The Making of the American Health Care System

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A colleague gave this to me to post anonymously.

October 26, 1943: Healthcare’s Pearl Harbor

Unlike that actual Pearl Harbor attack on Dec. 7, 1941, the health care Pearl Harbor which occurred two years later did not make headlines, was not addressed by President Roosevelt in a joint session of Congress and did not result in massive death and destruction. Indeed, there were probably only a small handful of people who were even aware that some happened on October 26 that affected health care.

But like Pearl Harbor, the events of October 26, 1943, were cataclysmic. They changed, fundamentally, irrevocably and for the worse, the trajectory of the health care system for the next 66 years (and counting). To understand the events of that day we have to back up a few years to beginning of WW II. Within months of our entry into WW II the size or our armed forces swelled from a few hundred thousand to many millions, eventually peaking at 16 million men and women in uniform. Almost all of these 16 million were taken from the existing workforce. This resulted in very severe manpower shortages in industry. As well, the Defense Department (known then as the War Department) consumed huge quantities of natural resources (rubber, iron, coal, gas, etc.). These manpower and resource shortages necessitated the implementation of wage and price controls for the duration of the war.

Private sector industries were desperate for workers but were prohibited from offering high wages to attract them. They were permitted to offer some benefits, health insurance among them, without violating the wage and price rules. It’s worth recalling the state of health insurance (and health care itself) at this time in history. Health insurance in 1941 was an anomaly. Both the Kaiser system and the Blue Cross systems were developed in the 1930s, but these touched very few lives. Overall, more than 95% of the population was uninsured. In 1941 health care expenditures accounted for less than 2.5% of GDP as compared to 17.6% of GDP today. But this data point doesn’t even begin to describe the minimal state of health care at the time. Today we spend $8,300 per capita on health care. In 1941 we spent, in 2009 dollars, $325 per capita on health care. (I spent twice that much last week in one dental appointment.) As compared to the health care industrial complex of today, the health care system was a cottage industry in 1941.

In any case, the wartime health insurance benefit did become a popular and effective means of attracting workers. And then came October 26, 1943. On that date the question was answered: Are employer-based health insurance benefits taxable as income? Until that day there was no answer to this question. Mostly companies offering health insurance did not report this as income, but some did. All these companies wanted a clarification from the IRS.

It is not recorded whether there was any political debate on this question. Were there advocates (perhaps the insurance companies) of tax-free health insurance? We don’t know. Were there opponents of such (perhaps budget-conscious Congressmen)? We have no idea. Were there any discussions of the possible implications of this ruling on our health care system? It’s very unlikely. Certainly given the state of our health care system at that time no one would have thought to utter the phrase, “We have to get our health care spending under control.” This would have been nonsensical. If there was any active consideration of this policy it surely would have been something like, “Health insurance? More people having health insurance is a good thing. Let’s leave it alone.” Or something like that. So, on October 26, 1943, a person, panel, of committee who to this day is unknown and un-named, ruled that employer-provided health insurance is not taxable income. And the rest is history. (In 1954 an act of Congress finally ratified and made permanent this IRS ruling.) Before detailing the mostly deleterious effects of this event, lets’ quickly recount the trajectory of the health care system over the next few generations.

As millions of servicemen and women were demobilized and returned to the civilian workforce the concept of the health insurance benefit had reached a critical mass. In the heavily unionized industries the addition of a health insurance benefit became one the most sought-after benefits of collective bargaining. And in the professional and managerial classes the offering of a health insurance benefit continued to be useful recruiting tool. In 1941 there were fewer than 5 million people in the US who had some sort of medical/hospital insurance. By 1950 that had grown to over 100 million, most of this based on employer-provided insurance. (Interestingly, individually purchased health insurance also increased rapidly during this period and peaked in about 1970 and thereafter steadily shrank as a mode of health insurance purchase.)
Along with this revolution in health care funding came a revolution in health care itself. In 1941 Sulfa drugs were just being introduced. Penicillin and other antibiotics were still several years away from practical use. Insulin to treat diabetes had been in regular use for several at this point and you did have a good chance of surviving appendicitis surgery and basic obstetrical care was probably doing some good as well. And if you had a serious cut or laceration could stitch you up and hopefully avoid infection. But that was about it. Even with the best health insurance plan in existence it would still have been very difficult to find much to spend health care dollars on. And then everything changed. Without belaboring the point there was an explosion of health care technology: New antibiotics, new steroids, new psychoactive drugs, heart surgery, transplant surgery, chemotherapy, radiation therapy (not entirely new), CT, MRI, PET scans, Gamma knives, stents, implants, new hips, news knees, new lenses, cochlear implants…the list goes on and on. (It is another story whether or not all of these advances are in fact advances, but that’s a different story.)

All of this increased health care purchasing power and expansion of medical technology obviously dramatically increased the demand for services and it quickly became clear that our health care infrastructure was inadequate to service this demand. Multiple pieces of legislation were enacted to correct this. Most notably the Hill-Burton act of 1946 provided funding for the construction of new hospital facilities. The goal was to achieve a density of 4.5 hospital beds per 1,000 in all locales of the country. Many other pieces of legislation during this post-war period subsidized and expanded the health care infra-structure including a dramatic expansion of the health care workforce.
Thus there were three forces that drove health care from being a cottage industry to being a Mega-industry:

• Increased health care purchasing power
• Increased health care technology
• Expanded health care infra-structure

Collectively these three forces have produced a 25-fold increase in per-capita health care spending since WW II. The principle engine that drives this explosion of health care spending is employer-based health insurance.

Which brings us finally to the issue of why the October 26, 1943 tax ruling has been so damaging to our health care system:

1. It has tied health insurance to employment. One thing that everyone hates about our health care system is that for most people the only practical way to secure health insurance is through one’s employer. The tax advantage offered by this mode of insurance makes other options impractical or unavailable. And so our health insurance is only as secure as our job and we end up making career decisions based on the effect if will have on our health insurance status. All of this is a stupid, inefficient and arbitrary way to organize both our health care system and our workforce.

2. It has subsidized the purchase of health insurance. In 1943 the idea of subsidizing the purchase of health insurance probably seemed like a pretty good idea. It could hardly be said at the time that we were over-insured. But over the decades those of us who do have employer-based health insurance are typically over-insured. When it is possible to buy $1 dollars worth of insurance for $0.75 (which is the effect of the tax subsidy) we will rationally choose to buy more health insurance that would otherwise be the case. When health insurance was still in its formative years (1945-1965) most insured people had what as called “major medical” insurance, that is, catastrophic insurance. But over time this has become the exception rather than the rule and the insurance subsidy has resulting increasingly lavish and comprehensive insurance policies. The idea of insuring against large and unforeseen health care expenditures has been replaced by the idea of insuring against routine and predictable health care costs.

3. It has separated the purchaser (patient) and seller (doctor, hospital) from the cost implications of health care. In 1965 a threshold was passed: more than half of all health care expenditures were paid by third parties. Prior to the health insurance revolution most health care was paid for as you would pay for anything else—out of pocket. And since 1965 the percentage paid by third parties has continued to rise and has now leveled-off at about 80%. No other sector of our economy is characterized by such a triad (buyer, seller, payer). In this triad the buyer is essentially indifferent to cost and provides no brake on utilization or price. The seller is of course is incentivized to increase price utilization and finds little resistance from the buyer. And the payer tries vainly, and to no one’s satisfaction, to apply some brakes to the system. The buyer’s indifference to cost is further manifested by their indifference to the cost of health insurance itself. The perception on the part of the employee is that their company’s health benefit is “free” or most free depending upon their contribution. In fact the cost of employer provided health care is 100% paid for by employees in the form of lower wages. But this fact is not visible and in fact believed by most even when they are apprised of this fact. (It must be noted that economists have extensively studied this question and there is no disagreement on this issue.) Being indifferent to the cost of insurance employees are only interested in expanding the benefit as much as possible in the mistaken belief that it is free to them and this of course further exacerbates the problem of over-insurance.

4. It has artificially increased the demand for health care services. In 2009 over 100 million advanced imaging studies (CT/MRI) will be performed in the US. One in four Americans will have an imaging study of some sort, some of them, multiple studies. No, not all of them are unnecessary. I imagine there are several million people who will benefit from these studies. But most of these 75 million imagees (is that a word?) will not benefit and the fact that they will not is entirely understood and predictable. This excess (and the excesses of every other procedure, device, drug that is a part of our health care system) is only possible through the artificially pumped-pumped up demand created by subsidized employer sponsored health insurance.

5. It has crowed out other forms of health insurance. If one is employed and if one’s employer offers a health insurance benefit, it would be economically irrational to forgo this benefit and attempt to buy an individual policy with after-tax dollars. There is no possibility of getting as much for your money as you would with your employer’s plan. And so no one acts in this manner and thus the individual and small group insurance market is atrophied and inefficient. To be sure, without the tax incentive, employer-based health insurance would still be a viable option. We do, after all, sometimes get life insurance and disability insurance through our employers without the inducement of tax subsidies. And employer-based health insurance is an effective way to pool risk. But an efficient and effective insurance market needs more than just one viable and practical option.

6. It has ultimately resulted in a positive feedback loop of cost escalation. And so, for the past 67 years we have been caught in an ever accelerating positive feedback loop of health care cost increases. As medical technology and infrastructure expand the need to fund this expansion drives up the cost and the need for health insurance. An anxious public is frightened to death at the prospect of paying for the scan, the surgery, the drugs and this public makes clear to the employers that their health insurance benefit must keep pace with these costs. The employers oblige as best they can and continue to fund premiums which tend to increase at about twice the rate of underlying inflation. And the next round of technology and price increases is thus funded and the process continues. Thus, we spend 17.6% of our incomes on health care, soon to break the 20% barrier.

It would be a vast oversimplification and simply wrong to suggest that all of our health care woes are caused by tax-subsidized, employer-based health insurance. But it is not wrong or an oversimplification to suggest that this is the single biggest factor driving the inefficiencies of our system. And it is, frankly, an easy problem to fix. But it appears that we won’t get this fix. Instead we are being to treated 1000+ page health legislation which will not become law in any case. Let me offer a 39-word health care reform bill that just might do the trick:

The Commissioner of the IRS shall revise the tax code such that from 2010 to 2015 the portion of employer-based health insurance benefits that is treated as taxable income shall increase in a linear fashion from 0% to 100%.

Preventing Deaths From Treatable and Preventable conditions

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The health care debate rages on and most of the discourse seems to be full of opinions that are bereft of data. A recent NYTimes editorial notes that an Urban Institute study shows that American health care does somethings right and others wrong. The Times editorial highlights the fact that American health care seems to fail at preventing deaths from treatable and preventable diseases.
While the most jingoistic Americans are blind to the quality problems in our health care system, the recognition that the American health care system could do better has been known for a long time. One of the most through studies about quality of American health care was published by the Institute of Medicine over a decade ago.
Crossing the Quality Chasm: The IOM Health Care Quality Initiative

The IOM Definition of Quality is one I think everyone should keep in mind:

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

With so many people complaining that they don't want the government to decide on health care decisions, I wonder why we have assumed that insurance companies, for whom less payments to health care providers means more profit, are some how better than the government without profit motive would do. Whether it is the government or a for profit company making decisions on what health care interventions are appropriate and should be paid for, it would be nice if this definition of quality were foremost in everyone's mind.
SMP

Stupid Until Proven Intelligent - MD & DC Relations

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Around 1986-7 I was the medical director for a track meet at West Point. At that time I was in charge of all medical care for all of the Metropolitan Athletics Congresses events. I must have worked at 40-50 track and cross country events a year.

Whoever was a top US 100m high hurdler fell and hurt her leg. The pain was on the lateral side of her lower leg. A tuning fork test suggested an unusual fracture one of the fibula. The tuning fork test is where one puts a 128Hz turning fork on a bone with a suspected fracture (not right over the site of injury) and the vibration is supposed to irritate the fracture side and cause pain.

I drove this woman to the base hospital and spoke to the admission clerk, reporting a suspected fibular fracture. The attending was standing nearby and overheard me. He said, “don’t you mean tibia?” I replied, “no, fibula.” He asked why I thought fibula. As I said this is not a common fracture.

I said location of pain and a positive tuning fork test. That of course provoked questions about the tuning fork. I said that it was a standard on-field screening test in sport medicine.

MD: “Sports medicine? That’s a specialty?”

Me: “I’m certified” {I was a CCSP (Certified Chiropractic Sports Physician - except due to NYS bizzar rules I was supposed to call myself a Certified Chiropractic Sports Practioner}

MD: “I didn’t know there were fellowships in that?”

Me: “I did post grad training”

He then asked if I could show him how to do it on a woman just brought in by ambulance. She crashed on the base ski run. He had to get a nurse to unlock the cabinet with the tuning forks. They had the box set with every frequency. I took out the 128Hz and showed him how to use it. Later after my athlete’s radiographs came back negative we talked some more. He asked what hospital I work at and then I said, “I don’t, I’m a chiropractor.”

Lindsay Rowe, DC, MD taught me this "technique" to deal with medical prejudice towards chiropractors. He said that to many MDs you are stupid until proven intelligent if they know you are a chiropractor. So prove you are intelligent and then let them know you are a chiropractor. I’ve used it often to great effect.

The example Lindsay gave me was that before he went back to get his medical degree, he used to travel the US. Wherever he was he'd call the local medical school and try to speak to the head of radiology department. On the phone he would introduced himself as a radiologist from NZ with interesting cases. Lindsey is a board certified chiropractic radiologist. {BTW two studies have shown that chiropractic radiologists (DACBR) are as good as anyone else in reading skeletal films.(1, 2)} If he got to meet with the radiologist they'd play what I call, "stump the radiologist."

Then when they were done trying to stump each other he’d reveal he was “only” a DC. Lots of surprised looks. He was invited to give grand rounds a few times and audience was only told what his training was at the end. Most couldn’t believe it because of course we’re all dumb as door-nails.

I've used this technique for many years. Fortunately, I don't run into such overt prejudice as often as I once did. My favorite example was the MD at a cocktail party who upon hearing I was a chiropractor dropped my hand, mid-handshake, spun on his heels and walked away without a single word.

Because of my work with the ING New York City Marathon and the New York Road Runners I often come in contact with MDs and haven't had that kind of thing happen. I guess that means my profession is moving more into the mainstream of health care, but we have work yet to do to be completely in mainstream health-care.

SMP

1. Taylor JA, Clopton P, Bosch E, Miller KA, Marcelis S. Interpretation of abnormal lumbosacral spine radiographs: A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic. Spine. 1995;20(10):1147-54.
2. de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD. Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists. Spine. 2002 Sep 1;27(17):1926-33; discussion 33.

Uncientific America - A Pluto Moment

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The LA Times (what not the NY Times) has an article about Chris Mooney & Sheril Kirshenbaum's new book, Unscientific America. The article, by Lori Kozlowski, Bringing science back into America's sphere laments the pitiful state of America's understanding of science.

The "demotion" of Pluto from a planet is used as a metaphor for what people know about science. It seems that the Pew Research Center did a study about what the public understands when it comes to science. They found that 60% knew that Pluto had been reclassified. On the other hand 54% thought that antibiotics kill viruses and 46% knew that electrons are smaller than atoms.
Given how little the public knows about science Kozlowski writes:

It is exceedingly rare that science does anything that reaches almost everybody anymore. So, when you get your moment to put it all before everybody, you don't want it to be a Pluto moment.

If science is going to be a candle in the darkness (as the late Carl Sagan subtitled his great book: The Demon-Haunted World) then it needs to go viral. It has to grab the imagination of the public. In the preface to The Demon-Haunted World, Sagan relates how he had a limo driver ask why science guys, like Sagan, didn't work on finding the secret to unlimited power that supposedly powered the mythical island of Atlantis. This event was one reason why such a serious scientist, as Sagan, would write popular books. He wanted to make science interesting to the masses.

Kozlowski then talks about how so many people erroneously believe that vaccinations cause autism. These people are often well to do and educated. In a book that is similar to Sagan's Michael Shermer, in
"Why people believe weird things: Pseudoscience, Superstition, and Other Confusions of Our Time" writes:

In day-to-day life, as in science, we all resist fundamental paradigm change. Social scientist Jay Stuart Snelson calls this resistance an ideological immune system: 'educated, intelligent, and successful adults rarely change their most fundamental presuppositions.' ... That is, the higher the IQ, the greater the potential for ideological immunity.

Maybe Mooney & Kirshenbaum have figured out how to break though ideological immunity and to make the excitement of the discoveries of science go viral. I'll have to add their book to my list to read.

SMP

You can only do the best you can do

Image by hbp_pix via Flickr

This weekend I helped supervise triage at the NYC Half Marathon. It was to say the least a HOT day. The vast majority of people I saw were with a little support, and salt able to leave my area under the own power. A few were not able to and went to the hospital. It's rather nerve racking to stand by as those who do the next level of care take over. It gets worse when they get carted off to the hospital and one is left without knowing what is going on. You run the event though your mind, was there something I could have done better, could I have gotten to the athlete sooner, etc. And then you hopefully come to the conclusion, as I did, that lacking a finish line in an ER I did the best and I know those I handed the athlete off to, likewise did their best. In the end the athletes recovered and you can only do the best you can do.

Diet

Image by Getty Images via Daylife

If you have not seen it Time has a great series on eating, diet etc. titles The Way We Eat.

SMP

Biking & Bones

Recent studies, discussed in a NYTimes blog have found that cycling is a risk factor for low bone density or osteopenia. This finding is actually not unexpected. Bone mass is in part determined by the amount of load / force applied to the bone. Thus, as noted in the blog runners, weight lifters and triathletes have higher bone mass than cyclists (keep in mind that triathletes do a significant amount of running too).
These findings stress the importance of weight bearing exercise and especially for females. Swimming and cycling while both great exercises do not put adequate stress on bone to stimulate bone deposition thus predisposing the swimmer and cyclist to osteopenia and osteoporosis.

SMP

Vaccines: "Wading through the Confusion"

I was invited last year to participate in a webcast about vaccinations. This was conducted by the California Department of Public Health. They invited me because they had searched the web and found an article that I did with Randy Ferrance, DC, MD on vaccinations for Dynamic Chiropractic in February of 2005: What's Good for the Goose Is ... Ethics and Vaccinations

Here is a link to the webcast on vaccinations. It is a 60 minute program. We taped about hours of material which were edited down to this.

I think the production team headed by Lars Ullberg (he's the on camera moderator) did a great editing job.

Other members of the panel were:

• Ken Reibel is a journalist with a autistic son who blogs at Autism News Beat An evidence-based resource for journalists
• Frankie Milley (and her husband Bob) lost their only child Ryan Wayne Milley, to Meningococcemia/Meningococcal Meningitis on June 22, 1998 - she started meningitis advocacy group for meningitis a vaccine-preventable disease called Meningitis Angels
• Mark Sawyer, MD from the San Diego County Immunization Branch, and a pediatrics professor at the University of California, San Diego,
• Rahul K. Parikh, MD is a physician and writer in the San Francisco Bay Area.
• S. Michael Marcy, MD, UCLA Center for Vaccine Research
• David G. Amaral, PhD is an autism researcher from the UC Davis MIND Institute
• Kristine Sheedy, Ph.D., Associate Director for Communication Science, National Center for Immunization and Respiratory Diseases, CDC Atlanta, GA
• Jamie Betters, a parent of small children
  

A few of the panelists have written papers on the topic of immunization which I think are very important. Citations below:

• Gust D, Brown C, Sheedy K, Hibbs B, Weaver D, Nowak G. Immunization attitudes and beliefs among parents: beyond a dichotomous perspective. Am J Health Behav. 2005 Jan-Feb;29(1):81-92. pubmed record
• Amaral DG, Schumann CM, Nordahl CW. Neuroanatomy of autism. Trends Neurosci. 2008 Mar;31(3):137-45. pubmed record
  
• Thompson WW, Price C, Goodson B, Shay DK, Benson P, Hinrichsen VL, et al. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. N Engl J Med. 2007 Sep 27;357(13):1281-92. Marcy SM is one of the et al pubmed record
• Parikh RK. Fighting for the reputation of vaccines: lessons from American politics. Pediatrics. 2008 Mar;121(3):621-2. pubmed record
  

There are a lot of web sites that present theories or vitriol regarding vaccinations. The link to the video also links to other valuable web sites on vaccinations.

SMP

What does it take to put an ugly fact through the heart of a beautiful hypothesis?

NPR yesterday did a piece on treating fractured vertebra and so did the NYTimes This is hot news because two papers appeared in the New England Journal of Medicine that compared vertebroplasty to placebo and found them comparable.

The great problem is that the treatment is perceived by both doctors and patients as effective. This treatment provides opportunity for discussion about a huge problem for health care reform. When common knowledge suggests a treatment is effective but the data show, in a compelling way, that the treatment (which has risks and financial costs) is no better than placebo should insurance pay for the treatment?

The fear of some is that because a treatment does not appear to be clinically effective "big brother" will say, "we won't pay." I understand the fear that some all powerful insurance company will get to decide what is and is not effective. But is this bad, per se? I do not think so. Both doctors and patients have for years mistakenly believed that various treatments that aren't effective actually are. I've blogged on this before, see Treatments That Don't Work.

I recently read a great paper whose title I love: What does it take to put an ugly fact through the heart of a beautiful hypothesis? (1) The title is from a quote by Thomas Huxley who lamented "The great tragedy of Science - the slaying of a beautiful hypothesis by an ugly fact." The point in this article is that our modern history of health care is full of beautiful hypotheses, that some treatment is effective, slayed by a ugly fact, research showing the treatment to be ineffective. The problem is that although the hypothesis, that the treatment is effective is dead, the belief in the effectiveness of the treatment isn't dead. Both doctors and patients alike have resurrected these treatments that ugly facts have slayed like the zombies in the classic Night of the Living Dead.

Another quote from Haynes (1) paper from Max Planck, renowned physicist

‘‘A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.’’

However, it seems that while opponents of the new scientific truth die they unfortunately are capable of infecting a new generation that because of truthiness will accept these slain hypotheses.

Truthiness, is defined by Merriam-Webster as:

Truth that comes from the gut, not books
The quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true.

For more on truthiness and the danger it poses for patients see my article in Dynamic Chiropractic, The Dangers of Truthiness

As Prof. Dov Cooperman of the University of Maryland wrote in a letter to the editor of Newsweek: "...our society is more than happy to accept spin and cant because we have come to believe that all expertise is bias, that all knowledge is opinion, that every judgment is relative. I see this daily in my university classroom. Many of even my best students seem to have lost the ability to think critically about the world. They do not believe in the transformative power of knowledge because they do not believe in knowledge itself"

Unfortunately I see it everyday in my classroom and hear it from many of my professional colleagues too.

My final quote from Haynes (1): Samuel Johnson, the 18th century poet and critic

‘‘The chains of habit are too weak to be felt until they are too strong to be broken.’’

The habits that are so problematic are a lack of critical thinking skills and reliance upon the "wisdom" of others (i.e. dogma), unsystematic and uncontrolled observation, and just truthiness.

For more information on critical thinking I recommend the Foundation for Critical Thinking.

SMP

1. Haynes RB, Haynes GA. What does it take to put an ugly fact through the heart of a beautiful hypothesis? Evid Based Med. 2009 Jun;14(3):68-9. Pubmed link

Talent is Long Patience

Photography has been a hobby of mine since my dad took money I saved for a Minox (a spy camera) and instead bought me an Exacta 35mm SLR camera. I was very disappointed that he got that camera. However, the disappointment went away as I fell in love with 35 mm photography. Back then I developed and printed my own B&W film. To see some of my photography (a few go back to when I got that Exacta in 1972) check out my photoblog Perle's Vision.

BTW Exacta invented the penta prism which allows one to look thought the eyepiece of the standard SLR and see the image right side up. That's the bump on the top of a SLR.

I bring this up because I get a lot of different photography newsletters and one lead me to a photographer's web site and a discussion about the myth of talent. On that page I found this quote:

“Talent is long patience.” – Gustave Flaubert (writer of Madame Bovary)

This resonated with me because of something I've always remembered from late M. Scott Peck's book, The Road Less Traveled. There's a part of the book where Dr. Peck discusses his complete and total lack of mechanical aptitude, talent if you will.

One day he walks up to a neighbor who is taking apart a lawn mower. Peck expresses his astonishment that his neighbor can do this. He writes that his neighbor looked up and with the wisdom of Job says, "Scott, your problem is you don't take the time." To which Peck writes how angry he was because he knew the problem was a lack of talent.

Sometime later a female patient (Peck was a psychiatrist) returns to his office complaining that she can't release the parking brake on her car and expects that Dr. Peck, as a male, will be able to assist. So he goes out to see the car and decides to take his neighbor's advice. So he gets under the dashboard and gets comfortable (how is that possible?). Looking around he describes what he sees and I knew it was the kind of parking break where there is a peddle one pushes to set the break and a handle one pulls on to release it. Scott sees the pin that is holding the ratcheting peddle and releases the pin.

What I learned from this is that aptitude, ability or call it talent is often the patience to continue to learn some skill or art or...

I have seen this in my students over the years. Some pick up the skill to perform a manipulation easily. Typically they are athletes and thus already have, though patience gained, a large body of psychomotor skills. They are the uncommon and lucky few.

There are those then who do not pick up the skill quickly. I have found that these people then self select into two groups. One group lacks the "long patience" and gives up. These people often never get very good at the skills we teach. I call these people the quitters.

In the 1990s when I was first at the University of Bridgeport I would do locum tenens (cover another doctor's practice while they were on vacation). I was in this one doctor's office where the first patient I adjusted made a sound of surprise. I was surprised myself thinking I hurt the patient. Instead they said that they were shocked that the manipulation did not hurt. They said that usually it took their regular doctor multiple tries to adjust their neck (the doctor and the patients had this erroneous idea that manipulation is only successful if accompanied by a popping noise). I said I was lucky, one does not want to embarrass the doc one is covering for. However, almost every patient I performed a manipulation on said the same thing to me. I came to realize that this doctor couldn't properly perform a manipulation after 10 years more of practice than I had. The amazing thing is patients still went to him shows how poor patients are at picking good doctors. I figure a good chiropractor has good hands, good mind and a good heart. I hope at least he had the other two.

The final group of students are those who do not pick up the skills easily but persist in their attempts to acquire the skill - they have Flaubert's "long patience". I know this path because as a student at The Texas Chiropractic College, starting in 1979, I persisted for almost a semester and a half of not being able to perform a manipulation until the break through came for me. I had made a different decision than the quitters. I thought if HE (my teacher) could do it, then so can I. Never really one with considerable athletic ability I learned that persistence was the key. But one must have patience to persist through times of poor performance (and as a child ridicule for air balls in basketball and missed pop flies etc.).

Last year, I had a student, a few months from graduation, lament an unacceptable skill level at some manipulative procedures we teach at UBCC. I told the student that this was a good thing and I was pleased to hear how much this distressed the student. The student was shocked that I'd say that. I continued, the fact that the student was greatly distressed by the lack of skill means that unlike that doctor I did locum for, the student's distress would motivate attempts at improvement.

I think life should be process where by we are continually improving and trying to get more talented with the long patience of trying to do better. And no I'm not yet happy with my skills and knowledge as a doctor, teacher, friend, father, husband or even photographer, and that's a really good thing!

SMP

A couple of other articles on the need to practice

Secrets of Greatness
The Expert Mind

Preventing vs. Postponing - will health care reform save money

I'd love to say that the what you'll read below, about how health care reform, specifically preventive health care, is my work. It is not. It comes with permission from a friend, colleague and brilliant chiropractor.
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Previously I posted a note that suggested that the Congressional Budget Office (CBO) will be the linchpin in health care reform. That Office will be required to calculate the budget implications of any reform package. And if that calculation reveals that the reform is underfunded by about a trillion dollars (as it is right now) this will create insurmountable problems to its passage.

Nervous congressional Democrats are trying to figure out how to circumvent the CBO. One strategy is to bypass the CBO and rely on the administrations calculations from their Office of Management and Budget, a sort of parallel organization to the CBO, the difference being that the CBO can be relied up to come up with whatever number is needed to pass the legislation. One of the areas of contention between the CBO and the OMB is how much to credit preventive care as a money saving element of reform. The CBO credits it with zero dollars and the OMB with hundreds of billions of dollars. Here’s a news item from yesterday that highlights this:

Sen. Barbara Boxer said she would not feel obliged to abide by CBO’s work if it does not take into account savings from preventive healthcare and other reforms.

"I haven’t seen [the CBO score] but if they don’t take into account prevention, I certainly won’t. I will not follow it — we just heard from the CEO of Safeway, who said his insurance costs went steadily down since they instigated incentives for prevention.

Any scoring that doesn’t understand that, is not relevant to the way we work.”

Who’s right, the CBO (zero savings from prevention) or the OMB (hundreds of billions saved from prevention)? The CBO is correct (zero savings). Here’s why—

It is endlessly repeated by politicians, public health advocates, physicians, TV talking heads that we spend a huge percentage (the figure 30%) is often used to treat “preventable” illness. What is usually meant by this are those chronic diseases that are driven by lifestyle—diabetes, heart disease, COPD, smoking-related cancers etc. This is undeniable. This set of conditions easily accounts for at least 30% of our health care budget. There is in fact an exploding industry devoted to both the primary and secondary prevention of these problems, the so-called Disease Management and Wellness industry. These programs target the high risk population and attempt (with varying degrees of success) to change behavior and thereby reduce health care costs. It can be shown that well engineered and properly implemented programs of this type can indeed pay for themselves and even return savings in the form of reduced health care costs. So what’s the problem? If a company of, say, 500 employees can do this, why can’t be implement this on a scale of the entire US population?

Here’s the problem. If I’m an employer considering such a program one of the questions I have to ask is, “Will I, as the employer, realize the savings from such a program? So what if I spend money to get an employee to quit smoking and then he leaves this job to work somewhere else…I’ve just financed the savings for some other company.”

And indeed if a particular company has a high employee turnover rate these programs will not save money. The reduced health care expenditures have to occur under the watch of the employer who paid for the program for this to make sense. There are algorithms that will tell you if a particular employee turn-over rate will or will not allow for such savings. From the employers perspective the healthy employee has to remain in his employ to realize the savings. The key word here is “perspective.” We must always ask from whose perspective are we calculating health care costs or savings.

When doing the calculations that the OMB and CBO are doing the correct perspective from which to view this is the societal perspective. We are interested in the total net costs or savings in our entire health care system for all persons at all stages of their life. An individual might leave and employer but he never leaves the umbrella of the societal perspective.

Ah, but this is good news, you might think. Any ex-smoker, reformed couch potato or otherwise newly healthy person is always under the societal umbrella and thus all savings will eventually accrue at a societal level. Ergo, we save billions.

But this societal perspective is precisely the problem. Let’s consider several scenarios from both the employer’s perspective and from the societal perspective:

Scenario 1. Joe Blow is a 32-year old smoker who works for the Megatron Corp. Joe says the hell with it. I like cigarettes. I’m not quitting. Joe stays with Megatron his whole career. He experiences a variety of smoking-related illnesses (chronic bronchitis) and eventually dies of lung cancer at age 59. The Megatron Corp. spends a good deal on money on Joe’s health care over the years and eventually pays for the the futile treatment of his lung cancer.

Scenario 2. The Megatron Corp. implements a worksite wellness program that includes a tobacco cessation program. After couple of failed attempts Joe eventually quits smoking at age 36 and continues to work productively for Megatron Corp until he retires at age 62. During his employment Joe enjoyed generally good health and had only routine medical care with the exception of knee surgery to repair the ligaments he tore skiing. (Joe really did reform himself…he became an avid outdoorsman, hiker, skier.) The couple of hundred dollars Megatron spent to get Joe to quit smoking saved many tens of thousand of dollars in related health care costs.

Success!! Prevention works. It saves money. At least from the employer’s perspective. But from a societal perspective Joe’s story continues:

Joe enters retirement (and Medicare) in good health. He remains active, but eventually that repaired knee gets worn out and he gets a total knee replacement. By his mid-70s one of his hips is gone and that gets replaced too. But Joe is still going strong. Soon he needs cataract surgery and some lens implants as well. Joe is becoming all spare parts!! In his late 70’s he suffers a mild stroke…his skiing days are over. Two years later he’s diagnosed with colon cancer. Surgery and radiation go pretty well, but one never knows.

What finally gets him, though, is dementia. After a few years his children realize that Joe can no longer care for himself and his children put him in a long-term care facility. He doesn’t last long there, only 3 years, an Joe dies at age 83. Not that anyone is keeping track, but Medicare ended up spending $400k on Joe during his retirement.

Alright, this is all make-believe, but what this illustrates is this: From a societal perspective, prevention of chronic illness is impossible. All that is possible is to postpone chronic illness. Every case of lung cancer that is prevented exposes society to future cases of colon cancer, stroke, Parkinsonism, dementia, and well, everything else. Every premature diabetes-related death that is prevented exposes society to future cases of breast cancer, skin cancer, kidney failure, liver disease, and well, everything else.

Now of course, if we can prevent lung cancer and diabetes and emphysema and other chronic disease, we should. This is the point, after all. But we cannot do so with the illusion that somehow we will never end up spending boat-loads of money as we age and become infirm. In nearly all cases, preventing early chronic illness will end up costing us far more money to treat later-life chronic illness. But that’s the price of success.

Anyway, watch for the battle between CBO (who are professionals) and the OMB (who are political hacks) on this.
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As one who teaches a class in wellness, I certainly thought that prevention saved money. As you can see from what my colleague has written, it all depends upon the perspective of who pays for the prevention on who saves money. Obviously, preventive measures that are effective: proper diet, regular exercise, no smoking, use of seat belts, safe sex, should be implemented.

I often hear people say we all have to die sometime. In fact, someone trying to get me to buy tobacco in Mexico a couple of weeks ago said that to me. But the reduced disability, prolonged and productive life is good for each of us, no?

Frankly, my mother’s death at age 66 from cigarette smoking deprived my children of a grandmother. I was very fortunate that my own grandmother and great grandmother died when they were in their late 90s and early 100s, respectively. I miss them both but have vivid memories as they both died when I was an adult. My children don’t have that. Likewise, my mother’s early death meant she didn’t see my daughters grow to become a bat mitzvah, let alone married and have children.

Thus, I think the benefits outweigh the economic cost and we do need to implement more and better prevention programs. If it takes the deep pocket of the government to do it so be it but let's be honest about the costs unless do we really need a white lie is needed to get the reform package passed.

SMP

Cultural Authority and the Chiropractic Profession

Cultural authority: an editorial by John M Ventura, DC

In the excellent text, Surviving in Health Care by Dieter Enzman, MD, (Mosby, 1997) a working definition of cultural authority is proposed, and more importantly, a strategy for achieving cultural authority is outlined.

The ability of medicine to achieve cultural authority in the early 1900s was a “confluence of factors encompassing professionalism, the Industrial Age and an incentive-skewed market.” What may be most remarkable, given the almost exponential growth of health care costs through the 20th century, was the duration that medical cultural authority went unchecked. Medicine was said to have achieved “professional sovereignty.” Whether consequential to, or simply a reflection of, the constraints of managed care, medicine has lost some of its authority. Dr Enzman’s book is an effort to place medicine back on a path to achieving a new measure of cultural authority. The relevance for the chiropractic profession is that cultural authority is defined in a manner which may be pragmatically applied, and Dr Enzman has a lot to teach the chiropractic profession with his recommendations to the medical profession. If and when the chiropractic profession takes on this challenge may be the determining factor between merely surviving into the 21st century versus thriving. Our future is not guaranteed. A collective effort of well thought out strategies will be needed to implement the requirements for achieving cultural authority.

Cultural authority allows a profession to define its own professional truth. The profession decides what is fact and what is fiction and the public accepts the rules set forth. Cultural authority is characteristically unique in “having authority without having to overtly exercise it” as opposed to social authority, which is the ability to command people. There are two primary features of cultural authority: competency and legitimacy. Competency is a demonstration of technical expertise. Legitimacy is achieved by using competency to advance public health.

Competency requires validation by peers and rational foundation (scientific basis). A key feature of this technical expertise is that competency must be gained as a group - not individually. The beginning of shared professional competency for medicine was achieved by standardized training, based upon the principles of science. An intended benefit of professional competency is that when any individual member of a profession gives advice, that advice is representative of “shared professional standards”, not the idiosyncratic recommendations of a renegade practitioner. Professional legitimacy includes collegiality, cognitive approach, moral attributes. You be the judge of how well the chiropractic profession has demonstrated collegiality, a cognitive approach to health issues and high moral attributes.

If we can agree that achieving cultural authority is in the best interests of the chiropractic profession (the ability to define our own professional truth), then we might ask what steps the chiropractic profession can take to achieve some measure of cultural authority? As was the case for medicine, chiropractors need to demonstrate competency and legitimacy to the public. And this must be done by the collective efforts of the entire profession.

Dr Enzman describes the following for the medical profession to regain some its lost cultural authority:

• Continually demonstrate competency to the public; proof of training and licensing is no longer sufficient
• Provide ‘credible data’ to validate medical claims and recommendations
• Focus upon outcome analysis, a ‘crucial’ factor for the medical profession
• Standardization of practice patterns, both regionally and within each specialty
• Standardize the lexicon, which demonstrate peer validation of competency
• Focus upon the societal value of health, not upon reimbursement
• Avoid ‘filtering and restricting information available to patients’; embrace the informed consumer(patient)
• Be leaders and therefore, be honest, at all times

There is a theme that surfaces in the above recommendations of Dr Enzman – patient centered, evidence based care. Patient centered, evidence based care needs to be the mantra of the chiropractic profession. The following represents a partial list of the steps necessary to place the chiropractic profession on the road towards cultural authority:

• Standardize the training of chiropractors using principles of science, best available evidence, and consensus (though the consensus must be based upon the previous two attributes).
  
• Raise the standards for admission to and graduation from chiropractic colleges, and raise the standards for licensing
  
• Standardize the chiropractic lexicon
  
• Affiliate chiropractic colleges with established and proven universities so that resources (faculty, research facilities, etc.) can be shared
  
• Define the most fundamental aspects of chiropractic care: subluxation (in a quantifiable, testable manner); treatment frequency and duration for given clinical presentations;
• Standardize clinical outcome measures to validate responses to chiropractic care (“credible data”)
  
• Increase funding towards chiropractic research
  
• Encourage attendance at research symposiums
  
• Professional unity: one primary organization to represent the profession politically; all chiropractic colleges embrace and implement collectively determined standards of care;
  
• Patient centered, evidence based care is the foundation for training of chiropractors
• Reduce variation of approaches to diagnosis and treatment within the profession
• Increase training in all manner of public health issues for chiropractors
• Encourage chiropractors to become involved with APHA

The public perception of the chiropractic profession, by and large, is not one of trust. In 1990, the McLean County (Illinois) Chamber of Commerce's Professional Committee surveyed a population of people (12% of which were chiropractic patients) with the following results: only stockbrokers scored lower on a scale of trustworthiness than chiropractors, over 45% of those surveyed felt chiropractic ethics were below average. In the Canada Speaks survey, held in 2002 and again in 2006, chiropractic trustworthiness improved from 15th place to 12th place (49% of those surveyed felt chiropractors to be trustworthy), but still well below medical physicians(80%) and nurses(87%). Clear demonstrations of competency and legitimacy, by the profession as a whole, are required to increase public trust, and therefore, increase the cultural authority of the chiropractic profession.

Chiropractic Business - What is the nature of the business

A few friends of mine sent me a great book to read by Jeff Jarvis, What would Google do. There is a chapter in the book that talks about what is the nature of your business and how most people don't know what business they are in.

Approximately 25 years ago a NYRR volunteer (non-medical) I was friendly with explained this concept to me. He worked in fleet rentals for Hertz and asked me what business is Hertz in? The obvious answer, which I said, was renting cars. He told me I was wrong. Renting cars wasn't a profitable business. The cost of advertising, reservation system, rental counters at airports, buses, lots, carrying charges on the cars and their maintenance was barely offset by the actual money received for the rentals. Thus, one can't really say that Hertz was in the car rental business.

He said that what Hertz did was the largest manufacturer and seller of used cars. That was because they sold the used car for more money than they bought the new car for but couldn't do this until it was used "enough." Those of us who rented from Hertz actually paid for the privilege of working to turn the new car into a used enough car so that Hertz could sell the used car we made back to us for a profit.

He used this as a metaphor for his belief that most companies have no idea what business they are in. This made me think about what business I, a practicing chiropractor was in.

As I said I was reminded of this by Jeff Jarvis' book WWGD. The question then is what business is a chiropractor in? Some in my profession would say that we are in the subluxation removal business. This is delusional. How many people who have never heard of chiropractic wake up and say, "gee I wish there was someone who could get rid of these darn subluxation." The obvious answer is no one. Now that could of course be because they didn't know the word. However, there isn't a vernacular term for the subluxation as is true with other medical conditions. People say that someone broke a bone, and might not know the term fracture. Or they'll know heart attack or stroke rather than myocardial infarction or cerebral infarction.

Some of my colleagues would say, but a person dying of heart disease, of cancer or diabetes or... does not know that they have these diseases until they become symptomatic. That is true. However, at this point in time my profession, chiropractic, has yet to find a valid or even reliable way to find a subluxation. Nor have we found that getting rid of them helps people or that a person with a subluxation is less healthy then a person without one.

On the other had there are valid and reliable tests for heart disease, cancers and diabetes. We also have good evidence that left untreated these diseases do kill and that with treatment patients can sometimes live much longer lives (depending on the specific disease, the stage at diagnosis).

Clearly there is good scientific evidence that spinal manipulation is a beneficial intervention. While the physical therapy profession and others have newly discovered the benefits of manipulation, after years of saying it was quackery, those benefits are found without the metaphysical aspects of the subluxation dogma some in chiropractic espouse.

Then what is a chiropractic business? Generally it is non-surgical spine care or another way to think of mainstream chiropractic is it is the non-surgical management of spinal pain disorders.

I say management because that might mean that chiropractor does all the diagnosis and treatment or it might involve an integrated approach where the doctor of chiropractic works to lead a team or be a member of a team whose goal is the improvement in a patient's spinal function.

Do chiropractors' management skills extend beyond the spine? Depending on the doctor the answer is yes. My own practice in NYC in the 1980s was mostly lower extremity conditions as most of my patients were runners. But I also treated a lot of cyclists, swimmers and triathletes so also saw a lot of upper extremity problems too. I was a sports chiropractor and thus had competency that extended beyond the spine.

Some of my peers think because I was a co-author on a paper titled: Chiropractic as spine care: a model for the profession that my co-authors and I believe that chiropractic has no place outside the spine. This is very far from the facts of our paper. We just believe that as a profession all of us need to, at minimum, be competent in non-surgical spine care and the profession needs to maintain the spine and its non-surgical care as the basic minimum competency. And come on when the public thinks of a chiropractor what do they think of? SPINE. I travel a lot and when people find out I'm a chiropractor they either grab their neck or the their back and say can you help me. No one has ever said - "oh I have a subluxation." That is despite the fact that so many chiropractors talk subluxation 24/7 even on the web.

An analogy. My family has had two occasions to consult oral surgeons. These doctors are trained as dentists. However, they do not have additional professional training at medical doctors. These dentists do not fill any cavities, or do other restorations that we ordinarily associate with dentists. Yet they are dentists. But the American Dental Association does not market dentistry as oral surgery. Still while these oral surgeons do not have training as medical doctors they do have additional training beyond what a general dentist has.

Likewise, for a chiropractor, such as myself, specializing in sports chiropractic there is the need for post-graduate training without that then the general chiropractic physician is a non-surgical spine specialist. Not a bad business to be in when over 90% of people will get back pain sometime in their life.

SMP