Mistreated

Mistreated is a new book by Robert Pearl, CEO of the Permanente (Kaiser) Medical Group, which is by far the largest physician group in the United States. Dr. Pearl is a plastic surgeon who is also a professor at both Stanford's Medical and Business Schools. In Mistreated he discusses the current status of medical care and practice in America together with his ideas on what needs to be changed.

Pearl feels that our system is poorly designed and is failing in many respects. We pay a huge amount of money for medical care that, by many standards, is the worst in the developed world. One third of American physicians are very unhappy with their job and over half tell their children not to pursue a medical career primarily because of the huge amount of time necessary for record keeping and battles with insurance companies.

Pearl uses the term "legacy players" to describe powerful groups who control how medicine is practiced and who profit from our current system. These are: insurance companies; hospitals; physician specialty groups; drug and equipment manufacturers. To this list I would add a fifth group: medical education including medical schools, residency training and postgraduate education programs. Our medical education determines what physicians learn and value. It is tailored to sustain and perpetuate our current failing system, allowing the other legacy players to continue taking unreasonable amounts of money from health care.

Patients want Pearl's four "C's": cost at the lowest possible level; clinical excellence; coordination of services and information; compassion from their health care providers.
Our current fee for service system pays more for doing more, not for doing things in the best interest of the patient. Such a system is destined to be wasteful and to harm patients by unnecessary procedures and treatments. Specialty physicians are paid much more than primary care givers and preventive services are poorly reimbursed.
200,000 people a year are killed by avoidable medical errors in the United States. Most of these deaths can be prevented by better systems and following proven protocols. Examples offered by Pearl include unintegrated medical record systems in which critical patient information is not shared; failure to follow proven accepted protocols (e.g. hand washing between every patient contact); unwillingness to accept proven life saving approaches (e. g. sepsis work up); hospitals or practices with insufficient experience (volume) in intricate procedures.
He also faults systems and physicians who are not centered around patient convenience and need to know information. Emails and telemedicine visits can save enormous amounts of patient time and expense. Patients have the right to convenience and correct information about procedures and prognosis. Oncology is particularly at fault in this regard. Palliative care without surgery, radiation or drugs is often the best option for a cancer patient, but this frequently is not offered or appropriately discussed.
Medical record systems are poorly coordinated between institutions and are often poorly designed. This can be to hospitals and system purveyors advantage. It's difficult for patients to move to another medical center and more efficient system designers are frozen out of the market. Pearl correctly advocates that all medical record systems must be inter-compatible and open to improvements by outside competition. Most other businesses have this model and their electronic systems change faster and are much more effective.

Pearl's conclusion is that pre-paid, large, multi-disciplinary groups like the Mayo Clinic, Intermountain Health Care, Virginia Mason and Kaiser offer the best medical model- good health care at the best price. His caveat is that individuals in these huge groups have to be very attentive to personal needs and preferences which can get lost in large organizations.

This is a wonderful book which I recommend to anyone interested in health care. It should be required reading for premeds, medical students and residents. 
I have two major disagreements with Mistreated. Best practice is lifestyle medicine which focuses on diet as the first way of preventing and managing chronic disease. Pearl does not even mention this in a book about optimizing health care. He emphasizes screening as an excellent preventive service. There are situations where screening is warranted but it is not the panacea Pearl suggests. Dr. H. Gilbert Welch of Dartmouth Medical School has written several excellent books and many articles explaining the problems with over utilization of screening techniques. A subsequent blog will discuss Welch's research.