Taking Advantage of the Medical Specialist
During the past four decades I have witnessed the rise in power and prevalence of the medical specialist, largely due to incentives that have been brought about by advances in technologies in the medical device and pharmaceutical industries. Unfortunately, the life-improving benefits for the patients from these advances have been few and the harms caused have been substantial. However, the well-informed patient can work, to his or her advantage, the present system dominated by specialty care.
About two-thirds of the medical doctors in the US are specialists, compared to about half in other industrialized countries. The American health-care system prides itself on having so many specialists; however, the results of this dominance of experts are far from flattering. For example, the rates of heart surgeries are highest in populations living in Brazil and the USA, intermediate in Canada and Australia, and lowest in Hungary and Poland. Yet, there were no differences in rates of death by heart disease or heart attacks among these countries. Plus, the rates of stroke were higher in Brazil and the USA than in the countries with lower intervention rates. In the USA, patients with heart attacks are 1.7 times more likely to be treated in a coronary care unit and receive cardiac procedures, calcium channel blockers, and thrombolytic agents than in Poland, yet the death rates are identical.
The desire of Americans for more high tech medicine is based on the common belief that specialized care means better care. All of this expensive and dangerous testing and treating might be acceptable if it resulted in an improved outcome for the patient. A study of 13,270 adults found people with a primary care physician, rather than a specialist, as a personal physician were more likely to report fewer medical diagnoses, have one-third lower annual healthcare expenditures (mean: $2029 vs $3100) and about one-quarter lower mortality.
The Hard Sell from the Specialist
As part of their formal education medical students are taught highly effective, standardized, messages to sell various treatments to their patients. Here are some common examples:
The Sales Pitch: Bypass Surgeon talking to the distraught wife after her husband’s heart attack, “Mrs. Jones, do you know what we call this kind of heart blockage?” (Doctor is pointing to the angiogram of her husband’s heart arteries). “We call this a widow maker.
The Truth: Because the large blockages that are bypassed, by this heart surgery are stable they cause almost no risk for death, so bypass surgery in most cases does not save lives compared to no surgery. The tiny volatile pustules distributed along the inner surfaces of the arteries which rupture, forming blood clots, are the actual killers. Surgery does not affect these potentially fatal lesions.
The Sales Pitch: Cardiologist, in the room alone with the husband following the diagnosis of heart disease says, “I met your wife and kids. Nice family. You must understand that unless you have an angioplasty to open your blockages you won’t live to reach the hospital doors.”
The Truth: Angioplasty has never been shown to save lives. Actually, this treatment ruptures the hard stable plaques. In fact, after such meddling by the doctor, 20% to 50% of the arteries so treated close completely down.
The Sales Pitch: Surgeon discussing benefits of a mastectomy. “The only way we can get all the cancer is to remove your entire breast.”
The Truth: By the time of diagnosis by mammogram or self-examination, the cancer has been slowly growing for an average of 10 years and is beyond the reach of any local surgery (rarely may the cancer still be confined to the lump). Simple removal of the local tumor (lumpectomy) results in the same survival rates as a mutilating mastectomy.
The Sales Pitch: Oncologist talking to a man just diagnosed with colon cancer. “Modern chemotherapy is so effective these days that you would be foolish not to take it. This is your only chance for a cure.”
The Truth: Most of the cancer drugs used today are the same ones I used in my medical school training nearly 40 years ago. Chemotherapy didn’t cure patients then, nor does it work any better now. For most solid tumors, such as colon cancers, the drugs used are highly toxic to the person’s body and have little specific killing effect on the tumor. The overall results are that the prolongation of life is almost imperceptible, yet the deterioration in the patient’s quality of life is undeniable.
The Sales Pitch: Gynecologist explains to a middle-aged woman, “Since you’re not going to have any more children there is no reason to keep your uterus. After the surgery; no more painful periods, no more risk of pregnancy, and no more risk of cancer.”
The Truth: A woman’s uterus is not a “throw-away-organ.” It produces heart-disease-preventing hormones, provides support for the other pelvic organs, and produces important lubrication for sexual intercourse. This organ is uniquely female and many people (men AND women) regret its loss. Plus, any surgery is risky.
The Sales Pitch: Endocrinologist adamantly admonishing the patient, “If you don’t take your blood pressure and diabetic pills you are a fool—you will die of a heart attack.”
The Truth: The treatment of high blood pressure with pills does not decrease the risk of death from heart attacks and makes little absolute difference for risk of stroke. The common pills used to treat type 2 diabetes (sulfonylureas) increase the risk of dying of heart disease.
Why Do Doctors Specialize?
Why after 12 years of grade school, 4 to 5 years of college, and 4 to 5 years of medical school, would a young doctor want to dedicate 3 to 7 more years to becoming a specialist? Ideally, the motivation would be altruistic, such as specializing to become a more knowledgeable and skilled expert, better able to help patients live healthier lives. Unfortunately, the drives to make more money and to enhance one’s status are equally correct answers. Being a specialist garners respect from patients and from fellow doctors. As a result, these experts provide the bulk of continuing education for fellow physicians (often sponsored by pharmaceutical companies), generate the vast majority of a hospital’s revenue, have a major influence on health care policy at a local and national level and receive the highest incomes among doctors.
The money-motive for specializing is not hidden. Consider what the physician recruitment and staffing company, Martin, Fletcher, writes about cardiology: “New medical developments such as drug-eluting stents are fueling the rise in demand for Interventional Cardiology. The whole market for Interventional Cardiology is expected to double by 2006. Finding a Noninvasive Cardiologist can be extremely difficult as well because most want to expand their practice to include Invasive Interventional Cardiology because of the income potential. Cardiology remains in the top 2 income generating specialties for rural hospitals and top 5 for urban hospitals, so the demand and compensation for Cardiologists will continue to rise at or above the 12% rise that was seen last year.”
Specialists Show No Mercy (Even to Fellow Doctors)
In 2000, Mary and I took a group of people on a McDougall Adventure trip to Peru. Immediately following the trip Mary developed abdominal distress, which I suspected was due to a condition called tropical sprue. After several months of her suffering, I finally convinced her to see a gastroenterologist specialist to confirm my diagnosis. After a brief examination of Mary, I was called into his office and told that this was indeed tropical sprue and would eventually go away. He then proceeded to tell Mary she needed a colonoscopy exam as a screening test in order to find and remove polyps, a common precursor to colon cancer. I thanked him for his suggestion and tried to leave. He continued to insist on the necessity for this $4000 examination. “But this is not why we came to you for a consultation,” I explained. The harder I tried to stop his sales pitch, the more aggressive he became. Finally, we walked out of his office, and as I departed I said, “Remember, I am also a medical doctor, and I happen to know the scientific research behind colonoscopy and colon cancer prevention at least as well as you do. You have spent the past 20 minutes trying to bully us into a test we have no desire to take. This makes me feel especially sad for your other patients, with almost no medical knowledge, whom you treat with such disrespect.”
How to Use a Specialist to Your Advantage
A generalist must serve as your doctor—the specialist serves only as a consultant to you and your general doctor. When additional knowledge or skills are needed, then an arrangement—a referral—is made to see a specialist. The expert then gathers information about you, comes to conclusions and recommendations, and then sends a report back to your generalist. Together, the two of you, then discuss this valuable information and decide on the next courses of action. This may be to go ahead with the recommendations or to seek other opinions from different kinds of specialists. After sufficient research—such as you do when you buy an expensive car or home—a decision can be made by you with the aid of your advocate generalist on the proper course to take.
Ping-ponging the Patient around the Clinic
The bigger the business you are dealing with, the more you have to be on your guard. Medical groups consisting of many doctors present a special challenge. You go in for a sore throat and you are notified that you are overdue for your PAP smear and must see the gynecologist—this doctor then sends you for a colonoscopy—and from there you are referred to the group’s dermatologist for a discoloration on your thigh—and the process continues until you have seen every possible professional in the medical group. This profitable business practice is known as ping-ponging.
Get Out of the Medical Businesses
I once owned a 560 SL convertible Mercedes (a used car, but helpful during my 40s midlife crisis). I soon became all too familiar with my Mercedes’ repair shop. I knew my mechanic on a first name basis. After multiple visits, I learned about his wife, his kids, and the intimate details of their summer vacation. I will never buy another Mercedes. You don’t want to have a doctor as a familiar friend either. All of the challenges you have faced with various medical businesses may have left you overwhelmed and confused (See previous newsletters with discussions below). You have questions about: what doctors to see, which medications to take, what tests to choose to avoid future diseases, and much more? There is one simple answer to these dilemmas: Get out of the medical businesses. Don’t have a doctor, take pills or tests. And the only safe and effective way to get out of the medical businesses is to become healthy. Sick people take drugs, undergo multiple surgeries and examinations and know many doctors. Healthy people live outside of these businesses. The surest way to be healthy is to eat a low-fat, plant-food based diet (The McDougall diet), exercise a little, and have clean habits. Freed from the medical businesses you can focus your life on your career, family, sports, and hobbies. Now that’s living.
McDougall Newsletters about the Medical Businesses:
November 2004: Sick People Take Medications – Healthy People Are Drug-Free
July 2005: The Annual Physical Exam – A Ritual to Be Avoided
October 2005: How to Choose a Primary Care Doctor – If You Must
April 2006: Securing Respectful Medical Care
References:
3) Franks P. Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. J Fam Pract. 1998 Aug;47(2):105-9.
4) (Annual Physician Compensation and Benefits Report May, 2003 http://www.martinfletcher.com/reports/Physician_Comp_Benefit_Report_2003.pdf)
5) From Martin,Fletcher http://www.martinfletcher.com/reports/Physician_Comp_Benefit_Report_2003.pdf
6) Xakellis GC. Are patients who use a generalist physician healthier than those who seek specialty care directly? Fam Med. 2005 Nov-Dec;37(10):719-26.
7) Roos N. Hysterectomy: variations in rates across small areas and across physicians’ practices. Am J Public Health 74:327, 1984.
8) Legorreta AP, Silber JH, Costantino GN, Kobylinski RW, Zatz SL. Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy. JAMA 1993;270:1429-32.
9) Nicod P, Scherrer U. Money, fun, and angioplasty. Ann Intern Med. 1992 May 1;116(9):779.
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