The Doctor Will See You Now
Copyright © 2018 by Cory Franklin
All rights reserved
Published by Academy Chicago Publishers
An imprint of Chicago Review Press Incorporated
814 North Franklin Street
Chicago, Illinois 60610
ISBN 978-0-89733-932-2
A list of credits for the previously published pieces in this collection can be found on pages 269–270.
Library of Congress Cataloging-in-Publication Data
Names: Franklin, Cory M., author.
Title: The doctor will see you now : essays on the changing practice of
medicine / Cory Franklin.
Description: Chicago, Illinois : Academy Chicago Publishers, [2018] |
Identifiers: LCCN 2017039624 (print) | LCCN 2017043313 (ebook) | ISBN
9780897339308 (adobe pdf) | ISBN 9780897339322 (epub) | ISBN 9780897339315
( kindle) | ISBN 9780897339292 (trade paper)
Subjects: LCSH: Medicine—Practice—Miscellanea.
Classification: LCC R728 (ebook) | LCC R728 .F73 2018 (print) | DDC
610.68—dc23
LC record available at https://lccn.loc.gov/2017039624
Cover design: Andrew Brozyna
Cover images: Doctor: Golden Sikorka/Shutterstock; pen: vladwel/Shutterstock.
Typesetting: Nord Compo
Printed in the United States of America
5 4 3 2 1
This digital document has been produced by Nord Compo.
CONTENTS
* * *
Part I: The Patient/Physician Relationship and Reporting Medicine
1 The Bond Between Patients and Physicians Is in Jeopardy
2 Is It Smart to Skip Your Annual Physical?
3 How Old Is Too Old?
4 The Missing Pieces of Breast Cancer
5 Aching for Some Undivided Medical Attention
6 Reporting Science Without the Drama
7 Dr. Oz, Heal Thyself, and “Broadcast Doctors” on TV
8 Physician-Journalists
Part II: Heroes and Villains
9 In Praise of First-Rate Medicine
10 The Ghosts of Cook County
11 The Man Who Saved Pitchers’ Arms
12 The Woman Who Protected Us
13 Needles to Say
14 Air-Conditioning: A Lifesaver
15 Flight 191 on a Spring Day
16 Newtown PTSD
17 Notorious Patients: The Boston Marathon Bomber
18 Born to Raise Hell
19 Who Was Nancy Reagan’s Father?
20 Elementary, My Dear Watson
21 The Sacrifice of Our Valiant Men and Women
Part III: Hospitals and Hospital Practices: The Twilight Zone
22 Hospitals: Scary Places Even for Doctors
23 ER Overload
24 Protect Patients’ Medical Records from Prying Eyes
25 Retracing Your Footsteps
26 Medical Protocols and Checklist Manifestos
27 An American Disgrace
28 The Future of Health Care: Much Like the Present, Only Longer
29 The Digital Intrusion into Health Care and the Creepy Line
Part IV: Research, Ethics, Drugs, and Money
30 Should You Put Your Trust in Medical Research?
31 Comparative Effectiveness Research: But What If the Research Doesn’t Show What You Want?
32 The Easiest Person to Fool Is Yourself
33 Physician, Heal Thyself
34 Signpost Up Ahead: Good Intentions
35 Concussion and Conflict of Interest
36 I Ain’t Afraid of No Medical Ghostwriters
37 The Blackest of All Black Markets
38 Doped: Performance-Enhancing Drugs Keep Winning the Race Against Testing
39 A Pill Not in the Best Interests of Healthy Students
40 Is “Low T” an Actual Disease?
41 Just Because You Are Rich Doesn’t Mean You Are Smart
42 Flying Too Close to the Sun
43 How Movies and Pharmaceuticals Are Alike
44 Unprofessional Professionals
45 Assisted Suicide: How Can We Be Sure When It Is Right?
Part V: The Brave New World of Neurology
46 Better Use of Our New Tools for Patients in Coma
47 How a Telltale Heart Could Change Medicine Forever
48 The New Paradigm of Assistive Technology
49 Google, Gene Mapping, and A Christmas Carol
50 I Have Lost My Mental Faculties but Am Quite Well
Part VI: Past Epidemics and Future Threats
51 When the Climate Changes, So Does Health
52 Zika: The Latest Exotic Traveler to Stir Up Trouble
53 Ebola: Humility in the Face of Nature Is Essential
54 Measles: A Never-Ending Threat
55 Anti-Vaxxers
56 When the Avian Flu Comes
57 The Chicago Experience with a Nineteenth-Century Epidemic That Kills Again Today
Part VII: Scientific Philosophy
58 Can Science and Religion Coexist?
59 Back to the Future: Navigating by the Stars
60 Volkswagen: Primum non nocere
61 What Is Life, and Who Is Carl Woese?
62 The NFL May Become Extinct If We Do Not Pay Attention to Youth Football
Part VIII: Clinical Vignettes and a Humorous Interlude
63 Elena and Angela
64 An Unusual Side Effect of My Medicine: I Can’t Remember My Lines
65 Twenty-First-Century Medicine, or “Mom, I Want to Be a Doctor”
66 A Guide to Health Care Policy—with Apologies to Mort Sahl
67 My First Encounter with Ilse and Robot Dentistry
68 The Rip Van Winkle Story at the Hospital—with Apologies to Washington Irving
Credits
I
THE PATIENT/PHYSICIAN
RELATIONSHIP AND REPORTING
MEDICINE
1
THE BOND BETWEEN PATIENTS AND PHYSICIANS IS IN JEOPARDY
* * *
The good physician treats the disease; the great physician treats the patient who has the disease.
—SIR WILLIAM OSLER, MD
REMEMBER YOUR PERSONAL PHYSICIAN? He or she may not be yours much longer. And even if you keep your doctor, the odds are he or she is not really working for you. Soon most doctors will have abandoned their private practices and become employees of hospitals, multihospital affiliations, or the government. Only 35 percent of doctors currently describe themselves as independent, compared with 62 percent in 2008. This trend will undoubtedly continue; a medical student starting training today has virtually no chance of starting his or her own solo practice.
How did this happen, and why is it a threat to patients? The main culprits are the government and the insurance companies. As a result of the payment provisions under the Affordable Care Act (ACA), the government essentially encouraged hospitals to “own” doctors, and it is likely these provisions will remain in any modifications of the ACA. With inscrutable logic, the government pays more for the exact same medical procedure or doctor’s visit if it is done in a hospital clinic rather than in an independent doctor’s office. This is a strong incentive for hospitals to buy physicians and their practices. Doctors may have little alternative but to take salaried hospital positions if their practices disband. Combine this with federal rules and regulations regarding electronic records and medical partnerships that make it prohibitively expensive for all but the largest physician partnerships to compete.
Over the past several years, more than a quarter of a million doctors have been informed their Medicare and Medicaid payments would be reduced because th
ey have not sufficiently implemented electronic medical records. Small physician practices unable to afford the capital investment are hurt the worst—just another nail in their coffin.
The government’s willing partner in the dismantling of private practice is the insurance industry. Even before the Affordable Care Act, insurance companies advocated “narrow networks”—business speak for deciding which doctors patients could choose—as the means to control costs, offer reduced premiums, and broaden coverage (without mentioning the opportunity to realize higher company profits).
Put simply: one way for insurance companies to control premiums is by limiting patients’ choices of doctors. These networks could change every few years; every time they do, some doctors will be shown the door. None of this bodes well for either American medicine or patients, no matter how the insurance industry and the federal bureaucracy spin it with corporate jargon like “consolidated health systems,” “coordinated care delivery,” or “pooled financial risk.” These large consolidated health systems eliminate any possible benefit derived from local competition. Consider that when Wal-Mart comes into a community and forces out the corner mom-and-pop grocery store, the locals may be opposed, but at least everyone generally benefits from greater product selection and lower prices. In today’s brave new health care world, as corporatization increases there is less selection and prices do not drop.
But there is a far more ominous implication. The centuries-old bond between patient and physician, described by Hippocrates twenty-five hundred years ago, is in jeopardy. The mutual-trust relationship is frayed when physicians become corporate (or government) employees; their loyalties are divided between their employer and their patient. How does the doctor determine how to advise or treat a patient? Is it what is in the patient’s best interests, or is it adhering to performance goals and satisfaction surveys, which are increasingly being used as rewards or penalties that factor into the doctor’s salary?
Fortunately, in most cases, there is no conflict, and when there is, most doctors still act in their patients’ best interests. But now there is an ever-present threat the doctor will defer to a “quality improvement initiative” designed by a faceless manager in some distant corporate headquarters.
This new disconnect between patient and physician is typified by the electronic medical record. Despite never being adequately tested for actual utility, the computerized record was introduced to medicine over the last two decades at a cost of billions of dollars. In 2009 the government provided even more billions of dollars in bonuses if providers implemented the electronic medical record. The electronic record is admittedly easier to read and transmits information off-site better than paper records. But it has introduced an invisible barrier between patient and physician. Doctors now stare at a computer screen while they talk to patients and then spend an inordinate amount of time completing electronic records, time that would be better spent talking to patients. Cut-and-paste and poorly designed software templates create bad habits when doctors question and examine patients. And the records are anything but secure: millions of electronic medical records have been hacked or stolen; the information in millions more is routinely sold to third parties. Hardly a technology that engenders trust.
There has always been a love-hate relationship between doctors and society. Some physicians are lampooned as imperious jerks, and others are accused of doing too many tests and procedures. (President Obama famously made that assertion early in his presidency.) However valid these charges, one thing has always been true: with rare exception, even the most arrogant or venal physician has had the patient’s best interests at heart. Can the same be said of the new business mandarins in charge of health care? With physicians becoming pawns in a much larger game, who will look out for patients? We may never again be completely sure.
2
IS IT SMART TO SKIP YOUR ANNUAL PHYSICAL?
* * *
Well, first of all, let me say that I might have made a tactical error in not going to a physician for 20 years. It was one of those phobias that really didn’t pay off.
—WARREN ZEVON
THE POORLY TOLD TRUTH may be the most misleading falsehood. Ezekiel Emanuel, a leading American physician, provoked national debate in 2014 by suggesting that most people should not live past age seventy-five. Later he sparked further controversy, advising healthy people to forgo annual physical exams. He wrote in the New York Times, “Not having my annual physical is one small way I can help reduce health care costs—and save myself time, worry and a worthless exam. . . . Those who preach the gospel of the routine physical have to produce the data to show why these physician visits are beneficial. If they cannot, join me and make a new resolution: My medical routine won’t include an annual exam.”
The medical community has debated this issue for decades. Emanuel, displaying great assurance, relied on an analysis that pooled data from fourteen studies. He wrote, “In 2012, the Cochrane Collaboration, an international group of medical researchers who systematically review the world’s biomedical research, analyzed 14 randomized controlled trials with over 182,000 people followed for a median of nine years that sought to evaluate the benefits of routine, general health checkups. . . . The unequivocal conclusion: The appointments are unlikely to be beneficial.”
This is strong stuff, especially coming from an éminence grise like Dr. Emanuel when he cites the Cochrane Collaboration, a respected not-for-profit network of health experts. Unfortunately, a careful reading of the report on general health checkups reveals surprising limitations in the data of Emanuel’s source—which question whether Emanuel’s conclusions are applicable today. Some limitations in the Cochrane report, and the studies comprising it, include:
Six of the fourteen studies were done in the 1960s. Nine were done more than forty years ago.
Not a single study was initiated in the twenty-first century.
No study included patients over age sixty-five or under eighteen.
Five studies excluded women.
The actual median follow-up time for the patients was closer to six years rather than nine, insufficient time to prove or disprove the value of annual checkups for patients in whom chronic diseases are identified. The only studies that followed patients for more than ten years all began before 1971. Five studies did not track mortality in the patients. The nine that did all began before 1993.
An entire generation of medicine has elapsed since these studies were clinically relevant; for some studies, two generations. Is this credible evidence that routine doctor visits are worthless? Consider heart disease. Virtually all the Cochrane patients were studied when cardiac catheterization was in its infancy, when many effective blood pressure medicines had not yet been discovered, and before statin drugs became routine treatment for high cholesterol. Today asymptomatic patients found by their doctors to have hypertension or hyperlipidemia are far more likely to receive effective therapy than was possible during the study period.
For children and the elderly, excluded from this report, vaccination is more effective today than when these studies were performed. In terms of cancer treatment, most current chemotherapy had not yet been developed, and screening colonoscopy was not yet the standard for detecting colon cancer. More than half the Cochrane studies were done before CT scans, an invaluable tool in cancer management, were available. None of this demonstrates the benefit of annual doctor visits. A narrow interpretation of Emanuel’s point may be valid. In healthy patients with no complaints, detailed physical examination is unlikely to detect lifesaving findings. Assuming one is healthy and asymptomatic, many doctor visits result in excessive blood testing and X-rays, merely provoking concern, leading to more testing and driving up costs.
Yet the absence of value in a comprehensive physical exam does not mean people should avoid doctor visits. Most people, even the healthy, should visit the doctor at reasonable intervals for personalized evaluation and age-specific testing and intervention. Young people should have vacci
nations, developmental evaluation, and counseling. The elderly, more prone to developing chronic conditions, should be screened and also counseled about safety issues (e.g., driving difficulties, falls), memory problems, and medication evaluation. (The elderly are on more medications than ever before.)
For everyone else, routine visits to the doctor should be a serious consideration. Yearly intervals are a decent target and easy to remember. Visit frequency should be based on individual health history, family history, personal habits, occupation, and personal concerns. A complete physical exam may only be necessary if you have specific symptoms, but weight and blood pressure checks are essential, especially if you have a family history of hypertension or are African American, where hypertension occurs more commonly and at an earlier age. Cancer screenings—mammography, Pap smear, and colonoscopy—are not annual tests but should be benchmarked at regular intervals. Skin screening for cancer is important when someone has significant sun exposure, and the doctor should inquire about smoking, drinking, drug use, occupation-related conditions (e.g., repetitive stress injury), and excessive stress. All these are important to your ongoing health history.
There is no hard-and-fast rule regarding bloodwork and X-rays, other than to ask your doctor whether you need specific tests and why he or she is ordering them. The medical community continues to research appropriate indications for testing; different doctors take different approaches. Just be informed as to the whys and wherefores of the tests. Younger patients, especially, should have ongoing records of their radiation exposure history from X-rays and CT scans. We may not know for decades whether we will confront an epidemic of medically related radiation cancers.
A final word on the routine doctor visit. Just talking with your doctor, so you know he or she cares, is a good way to spend a couple of minutes once a year. Yes, time spent thumbing through outdated magazines in the waiting rooms may be tiresome (doctors have to work on that), but getting to know your physician is a good idea. It might be old-school, but trust in your doctor is a vital element of your health, and that wasn’t mentioned in the studies cited by Dr. Emanuel.