Zeke Emanuel can be his own worst enemy (sometimes ours too)

NOTE: I posted this as a reply on another site and decided to add it to my DU journal. This mostly examines one of Zeke's recent articles in its context and my critique is so limited.



I posted earlier that those for HC/HI reform could not allow its opponents to make Zeke the "face" to be feared by the general public. Until we get closer to a "real" bill, the debate will be vulnerable to misleading claims not supported by any likely variant of a bill but rather by various other statements. Zeke in his extensive writings and talks has provided too many quotes ripe for "out of context" exploitation. Even worse are those that with complete context can still cause damage and confusion.

I attribute some of this to his writing mostly for an audience of medical insiders and not for the general public and to a style that intermixes "hard" facts, figures, and programs with very general statements of policy, society, greater good, etc. Thus, an article like "The Perfect Storm of Overutilization" in JAMA is at best carelessly written, open to misinterpretation, and only "peer" reviewed when it should have been critically reviewed by various outsiders (given his NIH position at the time). (Curious who reviewed this article.)

Zeke openly confronts in his works a number of quite difficult issues and often provides useful insight thereof. I believe his intentions are good, with genuine concern for patients and families, but his work is severely flawed because he repeatedly misses large factors controlling patient decisions, states his "assumptions" as facts which in turn are used to support his conclusions.

I routinely post here and elsewhere about flawed medical and dietary research and publications. It is extremely difficult to do medical research of any type, most times the underlying data is not adequate to support the research conclusions - much less the popular press inflated claims. Few MDs have the personality, training, and resources required to produce quality, unbiased research. And few doctors are willing to counter the work of prominent peers (excepting certain "competing" groups).

The social sciences often present even greater inherent difficulties, lacking an equivalent to studies on lab animals in most cases. I see economics mostly at the bottom of the heap.

Now back to Zeke and "overutilization". It starts fairly well discussing several extra costs in the current US health system: administrative overhead, higher costs for drugs, selling costs for insurance, higher earnings for doctors, more amenities in hospitals, etc. Next comes a look at compartive data with other countries which shows that Americans have relatively low rates of hospitalization and of physician visits per year. The article quickly attributes the extra costs to more expensive labs, meds, etc. and quickly moves on (not much "overutilization" to see).

The next section begins "At least 7 factors drive overuse, 4 related to physicians and 3 related to patients." (1) Overly thorough and aggressive doctors which he attributes to their training and to the Hippocratic Oath (the article does not discuss the importance of the word "judgment" in the Oath.); (2) Financial incentives to physicians from additional tests and procedures; (3) Confusing and large amounts of research, few "best practices", and aggressive marketing by suppliers; and (4) Possible actions in defense of malpractice (probably not a significant factor).

While the article attributes these items to physicians, I suspect that the one with the greatest impact, (3), is really a problem with the drug, device, and equipment suppliers and their sponsored research and resulting bad research. In my and my family's experiences, I see very little of the other things described.

Now on the patient side: (5) "US patients prefer high technology over high touch." (6) Direct to consumer marketing of drugs, etc.; and (7) Patients are significantly shielded from the costs of care. Number (6) is the same as (3) and is only patient-related in a passive sense.

I LOL at number (7); doubt many patients feel very shielded from costs. I don't see the data to support (5), have rarely seen that personally, and usually hear statements like "I don't want just be hooked up to a bunch of machines.

Since I see other possible causes for higher US costs in last three months of life (hospital costs covered by Medicare, less expensive options are not), this article seems little more than justifying a talking point about savings while laying-off much of the "blame" to the indulgent patients and greedy doctors and claiming that single-payer would likely make things worse.

I call BS.