The wonks are wrong—and right

Over at The Health Care Blog, Dr. Richard Reece declares “the wonks are wrong”.  In general, that’s a pretty defensible statement, no matter the subject, and by his picture, he’s old and wears a bow-tie, which lends some extra credibility.

Despite this, he’s half wrong.

Dr. Reece’s interpretation of “the wonkage” is this:

The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.

That’s pretty much the line we’re all being fed here in Doctorland.  He goes on to describe a patient whose primary care doctor diagnoses her with diabetes and the patient then demands a specialist, despite lacking any reason to need one.

After a bit of analysis, Dr. Reece concludes:

In choosing doctors, patients still prefer to think for themselves, rather than having others think for them.

If their decision involves “waste” for the system, so be it. One person’s idea of waste may not be reality-based.

And here lies one of the biggest problems with our health care system.  The “wonks” are right, we have a horrible health care system, full of waste, poor outcomes, fragmented information systems, and expensive care.  The reason for this is, at least in part, our national ideology, well-encapsulated by Dr. Reece: “Who cares how crappy we are, just let everyone do whatever they want, and damn the consequences.”

This libertarian approach to health care is making us broke and killing us.  That’s a bad combination.  We need leaders, including physicians, to say, “No.  That’s not how to go about this.”  I have plenty of patients who want to go to chiropractors and whose insurance covers it, but I don’t refer to chiropractors because chiropractic doesn’t work.  I also avoid unnecessary referrals to specialists because I am a specialist.  When I’m out of my depth, I refer.  If a patient wants a to see a specialist, or get certified for cannabis, or visit a chiropractor, they are free to do that, but they don’t need my blessing—for the most part, at least.  If they have certain HMOs they do need a referral, and if I think it’s potentially harmful (like cannabis or chiropractic), I’m not going to refer them.  They can still go, but they have to pay for it.

And that seems to me a very libertarian idea.  Why should we as a nation, or an insurance company, pay for unnecessary care?  If a primary care doc diagnoses diabetes and comes up with a treatment plan, but the patient wants an endocrinologist, fine: but they can pay for the unnecessary care.

What say you?


  1. I’ve noticed this overuse of specialists, but I think the blame needs to be parceled out. Everyone feeds it, doctors and patients alike. We wind up with a perception that an FP or internist can’t handle any more than a midlevel (creating its own set of problems). I’ve encountered people screaming that a PCP absolutely can’t handle any thyroid issues. This is a problematic example because many PCPs don’t handle them well and then there’s the reference range wars, but it’s not actually that complicated to manage hypothyroidism (I have it, my internist manages it).

    I lived in the UK for several years and saw the absolute reverse–GPs really discourage referrals to specialists even in cases where maybe they shouldn’t, but it did mean that GPs actually got to handle a lot of different things and there was a lot more coordination.

  2. saffronrose

     /  September 12, 2011

    My internist, my PCP, sent me to the endo in the practice. At this point, since most of my medical issues ARE endocrinological, I just see him. He handles the areas of my Metabolic Syndrome (diabetes, blood pressure, and cholesterol) and my thyroid. I certainly haven’t needed an antibiotic since I started seeing either of them.

    I’ve had two basal cell clumps removed, and I have psoriasis on my scalp (and in my ears, not being treated, dammit), thus I see a dermatologist once a year, with an additional visit if I see something suspicious. I need a derm. who is closer to me, and treats my psoriasis more agreesively than a medicated shampoo.

    Last year, I went to a podiatrist: I thought I had plantar fasciitis that was not responding to exercises. Nope. Achilles tendonitis due to a honking bone spur. It was removed NYE, and there are a number of followups yet to come, but once I’m healed, I don’t think I’ll need to continue to see him.

    Of course, I also see an ophthalmologist. It turns out this last thorogh exam showed the two different glaucomas for each eye, and mid-stage cataracts. I use drops, and will probably get the cataracts removed next year, and in the process correct the astigmatism in my right eye during reconstruction.

    I have no interest in medical marijuana. Can’t smoke, am nauseated by the scent of the smoke. Know squat about today’s culinary varieties.

  3. I’m not sure I understand what was going on with the wonks stuff,but your proposal is not libertarian to my mind. In fact, it is very corporatist, in that it limits people to the treatments that are approved (in this case by you, but in many cases by the state, e.g. in the UK or France). And indeed, despite the anecdotal evidence about the UK in the above comment, the truth is that people in other countries *are* limited in their care. Which is why people come to the United States for cutting-edge treatment. On the whole, however — for run-of-the-mill illnesses like diabetes — they have better life expectancy and lower costs.

  4. Old Geezer

     /  September 12, 2011

    This is a difficult subject. There is no doubt in my mind that far too many patients and doctors believe that the only valuable care possible is that given by a “specialist.” However….I work in the Hospice field. *Very* often we see patients who have been held under the care of the PCP long after it is obvious that death is imminent. “Let’s try one more thing,” leaves the family and the patient with unwarranted hope until, two days before death, the doctor says, “Now you are hospice eligible.” Sometimes knowing when to hang on to a patient and when to let go is very difficult indeed.

    • saffronrose

       /  September 12, 2011

      Old Geezer, thank you for your involvement in hospice. In my FiL’s last month, when it was clear he was not going to have an upswing again, the local hospice was very helpful to us. Most of his care was through the Palo Alto VA Hospital, and they were very good, but his CHF had progressed past any treatment, and we used only paliative care, at home. He was as comfortable as we, and Hospice-provided medication, could make him. His body was shutting down the last week–no interest in food is usually the hint that death is imminent.

      We would have resisted any suggestion of “one more thing”, as it was clear to us that his quality of life was not going to improve no matter what, and we wanted him to have some dignity in his passing.

      My husband has yet to complete an AHCD, but in mine, and in his mother’s, we have No Extreme Measures specified. I have said further that if I’m in a coma for a month, and there is no sign of improvement, free me from any life support, and maybe take me home to die. I know my chances of having a stroke–genetically–is high. My mother and two of my aunts died from repeated strokes over a month, after an earlier larger one. My only sister has had a stroke three years ago, and she needs board&care for the rest of her life: mobility is limited, as is language capacity. I’m doing what I can to fight the odds, but my AHCD is there if I have a large stroke.

  5. Melissa Travis

     /  September 13, 2011

    I guess as a life long chronically ill patient (who has 7 NECESSARY specialists and lives a *very* productive life) – I go to my PCP when I NEED to see her and my specialists for specialty care when I need to see them. And I count on a mixture of zen, special sauce, consultations, and my bullshit-meter when I get incredibly conflicting information from any of them (which DOES happen). After all- medicine is an art, right. Meanwhile, I’ve had my life saved on more than one occasion by this group of people working together, and I’d sure not wish to discount how much counting on only ONE PERSON makes me feel personally unsafe. I like checks and balances when it comes to my life. Especially because doctors are over worked and sleep deprived error prone and HUMAN. (and they do NOT CARE about my life as much as I do).

    Secondly – To presume a one type fist all, or a “typical patient” is to presume badly. I would far rather a patient receive chiropractic care for their lbp (or get massage, PT, and other non opiate palliative care) than take fist fulls of opiates and blow out their liver or receive multiple spine surgeries which also show NO effectiveness for PAIN yet they get at an alarming rate because there is boom boom big money in it. AND NO ONE SEEMS TO BE CALLING BULLSHIT ON IT OR CALLING IT A SHAM.

  6. Old Geezer

     /  September 13, 2011

    Melissa, the irony in your post is that you decry the surgeons who suggest “multiple spine surgeries…because there is …big money in it AND NO ONE SEEMS TO BE CALLING BULLSHIT ON IT OR CALLING IT A SHAM.” Yet, you strongly disagree with PalMD who is making substantially the same point. Yes, there is a time for specialists, but someone has to be in charge. Unless you have extensive medical training your “bullshit meter” isn’t sufficiently well tuned to determine which of the conflicting pieces of advice is valid. Failing to have a strong, experienced and understanding PCP to filter through the BS is a good way to land multiple times under that specialist’s knife.

    And while I’ve never met your doctors, I can tell you that most doctors I’ve met care every bit as much about your life as you do.

  7. Ria

     /  September 13, 2011

    There are some types of care for which a primary care physician is perfectly well suited to provide care, and some for which they are well out of their league: specifically, anything that falls outside of the regularly observed illnesses like diabetes, CHF, CHD, strep throat, etc. When a patient comes in with severe migraine and is continually diagnosed with sinus headache and sent home, that’s a problem. Or if the patient has allergies that require more than just putting them on Claritin…again, most PCPs are unequipped to handle these patients. Many PCPs have a tendency to assume that if the patient comes in repeatedly for the same problem (because the treatment from the PCP did not solve the problem), then the patient is the problem…not that the diagnosis or treatment were wrong or insufficient. I’ve run into this many times. I’ve had too many doctors tell me that I don’t know what I’m talking about…and I’ve got a PhD in genetics. Please. Ultimately, a patient’s healthcare responsibility lies with the patient to receive the correct care, and this means that the patient must continue to have the freedom to choose the doctors that they will see and/or believe, even if the patient chooses in error. The patient must take the time and effort to educate herself about her own symptoms in advance of any doctor visit to know what questions to ask the doctor, and to work with the doctor to achieve the best care. Paternalistic attitudes on the part of the doctor do not help anyone.

    • saffronrose

       /  September 13, 2011

      Ria says:
      The patient must take the time and effort to educate herself about her own symptoms in advance of any doctor visit to know what questions to ask the doctor, and to work with the doctor to achieve the best care. Paternalistic attitudes on the part of the doctor do not help anyone.

      My pdoc (I’m bipolar NOS) really does appreciate my actively working with her–she said she tires of patients who say “Whatever you say, Dr. I’m sure you know best”. She was chosen, 10 years ago, because she liked the fact that when I called to check on her availability, I left answers to all the questions she was going to have asked in the return call. When I have given a patient summary to some doctors, they’ve tossed it aside, and asked me the same questions to which I had provided answers…

      I’ve had my fill of paternalistic attitudes: first two pdocs, the GP at college, any number of physicians since then. They seemed to resent a patient who asked more questions than usual, who HAD done their own research, and in the case of a small number of them, been defensive because I could speak “medical”.

      When I was dx’d early with gestational diabetes, and sent to a diabetes educator for a new eating & exercise plan, I saw she was rather brick-wallish. I told her that I’m curious, and ask a lot of questions, but I’m not challenging her authority in doing so. I needed the info to be healthier in pregnancy and for a healthy child to emerge at the end of it. She was highly reserved. She was shy, yes, but she also got many newly dx’d clients yelling at her, taking out their frustrations with their need to change their life on her. I was with her longer than most, and I finally did get her to laugh. She helped me understand what I was dealing with, so that I didn’t panic when I had one bad reading in a week.

      I don’t seem to have that reaction to bad medical news–I just want to know how to treat and overcome it. After all, getting angry about it doesn’t solve the problem at all.

  8. My GP is quite ready to refer to specialists, but it’s not her, or my, first thought, and some of the referrals are to people other than doctors. A few years ago, it was a physical therapist. Right now, I’m seeing an occupational therapist who we hope can do something about carpal tunnel syndrome other than surgery (I am pretty discouraged at the instant, frankly, but that’s not a policy issue). But first she tried handling it herself, with NSAIDs and a hand brace.

    Sometimes I don’t need a referral to see a specialist. I just call the ophthalmologist for an appointment the same way I’d call the dentist. But if I get a diagnosis or treatment more complicated than “you need bifocals now,” I let my GP know.

    That’s a piece of the problem: getting the information back to the general practitioners. I had gall bladder surgery a few years ago, admitted via the emergency room when I’d not previously realized I had gall bladder problems. A few months later, after I recovered, I saw my GP for something else and told her about it: despite asking who my GP was, neither the hospital nor the surgeon’s office contacted her office to tell them “your patient had her gall bladder out on thus-and-such a date.” (The surgeon did see me for follow-up, but that was a single office visit.)

    I suspect there are patients who assume their regular doctor knows these things, knows what medications they’ve been prescribed and so on, without verifying that.

  9. In a past life, I spent several years working as a project coordinator for a general (commercial building) contractor. I’m probably way off-base, but I tend to think of my internist as a project manger who oversees the entire project. This is the one person who has the entire and most up-to-date set of red-lined plans and specs. The specialist trades have very valuable knowledge and skillsets, but their individual scope of work and project oversight is extremely limited.

  10. Melissa Travis

     /  September 13, 2011

    Old Geezer – guess who gets to be “in charge” of MY HEALTH. ME.

    Guess who should be in charge of anyones health Old Geezer? THE PATIENT.

    Working in tandem with a physician is HOW PEOPLE SHOULD DO IT. Period.

    Being in charge is a paternalistic bullshit jacked up thing to say. I used to avoid male doctors for this exact reason and then I found over time that PLENTY of men were willing to take a team approach in MY HEALTHCARE.

    Also- surprisingly – TONS AND TONS AND TONS of physcians are STUPID AS HELL in the words of one doctor, “couldn’t diagnose themselves out of a paper bag.” So presuming that I ALLOW a pcp to “be in charge” of my health means trusting they won’t let me die. Which is stupid.

    How about we all work together.

    I’ve had TOO MANY stupid doctors (arrogant doctors) say things like, “all americans think they are allergic to pcn.” THAT is not the PCP for me. You can have them in charge of YOUR HEALTH and YOUR FAMILY’s health if you want!!! Enjoy!!!

    Meanwhile -I have heard PLENTY of spine surgeons admit they do unnecessary spine surgeries in their cities only because they know if they don’t their patients will go to a chop shop surgeon who will do it WORSE.

    Perhaps you should know a little about who you are talking to BEFORE you ASSUME I know nothing about medical culture or how doctors feel about their patients (or patients feel about their doctors). I spend a good deal of my life studying just that.

    And yes SOME doctors do love their patients and care about them. And some doctors are burnt out and should have retired YEARS AND YEARS AGO or should have gone into research or never been doctors at all. (Same as with all people in all professions.) Because amazingly enough, doctors are human. I put medicine neither on a pedestal, nor on a whipping post. But I am allowed to call bullshit on it and the people who engage in it badly yet point fingers at alt/cam as though they themselves are innocent of the same.

    Bring it Old Geezer. I adore PalMD and know that I can both agree and disagree with him anytime. Step up – I’m avoiding my real work to comment on a blog. It’s more fun!

  11. Melissa T, I’m not “bringing it,” but I want to explore the allergy thing. I think there can be a cultural component to which allergies are dominant in a population. I think sometimes people’s identity gets wrapped up with their medical history, especially if there is some new and trendy allergy in the news. I’m thinking here about celiac disease. Some people are legitimately physiologically unable to process gluten, and others self-diagnose because it makes them feel like extra-special snowflakes. Or something else makes them sick, but they blame the bread.

    I read an article awhile ago, maybe in Slate, about this phenomenon. Interestingly, as those folks who don’t actually need to do so avoid gluten, their intestinal flora evolves away from processing gluten. When they are exposed, they feel sick-not because they actually have celiac disease, but because their gluten-free diet altered their ability to process gluten.

    Let’s say you (hypothetical you, not you personally….) were a self-diagnosed patient who had unwittingly evolved your own gluten intolerance. You’re in a mutually trusting relationship with a very nice doctor who gently explores this history with you. Would you be offended if that doc suggested that you didn’t actually have celiac disease and suggested ways you could begin eating gluten again? I think it would be really hard to back off from the gluten-free position after years of avoiding wheat, requiring special treatment at dinner parties and restaurants, and demanding gluten-free expensive foods from producers.

  12. Melissa Travis

     /  September 14, 2011

    Anthropologist Underground:

    1) sure people play to trends. 2) doctors aren’t god 3) many doctors disagree on things.

    I’ve had multiple doctors disagree about not only a disease but a treatment before.

    Did you ask if the patient’s blood glucose goes up when they eat gluten? Did you see if their thyroid values or autoimmunities calm when they are gluten free? Does their depression or projectile poo calm? Plenty of common sense doctors will say, “If you feel better when you stop eating it, don’t eat it.”

    Another 55 year old patient just told me last night, “I feel like I went 55 years undiagnosed from celiac disease because it was easier for my doctors to write out prescriptions for antidepressants, ignore my anorgasmia from them, and write out more prescriptions for my awful diarrhea than test for celiac because there was nothing THEY could do for celiac. Only I could actually do something about that.”

    There is something to that perhaps? Are doctors really that afraid of giving patients control that they ignore or over look simple life style changes? Do they get so angry when we DO take control that we are “special snow flakes” when we have the disease du jour when it doesn’t involve an Rx pad and multi thousand dollar treatment but our own initiatives?

    Meanwhile, people have EVERY right to eat or not eat what they wish. Diary, meat, wheat, gluten, soy, nuts. They also get to decide what works for them. It isn’t like doctors eat that great anyway. They have one or two nutrition classes specializing in CHEMISTRY of food, not psychology of eating or behavior AND doctors RARELY refer to nutritionists for over or under weight. What do they do instead? (Look at alllll the weight loss surgeries patients undergo).

    And – as one post-op bariatric patient told me, “You can put a band on my stomach, but NOT on my brain.” She tells me is that her doctors NEVER suggested sending her to counseling or a nutritionist (or both) but did recommend lapband for her obesity. Shame on them! SHAME ON THEM! She will always struggle with the same issues regardless of her weight. A lifetime of those issues don’t disappear with a knife or an Rx pad.

    So – I’d MUCH rather see someone go gluten free by taking their life and their actions in their OWN HANDS (incidentally – foods like meat, salad, veggies, and fruits are ALL naturally gluten free) than eat fast food 3 times a day. Which one is more expensive? Which one is healthier?

    Meanwhile, doctors huff and puff if a patient is “non-compliant” but don’t seem to recognize just how many times patients get contradicting advice from other doctors (their own peers and colleagues) about the SAME ISSUES.

    Amusingly as an example: I’ve been told by 4 different “medical experts” (aka doctors) how to wipe my butt starting when I was a little girl and moving throughout life. On none of those occasions did I ever ask, or did I ever have a medical need for being given this advice, NOR did they EVER tell me something I didn’t know, my mother didn’t tell me, or correct something I was doing wrong. BUT- all of them wildly disagreed with each other on products, technique, and tools (paper vs wipes vs solutions etc). ALL OF THEM. And except for my pediatrician, they we all selling something. (I’m an old fashioned girl and pretty much IGNORED THEM. DOING FINE, THANKS). This is the SAME for both diagnosing and treatments of life and death diseases as for butt wiping. I am illustrating a point. (surgery vs lifestyle change, vs medication or a combo of them etc – it varies by specialist and it can get VERY confusing. And often a PCP will simply direct a patient to the specialist they know OR the one in the HMO OR the one the insurance pays for… OR sometimes sadly, the PCP is selling something. It does happen.)

    Back to YOUR point:

    Yes I would be very offended if my doctor wanted me to start eating something again IF I were feeling better. I would tell them I was doing FINE and if I wasn’t broken don’t fix it and to look to other things to keep me on track. ESPECIALLY if I were FEELING BETTER. Doctors essentially need to mind their own business when it comes to some things that aren’t bad (like diets that aren’t dangerous or exercises – who cares if someone bikes versus swims IF it isn’t contra indicated).

    If a doctor was insistent, I would find a doctor who worked for me and WITH ME. They need to keep me HEALTHY not try to preach a lifestyle that THEY WANTED- like eating foods they thought I NEEDED TO EAT.

    Going gluten free is FAR less costly to society and to an individual patient than hoovering fast food multiple times a day. The health implications of eating crap that are gluten filled are tremendous, and are backed by lobbies and subsidized by the govt. I don’t see THAT being complained about. Just complain about a patient’s “lack of will power, lack of lifestyle changes, lack of etc etc etc”… but then complain about them attempting and making a positive lifestyle change and actually doing something that is VERY VERY VERY difficult to maintain and manage?

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