Procrustes, the new god of medicine (or one size fits all)
... Or one size fits all
By Dr. Dennis L. Hill
For the Salisbury Post
From Watson and Crick (DNA) to Salk and Sabin (polio) to Cotzias (levodopa) to Hounsfield (CAT scan) to Damadian (MRI) to Gazzaniga (neuroscience) it has been a privilege to practice during what history will come to recognize as American medicine’s greatest generation.
When I entered medical school more than 50 years ago, hospital wards were still filled with patients living in Drinker respirators (the old iron lung), paralyzed by polio. There was no effective treatment for multiple sclerosis, Parkinson disease, acute stroke or Alzheimer disease. Neurological diagnostic procedures were nonspecific, painful and dangerous.
The experienced neurologist’s tool kit consisted of his ability to take a careful history, perform a detailed neurological examination using a well-worn brass safety pin (before the AIDS epidemic), a tuning fork, an ophthalmoscope and a fancy reflex hammer. Laboratory tests were generally limited to a skull X-ray, a brain wave test (EEG) and maybe a spinal tap.
Brain tumor suspects might undergo a pneumoencephalogram, an extremely uncomfortable procedure where several ounces of air were introduced through a spinal needle into the space surrounding the spinal cord and the brain, forcing air to bubble in and around the brain to allow X-ray imaging. The procedure itself generally resulted in several days in the hospital just to recover. Patients with suspected stroke or hemorrhage might undergo angiography in which a large bore, 2-1/2- to 3-inch needle would be inserted directly into the carotid artery in the neck and dye injected, with a significant risk of serious complications.
In the late 1960s, ultrasound was introduced, and we could determine the midline of the brain noninvasively for the first time. We could also obtain an approximation of the size of the fluid-filled cavities inside the brain. By the late 1970s, we could image the carotid arteries by ultrasound. Radioactive nuclide scans became available in the late 1960s. A radioactive isotope could be injected intravenously, and some brain tumors and infections could be visualized.
The first CAT scans appeared in the mid-1970s and revolutionized diagnosis of diseases of the nervous system. Brain tumors, strokes and hemorrhage could be safely and comfortably imaged for the first time. My neurology group in Charlotte teamed with the Charlotte Neurosurgical Clinic to purchase the first CAT scanner. We could not convince the administration at either Presbyterian in Charlotte or Charlotte Memorial Hospital (now CMC) that a CAT scan was more than an expensive curiosity.
A further revolution in neurologic diagnosis appeared in the mid-1980s with magnetic resonance imaging (MRI). For the first time, new tools in the diagnosis of multiple sclerosis, tumor type, acute stroke and dementia were available. In the late 1990s, radioactive isotopes were developed that could image the pathology in Alzheimer’s disease and Parkinsonism. These have been further refined in the 21st century.
Neurological diagnosis has become more refined, less dangerous, less painful, easily accessible, but much more expensive.
When I attended my first meeting of what was then called the Association Of Sleep Disorders Centers in the late 1970s, there were probably 150 to 175 participants. Most were neurologists, psychiatrists and psychologists. Most presentations were associated with the research into causes of daytime sleepiness, insomnia and narcolepsy, with some interest in sleep-disordered breathing. Therapy for sleep apnea at that time included dental appliances, a tracheotomy for the most severe cases, and some surgical procedures on the throat. When the Australian, Colin Sullivan, developed CPAP in the early 1980s, the field exploded. Now there was an effective simple non-invasive treatment for a common sometimes fatal disease. Currently thousands attend the annual meetings of what is now the American Academy of Sleep Medicine. The majority are interested in management of sleep apnea.
Richard Allen and his colleagues at Johns Hopkins began to study Restless Legs Syndrome in the 1990s. They discovered the association with restless legs and decreased brain and spinal cord iron levels and began to develop effective therapies with dopa agonists and medications such as gabapentin. Now, thousands of patients are able to get a comfortable night’s sleep with appropriate management of this frustratingly common affliction.
The Salk and Sabin vaccines became available in the late 1950s and saved millions of people from the devastating effects of polio. Through the support of Rotary International and other agencies, the eradication of polio is almost in sight.
Before the 1960s, Parkinson’s disease was ineffectively treated with a combination of benadryl, artane and dexedrine. Lives were dramatically altered by the discovery of L-dopa in the mid-1960s. For the first time, many patients with Parkinson’s disease could expect to live years with limited disability. Further developments, including deep brain stimulation, have increased useful functioning for those many years into the illness.
Disease-modifying therapies for multiple sclerosis began to appear in the late 1980s and 1990s, initially cutting the annual relapse rate by 33 percent. Newer therapies have even greater impact. New oral therapies are beginning to replace injectables with the same or improved efficacy.
In the late 1980s and 1990s, research in Alzheimer’s disease began to pay off with the development of agents to improve memory and to allow the patients to stay in their homes longer.
The year 1996 saw FDA approval for the clot-busting drug TPA. For the first time, effective treatment for acute stroke was available. Acute stroke teams were developed, and hospitals on the cutting edge could become American Heart- and American Stroke Association-certified for acute stroke care. Rowan Regional Medical Center was one of the first to be certified in our area and has been recertified repeatedly since that time.
When my great-grandfather, a general practitioner living in the Ozarks of northwest Arkansas, cared for a patient, he negotiated face-to-face a reasonable compensation. It might have been cash, bacon, ham, corn, wood or a dozen eggs. During the Great Depression, many patients became unable to pay for their care. In 1929, the first Blue Cross plans were developed as charitable, nonprofit, tax-free entities. Free of insurance laws, these plans were structured essentially to save financially strapped community hospital systems. For the first time, someone else was paying the bills, and market forces were curtailed. Not surprisingly, prices went up.
Health insurance plans proliferated during the wage and price controls of World War II with the shortage in the labor market. These plans were largely nonprofit. On July 30, 1965, when I was a junior in medical school, President Lyndon Johnson signed Medicare into law, and the government became involved. The year 1994 saw the national Blue Cross and Blue Shield Organization decide to drop their nonprofit status.
Over the past 15 years, for-profit plans have proliferated, and with them, restrictions in the care they will provide, the drugs they will allow and the reimbursement they will offer physicians. Now we see for the first time evidence of the Golden Rule in medicine: “He who has the gold, rules.”
With limited government funds, medical care has become increasingly restrictive and regulated. Regulation, restriction, and price controls have made it increasingly difficult for the private practitioner to stay in business. Changes in social values and the government edict of the 70-hour workweek for interns and residents have led to a cadre of young physicians with a 9-to-5 mindset.
The subtle, purposeful evolution of substituting the designation “provider” for “physician” has further undermined a doctor’s professional reputation and prestige. Amazingly, we as physicians have allowed the bureaucrats to use this demeaning term without even flinching. Regulation, restriction, price control, lack of power and prestige have driven physicians into the arms of mega-practices, such as we see at CMC and Novant. While we see physicians’ incomes deteriorate annually, we see the administrators of these nonprofit mega-health-care conglomerates walk away with multimillion-dollar salaries and bonuses.
I do not see much hope for improvement in the future. As I see it, primary care will be delivered by mid-level “providers,” physicians’ assistants and nurse practitioners. The family physician as we know it will gradually disappear. With limited reimbursement, there will be no incentive to sacrifice the cost of 12 or more years of graduate education, not to mention one’s family life. Those who do go into medicine will gravitate into the highly reimbursable specialties, such as radiology, dermatology, ophthalmology, and away from family practice, internal medicine, general surgery and the cognitive specialties, such as psychiatry and neurology.
The new “provider” will be forced to place a laptop between him or her and the patient, posing as a clerk typist, generating pseudohistories, pseudo-exams, cutting and pasting, plagiarizing, generating jejune clones masquerading as meaningful information to satisfy a certain level of charge. Frantically typing, these providers will rarely be able to make eye contact or watch the patient’s subtle facial expression, movement, and mannerisms that so often yield diagnostic clues. Concierge practices will begin to emerge. Physicians opting out of the business of managed care, government regulation and price controls will move into a cash-only system for those willing and able to pay; that is, until the government declares those types of practices illegal or makes it impossible for them to survive. The bottom line is patients with Medicare and Medicaid coverage will have increasing difficulty finding a physician; physicians will continue to suffer economically; the best and brightest, if they go into medicine at all, will gravitate to health care administration or the highly-paid specialties. Expensive procedures for the aged and demented will undoubtedly be curtailed. It is not a question of whether health-care rationing will occur, it is just a question of when. With ever-eroding influence and prestige, the family physician as we know it will become extinct.
Is there hope? I do not think so. I believe that Obamacare has been developed and carefully crafted to become the medical equivalent of a hydra, eventually generating overwhelming support for a single-payer system controlled by Washington. Eventually, Procrustes will supplant Aesculapius as the god of medicine and medicine’s greatest generation will come to an end.
Dr. Dennis L. Hill, a Salisbury physician, is retiring at the end of May after 50 years of practice.