Much of U.S. Healthcare Is Broken: How to Fix It (Chapter 1, Part 3)

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 addresses healthcare’s focus on back end treatment rather than front end treatment: treating the symptoms rather than the causes of the health condition. Each Monday, a new section of the book is published, and all chapters are archived here.

Back End vs. Front End Treatment

The reader will find that I have a major criticism for many areas of healthcare in which therapy is focused on treating the back end of the health condition rather than addressing the causes of the health condition and treating it on the front end. The present seven-minute doctor-patient office visit guarantees a back end symptom reduction and prescription focus rather than often addressing the causes of the patient’s healthcare problem, which all too often lies in the patient’s health-injurious behavior or current life stresses. Many times, rather than medication, the patient needs knowledge and information to help to effectively treat their particular health problem, but all too frequently such vital knowledge is withheld from the patient. The patient is often in the best position to help and address their own health problems but patients need knowledge in order to help treat their health problem.

I will give only one example here of treatment on the back rather than the front end. All of the behavioral health disorders (or psychiatric “diseases” as psychiatry and perhaps the reader prefers) are diagnosed exclusively on the basis of the patient’s behavior. In the 1960s, psychiatrists believed they had found a lab marker for depression, but lab work for this marker was dropped within a year because the marker proved to be wrong. I know of no disease (aside from what psychiatrists refer to as the mental diseases) in which correct diagnosis does not require a physical examination, evidence of tissue damage, lab work and, in many cases, non-behavioral diagnostic procedures which are specific to diagnosing “real” disease. We know, for example, that a person’s behavior (mentally normal or mentally disturbed) shapes the respective brain activity of mentally normal and mentally impaired persons on several brain scans.

Psychiatrists, after many years, have come to prefer back end treatment of these conditions with psychiatric drugs, almost exclusively to change and alter one’s brain chemistry/brainwave activity to treat the various so called mental health brain “diseases.” In treating these disorders, many psychologists and a minority of psychiatrists prefer, on the other hand, to address and treat these disorders on the front end—that is, to determine the causes and then to address and treat the stress, personality, and life problem causes of the disorder but not treat the resulting brain consequences of the patient’s current life difficulties.

Much of what the psychologist does with these cases is behavior change, which incidentally should be a major focus of medical care rather than just symptom reduction! If we have a depressed person, we do not need an MRI to know that the depressed person’s brainwave activity will be altered substantially due to the brain effects of depression. Moreover, if the depressed person’s depression is remitted through behavioral treatment, we do not need an MRI to know that the brain wave activity of the previously depressed person will have returned to normal. Since the 1950s, manipulating brain chemistry by psychiatrists and primary care physicians (also physician’s assistants and advanced nurse practitioners with prescription privileges) has become the most popular treatment of all of the mental disorders; later I will examine whether or not this drug driven mental health movement has been effective. More about these back end treatments later.

With regard to false medical thinking in the 20th century and beyond, many readers will recall that for a long time, bed rest for two weeks was the recommended treatment for back pain. Finally, physicians learned that bed rest was the worst thing that one can do for back pain.

I will leave this topic with one other example of popular but false medical thinking. In the late 1950s and early 1960s, most pediatricians were opposed to breastfeeding and the accepted thinking at the time was that the baby was ready at six weeks to begin taking solid foods! My wife had our three children during this time and against much opposition she continued to breastfeed the babies beyond six weeks and against medical advice substantially delayed transfer from breast milk to solid foods. She did not follow the strong recommendation of solid food at six weeks (she disregarded her pediatrician’s advice but did not inform him) and later with breast feeding alone the pediatrician complimented her on the baby’s weight gain in the interim, which undoubtedly strengthened his erroneous belief that babies should start on solid foods at six weeks!

This is one example of many reasons why many false treatments in the past and currently have persisted without any scientific support for the popular “therapy.”  Past and present false and popular treatments can be assessed through application of the scientific method. Unfortunately, healthcare belief and opinion rather than science seem to rule too much of healthcare today.

Aside from the nuts and bolts of healthcare, these false beliefs tell us a great deal about the human psyche, especially the power of both need and fear in shaping one’s belief system. We are all prone to this “wanting to believe,” including me, and as we shall see in healthcare, this need to believe is no respecter of intelligence, level of training, expertise or lack thereof, including one’s ethical level and other qualities.

Health professionals have a strong need to help their patients, which is laudable, but this normal human desire can and does lead to some bad consequences at times, such as the reflex of prescribing medication if a patient complains of difficulty sleeping. One should ask “Why does this patient have a sleep problem? The answer to this question is outside of the physicians training and expertise. As health professionals, we have to continuously check our beliefs against the best scientific evidence available when the questions are applicable to the scientific method; rather than just accepting the conventional wisdom, why not subject the belief to the scientific method and proper experimentation?

We will find that many of today’s medical sacred cows are based not on science, but on the same “Mary’s health problem got better because of treatment X.” Many of us want to believe that modern medicine is now ruled by science and the bloodletting days are over, but unfortunately those days in many health areas are still with us, as we shall see. I will also point out that all of the current healthcare entities will not and cannot make the necessary changes to improve the quality (and lower the cost) of healthcare. In Chapter 7, as mentioned, I will describe the creation of a “new” entity that can achieve better quality of healthcare at lower cost.

Medicine is certainly not alone in operating on the basis of some false and unexamined beliefs, but perhaps healthcare can do more damage to patients than in many other disciplines. Note that I am using the word “damage” in a very broad sense, not only injury to the body or health and emotional well-being of the patient through bogus treatments but damage in an economic sense, that is, employing expensive procedures or prescriptions when alternative and less expensive procedures or drugs are equal or superior to the more expensive therapies. I will discuss:

• A number of examples of very expensive but less effective healthcare treatments that waste billions of dollars yearly (for example, treatment of depression) when there are cheaper and more effective alternatives available.
• Moreover, when a bad, inappropriate, unnecessary, or expensive therapy is prescribed to the patient, the patient is denied access to an available effective and, often, less costly treatment for the condition.

We have to continually examine the unexamined conventional wisdom in healthcare (as well as other disciplines) by applying the scientific method to test the “accepted but unverified truth”; eternal vigilance is mandatory because “What we know for sure” is extremely resistant to any change. Unfortunately, whistleblowers who challenge the conventional wisdom are not treated kindly by those who are emotionally and at times financially invested in the status quo.

Throughout this book, I and many others challenge the conventional wisdom with regard to a number of sacred cows of medicine. There is much resistance against our being heard, not only with providers of healthcare but the media as well. The media should be in an excellent position to challenge popular but damaging health practices by appealing to the available sound health research, but the media—with very few exceptions—has often been propagandized by pharmaceutical and medical device companies about the latest “breakthrough” drugs and other therapies.

I have used the term “sacred cows” of medicine to imply that some treatments and beliefs in medicine are so generally accepted as true by the profession that they do not merit any kind of challenge and like India’s sacred cows are considered “untouchable.”

One other very deeply held belief seems to arise from the nature of physician training at both the undergraduate and medical school level. I suspect, as I have said, that about 90% or more of physician course work is within the biological and physical sciences. I don’t think I would get any argument here, and I also believe that such emersion in the biophysical sciences is certainly very appropriate in physician training for treating “real” diseases and conducting many necessary surgical procedures. Physicians have a body of knowledge in the biophysical sciences second to none in the various health disciplines. but along with such positives there are some important negatives.

To me, the nature of physician training seems to shape physicians’ view of health problems and because of their training physicians are primed to look for biophysical treatments to address our health problems when in fact (as we shall see in Chapter 6) the vast majority of health problems are due to psychosocial factors in the patient’s life and not to “real” disease!

Physician training seems very consistent with a search for biophysical diseases and a search for biophysical treatments for these diseases. This is not to say that physicians are unaware of what might be consider psychosocial contributions to many health problems, but I would argue because of their training, physicians are more comfortable with the biophysical causes of health problems than the corresponding behavioral and psychosocial causes.

I think one would have to admit that physicians and their training have been the dominant force in shaping the delivery of healthcare as we know it and possibly that health services delivered may reflect too much of a biophysical model at the expense of the psychosocial factors—in both health problems and to “real” disease as well. Treating cancer as if it is only a biophysical disease does not address the emotional and psychosocial causes in the patient’s cancer profile. My major fault with current healthcare is that it is shaped by a disease model when in fact our most prevalent health problems are not diseases but arise from psychosocial and distressing life situational factors in patients’ day-to-day lives.

My opinion, as with any opinion, must be looked at in view of any supporting or non-supporting evidence.  I believe it was the physician Hippocrates who said it is better to know more about the person than their disease! Unfortunately, most physicians of today would not endorse his sage advice!

Before leaving this topic for the moment, my critique of current healthcare is that some healthcare professionals (mainly but not exclusively physicians) are providing health services for which they have insufficient training and expertise to competently provide the service. This is especially true with regard to mental health disorders and non-organic-caused health problems. The “new” healthcare entity I will propose to manage care must deny reimbursement for such health services by providers who do not have sufficient training or expertise to provide the quality health services required.

Dividing physician services between those health services which are and are not reimbursable because of deficient or sufficient training and expertise is necessary for improving the quality of care. Yet, this needed policy would not be acceptable to any of the major healthcare entities of today. Certainly, most physicians would fight against such a policy, as would the health insurance companies, health plan designers, managed care executives, most healthcare consultants and others as well. I believe I have a way of bringing such a policy about. I will describe a new entity in chapter 7 that can make such a policy change.

I realize most readers at this time would strongly disagree with such a policy change but, before doing so, let’s see in many of the following pages if there is merit to such a policy, namely, the health professional must have sufficient training and expertise to receive payment for the health services delivered to the patient. In many ways, physicians are very well trained for much of what they do, but let’s be open to examining some current physician practices for which physicians may not have sufficient expertise to deliver certain health services. To practice major surgery physicians must demonstrate that by specific training and experience they have the necessary competence to qualify for the practice of surgery. Shouldn’t all physicians have had the necessary training and expertise to be qualified to practice in certain areas of healthcare?

Lastly, I know that this book will challenge the conventional wisdom of most readers; however, I invite the reader to be at least open to the sound scientific research offered and agree to the application of the scientific method to examine some of these strongly held and cherished—but at times bogus—healthcare beliefs.