very practical, common sense tips. A good physician has to overcome approval seeking and prospectively manage appropriate expectations. Physicians can manage their legal fears by realizing that “lawsuits are not about bad outcomes. They are not about bad relationships. They are about expectations.” The higher we set patients’ level of expectations for outcomes, the greater the legal risk we assume. The most effective way to mitigate this is by educating patients and partnering with them in the pursuit of their objectives. This requires adapting medical knowledge to specific consumer needs. A physician should, for example, be able to tell a patient, in ordinary lay language, whether they are at high- or low-risk for any condition that is the target of a screening program, before advising his patient to participate. It is also appropriate to tell your patient honestly whether it is a screening program that you participate in yourself.

“When nothing seems like a good option, it is better to do nothing, than to rush in”—should be a mantra for both physicians and patients.

Dr. Reznik tells patients to be prepared to make decisions in the face of uncertainty because the medical system is simply unable to provide certainty. “The patient,” is the one, however, who “has to take the initiative about a decision to stop.” Often all that is needed is for her to give the physician permission to stop the pursuit of certainty. “Just stopping and accepting some uncertainty and some possibility of disease and death will almost always save one from additional unnecessary suffering.” As for testing, he says, “If a physician in the U.S. did not offer it himself, you probably do not need it.” In treatment of a medical condition, patients should realize that, “if the doctor who offers you the treatment cannot give you the likelihood of benefit, it is best not to proceed with the treatment.” “Do not go along with what you are asked to do just to be nice to your doctor.” “…If you feel you're being convinced, sold, or pressured—[the] doctor's motives are probably questionable. When being pressured, do not give in.” Patients would do well to heed his advice, “[I]f a doctor makes you feel afraid, recognize it as a signal not to follow his advice, and smile.” Patients should also listen to Dr. Reznik when he shows how too much of a ‘good thing’—health insurance—can lead to some very bad results; in particular, stay away from “routine” tests. “It is better for a patient not to undergo a screening test at all rather then undergoing one without understanding it.” In one of his final chapters he has compassionate and down-to-earth tips for families coping with terminal decisions for their loved ones and good advice on how to avoid unnecessary medicalization of the normal process of dying.

Dr. Reznik is even informative for situations in which the doctor-patient relationship has broken down. “Do not threaten the physician who is still taking care of you. This will usually just lead to an increase in defensive medicine… If you must threaten, save it for the time when this doctor is no longer caring for you or your relative. Switch to a different doctor first.”

While much of the case that this book presents is discomforting, e.g., that we haven't really beat cancer, that we don't really practice “best evidence” uniformly in medicine, that vested interests of large corporate entities have directly and adversely influenced ordinary doctor-patient encounters, that we aren't going to live forever no matter what we do, and that our doctors are not omnipotent, he has adduced a sensible prescription for change. Each physician and each patient needs to change, one by one. This starts just by becoming conscious and informed in each medical decision that we make; we could have a far better health care system than we do now. This is Dr. Reznik's message.

In the end this is a very affirming book. It is affirming for physicians because it brings a lot of automatic and unconscious behaviors into focus for conscious inspection. It clearly illustrates a number of paths that can lead physicians out of the “medical box.” It can have the result of relieving the average physician of the huge burden of “omnipotence.” Very interesting things can happen when you don't have to be perfect anymore, where “good enough” is, well, good enough.

The bottom line he offers for patients is revolutionary—a new paradigm: “I would argue that, as in matters of personal safety, in the matters of personal health an individual has to have a choice, and no one has the right to judge this choice…When the true limits of medicine are realized and accepted, there is a possibility of more preparedness, clearer decision-making, and peace of mind. …As a physician, when I'm dealing with a patient who is comfortable refusing what I offer, I know that this person is not likely to become a victim of the system. They preserve their integrity by not putting me (and the institution of medical care) above themselves. They are more likely to live and die free.”

Dr. Oleg Reznik is a very good physician. I know because I supervised his training as a family physician. He had the unusual conviction and ability to question what the “medical machine” was doing even as an intern, which created a few problems for me. In fact, this created a fair number of headaches for both of us, but that is his point. Good medicine can only occur when we acknowledge the exceptions, the unique personal circumstances and needs inherent in every situation, and deal open-mindedly with the headaches that ensue. In his training he was diligent and conscientious in support of the style of practice he aspired to, and this met my needs. This book now shows a wisdom that is very rare for a physician so early in his career. It is a brief, but accomplished synthesis of current medical data and all too common medical practices. His perspective is undeniably somewhat contrarian. To that concern I can respond, if you've been successful in all your medical encounters and have the health that you want, you probably don't need to listen to him. In all other cases it will definitely be worth your while to spend a couple of hours with this articulate and perceptive physician, accompany him as he accomplishes his rounds in the office and at the hospital, meet real patients, and share his reflections on what he has observed. In fact, I believe that you will be significantly more autonomous and healthier for it.

     —Colin P Kopes-Kerr, MD, JD, MPH

Vice Chairman, Department of Family Medicine, and Program Director of the Family Medicine Residency Program, at University Hospital and SUNY Stony Brook School of Medicine, Stony Brook, NY.

1Introduction

Health care is becoming increasingly complex, with multiple factors affecting decision making. You may have heard about or experienced some of the shortcomings of this system first hand. People of all ages and all degrees of health are affected by the current way of medical practice. It starts with infants, who are put through a variety of tests by overzealous physicians responding to their own or their parent's fears. Young women become unnecessarily worried from their Pap smear screening, prenatal testing, and encountering a wall of defensive medicine during childbirth. Middle aged men are enticed into a highly questionable practice of prostate cancer screening and ending up with surgeries that, instead of prolonging their life, leave them deprived of their basic human capacities. There are a slew of breast biopsies and mastectomies as a result of screening mammography in women, without concomitant prolongation of life but with an enormous mental and physical toll. Finally, the elderly are put through testing and procedures in the last six months of life—the evidence now clearly shows that this actually slightly shorten their lives when compared with those who did not have the option of utilizing health care system to the same extent (due to living in regions of the US with lower Health Care funding).

When we enter the system as patients, we are simply hoping that a physician will take good care of us. We also sometimes hope that health care will prevent us from getting sick, discover and diagnose any hidden illness, cure or treat it, and possibly make us live longer. The physician of course tries to live up to some of these expectations.

I am a doctor, but this doesn't protect me from health problems. Recently, I had a kidney stone, and became a patient. The physician taking care of me in the emergency room accurately diagnosed and treated the problem. At the discharge, the physician told me that I “needed” to follow up with a urologist. Now that I have a kidney stone I should have a urologist. Those two go together in her mind. She was the usual overworked senior resident in the emergency room of a university hospital. She told me what she tells all the patients discharged after the discovery of a kidney stone. From the point of view of the usual medical training, she was an exemplary physician. She gave her recommendation with the best intentions: she truly believed that she was doing me good by giving that advice. Physicians are systematically taught to give the same advice to everyone; we do not have the time nor the training to pay attention to individual differences.

She was quite surprised when I told her that I wasn't planning to follow her advice, that I simply intended to alter my diet. At that point I opted not to follow her medical advice and not to subject myself to additional testing with the time commitment, inconvenience, and expense that it entails, let alone the risks of false-positive results and unnecessary procedures with their side-effects. That was my personal preference. Whether or not my decisions were wise is not the issue. Rather, it is my hope to empower patients and their family members to recognize the freedom of choice even when none is presented and to know that the information they lack for decision making can be obtained by directly questioning the system. It is also my intention to decrease undue expectations that the medical system itself fosters, and to deflate the balloon of medical omnipotence.

I call this system The Health Care Machine because it has become mechanical. The race for ‘clinical productivity’ is turning health care into another form of an assembly line. There are other factors I'll soon discuss that push us in the same direction. A physician who sees you is no longer an agent who works for you. Rather, he or she is trying to balance a number of conflicting demands. As I watched a TV interview at an advertising agency that created a television ad for one of the frequently used drugs, the spokesperson stated “…the medications now are a part of a healthy lifestyle…” She truly believed that and wanted the rest of the world to believe it as well. So it is with the physicians and other health care workers who are placed in a position (and I call this position The Medical Box) that pressures them to have only a standard, mechanical response to any given set of problems. Eventually, being in that box makes them believe that those are the only possible answers. I think a patient can navigate through this system much more successfully by being aware of its limitations.

In the body of this book, I present vignettes from my clinical practice, experience in the medical school and residency, and personal research. Mostly they are the accounts of actual patients I have cared for, directly or indirectly. I have altered the details to make them unrecognizable while maintaining the essence of each story intact. They all demonstrate the facets and influences of “the rules of the game”: the game of health care. It is my hope that from reading these accounts with the accompanying discussions, you will understand the motives influencing your doctor's decisions and will learn how to be more self-reliant.

Throughout the book I placed subheadings: Patient/Family Perspective, Physician's Perspective, Societal Perspective and Spiritual/Philosophical Perspective. Though these subdivisions are somewhat artificial, since to some degree, one perspective contains all of the others, I hope that they will ease the flow and absorption of the material. Patient/Family Perspective deals with the issues that most closely relate to, or would be most helpful for prospective patients and their families. Physician's Perspective reveals physicians perception of the issue. Societal Perspective shows the impact on the society as a whole. Spiritual/Philosophical Perspective addresses spiritual and philosophical aspects of medical care, aspects that cannot truly be separated from any endeavor seeking to understand a human being.

2The Medical Box

Physician's Perspective

The term ‘Medical Box‘ is my invention to show the boxed-in thinking imposed on physicians; the boundaries they need to overcome in order to do what's in the patient's best interest. I believe it is important for the patient to be aware of them too. Here are what I call the four corners of the Medical Box:

Fear of litigation.Financial and time pressure.Guidelines of Health Care authorities.The current Medical Model—disease oriented thinking.

I think most physicians wish to do good and to be genuinely helpful. This wish is impeded by the Medical Box.

Litigation has a potential of disrupting medical practice and increasing malpractice insurance premiums. Being labeled as high risk physician limits one's employability. According to the Association of American Medical Colleges, an average physician who graduated from medical school in 2004 had $115,000 of educational debts! This debt has been steadily increasing. After spending a minimum of eleven years of intense learning, one tends to want to have some degree of comfort, to be able to repay one's debts, and have a feeling of some financial security in order to support a family. All of that is threatened by a lawsuit. Medical mistakes do happen and it is fair to hold the doctor accountable for them. However, the success of a lawsuit does not always depend on the degree or even presence of a mistake on the doctor's part, but rather, on the gravity of the outcome or on chance alone. One of my obstetrical colleagues was successfully sued after her patient's unborn baby died. Though by the standards of medical practice there was no error, it is hard for the jury not to feel overwhelmed by such a tragedy. Consequently, she was deemed guilty, resulting in stigmatization, raised malpractice insurance premium, and a mark on the record that will be questioned whenever she may want to look for another job, or apply for another malpractice insurance.

This record is permanent. It is not surprising that fear of being sued is one of the major forces driving medical decision making in the US today. I attempt to illustrate some of the implications of this in the vignettes of the subsequent chapters where actual patients are described. I am not the only one to believe that the success of a lawsuit does not depend on the presence of an error. Linda Crawford, who is on the faculty of Harvard Law School, where she teaches trial advocacy and has been consulting people on research and evidence-based effectiveness for malpractice depositions, states that five out of six lawsuits involve good medicine, half the time there isn't even a bad outcome (Tracy, 2003). She further states: “Let's talk about brain-damaged children. All of us now go into labor and delivery presuming we will have a perfect outcome. The parents believe it. The family believes it. The community believes it, and frankly the providers believe it; yet, it is still true that we have not made any significant gains since 1965. Five percent of children are born with significant disabilities. There is a gap between what everybody is expecting and the reality. I am all for good relationships with your patients; I think it has a great deal to do with the quality of our professional lives. However, I also look at the specialties and the individual surgeons who are sued, and it often has to do with the expectations of your patients going into whatever the event is.” These expectations are not easily changed and are often the result of a well publicized boasting of the medical system about the great advances we've achieved.

Money and time are intimately related in our society and the medical system is no exception. Beginning in medical school, we (medical students) were repeatedly told that medicine is business. I do not share this opinion but it is now held by the vast majority of physicians. More than that, in medical school we were specifically taught that it is not important for us to care about the patients, what is important is to know how to create an impression of caring. We were then taught how to do that, how to fake a caring attitude. A doctor has to say “aha”, “ tell me more”, to make a pause after a patient says something he finds significant; one needs to make brief remarks indicating compassion and understanding so as not to make an impression of being uncaring. All this is so that the business part of medicine can go more smoothly.

Third party payers also drive some of the important changes in this realm. Health insurance attempts to cover health care needs and make some money off of this process. They have to find some quantifiable way of reimbursing physicians. This quantification (which is difficult to avoid) is one of the problems. My residency training was in a suburban university hospital. From time to time, in addition to the usual lectures by the faculty, we were lectured by the community physicians who were supposed to teach us how to “survive in the real world”. We were taught that “talking to the patient doesn't pay”, that in order to survive financially we needed to decrease the amount of talk to the minimum and instead to do as many office procedures as possible. Insurance won't pay for educating a patient, but they pay for throat cultures, wart removals, hearing, vision, blood and urine tests etc. An excerpt from a recent article for the physicians in the Family Practice Management Journal (Martz, 2003) illustrates this point: