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Going Against Medicine: Courageous Or Foolish?

Every once I awhile a story catches my eye as I scan the news websites. There was one this morning on CNN with this catchy title: “Mom Defies Doctor, Has Baby Her Way.” The article describes a story where a mother was going to have her fourth baby. Her previous three were born via C-section. Mom did not want another C-section done, and “defied” her doctor’s order for the procedure. “You’re being irresponsible,” the patient was told.

The middle of the article talks about the current thinking and statement of the American College of Obstetrics and Gynecology saying that “it’s reasonable to consider allowing women who’ve had two C-sections to try to have a vaginal delivery.” Of course, there’s risks with proceeding with a vaginal delivery and risks of another C-section.

What’s always interesting to me are the comments following the article. I applaud the physicians who are fighting back the anti-physician sentiment and those who are pushing (no pun intended) the only home birth agenda.

In the article, this person is being held up as a hero — as someone who defied the paternalistic medical establishment and did it her way. Good for her — or is it? What if that 0.4-0.9 percent possibility of severe complication occurred and there was a problem with mom and/or the baby? What would happen then? Read more »

*This blog post was originally published at Doctor Anonymous*

Are Health Policy Experts Anti-Physician?

Health policy experts have never been shy about their antagonism towards doctors.

The focus now appears to be on physician pay, with the Washington Post’s Steven Pearlstein, for one, continuing his anti-physician columns. Derek Thompson, over at The Atlantic (via @AllergyNotes), continues the assault, with a recent blog entry wondering if doctors deserve to be paid less.

I touched upon this topic last year, in a USA Today op-ed, Doctors’ pay cuts save little in health care costs, and paraphrased prominent Princeton economist Uwe Reinhardt saying that cutting physician pay 20 percent will only result in 2 percent of health care savings. And besides, if the current system stays in place, doctors whose pay is cut will simply respond by doing more procedures.

Furthermore, many health policy experts bring out the tired statistic comparing American physician salaries with those abroad. The problem is that these are not apples-to-apples comparisons. Both the cost of medical school and malpractice insurance are exponentially higher Stateside. Fully subsidize medical school and bring malpractice premiums down to the levels of other countries first, before talking about tackling doctors’ pay.

Until then, comparing physician salaries with those in Europe is a largely meaningless exercise, and only serves to expose many health wonks’ innate contempt for the medical profession.

*This blog post was originally published at*

Steven Pearlstein Joins The Doctor-Hater Club

Did you know that doctors are paid too much, wrongly complain about medical school debt, and falsely believe there is a medical malpractice crisis?

Did you know that doctors are hopelessly conflicted sellers of medical care, motivated by the search for extra income?

Well, then you haven’t read the Washington Post’s Steven Pearlstein’s work on health care reform.

“It’s the doctors, stupid,” he begins his column today.  At once, he recycles the tiredest of political phrases and tells his readers exactly what he thinks of them.  But it’s not the column that is most telling, it’s the live web discussion that followed.  I participated in it, and can share with you the highlights.  It’s a revealing insight into the thinking of a mainstream DC columnist.

To save you the trouble, here’s a summary of Pearlstein’s views:  Doctors learn a craft that they owe to the rest of us as a public good.  But instead of doing this, they take advantage of knowledge to make as much money as they can.  They do it willfully – like an insider-trading stock broker – but they also do it because they just aren’t all that competent at what they do.

Think I’m making this up?  Read:

On medical school debt:

I think we allow doctors to make too much of their debt. . . In major metropolitan areas, that debt looks pretty small when compared to the lifetime earnings that doctors accumulate in private practice over many years.  They more than make up for their investment, as it were.  But they use this debt to justify their elevated incomes for the next 30 years — and make no mistake about it, doctors in the U.S. do make ALOT more than docs elsewhere, on average. . . . My suggestion is that we socialize the cost of medical education, that is have the government pay for it, in exchange for a couple of years of community service.  That way, we get the community service and we eliminate the No. 1 reason given by docs to justify getting paid more than docs everywhere else.

According to the Bureau of Labor Statistics, a freshly minted family care doctor has a median wage of less than $140,000 a year.  According to the AMA, these same doctors have, on average, about $140,000 in educational debt.  Thirty years seems about how long it would take to pay off that debt, and you can forget about buying a house, a car, or paying for your own kids’ school under those circumstances.  I’m sure many medical students would love the Joel Fleischman plan, but we should do that because maybe it will help more people become doctors, not because we think doctors are exaggerating the impact of debt equal to 100% of your gross pay.

On how our system ought to allocate medical resources:

There is no reason why people can’t travel an hour to a big hospital to have a baby, for example, in a big modern maternity ward that does lots of deliveries and has enough volume to be able to afford all the latest equipment in case something goes wrong.  I mean how many times in your life do you have a baby that you can’t drive an hour to have it done, rather than insisting that every community hospital have its own maternity ward.  It’s just one example of the inefficiency built into the system by people — that would be you and me — who insist on things that, in the end, don’t have ANY impact on the quality of care.  In fact they have negative impact.

I don’t know if Pearlstein has ever had a baby before, but just being an hour away from a hospital is unthinkable for most expectant moms in the weeks prior to delivery.  And what is someone to do who lives an hour away and has a complication during the pregnancy?  Pearlstein’s prescription seems to be that they should eat cake.

On the freedom of patients to choose their medical care:

The emphasis on being able to choose your own doctor in every instance is another, as if most of us have a clue as to who are the best docs and who aren’t.  These are the kinds of irrational things we need to try to work out of the system, because they wind up being very costly.

Yes, for goodness’ sake, let’s get rid of the irrational desire of a sick person to want to pick their own doctor.  Even Senator Kennedy’s “American Choices Act” guarantees the right of patients to choose their own doctor.  I don’t know where Pearlstein is on the political spectrum with this view, except perhaps a certain territory between China and South Korea.

On how doctors are hopelessly conflicted in giving medical advice by their desire to make money:

But first we need the evidence to show that it isn’t a good idea.  Then, once we have the evidence the doc has to follow the protocol and explain to the family why it’s not a good idea and not merely blame the big, bad insurance company for being so heartless–which, by the way, a lot of docs do, so they can look like the good guys.  Of course they’d love to do the surgery in many cases because they’d like the business and the extra income, so they are hopelessly conflicted. . . . .

[B]uying medical care is not like buying lawn furniture. . . in medical care you rely to an extraordinary extent on the advice of the doctors (i.e. the sellers).  And its also not an area where you are inclined to be very price-sensitive — is anyone going to go the the Wal-Mart of surgeons if they think their life may depend on it. . . . But it is NOT true that a well-informed consumner will always make the right choice about medical options — they still need the advice of doctors, who under the current system have a very noticeable conflict of interest.

I’m actually not sure that Pearlstein has even been inside of a Wal-Mart.  Because they consistently have high quality merchandise at the lowest prices.  In fact, if more hospitals worked like Wal-Mart the problems that plague our health care system today probably wouldn’t exist.

Responding to a commenter who said that the notion that defensive medicine is a large expense is “totally false:”

Indeed.  But doctors don’t believe this, no matter what evidence you present them.

Yes, evidence is like kryptonite to doctors.

I asked Pearlstein if a doctor ran over his dog or something.  He didn’t directly respond, simply saying “Maybe you should talk to Atul [Gawande].”

Now that’s the only sensible thing he said.

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