Medical Hell, Part III: 7.5 Minutes

Most doctors schedule four to eight appointments every hour. Eight appointments an hour, which seems to be the norm for orthopedic surgeons, means an average of less than 7.5 minutes per patient, given that the doctor must spend some time walking from room to room, etc. We're probably lucky to get five to fifteen minutes of our doctors' attention in the average appointment. Next time you visit your doctor, look at the sign-in sheet and figure out how little time the doctor has allotted for your consultation or examination.

In these short appointments, we are expected to make important decisions about our health: whether to take a medication, to undergo a procedure, or to just let things be. It is simply impossible to make a good decision in such a limited amount of time, and I can think of no other profession that gives such short shrift to its clients. Yet there is no profession more important than medicine.

I am confident of the problem, but I am less sure of the cause(s) and solution(s). Nevertheless, in the spirit of the internet (speaking out when you are not really sure if you know what you are talking about), here goes:

The underlying problem is that we simply do not have enough doctors to go around. There are two reasons for this. First and foremost, we do not have enough medical schools. There are only about 125 medical schools in the entire United States, about 1 for every 2,500,000 people. As a result, there are many capable students who would be more than happy to pursue a career in medicine, but who are not able to qualify. We would do well to close a few law schools and open a few medical schools.

Second, medical training is unnecessarily long. Many doctors --dermatologists, for example -- do not use even a fraction of what they learn in medical school. These specialists should be given separate degrees, with training focused on what they will need in their practice. Think of dentists, for example. Reducing the length of training means that each medical school can produce more doctors.

Clearly, there is a need for some doctors who know all fields well, and there is a need for all medical practitioners to have a certain minimum understanding of how the human body works. But, in a world of limited resources, it makes sense to allocate education more carefully.

Phasing Out Pharmacies

There was a time, or so I was told, when pharmacies and pharmacists played an important role in our health care system. If those days existed at all, they are now long gone. It is high time that we begin to phase out the pharmacy. We should do so by progressively making more and more medications available without a prescription. At the same time, we should ban advertisements for any medication.

Pharmacies add a significant layer of expense to our health care system. While I can buy aspirin or ibuprofen at the 7-11 store, I can only get meloxicam (an anti-inflammatory that serves the same purpose as ibuprofen and is no more dangerous) at a pharmacy. That creates two different kinds of expense. First, it adds to the cost of the medication. A pharmacy must have a highly trained -- and highly paid -- pharmacist on duty at all times. In addition to the pharmacist, there is almost always a second employee who hands out the prescription medications and often rings them up on a separate cash register. Furthermore, the pharmacy incurs expenses in complying with various regulations. Compare that to the cost of selling aspirin. A store simply stocks the shelves with bottles, and the customers help themselves.

The pharmacy also imposes a non-monetary cost, one which I find particularly vexing. I can get an aspirin at the 7-11 or Trader Joes at any hour, without a prescription and without an appointment. Getting propanolol (a common beta blocker) requires a prescription, which must be presented at a licensed pharmacy. I must then wait until the pharmacist fills the prescription, and stand in a special line to receive that one item. That process is a waste of time, in addition to a waste of money.

I suspect that the prescription system imposes yet another cost, which may be even more important than the two costs described above. The prescription system discourages patients from being good consumers and paying attention to the choices they are making. Prescription drugs are treated as holy: only the doctor decides which ones we take, when and in what doses. The insurance companies have their secret formularies, which try to impose on the doctor's choice. Then, only the pharmacist can actually deliver the goods. Even a patient who wants to get involved in choosing a medication will have a hard time doing so in the face of those three forces.

Compare the purchase of pain killers, where the patient can select from a variety of over-the-counter medications, in various doses, brand name and generic. These medications quickly lose their magic aura, and patients learn to make intelligent choices. Consumers feel free to think for themselves and experiment appropriately with the available products. They learn to avoid overpriced brand names, and they learn which medications work best for them. I suspect that eliminating the prescription requirement on a medication would quickly create more savy consumers and thus reduce the price the market would bear in many instances. I bet the big pharmaceutical companies would hate the idea of phasing out the pharmacy.

We do not get anything worthwhile from pharmacies. Few, if any, patients actually seek the advice of the pharmacist. If a few patients want to pay for such advice, they should of course be free to do so, but there is no reason to require everyone to pay for advice which very few of us want or even receive. Pharmacists do not tell us how and when to take medication; doctors do that. The pharmacist simply copies what the doctor wrote down and, in my case, often makes mistakes in doing so. Theoretically, a pharmacist could alert a patient to conflicts between medicines. That only works, however, if the patient always uses the same pharmacy. The only time I have been alerted to a conflict was by my doctor, and one of the conflicting medications was non-prescription, so a pharmacy could not catch it, even if it knew all of the prescription drugs I was taking.

The prescription system most certainly does not protect those who would abuse drugs from getting what they want. Even making a drug completely illegal does not prevent determined buyers from getting ahold of it. The prescription system provides even less protection than an outright ban. One who is determined to get his hands on a prescription drug can always find a crooked doctor, forge a prescription, fake a symptom and/or send the same prescription to ten different online pharmacies. Pharmacies are not in the business of preventing the improper sale of medications.

Far more importantly, only a small minority of prescription medications are drugs of abuse, i.e., fun. No one is going to pop Lipitor at a party. Sudafed, on the other hand, can be turned into a drug of abuse.

Most prescription medications are no more dangerous than over the counter medications. It is easy enough to kill oneself with all sorts of household items, beginning with alcohol. I doubt that taking an entire bottle of Crestor is any worse than taking an entire bottle of ibuprofen.

In the end, pharmacies are just another entrenched special interest. We take it for granted that they are necessary, but they are not. It is time to start phasing them out.

Medical Hell, Part II: I Wish I Were a Dog

Our medical system is so badly broken, we would all be better off if we were all dogs or cats. I do not say that sarcastically; I believe my pets have received far superior medical care to what I have received, and at a far lower cost. We would do better to simply scrap our entire system, and replace it with what we give our pets.

My dog can get an appointment for a check-up within a day or two. I have to wait several months. My dog can see a specialist within a few days. Again, I wait for months. His wait at the emergency room is a fraction of mine. Moreover, his vet spends time with him and with me, explaining the situation, offering various options and even sympathizing when times are hard. Our vet returns phone calls. He even gave us his cell phone number, without me asking. Our vet also hands me all the medications my dog needs, without having to go to a pharmacy. Most importantly, our vet seems at least as knowledgable as any doctor I have met. The nurses I encountered while in the hospital were so bad I would have been better off without them. Doctors often seem to know their stuff, but spend so little time with each patient that it hardly matters. In every respect, our pets get far better medical care than we do.

The cost of this service is far lower than what we pay. My dog was hospitalized for five days, and the total cost was $1,900. I was in the hospital for 12 hours, and the co-pay to the hospital was over $3,000. The doctor charged me separately. Moreover, those are the amounts that I paid personally, with insurance. The insurance company paid more, and I paid the insurance company premiums every month for the privilege of paying those prices.

I am not sure why our medical system is so badly broken. Some might point to the high cost of medical malpractice insurance. While the cost is indeed high, it is not nearly high enough to play a material role in causing the problems we face. Perhaps different kinds of people become veterinarians rather than doctors. Maybe it is the absurd bureaucracy created by the insurance companies that has broken our medical system. It could be that the massive amount we spend on the last six months of life bogs the system down, whereas our pets euthenized when that is the merciful thing to do. I certainly am not qualified so say what is causing the problem, but I can say this: nex time I need medical care, I will be wishing I were a dog.

The End of Faith by Sam Harris

At its heart, The End of Faith is about the difference between faith and reason. Faith is blind. It is not based on evidence or reason, and therefore offering evidence or reasons will not shake the faithful from their beliefs. Harris thinks that is very, very dangerous. It will come as no surprise to anyone that he began writing this book on September 12, 2001.

Harris argues that relying on faith instead of reason is a bad way to lead your life. It leads to all sorts of weird and dangerous beliefs, prevents important scientific discoveries, and stirs hatred between people who hold mutually inconsistent faith-based beliefs. Of course, people make mistakes when they rely on evidence and reason, but at least if we rely on reason and evidence, we are moving in the right direction and we are open to changing our minds when we are wrong. If our beliefs are based on faith, we are stuck forever.

There can be no doubt that faith gets in the way of progress in areas such as medicine. For example, a sizeable and vocal minority of Americans do not believe in evolution because it clashes with their faith-based beliefs. Yes, there is a vital connection between evolution and medicine. Our bodies, and our minds, are the products of evolution. An understand of evolution is crucial to understanding how our bodies are designed, but because of the faith-based, unreasoned beliefs of a minority of people, evolution is not sufficiently taught in schools. As a result, we all suffer in terms of medical care, mental health and many other areas of life.

The End of Faith will make religious people uncomfortable. Harris says exactly what he thinks, without making an attempt to spare the feelings of the religious. He does not, however, call anyone names or say anything in order to be mean or offensive. He simply states that facts as he sees them. Some reviewers claim that Harris is "intolerant" or a "fundamentalist." They are wrong. Harris, unlike many religious leaders, fully supports the right to think, say and believe as you wish. He opposes any form of oppression.

On other hand, Harris also reserves the right to think some beliefs are foolish. You probably do not respect the belief that Elvis is alive. Harris feels the same way about religious beliefs. He certainly would not want to see Elvis believers put in jail or denied rights, but he feels free to say that belief in Elvis is just plain wrong.

Medical Hell, Part I: Sign Your Life Away

I'm planning on posting a short series of comments on the failings of our medical system, based on my experiences. In each case, my point is not to whine that I have been treated poorly. Quite the opposite, I believe that the treatment I received is typical or even "good" by our incredibly low standards. It is the medical system that I wish to criticize, not my particular health care providers. Here's the first installment:

A couple of months ago, I decided to undergo a relatively low risk heart procedure. The first available appointment was about six weeks in the future when I made the decision. During that six week period I visited the doctor once, received various papers in the mail with instructions on where to show up and when, as well as several phone calls asking to confirm the appointment and for information designed to make sure that the hospital can get paid for its services.

It was not until the just before the procedure, however, when the IV was already in my arm, that the hospital gave me detailed legal waivers to sign. Then, the nurse came in and told me she wanted to discuss the various risks of the procedure so that I could give my "informed consent." All this while I am already lying in a hospital gown with a rubber pipe sticking out of my arm. One other minor point: before all this happened, I had already passed out once when the nurse tried to get the IV into the back of my hand and, after several minutes of trying, failed and had to pull it out. My blood pressure dropped to 72/42: the perfect time to sign legal documents and make important decisions about one's health care.

I know I don't really need to say more, but I cannot resist. Just imagine me saying, "wait, nurse, I need to review the fine print in this release before I sign it." Or how about, "nurse, I'd like to negotiate here in paragraph 24.2(a)(2), where the arbitrator is JAMS. How about the AAA instead?" Or how about this one: "What? There is a risk of stroke in this procedure? Well, in that case, I changed my mind. Take this IV out of my arm, I'm going home!" Sadly, I was in no condition to be a smart-ass. What actually happened is that I signed the releases without reading them and told the nurse not to go over the risks with me, lest I pass out a second time. She beat a hasty retreat. (Yes, I knew the risks. I did my own research).

This "sneak attack" is standard operating procedure in our hospitals and doctors' offices. After the patient has bought the health insurance showing the doctor as a preferred provider, and after the patient has arrived for his appointment, the doctor presents forms waiving many important rights. Sign it or you get no treatment. Hospitals routinely wait until the patient is checked in before demanding that the patient sign their forms. Sign it or check back out.

I used to trust doctors and hospitals, but no more. This outrageous conduct is only one of the many reasons.