Economics

The Anti-Hypocrisy Rule

Martin SamuelsPundits abound when it comes to health care plans. They come from many different backgrounds: conservatives, liberals, academics, business people, doctors, politicians and more often all the time various combinations of these. But they all have one characteristic in common. They all want a different kind of health care for themselves and their families than they profess for everyone else.

I am acutely aware of this as I am in a position that demands that I find special appointments for them. A day virtually never passes when I don’t receive requests (often many in a single day) for me to either see these people myself or arrange for their special care elsewhere, including other parts of the county and the world. My own personal ethical code of conduct prevents me from mentioning their names or anything that could identify them. Suffice it to say that I have yet to see a single exception to this principle.

In academic and media articles, they proclaim that we are in a health care crisis; that health care is unsustainably expensive; that it is ridden with error and that there is no evidence that individual personalized care by an expert is any better than that provided by a system, such as the so-called “patient centered medical home.” They virtually all are certain that the system that has evolved over centuries of doctoring is now nothing but a quaint relic and is rapidly being replaced with a team approach with fewer specialists, more generalists and more non-physician health care providers. Yet, when they have a personal medical problem, in a loved one or even an acquaintance or important person whom they wish to impress, they seem to locate my antique email address.

If care by someone like me (an old specialist in an academic medical center) is not preferable to the team-based care that they profess, why do they insist (even demand depending on their level of political connections) that I see them personally, often urgently, even for mundane medical problems, such as longstanding headache, chronic dizziness and mundane back pain?

The reason seems self-evident.

Despite what they say, they believe that care by an expert is superior, and that is what they want for themselves, their families and their powerful friends. I will not list their names, but it would be a Who’s Who is medical punditry. Also included would be local and national politicians, titans of industry and anyone else who wants the best for themselves while advocating a different level for everyone else.

Some years ago, I was acting as a visiting professor in Canada. I was discussing a patient with a disorder that I thought required a rapid, though not urgent, intervention. I was discussing the optimal timing of the intervention, when a chuckle arose in the audience. I inquired about why people seemed so amused and they told me that considerations of that type did not apply to this particular patient because he was going to be “Buffaloed.”

What could that mean, I inquired?

It means that this patient had private insurance and would go to Buffalo for the procedure rather than wait in the queue in the regular Canadian health care system. The reason the Canadian health care system works as well as it does (and that is not by any means optimal) is because 90% of the population is within driving distance of the United States where the privately insured can be Seattled, Minneapolised, Mayoed, Detroited, Chicagoed, Clevelanded and Buffaloed, thus relieving the pressure by the rich and influential to change a system which works well enough for the other people but not for them, especially when they are worried or in pain.

In the United States, there is no analogous safety valve so the influential simply demand a different level of care and receive it. This includes all the authors of the major books, articles and policies that have been written to repair our allegedly hopelessly expensive and error prone system. The array of suggestions is practically incomprehensible partly because there is a secret hypocrisy. Will the pundit actually use their proposed system themselves?

So my suggestion is quite simple.

Whenever anyone writes about the rehabilitation of our health care system, they should be required to publish their own health care history, so the public can see where these experts obtain their own medical care. To protect their privacy, specific diseases need not be declared; just the method by which the pundit handled his or her own medical problems. This would be analogous to requiring that politicians reveal their income tax records or that academic doctors report any real or perceived conflict of interest when publishing a paper. Articles, proposals and laws written by anyone who is unwilling to publish his or her own health care history would simply not be considered or published. If just the leading newspapers and opinion magazines would agree to this system the degree of credibility of proposals for changes in our health care system would be dramatically improved.

Our health care system is not perfect, but any changes should be just as good for the gander as for the geese.

For the record, I have an internist of my own choosing (an antique doctor in my own hospital), who directs my medical care as he sees fit. As he is very skilled and experienced, unnecessary expensive testing and drugs are generally minimized, depending instead on his judgment, history taking and physical examination skills.

There you have it; my disclosure. For those who are tempted to respond to this piece, let’s see yours.

Martin Samuels is a practicing neurologist and founder of two Harvard-affiliated neurology departments. He holds a membership in the American Neurological Association, a fellowship in the American Academy of Neurology and a mastership in the American College of Physicians.

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24 replies »

  1. In all fairness the PCMH don’t exist so you are saying they prefer you to the stuff they hate and want to replace. Even advanced, rich “elite” hospitals like MGH have comically bad IT systems.

  2. Thanks very much for posting this for me. I was very frustrated getting it anywhere until David S. helped me. All the best, Marty

  3. “I guess people having choices about their coverage, their copays, their costs, etc., is a bad thing?”

    lawyerdoc, by diverse I meant Medicare, Medicaid, employer provided, cash pay self funded, and individually insured. Each one provides a different level of access, care, and coverage – mostly not of our choosing.

    As for so called “choices” there really isn’t much. No choice in employer provided, narrow networks pretty much eliminates choice, HDHPs are limited in choice depending on your income where most people have to choose a high deductible because they cannot afford the premium of a lower deductible.

  4. You say “overly diverse” when describing our healthcare system . . . by that do you mean to suggest that we have “too much diversity” in our health care delivery?

    I guess people having choices about their coverage, their copays, their costs, etc., is a bad thing?

  5. Ha ha!!

    This is EXACTLY what I thought when I read Dr. Samuel’s fine article!

    Of COURSE he (Obama) needs a CT scan for a sore throat!!!! After all, he is the prime example of the first rule of emergency care, which is:

    “Money is never an object when someone else is paying the bill”

    Kudos to Legacyflyer, above!!

  6. “Perhaps more myth than reality?”

    Thank you Dr. Elias. I wonder if we would describe Americans going overseas for quality affordable health care as a, “flock”. Certainly the “60 Minutes” show several years back documented American overseas health tourism as more of a flood than a flock.

  7. Apologies Perry, sarcasm is hard to pick up in posts, there should be an emoticon for it here. I do a lot of it myself and it gets construed as opinion.

  8. Perry, “ObamaCare” is private insurance with the same docs and hospitals as any private/company plan – it’s not another health rail of an already overly diverse system.

  9. The CPOE machine directing the care of Obama was misclicked. The doc wanted cxr but clicked on ct in error.

  10. Glad someone mentioned this. His insurance company should have denied that. I doubt he will endure any “cost sharing”. So much for Choose Wisely. Just when you think hypocrisy couldn’t possibly run any deeper….

  11. Great post from Dr. Samuels, this is easily one of the best posts we’ve run on THCB this year ..

  12. Good example of this phenomenon is President Obama’s recent CT for a sore throat.’

    When asked about it the Press Secretary said something like – “he’s the President, not a regular patient”

    Exactly!

  13. Get out of your lab & get some air & better “consumer” information, Dr Samuels.

    Everyone, everywhere, wants a) a more personal connection to their health care b) authoritative info from practically EVERY source they touch. People are people first, rather than patients. Many, maybe most, don’t want to spend any time thinking of themselves as a patient. They want to be, to imagine themselves to be, the captain of their health. They want you as a crew member.

    So, with regard to their interest in wanting to see you personally, you are not “special” – when those people get off the phone with you, they do what they can to engage others who they feel can also contribute to bettering their health condition/situation/call it what you will.

    What conventional siloed information-tech-laggard medical practice gets so poorly is that people dearly want you, one of their trusted clinical authorities, to be able to help them identify where they are on the health status organization chart – to point them to the box labeled “you are here” on the floor plan of their health status. You’re not the end point. You’re in their information mix TO point.

    Are you doing it? Are you doing it well? Or are you spending more time than is warranted congratulating yourself on the health-optimization-constraining exclusivity of your specialized knowledge? (No disrespect, but there are 15+ “I’s” and “me’s” in your 900-word post)

  14. “wants the best for themselves while advocating a different level for everyone else.”

    Finally an honest and truthful statement about what drives health attitudes and policy in this country.

    “It means that this patient had private insurance and would go to Buffalo for the procedure rather than wait in the queue in the regular Canadian health care system.”

    Yes, maybe private insurance held by the rich only. The Quebec Supreme Court decision several years back that ruled an individual can hold private insurance to circumvent the public system resulted in ZERO sales of private insurance in that province because it costs so much and most receive good and timely care from the public system.

    Canadians aren’t able to afford U.S. care or U.S. insurance premiums, but most will take out temporary travel health insurance when visiting the sunny south.

    People always want the front of the queue, not because they need the treatment, but because they feel special and deserve the extra attention. This is hardly a revelation Doctor Samuels.

  15. … it is a “global enterprise” (the same all over the World with different scales) indeed extremely difficult to overcome. Fighting to improve is not the same thing as “being perfect”. Worse, we do not know what is the best or the most ethical approach at every place on any timetable. However, I agree with you – we need to improve dramatically!
    But, what is the methodology? Where are the resources? Thank you!

  16. Your stellar reputation speaks for itself, Marty.

    Those making the laws and edicts are shameless, and the hypocrisy is the standard.

    So what else is new?

  17. A timely and poignant post, Dr. Samuels.
    There are several double standards in today’s healthcare debate, and this is a glaring one. Your proposal is elegant. Another double standard is the emphasis on evidence as far as medical practice is concerned, but the lack thereof when it comes to top-down implementation of new care delivery models. From what I read, small physician groups, many of whose members are probably “antique”, as you call us, have better outcomes. But government policies don’t have to be evidence based…

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