Lakeside Medical Musings

Where Have You Gone, Marcus Welby?

Once upon a time, people went to their physicians seeking medical advice for medical problems, and they actually tried to follow the advice they received for their $35.00 appointment. Times have certainly changed, and now people are just as likely to Google a medical question for their answers as go to their doctor for their $100.00 appointment. Medical consumers are eager now to find a person with a passion, a computer, and an agenda, and consumers are ready to follow these often uneducated medical advice-giving columnists, even if their guru’s advice runs directly counter to their physician’s advice.  Why did this happen?  Why do intelligent patients make important medical decisions and take health advice from non-medical people with a mission, but backed-up with little or no actual scientific facts? Are these people snake oil salesmen, self-promoters, or the future of medicine?  What has caused the respect for the medical establishment to erode so significantly over the past forty years?  I have thought about this quite a lot, and I have come to the conclusion that there are five major reasons that account for the change: television, advertising, a pervasive feeling of lack of control in our own lives, the internet, and our current medical system. I’ll take each one in turn; please read actively and note if you agree or disagree with my points, and then let me know in the comments section if I nailed this one, or if I completely blew it.

The first television drama set in a hospital and centered around the lives of medical personnel was City Hospital in 1951, followed by Medic in 1954, and then the better-remembered (by me, anyway) Dr. Kildare and Ben Casey in 1964 and the magical Marcus Welby, M.D. in 1969. From these sober, almost reverential medical dramas to the wildly unpredictable, anything-and-everything-goes shows like  MASH, House,  and Scrubs,  there has been a huge change in the way physicians are represented on television. The early shows portrayed physicians as all-knowing, infallible, and fatherly – remember, only 7.6% of all physicians in the United States were female in 1970, so of course, they were represented as the ideal father, i.e., somewhat remote, always right, firm but kindly.  Like Perry Mason, these physicians never lost a case, they never found themselves in out-of-control situations, and they were always on the side of goodness and truth. Real physicians were thus elevated to an undeserved pedestal, and children wanted to grow up to be doctors.  Surprisingly to me, actors who play doctors on television are often perceived by viewers to actually be doctors: “Robert Young, who played a doctor on Marcus Welby, MD … reported receiving mail every week with medical mysteries, asking for his expertise to help solve these cases.”  See this interesting article here.  More recent television shows have focused on physicians’ personal flaws, medical mistakes, eccentricities, and arrogance. It makes sense that if viewers at one time believed Marcus Welby could help them with real medical problems , viewers today would extrapolate from current medical shows  that physicians are flawed, arrogant, and distracted, routinely (weekly, anyway) making mistakes that cause people to die. Today’s shows, such as ER and Gray’s Anatomy are dramatic medical soap operas, portrayed as real life medicine, and many people – on some level — believe that this is what really happens in hospitals.  The current portrayal of physicians is certainly not the romantic, idealized, softly-lit view as it was in the 1960’s and 1970’s. It is deeply unsettling to see physicians – characteristically transferable to your physician — in the harsh spotlight that illuminates every wrinkle, all the human flaws that you know they would have to have, but you would prefer not to actually see when they’re on duty, taking care of patients. Would you want your child taken care of by any of the practitioners on Scrubs? Do you want to think your physician is also dealing with all the drama going on in Gray’s Anatomy while your husband fights for his life in the emergency room? No way! I think these portrayals, while probably pretty honest and accurate, have resulted in an overall reduced trust in the medical profession. If some physicians are going to be flawed, love-sick, inept buffoons, then your doctor might be like that, too, right?  Understand, I am not saying that it was better for the public to nurture an unrealistic, God-like reverence for physicians, but certainly today the pendulum has swung so far in the other direction that there is an outright distain in many quarters for the opinions of physicians who do not bear the label of “holistic,” or “integrative,” or “naturopathic.”

Then there’s advertising. There are two types of advertising that have had a major, negative (in my opinion – this is disputable) impact on medical care.  The first is pharmaceutical companies that promote their products through direct-to-consumer advertising. The first direct-to-consumer ad came from Merck in 1981, at a time “when the political climate in the U.S. became more and more favorable to the pharmaceutical industry,”see link here and today, direct-to-consumer prescription drug advertising accounts for 40% of the marketing budget of the entire pharmaceutical industry.  Did you know that the United States and New Zealand are the ONLY countries that allow this type of marketing? In every other industrialized nation, including every nation in Europe, this type of advertising is banned. In 2013, Nielsen estimated that 80 pharmaceutical ads ran every single hour, around the clock, on US television stations. Between Viagra and Cialis and Cymbalta and Celebrex, the number of ads are overwhelming and make me so glad I have a DVR so I can skip the endless parade of penis problems, depression, and joint pain.  Ads are effective for drug sales, or drug companies wouldn’t continue to bombard us with them.  Patients often arrive at their doctor’s office with a list of the medications they need – as seen on tv! — as opposed to asking for medical advice with a problem. I am not convinced that the education of the public by way of promotional advertising has been good for the public.

The second form of advertising is for non-FDA-regulated supplements.  These ads always include the disclaimer that “this product is not being sold to treat or diagnose any medical condition,” but the ads always state what result the product is intended to produce .  “I feel 20 years younger,” the tanned, buff, self-proclaimed 74-year-old man announces, as the giggling, gorgeous, half-his-age woman by his side winks and laughs, “I’ll say he does!” There are the self-promoters, the Dr. Oz’s of the world, who have huge followings, heavily promoted by such obvious successes as Oprah. While Dr. Oz denies, in response to direct questioning when testifying before Congress, that the supplements he endorses produce reasonable cures for anything at all, on his popular TV show he states just the opposite every day.  Get a couple of celebrities to rave about your solution to aging or the supplement that you developed for weight loss or hair loss or as a “blood strengthener,” whatever THAT is, and you have minted yourself some real coin.  People buy the hype because it is much more heartening than the reality. I am sure that Oprah could announce yet another medical miracle on her show tomorrow, and Americans would follow in droves. Here is a very interesting article from Forbes about this topic.

In a world as complex, overscheduled, tense, and chaotic as ours is today, many people feel they have lost any real control over their lives.  The politicians run the world. Their bosses run their work life.  There are endless demands from children and significant others, and there remains little free time in the average person’s life.  This lack of control leaves people feeling uncomfortable and often depressed, and this somewhat new obsession with health is one way to combat this feeling. That feeling of regained control might come from following the latest fad diet to improve strength, vitality, and youth.  Or it might come from mastering the latest extreme physical endurance challenge to improve strength, vitality, and youth.  No longer is a 10K considered a feat of fitness.  Now it’s ultramarathons, IronMans, Coast-to-Coasts, CrossFit, and bodybuilding competitions that win the cocktail party admiration awards. People feel they must accomplish feats well beyond the reasonable endurances of the human body.  The orthopedic surgeons must be loving this trend! It is certainly in the best interest of an individual to be involved in the promotion of his or her own health through good nutrition that produces a healthy weight, enough exercise to keep heart and lungs healthy, and a zero allowance for cigarette smoking, along with education about medical best practices.  But today there are millions of people spending inordinate amounts of time and money on Wizard of Oz products to attempt to squeeze out that last bit of youth, beauty, fitness, or sense of well being.

I would like to give you a couple of incontrovertible medical facts that have not changed over thousands of years.  We all die.  All of us are able to do less, physically, when we are 60 than when we are 20.  Many of the diseases that we develop are due to genetic dispositions and environmental exposures. For example, the incidence of gastric cancer is about four times greater in Japan than in the US, but the incidence of colon cancer is much lower in Japan than in America. Significantly, these numbers change when families immigrate, especially by the second generation after the move. The reasoning behind this is that first generation immigrants tend to keep their diets similar to their homeland, but by the time of the second generation, immigrants have adopted the diet, for better or worse, of their new homeland.  Here is an excellent study on this.    I bring this up because whenever you change your diet to reduce your risk of one disease, you are probably increasing your risk for another!  You can lessen your risk for cardiovascular disease by controlling your weight, getting a reasonable amount of exercise, and not smoking cigarettes.  But adopting a vegan, gluten-free, organic or paleo diet provides, in my opinion, little more than this ephemeral feeling of control but carries significant lifestyle tradeoffs while providing limited documented health benefits.

The internet is filled with lots of very good medical information, but it is also filled with a lot of hokum.  “I read it on the internet.  It must be true!”  This is an old joke, but it is surprising how many people actually do believe this.  Just looking at the links to articles that I see posted every day on Facebook , I know people tend to believe whatever they read, if they are pre-disposed to the ideas presented, whether or not these ideas are backed up by any significant, reliable, repeatable research from reputable sources.  We all tend to relate to (and believe) things that fit our own philosophy, and we ignore things that dispute our basic beliefs. If you read something about your medical condition and it “speaks to you,” you will, often to your detriment, tend to believe it, and if this is counter to what your physician has told you, it undermines your faith in your physician as well as the entire medical system.  The internet has made a lot of very good medical information widely available.  If you have been diagnosed with a condition, you can research the most up-to-date information and gain a much greater understanding of the problem and what the options are in treating it. Where some of this goes off the rails, though, is in making patients understand that the ability to treat complex medical problems is a developed skill, much more than reading a layman’s level medical article on the internet.  Obtaining information on the internet increases your knowledge, always a good thing, but it does not give you the ability to interpret complex medical data such as blood tests or PET scans that, when combined with detailed histories and physicals, allow well-trained and experienced physicians to make educated diagnoses and create reasonable treatment plans.

Here’s an example of what I’m talking about. Simon, a friend of ours, had chronic diarrhea and had seen multiple specialists without obtaining a diagnosis. So one day, he asked my advice.  As Simon was not my patient, my advice was simple. I said, “Simon, you have seen several excellent gastrointestinal specialists, and they haven’t been able to give you a diagnosis.  I have neither examined you nor know your actual medical history, so there’s just no way I could possibly diagnose you when they can’t. It’s clearly a problem, and I’m so sorry you’re so uncomfortable.”   Several weeks later, Simon’s wife called and left an astonishing message on our answering machine:  “Ruth, tell John I have a tip for him.  Radiation therapy can cause diarrhea and that is what Simon had three years ago.” Ok, I thought, but I didn’t even know he had had radiation therapy.  In fact, three years earlier, Simon had had a radioactive iodine treatment for a thyroid problem, which is not the type of radiation therapy that causes diarrhea, but my friend didn’t have the medical knowledge or experience to understand what he had read on the internet, and that misplaced knowledge caused him – and his snarky wife – to question to competency of the entire medical system that was trying its best to treat him.

The last component to the loss of trust in the medical system is a self-inflicted wound.  There are just so many documented episodes where physicians, hospital systems, and giant pharmaceutical and medical device companies put their own self-interest ahead of the needs of their patients.  It is an indisputable fact that Fee for Service medicine promotes unnecessary medical procedures and diagnostic tests.  Do you lose a little bit of faith in physicians when you read yet another story about a regularly performed medical procedure that is proven to be useless but is very lucrative to the physician?  I do.  Do you lose a little bit of faith in physicians when you see the huge sums of money some of them accept from drug companies to shill their products or from device makers to use their products?  I do.  Some of these abuses are being reduced by pressure from watchdog agencies, but Big Pharma’s lobby is one of the strongest in Washington, and the continuing anti-regulatory movement continues to grow, at our own peril.  Consumer distrust grows when investigations reveal that pharmaceutical companies routinely hide studies that show their products have more side effects or are less effective, reporting  only the positive studies that are conducted in their own labs, not by impartial independent testing.  Or when device makers hide data that reveal the existence of defective parts in their hip replacements or pacemaker leads long after the companies know there are problems. See this article  in today’s Wall Street Journal about  conflicts of interest even within the FDA.  It reminds me of the tobacco industry in the 1960’s – thoroughly protected by congressional lobbies and intentionally tampered data, abusing the public welfare, caring for little beyond their own profitable bottom line.

The medical community can’t do a lot about many of the things that have changed since the days of Marcus Welby.  I doubt the public trust in the American medical system will ever return to those long-lost days, but there is much we can do.  Fee for Service medicine needs to be replaced by a patient-oriented payment system.  Pharmaceutical and medical device companies need closer regulation and oversight. Conflict of interest issues need to be examined, faced, and resolved.  People will believe what they want to believe and, as physicians, we need to do what we can even when our advice is ignored in favor of that from an Herbalife salesman.  I really don’t want us to return to the days of Physician as God, but I don’t like where we are today, either, with Physician for Hire.  Trust between patients and their medical providers is too important a component of medical success to allow it to deteriorate to a point of no return.

 

 

 

 

 

 

3 thoughts on “Where Have You Gone, Marcus Welby?

  1. johnadams1782

    John – thanks for your explanation. Your points, as always, are very persuasive, particularly the last one about the oncologist. Capitation, as i understand it is where a managed care organization charges a set fee for medical care whether it is used or not. While it would seem to have merit for encouragement of preventative care, I think it might be a tough sell to a lot of folks in your profession. All of the same rate setting ideas of insurance companies including: age, sex preexisting conditions, etc, play a part in the rate setting. For example, a physician might not be quite as enthralled about providing care for a group of “sand hogs’ as he would a group of accountants. Workman’s Compensation rates would seem to be a good example. One of my doctors who is hospital based and salaried would have no problem with the idea. However, another who has an independent practice with all of the problems of any small businessman, would reject it in a flash. I will be anticipating your next “edition.”

  2. johnadams1782

    John, in your blog you stated that you thought that : “Fee for Service medicine needs to be replaced by a patient-oriented payment system”.
    I have been listening to this argument for years. Please explain how a patient oriented payment system would work.
    We are living in a completely “fee for service” society. When our cars need repaired, we pay a fee. I suppose we could have a automobile oriented payment system or a total warranty. If the paint deteriorates on our homes, I suppose we could have a home oriented payment system or a total home warranty. We pay fees when we get new clothes, obtain food or clothing.
    If you see what i am getting to, it is that what you are suggesting is pure socialism. You can argue that health care is too complicated for the average person to make sound decisions with what amounts to as their “purchases”. i agree that many, including myself, are guilty of quasi-learning just enough about medicine to be dangerous. Then, why not better educate the public? I don’t mean to attempt to diagnose their medical problems, but to make sound decisions as to when it is time to seek professional medical help.
    As I have mentioned previously, one of the main problems I see with our old medical system is that many of the insured patients, do not have very much, if any, financial interest in their health care. We will never be able to control health costs unless going to see a doctor has a financial impact. In the vernacular, everybody needs to have “some skin in the game”. The principle of insurance is to share risk for catastrophic problems which is just as fitting when dealing with health care as it is with our homeowner’s insurance.
    The vast expansion of Medicaid and highly subsidized ACA is only making the problem worse.
    Even if we go to a single payer system, which the public seem to want, the principle of insurance should be applied or it would be a complete financial disaster. Since I have very little confidence in our government, I would assume that instead of a complete, well funded, simple program, it would be full of “pork” for the political favorites and greatly unfunded. I hate to think how many thousand pages would be needed to satisfy all of the various political and lobbying interests in such a bill.
    One last note, the declining number of family physicians, is leading the general public to no longer have the bonds that used to exist between physicians and their patients with the trust, personal relations, and understanding of the past. Today, if you can find a harried family doctor, and you tell him you have a stomach ache you are likely to be promptly referred to an internist.
    I continue to look forward to each of your blogs. Thank you so much for your intelligent thought provoking perspectives. Your style of writing makes each one interesting, so that I usually reread them many times.

    1. John Post author

      There are lots of options for payment other than fee for service and none of them have to government controlled or related. Socialism, while an emotional trigger, has nothing to do with other payment systems.

      There are some major differences in fee for service when you get your car fixed or your haircut. You are getting a service that you can judge the quality. To be honest, a patient has no idea if the medical care they are getting is good, bad, appropriate or overpriced. Additionally a patient often views the quality of care based on the results or bedside manner of the physician.There are so many things that contribute to the end result of a specific medical care or procedure unrelated to the care provided. But there are evidenced based recommendations for care. Additionally, if you take your car in for a repair and it doesn’t get fixed what do you do? You bring it back and it gets fixed and you don’t pay anything else. With medicine, if you go to the doctor and the doctor does the wrong thing and you get sicker, you go back to the doctor. And you pay more for what the doctor does next. And if the doctor had done the right thing and you get sicker, you go back to the doctor and you pay more. As a patient you can not usually tell if what was done was the right thing or not. And you certainly can’t tell if some of the treatment or diagnostic tests that were done were motivated by money or were appropriate.

      The cost of medical care is also considerably more expensive than anything else that anyone pays for in their daily life. Regardless of the reason for this, it is a fact. You can go to the hospital for a 4 day stay and come home with a $100,000 bill.

      But the big issue that I have with Fee for Service is that it give incentives to do things as opposed to take care of the patient. One option for payment that has been used is capitation. Under this payment structure a physician or healthcare system is paid a set amount to provide care to a population of patients. There can, and should, be bonuses based on quality measures. But that way you are not incentivizing doctors or healthcare systems to do things to make money. You are paying for appropriate, good care.

      I will have some other posts in coming months that show some glaring examples of the abuse of fee for service. The amount of money that is wasted is huge. The public is not aware of these abuses except when there is an extreme example, but it pervasive. Let me leave you with something to think about. It is not uncommon for a cancer doctor to make 60-70 percent of their income from the chemotherapy drugs that they administer. Would you want your physician having this large of an incentive to do something? I wouldn’t.

      Thanks for reading and commenting.

Discussion