Why I am concerned about the future of medicine

Thanks to a memorable medical education at Duke University School of Medicine, and drawing as well on inspiration arising from 3 years of experience as a nurse in the Duke Medical Center Neurosurgical ICU, it has been a privilege to practice academic and private practice neurosurgery for 35 years. As my career draws to a close, I must confess to significant uneasiness and reservations about the future of the practice of medicine, particularly when measured against the vision and ideals with which I had been imbued by my medical education.

Two events while at Duke left particularly indelible impressions. The first occurred during 2^nd year Medicine rotation when I had the privilege of having as preceptor the revered internist/cardiologist, Eugene A Stead, MD. One day rounding on the Duke wards, characteristically hanging with lanky arm onto the overhead curtain rail of a patient's bed, Dr. Stead made an arresting observation: “96% of illnesses we would encounter during our career are inherently, naturally self-correcting, hence requiring little of us as physicians other than compassionate reassurance of the patient. Therefore our mission as physicians would be to correctly diagnose those 4% of illnesses which, without timely and appropriate intervention, would likely lead to life-altering consequences or death.” Stead's prescient observation speaks volumes to the current growing sentiment among many physicians that the fastest way to get a medical condition is to be screened for it. Today, more than ever, there exists a serious problem with both overdiagnosis and over-treatment, often driven by expensive diagnostic testing and imaging. One needs to look no further than the current controversies surrounding screening and treatment of breast and prostate cancers. I recall vividly during Duke Pathology rotation, my surprise upon learning that at autopsy, 85% of men over the age of 60 harbored microscopic evidence of in situ prostate cancer, yet prostate cancer was only rarely a primary cause of death. H. Gilbert Welch MD, Professor of Medicine at the Dartmouth Institute for Health Policy and Clinical Practice, writes compellingly about this in his book, “Over-diagnosed: Making People Sick in the Pursuit of Health,” as well as his New York Times 02/27/2012 Op-Ed: “If You Feel O.K., Maybe You Are O.K.”

The second seminal event occured during the Hippocratic Oath Ceremony at graduation. The first premise of that oath rings true in my heart to this day: “Primum non nocere” – first do no harm. This centuries-old sacred pledge speaks for itself and has stood the test of time.

Throughout my career, I have endeavored to the best of my ability to hold fast to the guiding wisdom of both Hippocrates and Stead.

Although I am neither perfect in the application of all I have been taught nor would dare hold myself as superior to my colleagues, I must say in all candor that these guiding ideals do NOT appear to be paramount considerations governing the everyday practice of the very big enterprise of healthcare delivery. Rather, I find far too much emphasis placed and energy expended on identifying opportunities for intervention, sometimes based on little more than junk science or empty tradition, and only very rarely supported by outcome studies. On the other hand, I observe correspondingly too little energy being devoted to fulfilling a physician's sacred first duty to engage in responsible and humanistic collaboration with the patients we are privileged to serve. I emphasize the concept of service, which I believe is at the very heart of our profession.

Sad to say, but for some time I have concluded that this disparity seems to boil down to misguided incentives in the flawed “fee-for-service” compensation model that has been in place throughout our careers. This is a model that richly rewards intervention through testing and invasive procedures but significantly undervalues the intellectual work-product of physicians. To rephrase it with a bit of wry humor: “TALK IS CHEAP; ACTION, HOWEVER, REWARDS HANDSOMELY….”

So, the race seems ever on to identify and capture those patients having so-called “indications” for intervention. This, perhaps, explains the embarrassing brevity of a typical surgical consultation which lasts just long enough to make the determination – surgical candidate or not – which I believe is nothing less than the social equivalent of a wallet biopsy. Again, I would suggest that much of this behavior seems the inevitable consequence of misaligned incentives when free market principles are applied inappropriately to the delivery of healthcare.

I propose to provide some specific examples and, forpurpose of authenticity and credibility, to draw all examples exclusively from the specialty of neurosurgery which I know most intimately.

Without question, the single most common problem treated by community-based neurosurgeons is radiculopathy from lumbar disc herniation. Most readers are likely familiar with the SPORT (Spinal Patient Outcome Research Trial) Study published in the New England Journal of Medicine in 2007. This reported a rare prospective and randomized outcome study of 3500 patients, all of whom had presented with complaints of radicular leg pain explained by correlative disc herniation as demonstrated by magnetic resonance imaging (MRI). One half of the patients were randomized to treatment with purely medical management and the other half were randomized to “gold standard” surgical management by microdiscectomy. The study's endpoint was a 2-year post diagnosis and treatment follow-up. Admittedly the study suffers slightly from some crossover after initial intent to treat in one arm to the other arm. That being said, the over-arching observation of the SPORT study was simply that 85% of patients in both groups had very satisfactory outcomes: Back to work and recreational activities, pain not an issue, and self-reported satisfactory quality of life. For the first time, the SPORT study revealed to primary care physicians and patients what most experienced spine surgeons had known all along, yet were perhaps selfishly loathe to disclose: Medical management is often equivalent to surgical management in outcome, thus surgery is not necessarily mandatory as many had previously naïvely assumed. The only advantage that could be attributed to surgical microdiscectomy was slightly quicker relief of symptoms, albeit in exchange for the inherent risks of surgery. Of course, the details and methodology of the SPORT study were extensively scrutinized and parsed by certain vocal elements within the spine surgery community with the seemingly obvious selfish intent to protect a “bread and butter” source of income.

Now if a neurosurgeon collaboratively shares such information with the patient, the education and dialog of which might require upward of an hour, the average consultation compensation is $400. On the other hand, if the neurosurgeon briefly confirms what the naïve and vulnerable patient typically thinks and fears when first referred to a specialist, i.e. that “surgery is likely both appropriate and necessary,” then an hour or so spent in the operating room (OR) will yield an average microdiscectomy compensation of $2800 – a sevenfold increase!

Now I ask you, “Which physician, needing to support a family, paymedical education and home mortgage loans, and eventually college tuitions, would not be inclined toward pursuing opportunities for interventions that yield far more robust compensation?” This simply reflects human nature and obeys Willy Sutton's Law: “Why rob banks? That is where the money is!” May I remind you that US healthcare is currently a 2.8 trillion dollar business from which very many people make their living and support families. Moreover, the business of healthcare delivery turns conventional economics on its head: As much, if not more, of the demand for healthcare services is determined by the provider rather than the consumer! Yet understandably, the typical healthcare consumer does not want to contemplate the unsettling possibility that a healthcare provider's recommendations might be driven as much by business considerations as by altruistic considerations. Most would prefer the insulation of blissful ignorance.

We have all heard dire predictions of the likely bankruptcy of Medicare – as early as 2017 or as late as 2024 – it is hard to know which sources to believe in the politically charged atmosphere of that debate. We also know that 25% of Medicare expenditures occur during the final 30 days of life. Some have suggested, therefore, that a significant waste of Medicare funds is attributable to futile care at the end of life. Surely some of this is attributable to lack of living wills and healthcare proxies, or what is now being popularized in the media as “The Conversation.” However, I would suggest that in fact some of the blame falls squarely on the shoulders of physician choice: Specifically, how a physician chooses to conduct the difficult educational and decision-making process in life-altering or end-of-life situations. Physicians often either actively advocate or passively accede to patient/family demands for interventions that they would never wish for themselves.

Let us look at the most common primary brain malignancy of adulthood, namely glioblastoma multiforme (GBM).

Glioblastoma was thrust into the limelight again by Senator Edward Kennedy's tragic affliction. In tribute to his considerable celebrity and the high regard he enjoyed in the state he represented, Kennedy was afforded “kid glove” treatment at the Massachusetts General Hospital Brain Tumor Center where he and his family were provided with compassionate, but unusually candid disclosure of the dauntingly brief survival statistics regardless of treatment modality. He rationally elected the minimalist approach of stereotactic needle biopsy for intellectual reassurance through histological confirmation of the diagnosis (though, arguably, formal histological confirmation may not have been absolutely necessary given the diagnostic accuracy of modern neuroimaging). As he was subsequently gearing up for palliative radiation therapy and concurrent temazolamide chemotherapy, well-intentioned advice began pouring in from all directions. This resulted in further consultation with Duke Neurosurgery, where neurosurgeon Allen Friedman, MD, along with many others had been working for years in the laboratory on a promising model of immunotherapy for GBM. Sen. Kennedy was enrolled in the Duke protocol and had a round of treatment. Rumor has it that the Massachusetts General Hospital (MGH) hierarchy found this to be an embarrassing “defection” and wooed Senator Kennedy back to their institution by offering proton beam radiation therapy (for which there existsvirtually no supportive clinical experience regarding its efficacy in GBM). Despite all well-intentioned efforts, he succumbed to inexorable progression of the malignancy just 15 months following diagnosis, a mere 6 months longer than median survival as reported by the SEER National Brain Tumor Registry data. The treatment Sen. Kennedy elected more closely approximates what a majority of knowledgeable physicians would elect for themselves, though perhaps not necessarily what they would recommend to their patients. The reader is likely familiar with the remarkably candid Zocalo Public Square essay of Kenneth Murray, MD, “How Doctors Die,” widely reprinted in the Wall Street Journal and elsewhere. He observed: “What is unusual about doctors is not how MUCH treatment they get compared to most Americans, but how LITTLE! Of course, doctors don’t want to die, they want to live. But they know enough about modern medicine to know its limits. And, they know enough about death to know what all people fear most: Dying in pain and dying alone. They want to be sure when the time comes, that no heroic measures will happen; that they will never experience in their last moments on earth someone breaking their ribs in an attempt to resuscitate them with CPR.”

Do you, like I, sense a double standard, one for the enlightened physician, the other for the naïve and supplicant patient? How has it come to pass that physicians administer so much care that they would not want for themselves? Allow me to compare Sen. Kennedy's care with that received by a more typical glioblastoma patient, Mr. “Common Man.” Recently, a neurosurgeon consulted on a 91-year-old widower, living alone, who had presented with rapidly progressive left hemiparesis due to GBM encroaching on the right motor cortex. Computed tomography (CT) and MRI characteristics were quite typical for the diagnosis of GBM. Nonetheless, “definitive intervention” was recommended to the patient and his heart-sick family in the form of Brain Lab image-guided craniotomy. This was justified in the dictated consultation note by an intellectual rationalization that there was the need to “differentiate between primary and metastatic brain malignancy.” At surgery, only minimal tumor removal was actually accomplished, confirming, of course, the obvious histological diagnosis, but causing the patient's hemiparesis to slightly worsen. This poor old gentleman recuperated in the acute care hospital first, followed by an inpatient rehabilitation hospital, then hospice where he died less than 30 days from surgery.

Take note: On average, a neurosurgeon's compensation for Sen. Kennedy's stereotactic biopsy is approximately $4000, whereas on average, the neurosurgeon's compensation for Mr. Common Man's Brain Lab image-guided craniotomy for tumor is twice as much (approximately $8000).

Of course, as all neurosurgeons know, both Sen. Kennedy and Mr. Common Man were doomed from the moment of GBM diagnosis. Sen. Kennedy at least enjoyed a relatively prolonged interval of quality survival which included the privilege of a touching valedictory moment when, during the 2008 presidential election cycle, he made one final impassioned plea to the country advocating for the national healthcare reform he had championed for so long.

Though Mr. Common Man's neurosurgeon walked away with twice the compensation, he can take no credit for salvaging any significant quality survival for Mr. Common Man. So, I ask, “Is it quality of (remaining) life for the patient or maximal compensation for the neurosurgeon that is being pursued?”

Brain tumors represent less than 1% of all tumors, but nonetheless fuel intense competition for the golden opportunity of neurosurgical intervention. This inescapable fact was crystallized for me when I chanced upon a Memorial Sloan-Kettering Cancer Center's full page advertisement in the Sunday New York Times magazine. It revealed to me just how far the truth might be manipulated in order to gain marketing advantage and, thus, the golden surgical opportunity.

The ad features an attractive, smiling young woman holding a piece of paper on which is handwritten emphatically: “Hey Brain Tumor: We are so over! – Colleen.” Underneath the photograph in boldface type it declares: “Cancer. Where you are treated first can make all the difference.” Follows a touching but manipulative narrative: “Having never spent a day in the hospital, Colleen was shocked when diagnosed with a rare, slow-growing brain tumor. She turned to Memorial Sloan-Kettering Cancer Center where patients often have better outcomes than at other hospitals. A world-renowned team of doctors specializing in neurological cancers removed her tumor and determined that no further treatment was necessary. Within weeks, she returned to her job as a physical therapist and completed her doctorate just nine months later.” Note the constant emphasis on “cancer.”

Of course, the average, naïve reader is led to conclude that Colleen had, indeed, a cancer but, mirabile dictu, because of the neurosurgical technical expertise at Memorial Sloan-Kettering, it had been cured by surgery alone, avoiding what the public particularly fears, i.e., radiation and chemotherapy. While it is quite true that brain tumors as a class are rare, what the advertisement fails to disclose is that Colleen's tumor was almost certainly an asymptomatic, benign meningioma that had been discovered quite incidentally in the course of CT or MRI imaging for unrelated symptoms. This is well known to neurosurgeons as an “incidentaloma,” an ever more frequent occurrence in the era of high-resolution diagnostic imaging. Such benign tumors are frequently simply observed by serial clinical examinations and imaging, with removal recommended only if there is future convincing evidence of tumor enlargement or symptom development.

Quite recently, a 12-mm-diameter meningioma in the posterior fossa adjacent to the pons was incidentally disclosed on brain CT performed for allergy-related sinus headaches in a 34 year-old schoolteacher daughter of very close friends. A few days before scheduled craniotomy to remove the tumor, she was informed that her young, seemingly charismatic, cranial base fellowship-trained, university neurosurgeon was on emergency family LOA, and his return was indeterminate. A faculty neurosurgeon was offered in substitute. Both patient and parents were in a state of shock and high anxiety, as they were under prior carefully cast misimpression that there was some urgency to having the tumor removed. At the eleventh hour, they were desperately trying to research the experience and reputation of the substitute neurosurgeon, when they contacted me. As it turned out, the substitute neurosurgeon had a fine reputation, though with little or no cranial base surgery credentials or experience. In the process, I had carefully reviewed the young woman's case history and diagnostic imaging. I felt obliged to cautiously broach with the patient and her parents the unthinkable: That perhaps the tumor did not have to be removed at all (fools rush in where angels fear to tread) and, at a very minimum, there was absolutely no urgency for “definitive treatment” of any sort. Of course, all were drop-jawed in disbelief, further intensifying their shock. I immediately prevailed upon a colleague, Frederick G. Barker, MD, Director of the Massachusetts General Hospital Brain Tumor Center, to see her in expedited consultation. His recommendation was identical to mine: Serial MRI follow-up; microsurgical removal or alternatively, stereotactic radiosurgery (Gamma Knife), IF AND ONLY IF the tumor was enlarging or clinical symptoms develop.

As an aside, I was interested to learn during my initial research through privileged channels that the original cranial base neurosurgeon was not on “family” LOA at all, but rather disciplinary LOA and was in the glacially slow process of dismissal for cause. Whether this neurosurgeon's overly aggressive judgment arose from misplaced desire to exercise surgical skills for which he had devoted many years of residency and fellowship, or from simple avarice, it would be idle to speculate. This clinical scenario does, however, remind me of what I once quite naïvely misconstrued to be a quaint, Southern saw when rattled off as an aside by one of our Duke professors: “Well, if you don’t want to have surgery, don’t go to see a surgeon.” As an inexperienced young medical student, ambitious to cure the ills of humanity, I found this wisecrack oddly nihilistic, possibly perverse. Only now, as a 35-year seasoned neurosurgeon, do I recognize the truth and wisdom behind his pithy admonition.

Recently, a lovely woman consulted me for a “second opinion,” quite obviously scared out of her wits by the perceived magnitude of a two-level, C5/6, C6/7 anterior cervical decompression and interbody fusion with anterior instrumentation that had been blithely recommended by a notoriously aggressive spine surgeon as necessary treatment for her acute arm pain, all based solely on review of her MRI imaging without any but the most cursory clinical examination. As a significant side issue, she had been afflicted with lifelong endogenous depression, severe enough to occasionally warrant hospitalization and electroconvulsive therapy. The intense muscular rigor/opisthotonos associated with her most recent ECT bore temporal relationship to the onset of acute arm pain. She was particularly distraught when contemplating the prospect of 3 months of restricted activity post-op that had been advised by the consultant. For it had been through daily vigorous aerobic exercise promoting endorphin release that she had found salvation from her lifelong depression and managed to keep it at bay. A careful neurological exam followed by scrutiny of her MRI revealed that her C7 radiculopathy was attributable to an acute lateral recess-foraminal disc herniation which had occurred in the setting of pre-existing C5/6, C6/7 degenerative disc disease and spondylosis. Therefore, all she really needed to relieve her arm pain was a much simpler procedure of C6-7 lateral hemilaminotomy/medial facetectomy and microdiscectomy: Requiring less than 24 h stay in the hospital, back running and exercising within a week or so, pain relieved, and depression controlled as usual.

Compare: 2-level anterior cervical decompression and interbody fusion with anterior instrumentation, average surgeon compensation approximately $11,000versus left C6/7 lateral hemilaminotomy/microdiscectomy, average surgeon compensation approximately $3400.

Yes: I may have left $7,600 in potential compensation on the table, but she is now a friend for life which is priceless reward for a neurosurgeon.

I can say, in all honesty, that overly aggressive treatment recommendations driven primarily by imaging findings are a scenario I witness repeatedly.

I think my message is by now clear: A flawed, antique, fee-for-service compensation model with misaligned incentives is encouraging excessive intervention, thereby fueling the unsustainable annual increase in the cost of US healthcare, which now stands at 18% of Gross Domestic Product (GDP), representing a very big business. We, Americans, spend twice as much per capita on healthcare as the average of all other developed countries; yet, pending full implementation of The Affordable Care Act, we are the only developed country that does not provide basic healthcare insurance to all its citizens.

I shall conclude by recalling the 1961 valedictory remarks of WW II hero, Supreme Allied Commander, 5-star General, Dwight David Eisenhower, 34^th President of the United States, when he surprised many by a stark warning:

“In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military–industrial complex. The potential for the disastrous rise of misplaced power exists and will persist. We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted. Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together.”

I would submit that the very same words and logic might well be applied now 50 years later to the healthcare–industrial complex of 2014. While military spending as a percentage of GDP has stayed relatively stable at between 4% and 6% since Eisenhower's warning, healthcare spending as a percentage of GDP has perennially climbed, now to a whopping 18%! Whether or not one supports universal healthcare as a fundamental right in the American Society, it seems very likely that much of current resistance to The Affordable Care Act “Obama care”, or its (Massachusetts) predecessor, “Romney care”, is reflective of pure self-interest and reactionary protectionism of the healthcare–industrial complex which, indeed, abhors any governance or fetters on its free market opportunity.