The Complete Patient

Though I believe Dr. Andrew Weil made a major strategic error in deciding to "go commercial"--that is, endorse products and put out his own line of nutritional supplements, per my new column on BusinessWeek.com--I continue to admire him for speaking his mind about the healthcare industry. Two points he made during my interview with him especially resonated:

1. He is highly skeptical of recent studies about nutritional supplements. He observed that "in the medical media there is an obvious agenda to discredit natural products, especially those commercially important and in competition with pharmaceutical drugs." Moreover, "Often the studies aren't very good." He cited in particular one about vitamin E that made the front page of many newspapers last year, which he pointed out is really an assessment of previous studies, rather than a fresh study in its own right.

2. He is unwilling to publicly endorse any one brand of products entirely, including his own. He pointed out, and the court documents bear him out, that drugstore.com sued him for breach of his $14 million contract with the online distributor because he wouldn't be a shill. "I'm not a sales person," he said. He may be paid, he suggests, but he can't be bought.

Unfortunately for Dr. Weil, the perception once you begin going down the endorsement path is that you are a shill. If he can successfully fight the perception, he'll be doing one heck of a job of image control. That would be nice, because his voice is needed in the ideological battle now taking place between traditional and complementary practice.

You can hear excerpts of my interview with Dr. Weil at my web site.

I know the heading sounds like a contradiction in terms. When was the last time you met with a doctor who struck you as idealistic? Yet that's the tag I feel like applying to Peter Salgo, a physician who wrote an op-ed in today's New York Times, "The Doctor Will See You for Exactly Seven Minutes". The author is a physician and professor at Columbia, and bemoans that "the doctor-patient relationship has become frayed." He says the problem is caused by "business jargon" becoming commonplace, most notably referring to patients as "customers" rather than "patients." If your doctor is treating you more distantly, like a customer, he advises seeking out another doctor.

I hate to be the bearer of bad news, Dr. Salgo, but the problem is a bit more complex than that. Most Americans are assigned to "networks" by their insurers, so if the patients seek out different doctors, the new ones are working under the same rules as the old ones in terms of how much time they can spend with patients and how their productivity is measured.

The main problem from doctors' perspectives is that most are "wholesalers" instead of "retailers." That is, the insurance companies and HMOs engage the doctors as service providers, and pay them at heavy discounts over published, or retail, rates. The insurance companies collect the retail prices as the monthly premiums collected from employers and consumers. The biggest margins go to the retailers, the insurance companies and HMOs,  who will continue to squeeze doctors in order to try to increase those margins. It's basic business.

I had wanted to write something about a major study that came out last week in the New England Journal of Medicine, which makes a strong case that nearly all Americans, no matter their wealth or education or where they live, receive less than 60% of “recommended care”—the procedures and tests they should be receiving. In other words, despite our huge and rapidly rising insurance and other healthcare outlays, we receive shoddy treatment. The authors concluded that “problems with the quality of care are indeed widespread and systemic and require a system-wide approach.”

Then, by chance, I met a man this past weekend who is challenging the quality of care provided by a major hospital and several of its doctors and nurses and realized that the problem is much worse than the study suggests. That the system is deficient is scary, because it says that if you find yourself in the wrong hospital at the wrong time, your life could be in danger because of negligence and/or incompetence. What is truly horrifying, though, is the absence of any sense of accountability when mistakes are made. The inmates truly are running the asylum, and for that reason, there seems no immediate way of getting it fixed.

The man challenging the system is Roberto Glaubach, an architect from Argentina. Some friends put him in touch with me because they know I write about business and health care. He is seeking a measure of justice for the death of his daughter, Veronica, nearly four years ago, at age 28. She died in Huntington Memorial Hospital, a teaching hospital near Los Angeles, just hours after giving birth to a daughter.

Veronica was a beautiful woman who loved to paint. From all the evidence Roberto has accumulated, and he has accumulated files full, Veronica died from complications of childbirth because she wasn’t receiving anything close to the “recommended care” for her rapidly escalating illness.

Veronica had shown some worrisome symptoms prior to giving birth, most notably unexplained protein in her urine and a complaint of “seeing spots” the day prior to being admitted to the hospital. But she had a seemingly normal delivery just before 7 a.m. July 1, 2002. From there, it was nearly all downhill. First, she complained of severe upper abdominal pain, nausea, and vomiting. Her blood pressure was rising. Her blood platelet count was declining. At 4:30 p.m., she had a seizure. A few hours later, she was unconscious and by 6:10 the next morning, less than 24 hours after giving birth, Veronica was brain dead.

A report by the Los Angeles County Public Health Department pointed to numerous lapses by both the nurses and doctors on duty at the time. The nurses seem not to have reviewed Veronica’s prenatal medical records showing the elevated protein in her urine, which is a warning sign of a condition known as preeclampsia. Nor had the nurses alerted doctors that Veronica’s blood pressure was rising to dangerous levels.

Two doctors who examined Veronica at various points did little independently to help Veronica. One doctor apparently came on the scene at several points, but his notes were completely illegible, to the extent that his signature couldn’t be identified, the report states. Another doctor whose notes could be read apparently never made the diagnosis of preeclampsia, which progressed to eclampsia, and caused Veronica’s death.

Preeclampsia and eclampsia are uncommon, though not rare, occurrences during childbirth, and happen most often in first pregnancies, like Veronica’s. There is no guarantee Veronica would have been saved had she been treated earlier, though one study I looked at indicated a better than 80% survival rate when the conditions are identified and appropriately handled.

While the Los Angeles County Public Health Department found serious problems, it’s not charged with handing out justice. All it does is recommend changes in hospital procedures, and it recommended a number to improve responses by nurses at Huntington Memorial.

Roberto has had to go elsewhere to seek justice. He hired a lawyer, who told him he had a malpractice case. The hospital quickly responded with a settlement offer, which the lawyer recommended Roberto accept. He went along with the lawyer, and several hundred thousand dollars was paid to support Veronica’s daughter.

Remember, Roberto is Argentinian, and is trying to wend his way through a foreign country’s legal and medical system. Knowing what he knows now, he isn’t sure he should have recommended that his granddaughter’s father accept the settlement. (Veronica wasn’t married; her boyfriend’s family cares for Veronica’s daughter.)

But Roberto says this isn’t about money. He wants to see the doctors involved called to task. Here he has run up squarely against a system in which the doctors police themselves.

He filed complaints with the Medical Board of California, which is responsible for licensing and disciplining physicians. Its investigators rely on the judgment of physicians they call in to evaluate cases.

Having read through its responses to Veronica’s death, I can tell you that even a well educated American accustomed to dealing with our legal system would have difficulty understanding its terminology and criteria for action. It certainly has upset Roberto. According to a letter from an area supervising investigator of the board, Laura Sweet, last August, if a doctor is found guilty of “a simple departure from the standard of care, the case is closed but maintained for a period of five years…The expert {physician} who reviewed the care rendered to Veronica identified simple departures from the standard of care.” In other words, case closed.

One thing is crystal clear from the Medical Board’s response: physicians rule the roost. As Ms. Sweet’s letter states, “The final determination as to whether a physician violated the law, in quality of care cases, must be made by an independent, board certified expert who practices in the same field of medicine as the subject physician.” In other words, colleagues judge each other. Have you ever heard a physician criticize another physician?

In a letter to Ms. Sweet, Roberto conveyed his “astonishment” at the Medical Board’s response. “{It is}one thing if your son or daughter died as a consequence of a terminal disease…But a very different thing if your child is killed in such a stupid way (as my healthy Veronica has been)…”

Roberto will continue pressing his case. But he realizes now that he is up against a system in which the accused police themselves. It’s time to open the windows of the medical ivory tower and get the stink out.

Today, it is Vitamin B. The New York Times has an advance summary about research to be published in the Journal of the AMA concluding that vitamins B6 and B12 don't prevent heart attacks in individuals with serious heart disease. The doctors quoted in the study are divided about whether the B vitamins might help individuals without heart disease prevent its onset.

Once again, I can't help but feel uncomfortable about such a study, this time on three counts. First, the Times seems to be strongly implying that the B vitamins are useless. Second, and related, the study has nothing to do with other areas where vitamin B is supposed to be quite important, such as in helping the nervous system, brain function, and cellular function. Finally, there is no consideration given to how vitamin B might work together with other vitamins.

I know it's impossible to test all aspects of a supplement's potential benefits in a single study. It just seems a disservice to imply that because a vitamin failed to help seriously ill patients in one specific area that it is without benefits.

Should nonprofit organizations in the healthcare arena be exploiting their nonprofit status to rake in big money? Pat Sullivan raises this question on his excellent blog with a critique about Planned Parenthood, and the sizable revenues it generates from abortions. He contends that its pro-abortion stance is driven by the fact that most of its revenues come from performing abortions.

I have long had the same concerns about another nonprofit organization, Life Extension Foundation. It purports to be devoted to research associated with improving health and longevity. But if you join the organization and receive the magazine, as I did for the last couple years, you realize that Life Extension is mostly about selling nutritional supplements. In fact, the organization is obnoxious about pushing supplements. The magazine is relentless in connecting nearly every article, supposedly about new research affecting heart disease or migraines, directly to supplement purchases. Nearly all its mailings to members are pushing supplements.

Based on the FAQs on its web site, it's clear Life Extension believes that supplement sales are merely a vehicle to support its research. I haven't yet been able to do the research to learn how Life Extension's revenues and expenses are divided. But as an outside observer, it looks like a classic case of the tail wagging the dog.