Why the cost of delivering medical care is bankrupting America - one example

In my previous post I discussed Dr. Marty Makary's book Unaccountable about what goes on behind the scenes in American hospitals. One of the issues he raises is the number of unnecessary or unwarranted procedures that are done on patients. In his aptly numbered chapter 11, entitled "Eat What You Kill", he describes the excesses of a system in which the doctor has become more a salesman than a primary healthcare provider. One result of this business model is that many procedures such as back operations, spinal fusions and angioplasties are done to excess, with huge costs to the system.

To support this Dr. Makary cites a 2012 study, entitled "Appropriateness of Percutaneous Coronary Intervention" (PCI, or more commonly known as angioplasty). The study found that in the space of a little over a year (July 2009 to September 2010), there were altogether 500,154 such operations, of which 355,417 (71.1%) were for acute indications (such as myocardial infarctions and unstable angina) and 144,737 (28.9%) were for nonacute indications, which I imagine means that the patient was experiencing symptoms, but not in distress or imminent danger.

Of the latter group, surgery for nonacute indications, "72,911 PCIs (50.4%) were classified as appropriate, 54,988 (38.0%) as uncertain, and 16,838 (11.6%) as inappropriate."

In short, that's almost 17,000 unnecessary operations, and almost 55,000 questionable ones, for a total of 72,000, all in the space of 15 months.

Out of curiosity, I next went on Google to find out how much an angioplasty costs. I found this topic discussed at angioplasty.org. The numbers varied wildly. One quoted price was this:

About the cost of angioplasty and stenting in the US based on medicare payment: Cardiologist fee: $838 for one vessel, each additional $233 Hospital fee: $10,371-$18,227

Then a man from Texas spoke up and said he paid $101,000.00 and it was worth every penny. Other people chimed in with numbers in the vicinity of $50,000 to $90,000, and people from outside the US gloated that theirs was free (in Canada) or a few hundred euros for the hospital stay (Ireland).

At any rate, the reason I bring these numbers up is to point out that those 72,000 unneccesary or questionable angioplasties from July 2009 to September 2010 cost Americans anywhere between $720,000,000 (if you calculate $10,000 per procedure) and $7,200,000,000 (if you calculate $100,000). That latter figure is $7.2 billion, by the way. Now add in all your unnecessary back operations and spinal fusions at $12,000 a pop, give or take a few thousand, and you have numbers for unnecessary or questionable surgeries that are not just in the stratosphere, but way beyond, hovering somewhere around Jupiter if not out of the solar system altogether. No wonder America is in danger of going bankrupt.

PS: And the true shocker is that according to a recent study angioplasty for these nonacute patients (who had stable angina or narrowed arteries) was no better than optimal medical therapy and lifestyle change. The study found that

getting angioplasty and a stent to hold open a narrowed artery didn’t offer any extra protection against a heart attack, stroke, hospitalization for acute coronary syndrome (the umbrella for heart attack and unstable angina), or premature death ... If you have chronic angina, it’s worth giving medical therapy the old college try. One of the findings from [the study] that surprised even researchers was how effective medical therapy was at relieving angina and improving quality of life. You might be surprised at how well exercise, a better diet, and medications can make you feel. If, after six months to a year, your angina is still bothering you or keeping you from doing activities you enjoy, angioplasty or bypass surgery are reasonable next steps.

If that is indeed the case, then the number for unnecessary angioplasties may be a lot higher than 17,000.

Iatrogenic disease - part 2

Oh my God. Oh ... my ... God. I am just reading a book, Dr. Marty Makary's Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Healthcare. Dr. Makary is a surgeon and an associate professor at Johns Hopkins. I can't put the book down. My blood pressure must be in the stratosphere. I am reading things that are making my hair stand on end.

Dr. Makary is scathingly honest about his profession. His candor burns like a cauterizing iron. In this book patients die; patients are maimed; mistakes are swept under the rug; surgeons who should never be allowed near patients continue to practice; professional bodies that are charged with overseeing doctors routinely fail to do so; and whistle-blowers who advocate for patients get fired or drummed out of the profession.

The scale of the problem is huge. In his introduction, and later in his chapter 8 (entitled "Impaired Physicians"), Dr. Makary writes of attending a conference where a renowned Harvard surgeon asked his audience if any of them had a colleague who they knew should not be performing surgery -- in an audience of thousands, every hand went up. He calculates that if only 2 per cent of America's doctors are impaired, that's 20,000 unsafe doctors, who altogether see about 10,000,000 patients a year. He calls this "a public health crisis".

As an intern at Harvard, Makary trained under a surgeon who was referred to behind his back as Dr. Hodad. "Hodad" stood for "Hands of Death and Destruction". Dr. Hodad had impeccable credentials, an unimpeachable presence, and a splendid bedside manner. His patients adored him and had no idea that his incompetence was the reason for their long hospital stays and their post-surgical complications.

Hospitals have no reason to rein in such surgeons, Makary tells the reader, because post-surgical complications add dollars to their coffers. The greater the number of procedures that need to be done, the longer a patient needs to stay, the more money a hospital makes: about $10,000 on average for each complication. Incompetence only becomes an issue if the patient who dies as a result is famous and the story gets wide-spread public airing, causing the hospital major embarrassment. There is a culture of omerta. Makary relates the story of a heart surgeon, one of four in a well-known hospital, who had "six consecutive deaths during routine bypass surgery". Soon after the sixth death, he was about to operate on yet another patient, when the patient asked the anasthesiologist, "Is my surgeon a good surgeon?" Thinking quickly on his feet, the anasthesiologist replied, "He is one of the four best heart surgeons we have here", and the patient luckily didn't ask how many there were. This young doctor was routinely protected by the other heart surgeons, who attributed the deaths of his patients to "extenuating patient circumstance".

Makary's point is that patients have no way of knowing whether they are in the hands of a competent doctor or a Dr. Hodad. Medical students who barely pass, or who have untreated substance abuse or psychiatric problems, also become doctors and receive a license to practice -- with little or no accountability. Doctors with known substance abuse problems may not be allowed to drive their cars, but they are still allowed to wield scalpels and prescribe potentially lethal drugs. Makary writes:

After we doctors graduate from medical school, the government, via state medical boards, pretty much gives us a pass to do whatever we want.... After ... I got my license based on a 70-per-cent-or-higher passing score on my board exam, I was literally licensed to do anything in medicine -- perform brain surgery, prescribe chemotherapy, remove varicose veins, or do electric-shock therapy for psychiatric disorders ... I can legally do anything.

The issue is not only a small percentage of incompetent physicians, but also the "Wild West" attitude endemic in the culture and practice of medicine. Much has been written about the conditions under which young doctors are trained: brutal work hours; little sleep; inadequate support; even psychological abuse. The conditions are such that it is often impossible for them to deliver even adequate care. Makary writes about one night when he was an intern at D.C. General Hospital, trying to handle twelve emergency cases all at once. He called his chief resident for help and got shouted at for his pains. He then did his best on his own, with the help of a medical student, but two of the patients died. He mentions other cases where patients died because the intern on duty was spread too thin. So when he also cites a study claiming that one in four hospitalized patients experience some kind of harm due to medical error, the surprise is not that the number is so high, but that it is so low.

Makary quit his medical training after one of his own patients came to grief despite his best efforts to prevent her having the entirely unnecessary procedure that harmed her. He says:

I felt disillusioned. It seemed as if, despite all the book knowledge I had gained, nearly half of the patients I saw in the clinics had problems for which modern medicine had nothing to offer except phony names for diseases we didn't understand. The other half .... seemed to be sick because they were obese, smoking or not taking care of themselves -- preventable problems.

He switched to the Harvard School of Public Health, where he learned a whole new perspective on disease, and later returned to medicine because he missed the contact with patients, resolving to practice medicine as he thought "it ought to be practiced -- with honesty".

The economic angle
The book also takes aim at the business model of medicine, in which doctors are encouraged to perform ever more procedures to generate income for the hospital, and in which the CEOs of children's hospitals are compensated to the tune of millions of dollars. As an example of the business attitude that pervades healthcare he quotes an email sent by a hospital administrator to the surgeons in his department, which reads, "As we approach the end of the fiscal year, try to do more operations. Your productivity will be used to determine your bonus." He points out that doctors and hospitals profit from prescribing chemotherapy, that doctors receive commissions, royalties and consulting fees from using prosthetics and surgical implants. Between paying for errors, unnecessary procedures, and excessive compensation under what Makary calls the "eat what you kill" model, it is little wonder that the U.S. is staggering under the costs of delivering healthcare to its citizens.

Parts of the book deal with solutions, which is just as well, because otherwise it would be an infuriating and depressing read. The larger perspective Makary attained at the Harvard School of Public Health allows him to provide suggestions for systemic improvement. He advocates salaries for doctors rather than payment per procedure; transparency about patient outcomes; public access to information; changing the workplace culture of hospitals to privilege teamwork over hierarchy and safety over profit. He especially highlights the importance of teamwork: in the interest of patient safety, everyone who works at the hospital, regardless of where they are in the hierarchy, should be able to speak up, just as anyone on the Honda assembly line is allowed to shut it down if they spot a problem.

After lambasting his profession for most of the book, Makary reveals at the end that he is optimistic about the future. The culture is changing; the medical students he now works with are more into openness and honesty with patients and are less willing to put up with hazing and shenanigans than his generation was. New technologies such as interactive patient records and video cameras in the operating rooms aid transparency. The internet has revolutionized the ability of patients to obtain information so they can ask more knowledgeable questions. There is a light at the end of the tunnel. My blood pressure back to normal, I was pleased to read that the new generation of medical students is open even to alternative therapies.

And in the meantime, until the system is thoroughly reformed, Dr. Makary offers patients a list of questions to ask their doctors on his website, www.unaccountablebook.com.

On palliative chemotherapy and "false hope"

Almost a year ago I posted an Open Letter to Oncologists in which I detailed our experiences with energy healing and terminal cancer and advocated offering patients who could not be cured with conventional methods the energy healing option. My reasoning was that in our experience bioenergy healing was better at palliation than chemo, offering improved quality of life without any debilitating side effects.

There are many cancer patients who come to the point in their treatment where their doctors tell them that they have run out of curative options and that further chemotherapy and radiation would only serve palliative ends. In other words, when the cancer gets bad enough, treatment is offered to shrink the tumour to make it interfere less with the body's functioning.

But now comes research from the Dana-Farber Cancer institute that shows that patients who receive such treatment are more often than not unclear about its purpose. A research article published in the New England Journal of Medicine entitled "Patients' Expectations About Effects of Chemotherapy for Advanced Cancer" shows that a large percentage of terminal cancer patients surveyed (69% of those with lung cancer and 81% of those with colorectal cancer) were not aware that the treatment they were receiving was meant to be palliative and not at all likely cure them. The rate of misunderstanding was higher among patients who rated their communication with their doctor very favourably.

I find it highly ironic that the same medical establishment that accuses alternative therapists of selling "false hope" and "snake oil" finds itself in the position of inadvertently doing just that. At the same time I can see the difficulty of making clear to patients that the treatments they will be receiving, which will likely make them feel quite awful, have no curative purpose. But perhaps it is time for the medical establishment to take off its blinkers and start looking at other therapies that may serve this patient population better than chemo.

Update November 13: Just ran across an informative article entitled "Palliative Chemo: When Enough is Too Much" in Clinical Oncology. Well worth the read on this topic.

Follow up to "Open Letter to Oncologists"

Recently I received an e-mail from a fellow energy healer, Reiki Master Alice Langholt. She and a colleague have been treating a woman with inoperable breast and bone cancer who had been bed-ridden for six weeks. The patient was exhausted and in pain, unable even to sit up on her own. With treatment she sat up, experienced more energy, developed better colour, then was eventually able to get up and to get around with a walker and even walked downstairs with the help of her physical therapist for the first time since July. She has been receiving bioenergetic support in the form of Reiki, Quantum Touch, or cranio-sacral therapy three to four times a week. Alice has also taught both her and her husband Reiki so they can do treatments on their own. While Reiki will likely not halt her cancer, for now she is feeling better.

In an earlier post I spoke directly to oncologists advocating bioenergy therapies for patients who in their view have come to the end of the road of curative treatment and were now looking at hospice and palliation. I pointed to our experience which showed that with energy healing the qualitative daily experience of life could be considerably improved for such patients, sometimes even bringing physical improvement.

Bioenergetic support makes sense for cancer patients in any phase of their illness. Many hospitals now offer Reiki or Therapeutic Touch, in most cases free. In most cities there are competent Reiki practitioners and teachers and there is now a growing number of Bengston Method and Domancic Method practitioners throughout North America. One single appointment can show a cancer patient what these therapies can do for his or her well-being.

"Iatrogenic disease": the view from up close

Here is a frightening statistic: an article published in the year 2000 in the Journal of the American Medical Association calculated "that between 230,000 and 284,000 deaths occur each year in the US due to iatrogenic causes, or physician error, making this number three in the leading causes of death for all Americans."* That's a quarter million Americans dying each year due to hospital mix-ups, adverse drug reactions from prescriptions drugs, hospital-acquired infections and botched surgeries. Quite a number to swallow: the equivalent of about five hundred 747s crashing every year, killing all passengers on board. And this number does not even included those are not killed by the error, but "only" maimed.

[Now you can also read "Iatrogenic disease - Part 2"]
My mother was only 51 when she died a few short hours after her first radiation treatment for a recurrence of breast cancer. Her tests showed her to be cancer free when her oncologist, whom she said she "trusted with her life", suggested "prophylactic radiation". She was on Tamoxifen, implicated in causing blood clots, and had to have the radiation rescheduled because her chest cavity had been "mismeasured". A second such mismeasurement could have led to radiation burns in her lungs, edema, and death. Yet there was no inquest into her unexpected and untimely death.

The mother of a friend of mine has had repeated, and devastating, experiences with iatrogenic disease. She was already suffering from Alzheimer's when she was diagnosed with a particularly deadly form of lung cancer. Her doctors were 99% sure she had this cancer and recommended surgery. So deadly was the cancer believed to be that they recommended against doing a biopsy. She had the "cancerous" lung removed. She then went into full-blown dementia as a result of the stress of this horribly invasive surgery. When the lung was sent to the lab, it turned out that what the doctors believed to have been cancer was in fact scar tissue from a bout of pneumonia. There was no cancer.

Fast forward a few years. Once again a doctor saw something he suspected to be cancer; this time skin cancer. He proposed doing multiple biopsies. The woman's daughter raised objections, which the doctor overrode. Two days after the biopsies were done, the elderly patient became septic. No antibiotic seemed able kill the bacteria raging through her system. By the time the infection was finally brought under control, the patient had lost the will to live and passed away.

Not all these patients die; some are "merely" maimed for life. While they don't become part of the statistics on medical error causing death, these instances cost untold amounts of money to an already overburdened system. First there is the cost of the initial, often unnecessary, intervention, then there is the cost of trying to fix the mistake, and then there is, in the case of younger patients, the economic loss when the victim becomes so disabled that he or she is no longer able to work.

And more important than cost is the burden of suffering, borne largely by the elderly. In my mother's case the judgment of a doctor ended up costing her her life, but at least her death was quick and relatively painless. My friend's mother's case became a textbook example of what Bill Bengston bluntly calls "torturing [the elderly] on the way out."

Simply put, what is the benefit of doing a biopsy for basal cell carcinoma on an elderly woman suffering from Alzheimer's? What is the benefit of doing a double mastectomy on an 86-year-old patient with a slow-growing cancer who then dies of a stroke less than a year later? How many painful procedures should the elderly have to endure? Shouldn't we ask, how necessary is this? Shouldn't we do a humane cost/benefit analysis as in "how much suffering is this going to cause? how likely is this to harm/benefit the patient?" This is a discussion that should take place in every single case, possibly in the presence of a medical ethicist or a professional who specializes in elder care. Many doctors are way too "intervention happy". If the only tool you have is a hammer, then you see everything as a nail. If intervention is the only tool in your toolkit, that's all you will do. Family members can also buy into the medical mystique and believe that more intervention is better, until their loved one comes to harm. In many cases palliation and alternative therapies offer better outcomes.

A study published in the New England Journal of Medicine in 2010 showed that lung cancer patients who received palliative care along with conventional treatment lived longer and had better quality of life than patients who received conventional cancer treatment alone. The study "showed that people who received the palliative support services were less likely to choose aggressive, and often futile, measures to prolong their lives." In contrast I recently heard a doctor say in an interview on CBC that he sees more and more advanced cancer patients going from chemotherapy straight to the ER, and then from there to the morgue, as many doctors prescribe more and more aggressive treatments. This is definitely "torturing them on the way out", and it's questionable how necessary it is.

Obviously no doctor or other medical professional does a procedure with an intent to injure. But the truth of the matter is that cookie-cutter medical protocols applied or mis-applied to unique human bodies will result in at least some of them being harmed when things go wrong. Should we continue to accept this "collateral damage" as part of the business of practicing medicine in North America?

Postscript Sept. 26: And now see this NBC article, which estimates that only about one percent of events that cause harm to patients are reported by hospitals and asks why patients themselves are reluctant to report medical errors.

And also this: The Drugs Don't Work, an alarming expose of how drugs are approved.

And now the medical perspective:

Bioenergy therapies and mainstream medicine

Two news items came my way recently offering encouragement that bioenergy therapies are gaining acceptance in the mainstream.

The first was a headline in Science News proclaiming that "Touch Therapy Helps Reduce Pain, Nausea in Cancer Patients, Study Suggests". The study, conducted by the University of Kentucky Markey Cancer Center and involving 159 patients, showed that Jin Shin Jyutsu, a form of acupressure similar to shiatsu, lessened the side effects of treatment, with patients reporting significant decreases in stress, pain, and nausea.

The second news item came from the Columbia University Department of Surgery no less, announcing that Dr. Sheldon Marc Feldman, Chief of the Division of Breast Surgery in New York-Presbyterian Hospital/Columbia University Medical Center, would be participating in an upcoming Reiki conference. Dr. Feldman (like his famous colleague Dr. Mehmet Oz before him) introduced healers into the operating room and has seen first hand the benefits that Reiki offers to his breast cancer patients.

This is huge news. I've been advocating for this kind of integrative approach for the benefit of patients for a while now (see my "Open Letter to Oncologists", posted last November).

Cats and the Domancic Method of Energy Healing

The last time I wrote about cats and energy healing, I raised the ire of some skeptics on Twitter, who proceeded to poke fun at me about the cosmetic effects of the treatment not offering any kind of proof for the efficacy of energy healing. This time I have something more concrete to offer: two cats, one with a case of hyper-thyroidism and the other with uncontrollable diabetes due to a benign pituitary tumour.

I treated both cats with the Domancic Method. Cat number one, the one with hyper-thyroidism, doesn't like energy healing. Aim it her way, and she'll be gone in a flash. Her response to the Domancic Method was interesting, to say the least. She growled. The first session she started growling the moment I began. She bristled and growled like a dog but stayed put. The second session she started growling a little later. The third, she didn't begin growling until towards the end, and the fourth, she didn't growl at all. What amazed me was that she stayed put. She didn't like it, but didn't run away, even though she had the option.

Two weeks after the fourth session, her owner called me to tell me that her thyroid had normalized. All her symptoms (over-vocalizing, excessive grooming, not eating) cleared. The improvement was lasting.

Cat number two apparently developed diabetes, which could not be controlled with insulin. His blood sugar was all over the place. I tried the Domancic diabetes protocol on him, and it didn't work. Although this would not in the least surprise the skeptics, it surprised me: Domancic protocols are usually quite effective on pets. Then the cat's vet finally came up with a diagnosis: the irregular blood sugar was caused by a benign pituitary tumour. She said the only way to control the condition would be radiation, which the cat's owner opted not to do. I then switched the cat to the Domancic protocol for tumours, and four series of treatments later, his blood sugar stabilized. This was about two months ago and it's still holding.

Years ago I worked on a cat that had a brain tumour that affected her nasal passages and caused her to sound like Darth Vader as she breathed. I treated her with the Bengston Method. After every treatment her breathing was normal for about three days. It quite amazed me. Animals don't do "placebo effect". If something works on them, it's not because they have some kind of magical belief in its effectiveness but because it really works.