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Bad Medicine: How the American Medical Establishment is Ruining Our Healthcare System

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O'Briens' Bad Medicine is an excellent discussion of how medical schools and teaching hospitals have contributed to the current health care crisis. As a family health psychologist on the clinical faculty of Harvard Medical school these last 20 years and an advocate for the collaborative family health care paradigm, I welcome this hard hitting, insightful, philosophically grounded presentation of how American medical priorities have often given us both poor health care and impossibly high health care costs. Many of my colleagues, health care practioners and medical school faculty are unhappy with what is happening, for our patients and ourselves. Some of us are beginning to see that we as doctors, medical school faculty and teaching hospital administrators, have been part of the problem. An example is an editorial (Aug 1,l999 Boston Globe) by Dr. Bernard Lown, senior physician at Brigham and Women's Hospital and Professor Emeritus at Harvard University School of Public Health. Dr. Lown writes, "Our health care system is on the verge of collapse..it began when doctors were seduced by financial incentives, with unquestioning third-party payers providing an open till. Care was fragmented among a bevy of super-specilists, with multiplication of mindless procedures, encouragement of un-called for office visits, and exposuer of patients to a glut of unnessary surgical intervention. Each procedure was converted into a profit center". Larry Obrien has written a strong book on the problem, tracing the history and philosophy of this medical/financial train wreck using his 25 years of experience in HMO administration. Bad Medicine is a great public policy contribution because it shows how and why the American government has colluded over the course of the 20th century. Congress has subsidized too many medical schools producing an oversupply of specilists, functioning for profit, with extraordinary high technology, to do often unnecessary procedures on individual body parts with an 18th century mechanistic mind set of repairing bodies like they were broken clocks. All this is still going on, when we health providers, consumers, administrators and legislators could and should be maintaining health defined as dynamic biopsychosocial functioning of human beings as we understand ourselves from the perspective of 20th century neuromolecular biological medical science and philosophy. Bad Medicine concludes with recomendations for collaborative health care, treating whole human beings by teams led by primary, family generalist health care doctors in local settings, in organizations given financial incentives to maintain health care with information systems that really help care and cost.

As a former federal health policy analyst I can't help but say "right on" to Lawrence O'Brien's thoughtful analysis of the problems endemic in the U.S. health care system and his carefully laid out steps for reform.

Certainly, the medical economic system and its incentives are awry, with demand set by the seller and the true price hidden from the consumer. But O'Brien also succinctly shows that the product is flawed explaining how and why the U.S. falls so far behind many other countries in indications of health and well being.

The litany of problems, linked to their roots, is a treasure trove of insight. Among them: How medical records are stored and handled contributes to the dearth of clinical science and evaluation. How medical schools create and then reinforce system problems. The effect on both medical outcome and economics of too many doctors practicing the wrong spcialties. How federal interventions have exacerbated problems.

Perhaps most instructive is O'Briens clear description and examples in everyday medicine of the important distinction between advances in true medical science, which discovers the causes and preventions of illness and disease, and advances in medical technology, which develops interventions designed to lessen the impact of disease for which no cure has yet been found. This is reflected not only in the banks of blinking and beeping machines in today's hospitals, but in the increasing specialization of physicians where technical skills are rewarded highly and payment for services aimed at preventing disease is almost non-existent.

O'Brien outlines steps needed for significant health care reform, adknowledging that the full-scale upheaval needed will be difficult to achieve. Nevertheless, he serves up an insightful and cogent framework for reform and, perhaps most importantly, prompts consumers to view the system in a different light. And that is perhaps the hardest task of all, convincing the patient that changes need to be made.

Finally, someone who's asking the right question.

Washington policymakers and the media ask the wrong questions about health care. How do we provide access? Control expenses? Pay the bills?

O'Brien asks: What are we buying? His answer is: "not much."

O'Brien is not a brainless firebrand. He drags us through the history of Western thought to make sure we understand the underpinnings of medical thinking. He wades through studies and statistics. Footnotes are everywhere.

In the end, he makes a levelheaded case: Medicine may not be good for you. His material about nosocomial infections--diseases you pick up in the hospital--was particularly frightening.

Pundits and policymakers are so busy yakking that they won't read this book. So you should.

Maybe you can convince them to stop trying to find the right answer to the wrong question.

And, you can be very careful when you go see the doctor.....

In 1965, I left a busy pediatric practice for academia (the School of Medicine at the University of Minnesota) to join an expanding group of health care professionals who were committed to a restructuring of medical education and training so as to promote more responsive and more comprehensive health care. It soon became apparent that those who had selected family medicine and who completed their residencies were having difficulty in finding a niche in the mainstream of medical care which was dominated by the technologically oriented specialists. Because of my frustration over the fate of these dedicated family doctors, in medical school and in their practice, I seized an opportunity to leave academia to be the medical director of an integrated health care system with a family practice base. This was several years before the name "health maintenance organization" had been coined. The fortunate choice to head this remarkable, embryonic organization in 1974 was the author of this book, Lawrence J. O'Brien. Because of that choice, I was fortunate to have had a seventeen year professional and personal relationship with an individual blessed with a vigorous intellect, an encompasing concern for human dignity and an insatiable curiosity as to the logic of people's behavior. The fact that Larry O'Brien's professional education was in the discipline of philosophy and not in the health field was not only unique, but allowed him to have a perspective that was insightful and different from the health administrators who became his colleagues. Larry approached health care as a personal social service with all of its human variables. However, he was often puzzled by the mind-set of the medical establishment and the strange logic that seemed to drive it. It is not surprising that, with his background in philosophy and logic, combined with a long and in-depth involvement in the medical care system, Larry should bring us the penetrating analysis of the current system that is represented in his book: Bad Medicine: How the American Medical Establishment Is Ruining Our Healthcare System. He has presented to us a whole fabric of basic logic applied to the medicine establishment which expresses the "wrong-headedness" of our current approach. I would hope that this scholarly but also pragmatic treatment of the need for change in the medical establishment will contribute to a restructuring that will result in better health care. We are fortunate, indeed, that Larry has shared with us the ideas that have evolved from his experiences

As a health care professional, I am also interested in reasonble critiques of the health care system. I agree with O'Brien that the complexity of the system revolves around economic issues as well. However, it is with premises that I disagree. Many (most?) physicians do not study to practice medicine primarily to "make money" or with solely financial goals. I say that because, if financial goals predominate, one goes to business school and gets an MBA, becomes a stockbroker, etc. It is quicker, cheaper (and probably easier) to get an MBA than an MD. (I personally have studied in both fields.)I do actually think that many good, honest physicians are to a large extent motivated by "helping people", science/technology, even just by social status. Honestly, this is true of many physicians I know. I believe that, once economists took a look at the health care field (broader than the "medical field"), they imposed a financial lens which they believe motivated (some? many?) physicians to seek the "lucrative" area of medicine.

The issue is the financing of health care, not the technicalities of health care itself. It is a "straw man" discussion to argue that physicians caused the economic problems (and therefore "they must be controlled"). Yes, some physicians caused problems (especially the entrepenuerially interested physicians, more closely allied to the business mentality themselves). But this self-serving argument, and the system itself has genuinely alienated the (many) decent physicians who really want to do well for their patients. Sure, physicians want to make "a good income", largely because of the time and expense of a medical education; but it is too narrow to think that is the sole (or even predominant) motive.

I would like to agree more with O'Brien as the author, but I also believe he presents a one-sided argument. The situation of health care (as a right? a social service? a commodity?)is an economic (political) policy question, not a question of "blaming" physicians and their cultural system.

Lawrence O'Brien has put together a thoughtful, thoroughly documented analysis of many of the critical problems with our medical practitioners. He has delved deeply into the practice of medicine as a business, and the manner in which financial and political motivations and incentives have caused practitioners to drift, sometimes widely, from the pure healing arts.
O'Brien understands these issues very well, having headed a large HMO for years and having followed the medical industry as it matured during the last several decades. His insights are very important to understand the practice of medicine in the U.S. and to assist in planning policy for its role in our society and its evolution into the future. MUST reading for anyone interested in or involved in the practice and business of medicine and the overall healthcare industry in America.

As a practicing surgeon, I am always interested in reading about ways of improving the health system. Although the description of the problems in healthcare were defined as a result of a misguided approach being practiced by "free barons of the Medical guild," other factors need to be considered.

Patients in the United States feel entitled to all the innovation and health care resources available without consideration of cost. Once patients realize that they have to take responsibility for their health (to prevent illness) then the need for technologically advanced treatments will diminish. While doctors do have a say in the need for procedures, patients must take ultimate responsibility for their health.

We must also consider that the present legal environment adds to the cost of health care. When malpractice premiums for surgeons are $65,000 - $100,000 per year that will impact how physicians practice medicine. Secondly, when the best and the brightest are seeking admission into medical school presently, does anyone expect that trend to continue if medical school debts can amount to $150,000 and limitations will be placed on the autonomy of physician decision making? HMOs may be the answer, but legal and financial jobs will be filled with the best and the brightest leaving medical jobs for dabblers.