First, Do No Harm – Reforming Health Care (Part One)

I had originally thought I’d write an essay covering my opinions on the problems in health care and my opinions on how we can reform the system. I quickly realized that such an essay would run many pages and no one wants to wade through that. I’ve decided, therefore to do this in installments. This essay is the first of a planned series on the subject.

Introduction

I don’t know that there is anyone who thinks that health care doesn’t need reformed. The straw man that President Obama posits, that those who oppose his brand of health care reform want the status quo, is just not true. The problems are complex and defy simple, or quick, solutions. The issue requires careful study, sober contemplation, and multi-faceted solutions rather than quick solutions based on political expediency and interest group politics. Unfortunately, serious attempts to comprehensively address these issues are in short supply in Washington these days. In this series, I will attempt to address some of the problems we face and will suggest some potential solutions for those problems.

My Qualifications

Simply put, I am a member of the health care industry. I have been a physician for 23 years, working both in primary care and as a specialist. I have worked for the government when I served in the U.S. Air Force and am now in a private practice. I currently am a radiologist and nuclear medicine physician in Grand Rapids, Michigan. I am a shareholder in one of the largest single-specialty private practice groups in Michigan. I work in several hospitals and a large private medical group. One of the hospitals in which I work is a large, level I trauma center that has the 13^th busiest emergency department in the United States. It is also within the top 10 in the United States in the number of joint replacement surgeries and heart surgeries performed. I am on faculty at the Michigan State University medical school and teach medical students and residents.

My father was a small-town family physician for almost 40 years. He was a true cradle to grave doctor who delivered babies, made house calls, and was on-call 24 hr./day.

One problem that I see with health care reform is that there is a dearth of practicing physicians among the reformers. Most of the people on these committees are politicians, businessmen, or physicians who have not seen the business end of a stethoscope for years. In a field that is growing and changing as quickly as medicine, someone who has not practiced for several years has no conception on how health care has changed. Ask any physician and they will tell you that the practice of medicine 10 years ago is almost unrecognizable today.

So, as far as my qualifications go, they are informed and limited by my daily life as a physician. I don’t claim to be an expert on the insurance industry, the hospital industry, or the pharmaceutical industry. This paper, therefore, shouldn’t be seen as a comprehensive solution, but as a piece of a much larger puzzle.

Primum, non nocere

I will begin with a premise of which I am absolutely convinced, and that is that the United States health care system is, by far and away, the best in the world and it isn’t even close. Our physicians, nurses, and ancillary personnel are better trained than anywhere else, our equipment is better and more plentiful, and our facilities are second to none. It is no accident that our medical schools and residency programs are filled with students from around the world. It is also not merely blind luck that almost every significant medical advance in the last 30 years has come from the United States.

Detractors will point to lower life span in the United States, as compared to other countries, but not account for the high rates of obesity, heart disease, and violent (primarily vehicular) deaths in the United States as compared with most of the rest of the world. These are not health care issues as much as lifestyle issues. As the late syndicated columnist, Mike Royko said

Let us talk about medical care and, one of the biggest problems we have. That problem is you, my fellow American. Yes, you, eating too much and eating the wrong foods; many of you guzzling too much hooch; still puffing away at $2.50 a pack; getting your daily exercise by lumbering from the fridge to the microwave to the couch; doing dope and bringing crack babies into the world; filling the big city emergency rooms with gunshot victims; engaging in unsafe sex and catching a deadly disease while blaming the world for not finding an instant cure.
You and your habits, not the doctors, are the single biggest health problem in this country. If anything, it is amazing that the doc’s keep you alive as long as they do. In fact, I don’t understand how they can stand looking at your blubbery bods all day.

According to the Center for Disease Control, the average life expectancy for white females in the United States born in 2005 is 80.4years. That of white men is 75.2 years. Average life expectancy for an African American female born in 2005 is 76.5 years. Do we really think that African American females receive better health care in the United States than white men? According to the Department of Health and Human Services, the group with the highest life expectancy in the United States is Oriental women, with a life expectancy of 85.8 years. So, according to those who use life expectancy as an indicator, Oriental women receive the best health care of all. The fact of the matter is that health care has little to do with life expectancy.

Another statistic that is often trotted out by detractors of the US health care system is that of the infant mortality rate. But again, as they say, there are lies, damned lies, and statistics. Infant mortality is defined as the death of any child who was born live and who dies before one year of age. One of the problems is what constitutes a live birth? An article in US News and World Report, published in 2006, sums up the problem this way:

First, it's shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don't reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country.

Some countries will not count any birth as a live birth if the baby is pre-term (38 weeks.) In fact, Russia and other former Soviet Union countries would not count a premature baby as having been born alive until it had lived for 7 days. Japan and Hong Kong both report a very high rate of stillborn infants to live births, almost certainly because those infants who die shortly after birth are being reported as stillborn rather than an infant death.

In the United States, 50% of all babies born at 25 weeks survive because of the extraordinary care we provide. Elsewhere around the world, it is rare that any attempt is made to care for these infants. They are more likely to die within minutes to hours after birth and be listed as a stillbirth or a miscarriage.

During my residency, I spent three months at Boston Children’s Hospital. I remember reading chest x-rays from the neonatal intensive care unit and remarking on how many children had a rare congenital heart disease (I don’t remember now which one.) My attending reminded me that the disease was exceedingly rare, but that Children’s Hospital was the only place in the world that offered the potential life-saving surgery for these babies. And it wasn’t just this one heart disease. It was a number of different conditions. During my three months there, I saw children that had been flown in from Canada, Mexico, Brazil, Portugal, France, and Saudi Arabia, just to name a few. Now, if one of these infants died, this would count against the United States statistics since that is where the death occurred. And Boston Children’s, while one of the finest pediatric hospitals in the United States, certainly isn’t unique. There are a number of pediatric hospitals in the US that perform similar services.

Probably a better indication of the quality and accessibility of health care is cancer survival rate, which is almost entirely due to differences in detection and treatment. The 5-yr. survival rate (those patients still alive 5 years after detection) for breast carcinoma in the United States is 90.1%, in Europe, it is 79.0%, and in Canada, 82%. For prostate carcinoma, the 5-yr. survival rate in the US is 99.3%, in Europe it is 77.5% and in Canada, it is 87%. In fact, for every cancer, the US 5-yr. survival rate is higher than that of Europe and Canada. For all cancers, no country in the world has better cancer survival rates than the US.

As far as quality of care, accessibility, and innovation, there is nowhere in the world that can equal the United States system of health care. Whatever else is done to reform health care, the reformers should adopt one of the first lessons taught in every medical school – Primum, non nocere. First, do no harm.