Biomedical Focus is Ruining US
An article by Andrew Weil indicates how "The Biomedical Model is Failing Us." Despite lofty claims, the drugs promoted have not done much for mental health. Not surprisingly the biomedical model may have failed most when applied to mental health where so much is about behaviors, relationships, and other people factors.
Weil points out, "In 1977, the journal Science published a provocative article titled “The Need for a New Medical Model: A Challenge for Biomedicine.” I consider it a landmark in medical philosophy and the intellectual foundation of today’s integrative medicine. The author, George L. Engel, M.D., was a professor of psychiatry at the University of Rochester (New York) School of Medicine. Determined to overcome the limiting influence of Cartesian dualism, which assigns mind and body to separate realms, Engel envisioned medical students of the future learning that health and illness result from an interaction of biological, psychological, social, and behavioral factors, not from biological factors alone. He fathered the field of psychosomatic medicine and devoted much of his career to broadening our understanding of disease. He was particularly interested in mental health.
George Engel died in 1999 with his vision largely unrealized. In fact, the field of psychosomatic medicine ran out of steam sometime before his death and was never able to challenge the ascendancy of biological medicine."
Engel was also a great influence upon those establishing family medicine. The Ecology of Health Care and other works illustrated the tiny contributions of academic teaching hospitals where students and residents are trained. Some much more important are homes, people, and local situations for health, health outcomes, and quality measures.
Health has been improved by working together on sanitation, clean water, better environments, immunizations, and basic treatments. The initial advances such as antibiotics have had some impact. But in areas such as cancer it took until 2005 before the various advances in drugs, scanning, and other technologies to have more impact compared to behavior changes such as stopping smoking.
The problem with technology is that it becomes the only approach, despite limitations such as cost and harm done. Breast biopsies have a 7% false positive rate - a huge problem not discovered until you have had the unnecessary surgery that leaves you injured and unimproved. Screening for lung cancer does not work for lower risk and is questionable for higher risk and leads to a cascade of consequences not fully evaluated.
From Dr. Weil, "In retrospect, seeing human beings as nothing more than the sum of biochemical interactions was probably a necessary stage of medical evolution. Medical systems of the past lacked the technology to study the biological underpinnings of human health with rigor and precision. Now we have that technology, and we’ve used it well to gain invaluable insights about our physical bodies. But it is impossible to restore or promote human health unless we begin with a complete definition of a human being. An incomplete definition will always result in incomplete diagnoses and less-than-optimal treatments."
How Did We Get So Off Track?
The Integrative and Global Approaches Are Most Essential to Guide Health Design
Deming noted quality as a matrix of relationships. The body-mind-body part relationships are important. The relationships of humans with each other and environments are important. Many technical interventions appear not to work at all when patients are not the typical higher income, more educated patients that have savings and paid time off so that they can tolerate being made sicker as treatments fight off cancer or aberrant immune responses.
Just when it appeared that biomedical was failing, the medical error focus came along. Now that this is failing, we have precision medicine focus and Moonshots that will add more hundreds of billions a year for little gain as profits will continue to flow to few for little result. We cut off a head and two appear.
We are moving away from value as we fail to value investing in people.
Why Not Huge Insurance and Software Cost Act instead of ACA or MACRA?
Why not Penalities for Providers caring for poor patients P4P instead of Pay for Performance?
Why Not Practice Consultant Makes Headlines instead of PCMH or Primary Care Medical Home?
Why not Marginalizing Actions Critical Recovery of Access for MACRA?
Cancer
Gets a Moonshot and STDs Get No Shot at All - Disease focus has found
new support. Public health and basic services will fall further behind.
Six
Degrees of Discrimination By Health Care Payment Design - Medicare
payment transparency exposes Medicare as paying less for primary care,
less in the states in most need of workforce, less in counties in most
need of workforce, and even less with Pay for Performance designs. Also
places with concentrations of patients with plans least supportive of
local care receive the fewest lines of revenue and have deficits of
workforce by design.
Primary Care Must Rise from the Ashes of the Last 20 Years of Policy
Recovering General Surgery Is Impossible
Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior - the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity
Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care
Does Anyone Understand that High Cost High Need Patients Drive Consumption?
Medicaid As Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with all types of insurance or lack thereof. Medicaid expansion with low payment compromises the workforce to care for Medicaid patients and other patients with or without insurance
Exploring the Health Consequences of Disease Focus
Weil points out, "In 1977, the journal Science published a provocative article titled “The Need for a New Medical Model: A Challenge for Biomedicine.” I consider it a landmark in medical philosophy and the intellectual foundation of today’s integrative medicine. The author, George L. Engel, M.D., was a professor of psychiatry at the University of Rochester (New York) School of Medicine. Determined to overcome the limiting influence of Cartesian dualism, which assigns mind and body to separate realms, Engel envisioned medical students of the future learning that health and illness result from an interaction of biological, psychological, social, and behavioral factors, not from biological factors alone. He fathered the field of psychosomatic medicine and devoted much of his career to broadening our understanding of disease. He was particularly interested in mental health.
George Engel died in 1999 with his vision largely unrealized. In fact, the field of psychosomatic medicine ran out of steam sometime before his death and was never able to challenge the ascendancy of biological medicine."
Engel was also a great influence upon those establishing family medicine. The Ecology of Health Care and other works illustrated the tiny contributions of academic teaching hospitals where students and residents are trained. Some much more important are homes, people, and local situations for health, health outcomes, and quality measures.
Health has been improved by working together on sanitation, clean water, better environments, immunizations, and basic treatments. The initial advances such as antibiotics have had some impact. But in areas such as cancer it took until 2005 before the various advances in drugs, scanning, and other technologies to have more impact compared to behavior changes such as stopping smoking.
The problem with technology is that it becomes the only approach, despite limitations such as cost and harm done. Breast biopsies have a 7% false positive rate - a huge problem not discovered until you have had the unnecessary surgery that leaves you injured and unimproved. Screening for lung cancer does not work for lower risk and is questionable for higher risk and leads to a cascade of consequences not fully evaluated.
From Dr. Weil, "In retrospect, seeing human beings as nothing more than the sum of biochemical interactions was probably a necessary stage of medical evolution. Medical systems of the past lacked the technology to study the biological underpinnings of human health with rigor and precision. Now we have that technology, and we’ve used it well to gain invaluable insights about our physical bodies. But it is impossible to restore or promote human health unless we begin with a complete definition of a human being. An incomplete definition will always result in incomplete diagnoses and less-than-optimal treatments."
How Did We Get So Off Track?
Many
of the wonder drugs have questionable benefit and in the studies the
placebo effect is often substantial. Replications of studies can be a
problem. The data was not specific to the hypothesis explored
originally. There has not been transparency in data, analysis, and more.
Deming noted quality as a matrix of relationships. The body-mind-body part relationships are important. The relationships of humans with each other and environments are important. Many technical interventions appear not to work at all when patients are not the typical higher income, more educated patients that have savings and paid time off so that they can tolerate being made sicker as treatments fight off cancer or aberrant immune responses.
In the global sense, 3 trillion a year for Biomedical is 17% of GDP largely wasted when it could be substantially invested in housing and better environments, better situations, better social determinants, starting with improved child well being. Humans function best when investing in each other - not technology that works well for a few for a few conditions leaving most far behind.
Biomedical Focus Fails US
Medical error focus 1999 to 2020 has resulted in hundreds of billions more added each year for no gain. The US still has marginal outcomes as costs spiral ever higher. EHR/digital focus has done much the same. Even worse, the high costs prevent investments in patients or in the teams to invest time and effort and talent in patients.
Why do we continue to invest so much in clinical interventions that can do so little (perhaps 10% of outcomes when people factors shape 60 - 70%)? The likely answer is entrenched thought reinforced by high profits diverted to support even higher profits.
The Biomedical Hydra
Just when it appeared that biomedical was failing, the medical error focus came along. Now that this is failing, we have precision medicine focus and Moonshots that will add more hundreds of billions a year for little gain as profits will continue to flow to few for little result. We cut off a head and two appear.
We are moving away from value as we fail to value investing in people.
Why Do We Tolerate Names of Programs That Cover Up Failure
How long do we tolerate No Child Left Behind and similar cover ups for tens of millions of children left behind? Even worse we now have been turned to measurement focus that cannot address children, teachers, parents, or home environments while moving dollars away from these efforts.
How long do we tolerate Value Based proposals that add cost for no gain in outcomes - the opposite of value? How has the rise from 10% to 17% GDP for health spending been valuable? As administrative and non-delivery costs go up for EHR, digital, maintenance, cost management, turnover, recruitment, and retention - how have we gained value?
Why Not Huge Insurance and Software Cost Act instead of ACA or MACRA?
Why not Penalities for Providers caring for poor patients P4P instead of Pay for Performance?
Why Not Practice Consultant Makes Headlines instead of PCMH or Primary Care Medical Home?
Why not Marginalizing Actions Critical Recovery of Access for MACRA?
Summaries of Recent Blogs
What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care.
Oregon Primary Care Medical Home Supposedly Saved 240 Million But Spent Over 250 Million - A minimum additional cost of 250 million dollars was required to save 240 million and the actual cost of delivery increases should be much higher.
Blood Clots or How Dr. House Breaks Down the United States - Physicians are pushed to be complete and are pushed to cut down costs. What is needed is much better studies and less media exaggerations
Seeds of Health Improvement Fail on Barren US Soil - Any number of interventions can work in a nation that invests in children and improved environments, situations, and social determinants. In nations with little or failing support, health interventions can be expensive and fail to work
Cancer
Gets a Moonshot and STDs Get No Shot at All - Disease focus has found
new support. Public health and basic services will fall further behind.
Six
Degrees of Discrimination By Health Care Payment Design - Medicare
payment transparency exposes Medicare as paying less for primary care,
less in the states in most need of workforce, less in counties in most
need of workforce, and even less with Pay for Performance designs. Also
places with concentrations of patients with plans least supportive of
local care receive the fewest lines of revenue and have deficits of
workforce by design. Primary Care Must Rise from the Ashes of the Last 20 Years of Policy
Recovering General Surgery Is Impossible
Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior - the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity
Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care
Does Anyone Understand that High Cost High Need Patients Drive Consumption?
Medicaid As Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with all types of insurance or lack thereof. Medicaid expansion with low payment compromises the workforce to care for Medicaid patients and other patients with or without insurance
Most Visited Early Blogs
Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care
Finance-me-cratic Constants in the Bureaucratic Universe
Meeting Primary Care Needs in the Last Half of the 21st Century
Exploring the Health Consequences of Disease Focus
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr.
Robert C. Bowman, M.D. Robert.Bowman@DignityHealth.org
The blogs represent the opinion of the blogger alone.
Copyright 2016
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
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