The raw estimate of 251,000 deaths per year is mind-numbing. What is even more disturbing is that the morbidity and mortality seems to be intractable. The number is not heading south, despite the 100,000 Lives Campaign from the Institute for Healthcare Improvement. Medicine's initiative to just-say-no to over-performance of services, Choosing Wisely: Things Providers Should Question has also not turned the tide. The estimate is up from the seminal work in 2000 from Barbara Starfield, MD, MPH that put the medical industry's death rate at 225,000 per year.
Since the number doesn't seem to be moving, reason suggests that powerful forces are holding the stasis. What are the barriers, then? My reflections led to a column in the Journal of Alternative and Complementary Medicine that is summarized here. Might it be the case that these 3 forces, together, will always create such havoc?
- The production focus of the medical industry Both CFOs of medical delivery organizations and the 80/20 rule of the insurers perversely incentivize doing more - and working faster. It's why the best players in regular medicine are promoting a revolution toward the Triple Aim and a "value-based" orientation. The present industry errs on the side of doing more in tertiary care while also promoting the fewest minutes possible of primary care practitioner contact. Produce!
- The limited state of quality decision-making tools/evidence We wouldn't have a move for "evidence-based medicine" if medicine was already in that category. The most frank statement on this topic that I have heard recently was from a University of Pittsburgh Medical Center CMO that in regular medicine "only about a quarter of what we do has strong evidence and we only do that about half the time."
- The reductive biomedical mindset In this industry, research, delivery, and payment each dance around a pole planted in our bodies by the dominance of the idea of a single agent, pharmaceutical, quick fix. The industry favors simplistic assessment and reductive prescription. Typical practice favors myopia.
Look at the cumulative effects. An industrial orientation to push to do more, faster, of what is most productive, remunerative (and dangerous). Making matters worse, this perversely-incented situation is guided by grossly incomplete evidence. Compounding the potential for misguided choices is that the evidence that is relied upon - when it exists - is a function of tunnel vision. The evidence base is infused by philosophically reductive preference for biomedical indicators rather than the complexity of the whole human being who walks through the door.
Here is one way to look at the portrait that emerges. Think of a hormonally-hyped, know-it-all and intoxicated adolescent at the wheel of a car: fast-paced activity amid tremendous ambiguity and compromised vision. Is this not a perfect storm for running a car into a telephone pole? Or to guarantee high levels of medical error and medical death?
Integrative health and medicine bring to this deeply and chronically embedded calculus of US medicine the revolutionary requirement to examine the whole person and system. Then, as holistically, the job of the practitioner team is to use all appropriate products, practitioners and practitioners. Placing the whole person at the center of care disrupts the focus on production, and on the biomarkers. The dance with evidence shifts. As such, the integrative health model is a fulcrum to overturn the tables of the industry's status quo.
The suggestion from this perfect storm is that we will not end medical deaths by focusing on excising errors from the existing way of doing business. It is important that we seek to engage these reductive solutions, through campaigns for hand-washing and other such 100,000 Lives methods. Yet at the same time, we need to acknowledge - as the value-based medicine movement is doing - that our present orientation in the way we do the business of medicine is and always will be a massive, guaranteed, error and death generator.
I believe that this is commonsense. Yet the Catch 22 for medical reform is that commonsense appears not to be an attribute of a reductive mind, but of a whole system one.