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Lessons - Why Public Confidence in Healthcare Is Declining | Brian L. Strom - Medical Ethics Expert
00:12:00
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- [00:00]
Host
In this lessons episode, discover why more people are turning to herbals and eastern medicine over conventional Western healthcare. Learn why a lack of trust in corporate medicine drives patients toward alternative treatments. Understand how diminished doctor patient interaction fuels this shift and uncover the potential of population based care models to realign incentives and improve outcomes. It actually seems just very, very anecdotally without the data to back it up, just through casual conversations, it seems like more people are trying herbals and eastern medicine and all of these things that don't seem to be western. And it's so interesting because I think there's cultures that seem to default to eastern medicine or herbal medicine. I mean, I'll give you an example. Growing up, I didn't, it was just, it was just regular drugs. I don't even know how to describe it. It's just like, it's like Western medicine and doctors and prescriptions and antibiotics and anything else. And then so, so my, my, my better half, she, she's, she's a couple different things but her, her mother is Jewish Israeli and her dad is Russian and she has tried so many different herbal things to get better. And when she's sick the default is herbal this or herbal that or try that. And there was like, like a, a Chinese doctor that she went to go see one time. I'm like, I don't understand any of this, isn't from my, my world or what I knew growing up. So I feel like, and maybe just because I have proximity to it, but I also hear it in con A not a complete lack of trust in Western medicine, but some lack of trust in Western medicine. And I'm so curious why you think that's happening. And, and if I'm incorrect in that assumption, you could tell me that too. But I, I felt that in conversations.
- [02:03]
Dr. Smith
I, I think you are correct in, in that assumption widely used and, and the herbals non typical treatment is entrusted are taken widely and people instead take herbals and other things. And it does come a lot from lack of trust. Part of it is that given where health care has, has come and how it is evolved physicians don't spend much time with patients. And as health care has more and more become a business rather than sort of the solo practitioner doctor who comes to your house and, and whatever, you know, trust people as much. If you talk to most patients, they'll all say health care is terrible, except my doctor is great. And you know, people who have a primary care doctor and I'm biased, I'm a primary care doctor, but people have a primary care doctor typically will trust their primary care doctor. But, but it's a. But more and more as medicine has become corporate and as healthcare has become much more expensive and hasn't become corporate, the times people spend, docs spend with patients is less and less. More of that is in front of a computer screen. And so the doctor is interacting with the computer rather than the patient. There's much, much less trust. And part of what alternative health care providers do is they're, they spend more time in patients in part because they're cheaper. So if you're going to make X number of dollars per hour that whatever that clinical specialty is, you know, if you're a surgeon, they want you in the operating room. If you're an anesthesiologist, they want you in the operating room giving anesthesia, not, not spending a lot of time talking to patients. And, and, and I think it has definitely hurt the trust of medicine. I think the other thing that has hurt ironically was years ago when, when the, the people came out with the 80 hour week, which probably doesn't mean anything to you, but expanding to your audience, there were people who clearly were hurt and they hit the press because the, the doctors taking care of them were too tired. And so they put in place a rule for residency. We talked before about, you know, treating your trainees like, like dirt as, you know, endless slaves as residents that you're not allowed to work more than 80 hours a week. Now the, the way the, where the word resident comes from is people, they lived in the hospital, they were resident hospital. They were also called house death because again, they lived, they were in the house, in the hospital. Accordingly, it was a commitment to your patient that, that was inherent in becoming a physician that you, the nature of professional ethics was your patient comes first and you stay in the hospital until your patient's going well, you do whatever's needed. The EDR weak, the rule imposed because of fear that people were too tired made doctors into ship workers that at the end of your 80 hours you have to leave or the program is penalized in accreditation. So it's changed the character of medicine and our trainees completely with that. And I think it's a big loss, it's a big loss to physicians in terms of self worth, but it's also a big loss in terms of patient, patient care. But I think the corporatization of medicine has been a big part of it as well.
- [05:25]
Host
Do you feel like there's a, an e, not an easy but even any solution to that? Because I mean that's not a great path that everybody's going down if they don't trust. And now you have this profit machine that not just profit machine you have. Okay, respecting the wellness physical mental of the residents. I understand where that comes into play. But when you're talking about surgeons are in the operating room, anesthesiologists are in the operating room, there's a dollar value attached to every hour of a medical professional. There's this, there is this industrial complex that's driving this behavior. Very hard to beat an industrial complex. So how do you, how do you create trust or space for medical, medical practitioners, medical providers to, to have that time with the patient so they can restore the trust. That seems to be the X factor that has to be solved for it.
- [06:21]
Dr. Smith
Certainly is one issue, no question, no question. I think one way is we need to make better use of other professions. You don't need a doctor to do everything. So in my career as a primary care doc, much of what I did, you did not need a physician's training to do. Why did I do it? Because physicians could build for it what we now know, nurse practitioners, physicians, assistants can often do it better and cheaper and more routine tasks. And one of the advantages we have in Rutgers Health is all of those schools are under us, under one roof. So if we need more nurse practitioners, we train them. If we need more PAs, we train them. And as the world moves to more population health going forward and we move away from fee for service accordingly because you know, we're bankrupting the country in healthcare and yet don't have good outcomes. One of, one of the solutions is we need to think more population based and, and we need to make better use of other professionals who can actually do a better and cheaper job of it and save the physicians who are the most expensive and the things that you really need the physicians time for. And you know, it's behavioral health has sort of done this using more time from psychologists and social workers and saving the physicians to write the prescriptions, in which case it's not as satisfying to the physicians that they don't have the relationships with the, with the patients. But you know, there's no one silver bullet here. But I think we've become too. Healthcare has become too much of a big corporate entity focusing not on health. It's really become sick care, not health care. It's really been, you know, people do bad behavior, they get sick, they come in, they're treated for the sickness, they're sent back out where they do the bad behavior again. Whether it's smoking or drinking or whatever it is that they're doing too much of, you're not focusing on keeping people healthy, you're focusing on only treating them when they're sick. And that's because the current incentive system, that's what it pays. And that's what is changing as we move to more to population now, because we're bankrupting the country, we're approaching 20% of the gross national product and yet we have bad outcomes. The countries that spend half as much as we have better clinical outcomes than we do because we focus. We don't need as many MRI machines, we don't need as many CT scans, we don't need as much surgery, we don't need as much testing. We need people to think more. But, but our, the health care system classically doesn't pay people to think, it pays people to do. Surgeons are paid a lot. Primary care docs are paid much more. Pediatricians, neurologists and psychiatrists are all paid much less than surgeons or other higher paid specialties. And we're in this cycle where if you want to maintain salaries, income, we need them to be spending all the time in the operating room and spending less time with patients going forward. So it's not one solution. I think the closest to one solution is really population health that's really sort of moving to a per patient per month basis for reimbursement, where suddenly the risk of the providers, instead of being paid to do too much, you're taking the risk of patient get sick.
- [09:49]
Host
Yeah, I understand. So now the incentives are aligned. Now the incentives are aligned.
- [09:53]
Dr. Smith
Yeah, but now the incentives are aligned in the wrong direction. Now the incentives are aligned to do too little. If you pay per month, it also changes the character because individual docs can't, or even individual hospital can't possibly afford that. One transplant patient would bankrupt you. So the docs come together, the hospitals come together, everything is all coming together. And that's what's happening. What is happening and healthcare is the consolidation accordingly. In order to deal with that, you also, in order to prevent undertreatment, you need a huge data infrastructure. You need to be able to say, has everyone has gotten that COVID vaccine, gotten their COVID vaccine? Has everyone who has a high blood pressure, are they getting treated? They've had high cholesterol, are they being treated? You need a huge data infrastructure to do that. And again, that requires a mass, a scale to be able to put that together and afford to do that. And so what you're saying, seeing of course, the country is this enormous consolidation as we move. We're in this funny in between now moving from a fee for service system to a population system. And the health systems have a very hard time at different speeds in different localities. If you move too slowly, you'll go bankrupt. If you move too fast, you go bankrupt. Because right now in many places reimbursement is still primarily fee for service. So if you move too much toward prevention, we go, you know, we keep people out of a hospital, the hospitals go make it. But we don't need anywhere near the number of hospitals we have if we actually focused on keeping people healthy rather than waiting for them to get sick and treating them when they get sick. It's a little twisted incentive system.
- [11:38]
Host
Thanks for tuning in. If you found this valuable, don't forget to hit that subscribe button so you never miss an episode. And if you want to dive deeper into this conversation, check out the links in the description to watch the full episode. See you in the next one.