American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, March 1, 2010

Once Upon A Time

AUTHOR'S NOTE: I am very frustrated with a system that increases cost dramatically and yet reduces what I get paid. The rest of the money is going somewhere, and since it is not improving the overall quality of care, it is mostly waste. We are enamored with MRI scans, stents, and expensive cancer treatments, with little to show for them except increased expenses and a lot of third parties getting rich off of this waste: drug and device manufacturers, medical imaging companies and other para-healthcare industries. This story, which originally appeared at Musings of Distractible Mind, is prompted by my frustration with waste and how it spurs unneeded health care delivery.

Once upon a time there was a land on the ocean. The people lived off of the food from the ocean and were very happy. But as they grew bigger, they had a problem: They made a lot of waste! Yuk! Nobody likes waste. What could they do about all of this that stuff that nobody needed?

Santa Cruz West Cliff Today by veeliam via FlickrSome said that they should find a way to make less waste. They said that the people of the land were not smart and should be making less waste. But most of the people in the land didn't like to change what they were doing. It's hard to change. So they built a large pipe that pumped the waste into the ocean.

The land was clean again and the people were happy!

As time went on, they had to build more and more pipes to handle their waste. Nobody ever tried to make less waste because they could just make more pipes and pump it into the ocean. This even built a very successful industry of pipe-workers. This helped the economy.

But then one day something terrible happened. The pipes pumping waste killed off several species of sea life. This made the environmentalists in the land cry out in protest. But as it stood, the number of species in the ocean were so vast that the killing off of a few of them was felt to be no harm. So the pipes kept pumping. The people still could be happy with a few less species.

And then came a day when something magical happened. New species of sea creatures formed around the pipes. These creatures fed off of the waste and thrived around these pipes. These new creatures became very big and very fancy, and this made the people of the land very happy. What were the environmentalists all worried about? So what if a few species had died off; there were new exciting species being formed! The people were so excited that they made even more waste and more pipes so they could make more new species of sea creatures.

What fun!

Now, these fancy new creatures were hungry. They ate all of the waste and wanted more. They ate most of the other sea animals and wanted still more. They couldn't get enough food. So they sent lobbyists to the government of the land to get them to build more pipes and send more waste. The creature lobby was very rich, and so poured lots of money at the government of the land. This made the politicians very happy. So the happy politicians told the companies of the land to make more pipes and send more waste out to the sea. And the sea creatures were happy.

And so it went for many years: more pipes sending more waste making more fancy sea creatures eating more waste sending more lobbyists to make politicians get more companies in the land to build more pipes. Everyone seemed to benefit from this nice arrangement! Maybe they'd be happy forever!

But one day, some of the people of the land got tired of putting all of their money into building pipes to send waste. They thought their land should stop making so much waste and start putting those resources into schools, food and fighting crime. The government was raising taxes more and more so that they could afford to make more pipes. This made these people mad because some people couldn't afford any more taxes. Paying for all of this waste was too much.

But the lobbyists from the sea creatures put commercials on television saying how good the waste was. In fact, having so much waste made the land one of the best lands anywhere. They pointed out how many new sea creatures came to be because of this waste and how other lands couldn't do this. The pipe manufacturers also made commercials telling about all of the jobs these pipes were creating. They all made so much sense!

They also sent more money to the politicians so they would ignore the people who couldn't afford paying for the waste.

But then some of the people of the land ran out of money and stopped paying taxes. This made the government mad, and so it left these bad people to live in their own waste. Many of these people became sick in their waste, and some of them died. Finally, the cry of the people was loud enough that the politicians in the land took notice. They decided that all of this waste was a real problem. No other land had so many pipes sending so much waste. True, there were lots of fancy new sea creatures, but the people in the land were getting angry, and some were dying.

But the politicians started fighting. One group of the politicians decided that the pipe-making companies were the problem. They thought that the government should take over the pipe-making job and guarantee waste pipes for every home. Others thought that the government could never do as good of a job as the companies did. They said that those people who couldn't afford pipes were dead-beats and probably deserved to die.

They held town hall meetings to talk about who should be making pipes, and people got very angry.

Finally, someone who wrote a waste-pipe blog suggested that perhaps the problem wasn't the pipes, but instead it was the waste. He said that the people should find a way to cut back on the waste, and so need fewer pipes. The blogger was criticized sternly, because his suggestion would have very bad consequences. The new fancy sea creatures that made everyone so proud would die off if they cut back on waste, and the pipe-workers would lose their jobs and be very sad. Plus, people didn't want the government telling them how much waste they could make. It's a free country, and people should be able to make waste without the government rationing it.

But as the people of the land thought about what this blogger said, they saw the sense in it. Yes, the sea creatures and the pipe manufacturing companies put very moving commercials on TV about dying sea creatures and unemployed pipe workers. They were very sad commercials and they made a lot of people weep. But the people of the land realized that this land was for people to live in, not for pipe companies or fancy sea creatures. Yes, it would be sad to not have those fancy creatures, and they'd have to get new jobs for the pipe company workers, but it was the only way.

Oh, it was hard to cut back on waste and kill off the fancy sea creatures. People got very mad and lobbyist groups tried to change laws or pay off politicians. But this was a good and smart kingdom, and they didn't listen to the creatures any more. And finally the day came when the sea was clean again.

And everyone was happy.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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Anonymous Nirav Patel said...

I just wish that we had more people who understood the story.

March 1, 2010 at 11:39 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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