I recently visited a hospital in the Midwest, and got a close-up look at how medicine is practiced outside of the very peculiar market in New York City.
I now have a better feel for the actual pulse of the nation’s medical care.
Here’s my report:
The good news is that practitioners are skilled, well trained, and devoted to patient care.
The bad news is that fewer physicians are delivering patient care.
Every physician I encountered employed one or more physician extenders — either a nurse practitioner or a physician’s assistant. This trend has been deepening over many years and will continue, due to many factors.
Doctors are being paid less for their services, so to maximize efficiency, extenders do the minutiae of documentation, medication review, review of systems, past history and family history, and take care of the never-ending requests for pre-authorization of an increasing number of routine medicines and tests.
The logical end game is the virtual elimination of physicians, to be replaced by non-MD practitioners, who will faithfully follow the centrally planned practice algorithms. Individualized care and the ability to think outside the box will become history.
The electronic health record is omnipresent and universally loathed.
Everyone I interacted with had only complaints about this intrusion into the patient-physician relationship. The sheer volume of documentation demanded is a major time killer, which obviously detracts from face-to-face patient time.
The quality of care suffers. An impressive amount of completely useless, repetitive information is generated. Sifting through this forest to find the fruit tree demands even more time, and leads to errors.
As my colleague Gerard Gianoli writes, the EHR
is the Potemkin Village of medicine; a glorious façade that hides the rot.
Middle Americans are massively obese, and massively over-medicated.
Even the farmers, who remain very active, are overweight.
The sedentary are in very bad shape.
A car culture that discourages walking or biking is partly to blame. So is the carb culture, created by the “food pyramid,” a misbegotten formula that virtually eliminates fat and promotes carbs.
Pushed by the federal government for decades, it has only recently been revised, slightly. Fat is a natural appetite suppressant; its removal promotes overeating.
I walked through two large supermarkets in search of a decent loaf of bread.
All the offerings had added sugar or high fructose corn syrup. Why must bread be sweetened? I finally found a decent baguette at a new French bakery in town.
The government-created obesity epidemic is behind the epidemic of type 2 diabetes, one of the manifestations of the metabolic syndrome. This syndrome is the major cause of hypertension, heart and kidney disease.
It is best treated by a combination of a healthy, low carb diet, exercise and perhaps some metformin. With correct treatment, the diabetes is cured.
Yet, the majority of patients I saw were treated with insulin, probably the worst of the lot.
In addition to producing hypoglycemia, which can be life-threatening, insulin invariably causes weight gain, exacerbating the underlying metabolic syndrome.
The lipid profile of the metabolic syndrome — low HDL (“good” cholesterol) and high triglycerides — is completely unaffected by statin drugs, yet almost every one with this syndrome is taking them.
Over-medication didn’t just happen. It is the direct result of a sophisticated campaign funded by Big Pharma, and aided by an elite cadre of physicians. The latter produced industry-sponsored studies that typically transform a clinically insignificant benefit into a statistically significant “relative risk reduction.”
These same doctors often sit on panels (also industry-funded) to create “clinical practice guidelines” that recommend treating patients with ever higher doses of various drugs to achieve ever-lower “targets” for blood pressure, LDL cholesterol, HbA1c, etc.
These targets will be finding their way into the EHR as the so-called quality benchmarks that will determine payment.
Thus, Americans’ unhealthy lifestyle is creating disease that is bandaged over with a panoply of drugs that either don’t help, or that make matters worse.
This sorry state of affairs is directly tied to our convoluted third party payment system. More on this next post.
Dr. Amerling is board certified by the American Board of Internal Medicine for Internal Medicine and Nephrology. He also is also immediate past president of the Association of American Physicians and Surgeons. For more of his reports, Go Here Now.
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