Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Les Ruthven’s book, Much of U.S. Healthcare is Broken: How to Fix It. In this blog, he introduces the book. Each Monday, a new section of the book is published, and all chapters are archived here.
In this preface I would like to explain briefly where I am coming from in my criticism of much of U.S. healthcare, primarily “everyday” healthcare. My views, which are based partly on my experience as a clinical psychologist/neuropsychologist and my 22-year career managing behavioral healthcare for large national employer health plans, are not those of most physicians or the vast majority of the media and general public.
I was founding president/CEO of a behavioral health managing firm; my company was unique in the industry at that time (and now) in that our psychologists had a telephonic assessment with every employee or covered member calling for behavioral health services and were referred after the assessment to one of our 10,000 contracted psychologists, clinical social workers or addiction specialists in all 50 states and Puerto Rico.
Sixty-five percent of these callers (approximately 100,000 outpatients) complained of anxiety and/or depressive symptoms. In recommending psychotherapy or behavioral treatment for these problems, our psychologists never recommended the popular and standard of care—namely, psychiatric drugs—for these problems. Callers who were already on psychiatric drugs were referred for behavioral treatment, leaving the matter of these drugs alone. However, if a caller asked if drugs were needed, our Preferred Mental Health Management staff psychologists advised starting therapy and, if drugs were warranted, they should call back and a referral would be made to one of our contracted psychiatrists, who would prescribe drug treatment.
As far as I know, not one caller who initially asked about drugs ever called back for drug treatment! At the time, those calling behavioral health management firms and reporting depressive or anxiety symptoms were offered the alternative of going to a behavioral health professional or conferring with their doctor about antidepressant medication or other psychiatric drugs as a first and perhaps a final step in their treatment! Since my company did not follow the conventional wisdom as a defensive measure, I soon began a review of the existing drug/behavioral outcome research, which found no support for the necessity of drug treatment for the large majority of behavioral health disorders. I expanded my review of research to include non-psychiatric health problems and my 22-year review of the health outcome research has culminated in this book.
The MD degree is a medical practitioner degree, and a Ph.D. (as in a Ph.D. clinical psychologist degree) is both a practitioner and a research degree. Physicians are for the most part trained at the undergraduate and medical school largely in the biophysical sciences such as biology, chemistry, physiology, anatomy and many others, but—unlike a Ph.D. in clinical psychology (which is my graduate training) —physicians are not trained to design experiments, conduct research experiments, or even to critically examine the soundness of the research of others, including research in their own field of medicine!
By “research in healthcare” in this manuscript I am concerned with questions of the science of determining the efficacy and safety of drug and non-drug therapies and whether or not the current FDA standard is adequate or needs major revisions.
I take the position that medical practitioners as a group are inclined to base their practice more on clinical experience (“I gave Mary this drug and she got a lot better”) than on the sound published health research, which many physicians seem to distrust. Consistent with this physician distrust of research, my personal physician, after he read a paper of mine on the popularity of steroid injections for back pain in which the research found no support for such treatment, said that often “research cannot be trusted and can prove anything”!
After reviewing healthcare research for many years, I have found that much of published health research, including papers in prestigious medical journals, are often of very poor quality with regard to adequate scientific controls and many times the conclusions from these studies are often not consistent with the data, and in fact the conclusions are often contradicted by the data! However, there is in healthcare I find a large body of sound outcome research, but unfortunately this research seems to be completely ignored by many practitioners.
I believe that sound health research should shape and govern healthcare delivery, but unfortunately much of health policy seems governed by clinical or anecdotal “evidence” and many times bogus research findings. Physicians, without training in the scientific method or ability to competently evaluate published health research, are vulnerable to accepting research findings that are really false, and continue to prescribe unproven drugs and other treatments. A “proven” drug is not just one approved by the FDA in a six- to eight-week clinical trial. In this manuscript a proven drug (or other therapy) is one in which the post-FDA subsequent sound research finds that the drug (or other therapy) demonstrates substantial efficacy and reasonable safety for the disorder being treated.
This book focuses on: (1) physicians—because of their bio physical training—are more prone to see the majority of health problems as arising from organic disease, when in fact we will learn in chapter 6 that the large majority of health problems (according to research) are caused by non-organic health and not organic health problems, (2) clinical opinion—and not sound scientific health outcome research—often shapes everyday medical practice in America, which (3) results in a great deal of unproven, inappropriate, unnecessary, and expensive treatments, (4) and since physician training shapes all of today’s health entities (health insurance companies, the FDA, managed care and others), clinical opinion to establish efficacy rules over the scientific method in the delivery of healthcare. Some of the consequences of the latter result in many unproven and often wasted healthcare dollars. A number of these bogus treatments have been popular for many years despite the absence of any proven efficacy or safety, and I am especially critical of the current Managed Care system for continuing to authorize payment for a number of erroneous treatments.
The following is a case example that summarizes what’s wrong with much of U.S. healthcare.
Medicine’s preference for directing treatment to the numbers (blood sugar readings, blood pressure readings) or symptoms and neglecting the causes of these health problems is a consistent theme in this book, underlying a great deal of poor, inappropriate and high-cost healthcare. For example, a 40-year-old sedentary, 40 pounds overweight male in seeming stress shows up to his physician’s office one day and the examination and lab work uncovers a fasting blood sugar level of 180 and a BP of 164 systolic, 95 diastolic and a heart rate of 96.
Chances are these types of patients will leave the office that day with a prescription for metformin, a diuretic BP drug, Xanax for the stress, and probably some advice to lose weight and start an exercise program is thrown into the mix at the end of the office visit. The patient returns to the physician in a month having taken the prescribed medication and low and behold his numbers are better just as the TV ads say. Patient and provider are both happy but as a third-party psychologist observer I am not, because the patient has gotten the message that the answer to his health problems is medicine and not a change in his behavior!
I went to the internet and found that the life span of the type 2 diabetic is shortened by an average of 10 years and most die of heart disease or stroke. If one asks of the internet what is the treatment for such cases one is informed that it is metformin and life style change. Shouldn’t the order be reversed? Also, in type 2 diabetes is the shortened life span due to the disease itself or to the injurious lifestyle of these patients? If the latter, we have a good example of just treating the symptoms and not treating the major source or sources of the patient’s health problem.
I mentioned above that physicians, probably because of their training, are immersed in the biophysical sciences, and are more comfortable in treating illness and diseases that are of organic rather than non-organic or psychosocially caused health problems. It has been known from the health literature for many years that the 14 most common symptoms (Chapter 6) that bring patients to their physicians for care and treatment can arise from either organic (disease-caused) or non-organic health problems. The vast majority of those with these common health symptoms have health problems due to non-organic causes and not from a disease!
Moreover, since physicians receive most of their training in the biophysical sciences, physicians are more at home in treating organic caused health problems with medications, surgery, or other biomechanical devices than in treating health problems that do not arise from organic causes. These non-organic health problems, because of their frequency, account perhaps for more health dollars than the organic diseases combined and the vast amount of inappropriate and wasted health dollars is compounded by treating these non-organically caused health problems as if these health problems were in fact “diseases” just like the organic diseases!
The sound research shows that in our healthcare system we provide large amounts of inappropriate “medical” treatment for non-organic or psychosocially caused health problems. Actually, the reader will learn that the vast majority of health problems arise not from organic disease but from psychosocial- and behavior-caused health problems that bring most of us to our physicians. Such inappropriate—and expensive mistreatment—is compounded by the physician’s false belief that psychiatric drugs are very effective in treating these psychosocial and behavior caused health problems!
One further word about disease- and non-disease-caused health problems. Even with disease (heart disease, the cancers, diabetes, and many others) these diseases are occurring in persons and because of this there are stress- and other psychosocial-caused health problems in these individuals which negatively affect treatment outcome. My position is that these non-organic health problems in disease for both quality and cost must be addressed and treated as well! A lonely man with cancer may not only need chemotherapy but his loneliness must also be treated for the best outcome, and loneliness is not treated by a drug!
Because of their training, physicians are best at treating diseases but are physicians competent enough to treat the associated psychosocially caused health problems of their patients with a real disease? However, psychiatry and the pharmaceutical industry, by skillfully manipulating the media, have convinced physicians and the public at large that these psychosocial factors in health are really brain diseases and there are drugs available that will effectively treat those psychosocial factors in physicians’ patients! The vast majority of physicians believe these drugs do indeed address the distressing symptoms of these psychosocial factors; however, to validate such a belief I suggest we take a look at the available research on this most important question, since the answer has a major bearing on the cost and quality of healthcare.
In the 1950s, health problems arising from stress or the mental disorders or adverse life factor situations were not treated by primary care physicians; these patients were referred to behavioral health professionals such as psychologists, clinical social workers, and psychiatrists. However, as psychiatry moved more and more toward drug treatment of the mental disorders—and physicians were marketed by drug detail persons and told by the profession of psychiatry and the pharmaceutical industry that the major mental health problems are diseases of the brain—primary care physicians were open to the idea of dispensing these medications to their patients rather than referring these patients to trained behavioral health professionals or psychiatrists.
This movement escalated by the marketing of Prozac in 1987, a medication which was said to effectively treat clinical depression and several anxiety disorders without the risk of overdose deaths of the earlier antidepressant drugs such as Elavil. Primary care physicians and pediatricians, armed with the Diagnostic and Statistical Manual of the Mental Disorders and a variety of the old and newer psychiatric drugs, became the largest provider of “mental health services” in the U.S.! The theory that these mental disorders are actually brain diseases—often considered chemical imbalances in the brain (the serotonin system for depression and the dopamine system for schizophrenia)—seemed to bring the mental disorders back into medicine, which can be competently treated by physicians just as well—or perhaps even better—than trained behavioral health professionals such as psychologists.
As a result, sales of psychiatric drugs began escalating and, in time, these drugs accounted for 50% or more of total prescription costs in many health plans! Such a statistic demonstrates the major role that mental health, psychosocial and other life difficulties play in overall health problems. Psychiatric drug treatment by psychiatrists and non-psychiatric physicians have come to represent a considerable expenditure of healthcare dollars. In view of this it would be wise to evaluate the effectiveness and safety of these drugs for such major non-disease health problems treated by primary medicine (see especially Chapters 2 and 3).
I have felt that behavioral health was always something of a stepchild in the health insurance industry. To the industry, these fuzzy psychological problems didn’t seem to fit in with the rest of medicine and the rest of the health plan; as a result, the industry was open to behavioral health carveouts to lower the costs but not necessarily to improve the quality of care. I suspect the health industry was very pleased when primary care physicians began prescribing psychiatric drugs which brought these “nebulous” health problems back into real medicine! When your only tool is a hammer, everything is a nail, which describes non-psychiatric physician treatment of the full range of the mental disorders.
In the above, I am not indicting all of healthcare, particularly what is referred to as Blue Ribbon or award-winning medicine, which I believe is undoubtedly the best in the world. I applaud many pharmaceuticals that cure disease or substantially reduce symptoms. I want more of these fine and effective drugs; however, the research clearly shows that many popular and “standard of care” drugs (and some other therapies) have very limited or no real effectiveness. In truth, health in this country would improve substantially if these drugs (and some non-drug therapies) were removed from the marketplace and physicians’ tool kit.
Drugs and therapies based only on clinical opinion rather than sound scientific outcome studies should be disallowed, but some of these unproven treatments are unfortunately viewed as the standard of care. In the light of this, one must remember that for well over 3,000 years bloodletting was considered the standard of care for dozens of diseases and health problems, including a cure for the black plague! Lest we think bloodletting was just a part of ancient medicine, it was still used for the Spanish flu in the U.S. in the 1918-1919 pandemic and a medical text recommended bloodletting as valid treatment in 1941!
All of us are at times open to accepting as true false beliefs and this can and does include many physicians. As with bloodletting, a number of current but bogus health treatments are resistant to change despite the availability of excellent published health research to the contrary, which I will be examining in many of the following pages.
I realize my candidness in the above, most of which is contrary to the accepted conventional wisdom on healthcare today, may risk that many readers will not go further with my narrative; however, I hope that many will stay with the reading and give my “radical” beliefs a fair hearing since these beliefs are well documented in the sound health research literature.
In reading the above the reader may say, “Dr. Ruthven, how can you expect to reform the current healthcare system and its many entities if such extensive reform is really needed? Isn’t your task unwinnable especially since you are not a physician?” However, if I had been trained as a physician, I seriously doubt that I would be writing a manuscript on reforming medical and healthcare!
The above are two very good questions since I am not naïve enough to think that I could change any part of the current healthcare industry directly. However, I believe there is a path to improve the quality of healthcare to lower its cost and it lies with the large employer self-insured employee health plans, to which this book is dedicated. In chapters 6 and 7 I will describe a new health managing entity that will base payment not on clinical opinion as much of today’s standard but on proven and safe treatments based on the sound health outcome research that is already available to all health entities today.
Moreover, the new managing entity will only authorize payment if the healthcare provider has the proper training and expertise to competently treat the patient’s health problem. From this last statement I think you would be right in thinking that I believe many health professionals (especially physicians) are treating some health problems for which they are unqualified by their inadequate training in non-organically caused health problems.
Before closing this preface, I would like to offer a brief tutorial on what is meant by the meaning of science and health science in this book. When the general public and many physicians think of science—and health science—the public envisions microscopes, genetics, DNA, discovering new cancer drugs and, in medicine, employing high-tech diagnostic devices such as MRI and other sophisticated diagnostic procedures. The foregoing are examples of scientific endeavors. However, in its broadest sense science is basically a rational method to determine truth, in the case at hand truth about many aspects of health including important questions of treatment efficacy and safety.
There have been truly marvelous advances in medicine in the 20th and 21st centuries but these will not be addressed in these pages. However, in the following I will make the case that health policy should be based on scientifically proven treatments and not everyday clinic experience.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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