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Why Your Doctor May Have PTSD

by PAUL SIMPSON, M.D.

I keep hearing that our healthcare system is broken and needs to be fixed. I disagree. We don’t have a broken healthcare system because the arrangement we have for healthcare in this country does not satisfy the definition of the word “system.” A system is, according to the dictionary, “a set of interacting or interdependent entities forming an integrated whole.” Although healthcare entities in this country may interact and are in some ways interdependent, they can in no way be credited with functioning as an integrated whole.

I’m sure you’ve seen news clips of angry people shouting at their Senators and representatives and even carrying guns to President Obama’s town hall meetings on health care reform. I’ve read that these people aren’t really angry over health care, but are, instead, mad about the economic collapse, the financial bailouts, or the fact that a black man has become President. But I believe they have every right to be angry about  the worsening national disgrace that masquerades as our healthcare system.

Medicine in America used to be a calling. It has been transformed into a $2.3 trillion per year industry. The individuals and institutions that provide medical care have now become little more than profit centers for this industry. Money has become more important than people’s lives. Profit-seeking has risen to the level of predation. With profit as the main driver of activity in medicine, patients have become consumers (witness the 1990s effort from within the industry to get doctors and nurses to call those they care for “clients” instead of “patients). These customers have come to view health care as a commodity they are purchasing. They are paying top dollar for this commodity, and as good consumers, they expect to get top value for the price they pay. They are tremendously disappointed and angry about the shoddy product they have purchased. Buyer’s remorse has set in.

The duty of the physician, as embodied in the Hippocratic Oath, is to place the interest of the patient ahead of his or her own interest. The drive for profit stands in direct opposition to this principle. Here are some figures to illustrate what has happened to us at the hands of this predatory industry:

A recent study by Dartmouth Medical School determined that 1/3 of our healthcare expenditures are for unnecessary care (including care to avoid malpractice suits)

Another 1/3 of our healthcare dollars go to profit and administrative costs for health insurers. Most of those administrative costs are incurred in the effort to avoid insuring those most likely to become ill and in avoiding payment for care rendered to those they do insure.

The top 5 insurers in California denied, on average, 21per cent  ($31.2 billion) of claims from 2002-2009.

During the first half of this year, United Healthcare’s Pacificare denied 40  per cent of claims. The other four big California insurers denied 30 per cent of claims.

A study this year by the American Medical Association showed that American doctors spend, on average, 44 minutes per day dealing with efforts by the insurance industry to avoid paying for care. The cost to doctors of this effort is $78,000 per doctor per year.

A Commonwealth Fund study reveals that since 2002, the average annual family premium paid for health insurance has increased by 87 per cent, now standing at $12,200. They project that figure will rise to $23, 800 by 2020.

Since 2002, profits of the top 10 health insurance companies have increased by 428 per cent

America’s five largest health insurers and their trade group, America’s Health Insurance Plans, spent over $6 million in lobbying during the first three months of 2009

Pfizer, the world’s biggest pharmaceutical manufacturer spent more than $9 million on lobbying during the last quarter of 2008 and the first quarter of 2009.

Pfizer just received the largest fine ever in world history, $2.2 billion for rigging the results of medical research to favor its products and for making false claims about the benefits of its drugs. $2.2 billion is two weeks of income for Pfizer

According to a Harvard School of Public health report, over 100,000 Americans die annually due to medical mistakes. Other analyses have suggested that figure is as high as 1 million deaths yearly.

22,000 die annually because they have no medical insurance.

President Obama recently announced that new U.S Census Bureau data shows 6 million Americans have lost their health insurance in the past 12 months.

A recent study of U.S. medical bankruptcies by researchers at Harvard Medical School published in the August American Journal of Medicine showed that:

In 1981, 8 per cent of bankruptcies resulted from medical bills

In 2001, 46 per cent

In 2007, 62 per cent

Between 2001 and 2007 the share of bankruptcies which could be attributed to  medical costs rose 50 per cent

37.2 million Americans were sent to collection agencies for medical debts in 2003.

At onset of illness, 78 per cent of those who later filed for bankruptcy had medical insurance. 3 per cent had no insurance because pre-existing conditions prevented their getting it. Although we keep hearing that most of the 47 million Americans without health insurance have simply chosen not to purchase it, only 0.3 per cent of those in medical bankruptcy had chosen not to buy insurance because they felt that coverage was not necessary.

From 1980 to 2006, radiation exposure to Americans per capita from medical tests increased more than fourfold

A 2008 study from the Archives of Internal Medicine showed that women who got mammograms every two years over a 6 year period were significantly more likely to get invasive breast cancer than those who got mammograms only once at the end of the 6 year study period. The authors attributed this effect to the possibility that some breast cancers in the latter group had spontaneously resolved. They were later taken to task by a letter writer for failing to even consider that the increase in breast cancers could have resulted from the increased radiation exposure of the more frequent mammograms.

A 2007 study from Columbia University Medical Center in the New England Journal of Medicine calculates that 1.5-2 per cent of all cancers in the U.S. may be caused by radiation exposure from CT scans. Another study has concluded that 1/3 of CT scans are unnecessary, with most of those being ordered in the practice of “defensive medicine”

A 2009 study in the Journal of the American Medical Association found that 95 per cent of emergency room doctors ordering CT scans and 50 per cent of radiologists performing the scans were unaware that CT scans cause radiation exposure.

We know radiation exposure can cause cancer, but those cancers appear years after the exposure, often 20-30 years later. It is virtually impossible to prove, at least by our current legal standards, that an individual case of cancer was caused by a particular exposure decades earlier. Most of the information used to educate doctors about x-ray technology comes from the companies manufacturing the machines. Emphasizing the dangers of radiation exposure during this education is not part of their business plan.

If you go to an emergency room with a headache, you will, almost without exception, get a CT scan of the head. I have patients with frequent headaches who have had over 10 head CT scans at various ER visits. Most of these scans were obtained even though the ER doctors were aware of the previous scans. Those doctors know that the likelihood of these serial scans showing anything helpful is almost zero. They also know that if they don’t get another scan, they will be held responsibly for not finding any problem that may show up in the patient’s head, even years later.

And let me tell you what happens when you are blamed for a patient’s problem. If you are aware there is a problem, say a bad outcome, even if you had no way of preventing that outcome, you will immediately fear a lawsuit. The statute of limitations is two years, and most suits are filed just before that limit. You will constantly ruminate on the event, questioning your own decisions, regretting the bad outcome, and wondering if you could have done something to prevent it. When the complaint is filed, it will portray you as a monster who deliberately injured the person you were supposed to be helping. You will be accused of causing injury either out of greed and reckless disregard for the patient’s safety or out of outright malice. You will be characterized as someone with moral standing beneath Dr. Kevorkian and  greed motivation larger than Bernie Madoff’s. Your actions may be portrayed as so outrageous that punitive damages are requested. Since punitive damage awards, by law, cannot be covered by your malpractice insurance, you will then be facing total financial ruin.

Even if punitive damages are not part of the suit, you face ruin if a jury awards the plaintiff an amount greater than the coverage limits of your insurance. Your defense attorney will instruct you not to talk to anyone about the case, thus isolating you in a time of extreme stress by cutting you off from the support from friends, loved ones, and colleagues. Some of your colleagues will line up to apply for the very lucrative job of testifying, either for or against you, as a so-called “expert” witness. The plaintiff’s experts will give “objective” scientific evidence to the effect that everything the complaint says about you is true. The defense expert will testify that you did everything right and are not responsible for the outcome. If you go to trial, which will usually last 1 to 3 weeks, the jury, faced with contradictory testimony, will usually accept the opinions of the “expert” who is most likeable or most entertaining. That trial will not occur until two or three years after the suit is filed. You will live in a constant state of stress, and since you can’t talk about the cause, those around you will not understand why, for four to five years, you have become increasingly difficult to live and work with. You will not seek professional help for the stress you are under because you are aware that, for the rest of your career, every time you apply for medical staff privileges or licensing, you will have to explain why you once sought psychological treatment. All too many physicians discontinue the practice of medicine, turn to addictive substances or commit suicide during malpractice suits. Regardless of the outcome, you will never view your patients, your colleagues or society the same way you did before.

In their 2006 book, Physician’s Survival Guide to Litigation Stress, physician Edward Davis, and Psychologist John James make a convincing case that the symptoms many physicians suffer for years after a malpractice suit best fit the diagnosis of post-traumatic stress disorder (PTSD). It is well understood in the field that if you practice medicine, you will eventually be sued. PTSD is best associated with the lasting psychological effects of combat trauma in veterans who are likely to manifest flashbacks, nightmares, anxiety, inattentiveness, aggression and violence, often leading to substance abuse, inability to work, incarceration, and/or homelessness. Do we really want our medical care delivered by people suffering from PTSD? Do you want your doctor to be afraid of you because you might be the next plaintiff? Do we want a system where fear of lawsuits drives doctors to perform unnecessary, expensive and potentially harmful tests and treatments? Such a system is neither ethical nor sustainable, and it certainly can’t deliver good medical care.

The other side of this coin is that the vast majority of injuries and deaths from medical mistakes are never compensated in any way. Clearly, we need a better way of identifying, treating, and compensating victims of medical errors. Meaningful healthcare reform is impossible without malpractice reform. Because of resistance from trial lawyers in the state legislature, malpractice reform was the first item dropped from the ongoing effort to reform healthcare in Pennsylvania. President Obama announced early in his presidency that malpractice reform would not be pursued because it would be a “distraction” from his healthcare reform proposal.

How can we untangle this mess? At the root of all the problems I’ve discussed is the profit motivation that drives healthcare in our society leading to a culture of predation that harms all of us. The great fallacy here is the idea that medicine is just another industry that will function best through a free market Our health is too important to trust to an arrangement driven by greed. Removing the profit motive will allow physicians to live up to our calling by truly embodying the Hippocratic principles on which our profession was founded. Taking away the profit motive will free us to assume our rightful role as advocates for our patients, both in the clinical setting and as public advocates for policies that promote health. Actively promoting safety, a healthy food supply, a healthy environment and a built environment that promotes an active healthy lifestyle should be seen by all physicians as part of the job. Under out current arrangement, little attention is given to this type of advocacy and education because these activities are not reimbursed. A step in the right direction would be adoption of a single-payer universal healthcare system that provides health care to all Americans and delivers us from the clutches of an industry that is unethical, unsustainable, and downright deadly.

Paul Simpson is a primary care Internal Medicine physician with thirty years practice and training experience in five states and five countries. He is currently practicing in central Pennsylvania. He can be reached at: pksimp@comcast.net

 

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