Former JAMA Editor Laments the State of Medical Care
In nearly 20 years as editor of the Journal of the American Medical Assn., Dr. George D. Lundberg transformed what was once a house organ into one of the world’s most influential medical journals. During his lengthy tenure, Lundberg wasn’t afraid to tackle such highly charged issues as abortion, assisted suicide and alternative medicine. He was fired by the AMA in 1999 after he published the results of a controversial sex survey during former President Clinton’s impeachment hearings.
But he hasn’t stepped back from his role as a watchdog of the profession. In his new book, “Severed Trust: Why American Medicine Hasn’t Been Fixed,” he writes about the changes in medicine he’s witnessed since he entered the profession in the 1950s, when doctors still made house calls. Among his charges are that business has taken over medicine, that professional standards have eroded and that the once-trusting relationship between doctor and patient has collapsed.
Lundberg, currently editor in chief of Medscape, a medical Web site, talked with The Times about the state of medicine today and its prognosis.
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Question: You’ve written: “In our quest to find multimillion-dollar cures, we physicians neglected to provide reasonable care for our patients.” That’s a pretty strong charge.
Answer: But accurate, I think. Patients feeling like they’re cared for is probably more important than the scientifically correct treatment being given. For most people, the disease they have usually heals in time, so their concerns are mostly about their symptoms. Consequently, their attitude toward themselves and their caregiver can have a lot to do with how they handle their symptoms and even how quickly they get well.
What’s more, we still don’t have cures or even treatments for many serious diseases that do any good. The way people live with their heart disease or with their cancer can greatly affect their quality of life and, in some instances, the length of their life. And the relationship of caring goes a long way toward influencing people to live with their disease well.
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Q: So you believe the mind-body connection is important in treating illness?
A: There’s no doubt that how a person thinks and behaves has a lot to do with physical illness in one way or another. And no greater example of this is addiction to drugs like tobacco and alcohol, which is the principle drug of abuse in our society. Ironically, the majority of the diseases that afflict Americans are preventable because they’re related to these two drugs. Tobacco is the major cause of heart disease and lung cancer, which is our No. 1 cancer. Throw in alcohol-related deaths from suicides, car accidents, and the carnage becomes overpowering.
But the way we treat addiction, especially to illegal drugs, is all wrong, and it’s safe to say the United States is doing the worst of any industrialized nation. We know scientifically it is more cost-effective to treat addiction than it is to do law enforcement. Yet our solution is to stop the importation and manufacture of illegal drugs, an approach that is always a failure.
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Q: What about marijuana?
A: Tobacco and alcohol are infinitely worse than marijuana. Medically, there’s no comparison. Marijuana isn’t usually addictive. I don’t think it should be legalized, but I do favor a more rational approach, especially in the use of marijuana to relieve pain.
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Q: What about alternative therapies?
A: There is no such thing as alternative medicine. There is only medicine--medicine that has been tested and found to work. That’s why all these alternative treatments need to be tested. And if they work, then they can enter the scientific mainstream the old-fashioned way--by earning it.
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Q: Have you ever tried alternative medicine?
A: I had one experience with acupuncture when I hurt my back before I was to give a presentation at a hotel in the High Sierra. And it worked. Within a half an hour after the needles were inserted, the pain disappeared and I went through my presentation with no back pain whatsoever.
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Q: So you’re a believer?
A: I believe there’s a lot of modalities that might work--and some things that are absolutely preposterous. But again, they should be tested and proven.
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Q: What about chiropractic? As you know, the AMA was behind a decades-long campaign to put chiropractors out of business.
A: I make a distinction between the theory of chiropractic and the way it is practiced. Many chiropractors have adopted methods of treatment that might ease back pain--and when they stick with that, they’re not doing any harm. I do know that a recent study showed that osteopathic manipulation, which is somewhat similar to chiropractic manipulation, relieves back pain as effectively as standard treatment with drugs. And many drugs to treat back pain have unpleasant side effects.
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Q: To switch gears a bit, you’ve been highly critical of managed care. . . .
A: Managed care is basically over. People hate it, and it’s no longer controlling costs. Health-care inflation is now back in the double digits. So if it’s not saving money, then why should we have it? But like an unembalmed corpse decomposing, dismantling managed care is going to be very messy and very smelly, and take awhile.
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Q: What do you see taking its place?
A: In the future, I think we’ll see some form of government health insurance, along the Medicare model. Not necessarily socialized medicine but one large insurance pool or one single payer where people and employers can buy in. I think we should have some kind of mandated health insurance, where every American has to buy a policy with a high deductible, and the individual has to pay above a certain point. People won’t spend their own money unless it’s justified. It’s the only way we can control costs.
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Q: You’ve said the AMA has lost its credibility. Why?
A: Right now, only 27% of American physicians are members, which means nearly three-fourths of doctors have voted with their feet. The reasons why this has happened are complicated. But primarily, it’s because business has taken over medicine. The AMA was so busy fighting the government it didn’t understand business was an even bigger enemy, and it just rolled over. Physicians need to take their profession back from business and start behaving like professionals and put patients first again without question.
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Q: You’re a proponent of using the Internet in the practice of medicine. But doesn’t that further erode the doctor-patient relationship?
A: Actually, it opens up great possibilities to rescue the doctor-patient relationship. As the use of electronic e-mail medicine becomes ubiquitous, it will permit one doctor and one patient to get back together to do the right thing--and bypass the insurance industry, managed care and all those allied health people that stand in between the doctor and patient today.
Of course, there are some things where a doctor simply must put physical hands on, or use a stethoscope or look into the eye of a patient. But there are many other times where none of that has to happen, and electronic dialogues will get to the nub of the matter very efficiently. You type in a request, the doctor responds--it takes five minutes and the problem is resolved. In the future, if you have a biopsy, why would you want it read by an inexperienced person when it can be read by a doctor who knows most about the disease? And that’s just one example. Eventually, the Internet will nudge us into handling medical licenses like driver’s licenses--a doctor will have a license in one state, but it will be good everywhere. It’s ridiculous for a doctor in northern Arizona not to be able to practice medicine in Southern California, too.
Of course, there’s resistance everywhere because this has moved so fast. But it’s a great new world. We just have to figure out the right way to do it.
