My spin in the vicious cycle of the American healthcare system.

(Picture from Forbes.com)

Chronic shortness of breath, chest pain, hives, other strange rashes, edema of my throat, left shoulder pain, acute food sensitivities that developed seemingly out of thin air, itching all over at random times, knots in my left shoulder that correlate with my breathing issues, cardiac arrhythmia, constant throat clearing. At first glance they seemed like nothing, but after many ED visits and even more passes through the outpatient system, all I have found is just enough reason to worry, but not enough information to drive action, which is seems to perfectly describe the vast rift in the American healthcare system. I only heard stories about how broken the system is, but now I’m in the same crack as millions of Americans, and it’s more bleak than I thought.

A few years ago, I began to develop rare but very acute breathing problems that I initially thought were heart attacks. They would come violently, last for days, and leave like they never happened. The times I went to an urgent care, they assumed it was asthma or anxiety and moved on. Not too long after that I began to clear my throat every time I ate. Breathing got difficult every time I drank alcohol. Then it got difficult for many other reasons, all somehow correlated my diet and environment. Today, my diet is so limited that going out to eat is impossible, a beer would send me to the ED, and sometimes for no reason at all I am left clearing my throat and endlessly struggling for air. I’ve repeated these cycles for years now, and I only become more frustrated.

Now this story isn’t all about me, it’s about the look in almost every doctor’s eyes when I begin to walk through my detailed (well documented) case with the new specialist of the month. It’s the same look that a less-than-average high school student gets during an English lit lecture that resembles a complete lack of presence. The sheer lack of intellectual engagement that I see from such educated people every time I go into a doctor’s office is the most terrifying thing about all of this. It is a symptom of a much broader diagnosis of systemic complacency, inequality, and breakdown of communication throughout a system that is supposed to be pushing our lives forward by making us feel better. Yes, I’m not living in a hospital, but how much better is that compared to living a muted life outside of any realm of proper care and attention? Western medicine is great at putting you back together if you suffer a car crash, finding a symptom and stopping it, and even managing some chronic conditions like diabetes. However, it still falls short in root cause analysis and systemic thinking in a quickly growing pool of more complex and chronic patients. It is easier to manage one symptom after another all while collecting a premium at each encounter than to engage in trying to understand the full case of each patient. The crack in western medicine is the patients that fall between cancer and common cold. Even then, many potentially dangerous treatments are handed out recklessly sometimes even before a causal diagnosis is made. I have had multiple doctors prescribe me a specialty medication with very serious side effects while at the same time shrugging their shoulders when I ask what they think the problem may be.

Now this story isn’t all about me, it’s about the look in almost every doctor’s eyes when I begin to walk through my detailed (well documented) case with the new specialist of the month. It’s the same look that a less-than-average high school student gets during an English lit lecture that resembles an a of complete absence. The sheer lack of intellectual engagement that I see from such educated people every time I go into a doctor’s office is the most terrifying thing about all of this. It is a symptom of a much broader diagnosis of systemic complacency, inequality, and breakdown of communication throughout a system that is supposed to be pushing our lives forward by making us feel better. No, I’m not living in a hospital, but how much better is that compared to living a muted life outside of any realm of proper care and attention? Western medicine is great at putting you back together if you suffer a car crash, finding a symptom and stopping it, and even managing some chronic conditions like diabetes. However, it still falls short in root cause analysis and systemic thinking in a quickly growing pool of more complex and chronic patients. It is easier to manage one symptom after another all while collecting a premium at each encounter than to engage in trying to understand the full case of each patient. For example, in all of my doctors visits, not a single doctor has asked about my diet (except for the naturopathic doctors). The crack in western medicine is the patients that fall between cancer and common cold. Even then, many potentially dangerous treatments are handed out recklessly sometimes even before a causal diagnosis is made. I have had multiple doctors prescribe me a specialty medication with very serious side effects while at the same time shrugging their shoulders when I ask what they think the problem may be.

What is a diagnosis?

(Photo from MerriamWebster.com)

Even in the very way diagnoses are codified (ICD-10), the symptoms intermingle with and are undifferentiated from diseases themselves, indicating that we have a deep mismanagement of the way we approach treatments.

1) Misdirected feedback loops in the medical system

• Misdirected incentive feedback loops throughout the healthcare continuum
• Transparency and accountability in outcomes
• Patient education and availability of information

Each of these bullet points alone amount to many hours of future articles, so I will be brief here.

First, this is a well known problem, but the solution is much less clear. The financial incentives in every piece of the health system generally boils down to a volume game. For-profit companies exist to maximize and perpetually grow shareholder value. Period. This is an antiquated model of capitalist based business, and many large companies are learning that it’s never that simple (this is also an entire article in itself), but healthcare is crawling down the road of what will be a long drive away from this level corporate self actualization. Although many health systems are not for profit, the drug and device manufacturers that power them are. This sparks a vicious circle that forces every other node in the healthcare network to structure their pricing models around perpetual growth in volume and unit based pricing.

(Also from Forbes.com)

The initial issue in transparency and accountability is that we are still in our infancy in the practice of even documenting outcomes data. EMRs are still maturing, and harnessing that data is even farther behind. Long story short, calculating accurate population wide outcomes data is extremely hard, but we are getting there. We need to incentivize and empower health systems to manage their outcomes data.

I admire doctors. Hell, I would even consider being one if the system wasn’t so hard on them (and if I could get into med school). Doctors usually deserve the respect they command, as they do the public a vital service. But, they often fall into a lull of complacency that is built by the controllers of the system. Many doctors quickly become tired and beat down by documentation and repetition of seeing patient after patient, many of which may be entirely responsible for their illness that they refuse to take any ownership for. A big problem is that they are drowning in paperwork and forced to be driven by fee for service based compensation. I try to put myself in the position of a doctor (as much as possible) and hope that I would not go through all those years of difficult education and debt just to turn into becoming a an over-educated drug dealer. I would want to be proud of the outcomes that I help provide for my patients. I would invest my career into ensuring my patients are cared for and that I am always pushing my knowledge base to help them. I would even bet on myself to help these patients and take on two sided risk. This would only push me further to the side of innovation. Although, this level of transparency is not great for the status quo. I’m not a doctor, so I suppose I just don’t know enough. Just like the free market judges products based on value generation and utility; physicians, drugs, and devices should also be subject to those same forces. That statement especially holds if we make the assumption the public health belongs in the free market at all. Either way, the system has mutated into something else entirely.

The first argument that a physician might make against bearing 2 sided risk for the outcome of the patients is one that I do not disagree with. The thing that makes this whole problem much more difficult, is that many people who have an illness are not willing to take responsibility for their health. There is evidence of this everywhere: our diets, habits, and even medication adherence patterns. We can’t even stick to a medication that we KNOW works because we forget or don’t have time. If we as patients aren’t willing to take responsibility for our outcomes, why should our doctors? The happy medium is this: patients deserve full access to their doctors full intellectual capacity, resources, and especially information. However, if a patient does not follow through, that is their risk to hold, not the doctors. The doctors and pharmacists only have a finite enough time to babysit patients with follow up calls and other monitoring programs.

The first argument that a physician might make against bearing 2 sided risk for the outcome of the patients is one that I do not disagree with. The thing that makes this whole problem much more difficult, is that many people who have an illness are not willing to take responsibility for their health have often even caused their issues directly. There is evidence of this everywhere: our diets, habits, and even medication adherence patterns. We can’t even stick to a medication that we KNOW works because we forget or don’t have time. If we as patients aren’t willing to take responsibility for our outcomes, why should our doctors? The happy medium is this: patients deserve full access to their doctor’s full intellectual capacity, resources, and especially information. However, if a patient does not follow through, that is their risk to hold, not the doctor. The doctors and pharmacists only have a finite amount of time to babysit patients with follow up calls and other monitoring programs.

At risk of sounding like I am dead set against the drug companies and PBMs (another topic in itself), I’m not ( at least not all of them). They provide tons of innovation that improves patient lives. However, it is getting harder and harder for some of them to argue that they are not severely misaligned with the public good. I do have a lot of respect the ones that are pushing to further demonstrate their outcomes in the real world. My theory is that no single entity is responsible. Everyone bears a piece of the blame, and everyone should bear a piece of the solution.

Lastly, some thoughts on alternative medicine. Alternative medicine can be boiled down to basically everything else that is not approved by the FDA, CMS, CDC, and other regulatory agencies. This includes popular therapies such as massage therapy, acupuncture, naturopathic medicine, ozone therapy, and much much more. While much of the alternative medicine landscape is likely speculation at best, and is often a scam by companies profiting off fears of others (I wonder who else does this), there are also many things that alternative medicine excels in such as systems oriented thinking, root cause analysis (to an extent), and patient centric care. There are many potential therapies that have been stuck in the land of alternative medicine and will likely stay there because the intellectual property of natural resource cannot be patented, so it becomes extremely difficult to fund rigorous research in these potentially promising therapies at scale. It is crucial that science explores all possibilities in a minimally biased way. Whoever solves this problem will likely give Jeff Bezos a run for his money.

Healthcare in the U.S. is tangled to say the least, but the solutions have to start with 3 simple concepts: transparency, accountability, and open mindedness. Science lies on the premise that anything could be possible until disproven with our existing knowledge. But even then, there is always more that we are not considering, and we should always push to find it. I know will continue to take ownership of my health issues while at the same time serving as a chance for doctors to push their knowledge and skills to help me.