Cheap And Accessible Medicine Is Worthless If It Is Shoddy

The place was Billings, Montana.  I was living with my husband in a posh downtown hotel.  Sounds nice, doesn’t it?

Oh yeah – I forgot to mention that it was the dead of winter.

You are probably wondering why the original “California Dreaming” girl would take off from a winter haven like Palm Springs to frost over in Montana – and the answer is the only one that would account for these circumstances: Somebody needed help.

Like the Lone Ranger, I could not refuse – and besides, it was a heck of a challenge.

The twist is –- I was helping out a managed care insurance company.  A huge one.

So now we have the makings of a first class mystery.  Renegade Doctor rushing to help out managed care corporation in the coldest part of the country when she could be warming her tootsies in the balmy desert oasis.

Let me go back and set this in perspective.This was relatively a long time ago.  To illustrate how long ago, the TV news I watched while eating breakfast featured the President of our country denying he had sex with “that woman” – although everybody knew he darn well had and there would be DNA evidence forthcoming.

Yes, I was younger and more idealistic.  Before turning renegade, I thought I could change managed care from the inside – by working within the system to make it the best, gosh darn system in the whole world!

Hoo boy – sometimes I need a serious reality check.

The state of Montana was in a pickle over taxpayer-provided public health care.  In most states, this is referred to as Medicaid.  In California it is “Medi-Cal.”  They were chronically under-funded and seemed to hemorrhage money, so they decided to call in a huge private insurance company from New York to take over the administration.

That company then offered me the job to take over the mental health division.

The offer was attractive – come take over as chief nay-sayer.  That’s right – I would not see any patients in this position, I would be the one doctors called to ask permission (meaning “would we pay”) to perform certain services.

In the wrong hands, this position can wreak a lot of havoc.  That’s what I’m concerned about today with managed care – denial of treatment because it isn’t “cost effective” (with no regard for the health or well-being of the patient).

But of course “Moi” – the Benevolent Dictator – would wield my veto with the wisdom of Solomon.

Let me say that there are a lot of good doctors in Montana.  However, reviewing the cases, I was aghast at some of the more egregious things happening to the good folks of Montana.

The company had established criteria, of course, but I also had leeway and was expected to use my medical training in my judgments.  When in doubt, I could always call others within the company – people who had been-there-done-that and had more experience in this type of thing.

One of the more frequent problems was newborn health.  Immense numbers of babies who fit the criteria for fetal alcohol syndrome (FAS) were being born on a reservation among Native American people.

These children — whose mothers who were alcohol abusers –- did not develop fully or correctly in the womb, and were born with neurological problems that made their lives extremely difficult.

I was concerned, but in my role as basically an insurance reviewer, I was pretty hopeless in terms of my own abilities to do things to help this.  We could authorize pediatricians and we could authorize Ritalin in large and wholesale quantities.  We could authorize treatments according to the diseases that were diagnosed.  I learned first-hand that FAS was a major cause of what is generally recognized as Attention Deficit Disorder (ADD).  This was a real “Aha!” for me.

Now I have come, after a fair amount of questioning, to wonder if Attention Deficit Disorder is a valid diagnostic entity, let alone something that should be treated with Ritalin. (I am not the only one who has at least wondered if it is not a simple case of differential maturation.)  I have treated several cases where high dose vitamins that cross the blood brain barrier seem to treat the problem just fine.

There are now other diagnoses that are found in the children of alcoholic mothers.  One of these groups of diagnoses is the autistic spectrum disorders.

Now I don’t know what is going on with this in Montana if anything. But I do know what I got answered when I asked the insurance company a few years ago what we were doing about the essentially epidemic portions of fetal alcohol syndrome. “We got a University in there, studying it.  They are collecting statistics.”

I pretty much had to shut up, the way I have had to shut up many times in my life, just to stay afloat.  I knew this was a bit suboptimal, but at the time, I told myself, at least somebody was trying to do something.

I am more cynical now.  I have known a few University researchers in psychiatric realms who try to do things that are consistent with the best ethical practices to help people in the present — and future.  I have known far more who manipulate to have their names in publications and have more “points” to get more pay and more glory.

But putting these people aside, I do wonder about academic research in general. At one point, when I had just finished my training as a psychiatrist, I thought I might dedicate myself to research.  Some of my few friends, especially the career researchers, still think I should do that.  I will not.

There are reasons.

I am often asked which is more important in my life — being a doctor or being a researcher.  I have always said and will always say it is being a doctor.  I have to take care of the suffering first, in the immediate, before worrying about future (unborn and unconceived) generations.

A lot of research, especially in psychiatry, seems to be dependent on statistics, as well as “nosology” or classification of illness.  Our classifications are listed in the Diagnostic and Statistical Manual, now in its fourth edition, amended with some text revisions (DSM-IV TR).

This manual makes it easy for a doctor to arrive at a diagnosis, giving simple descriptions of what has to happen so many times in a given period of time to classify someone as having a specific illness.

In fact, DSM-IV is practically worshiped by those who are very strict about getting the proper subjects to participate in research – so much so, that the late anti-psychiatrist R.D. Laing (a Scottish psychiatrist-psychotherapist) said, DSM-IV is somewhat like a “Nazi Handbook.”

It is my belief that we have plenty enough knowledge to look at medical and biochemical and neurotransmitter information and make a useful classification upon which to build research.  But since drug companies and insurance companies love classifications for many reasons, change is unlikely.

But wait, there’s more.  The Montana Reservation Babies given a diagnosis of ADD would probably now be additionally classified — at least in part — as having Autistic Spectrum Disorder.  Much has been written about increased rates of these disorders, which seem to have a genetic component or may be increasing because of environmental toxins.

I commend the writers a recent Scientific American article because they realize that one of the incredible biases of all research, scientific and otherwise, is that you are more likely to find what you are looking for.

Of course statistical studies are part of the necessary drudgery of doing clinical research, and may provide some clues as to reasons why illnesses present as they do.

But the truth of the matter is that even if people can overcome their own biases and believe what such research says, efficacy in treatment can take generations.  A good example of this is the discovery of scurvy, the development of treatment, and the eventual acceptance of the prevention and cure – a period of time that lasted from Ancient Egypt to the discovery of “the New World.”

But wait, there is still more.  The way we do trials to show if a treatment works has basically not changed since Avicenna, in the second century.  The biases and the recruitment methods involved in the performance of clinical trials are horrific.  I have been responsible for carrying out clinical trials both for prescription drugs and more recently, for a powerful natural compound.

Here is a summary of the problems involved.

What is a doctor to do?

There is one skill I learned at my French medical school that I think many of my beloved colleagues miss.

I remember in psychiatric residency, being assigned articles to read, and asked to comment on how they would affect how I chose to treat a patient.

I was not only the only one in my class who processed the data in a way my professor thought satisfactory, but he told me I was the only person he had taught in all of his career who knew how to process this kind of data.  (As they say in Montana: “It ain’t braggin’ if’n it’s true!”) I can read research reports and do a pretty good job of putting together everything I talk about above, and deciding what is likely to work with a patient.

I don’t know about the babies of Montana.  Probably, publications about them have made many junior academics into full professors.

To get a medicine that works, we have to have a relentless search for truth, and to realize that search requires processing of data for an individual case.

Down with cookie-cutter medicine and “physician extenders” who learned quickly to do a limited kind of practice.  Yes, they are less expensive – but therein lies the trouble with today’s medical ethos.

Since health care reforms never, ever focus on the quality of care and only on accessibility, that is what the population will receive.  A case in point is the current push for health care reform in the US – to achieve maximum accessibility, but without regard to quality.

It is lonely to fight alone, but it works.  I have happy patients, who generally do well.  I spend time with them, and I often research for them.

I have been deeply hurt by our national movement to make cheap medical care available to all when nobody, but nobody, has wondered if it will be good medical care.

If medicine, as it has been butchered by the machete of politics, still retains even one iota of the capacity to maximize the length and quality of individual life, we have to realize such value comes in leaving behind norming and classification and returning to the individual.

We must see medicine as an individual solution to an individual human’s physiological problems.