Monday, June 21, 2010

Pain management politics

Earlier this year, the Institute of Medicine (IOM) published a report calling for a culture change in the US healthcare services. There are major problems in the treatment of pain and, without urgent steps to reform the current practice standards, it's likely more people with be left suffering unnecessary pain. This is a serious indictment of the US in failing to even begin matching the clinical standards in other countries. So what's gone wrong and why? There are two quite different contributions to the present collapse of care. The first starts in the medical schools. We should be able to assume each new generation of doctors is being taught all they need to know about pain and how to manage it effectively. Across the country, we are lucky enough to have 117 university courses teaching medicine. But only five of them have mandatory course on pain management.

More generally, less than twenty have elective courses. It does not take a math genius to understand there's a chronic failure here. For decades, each new cohort of students has been passing through the academic courses and practical training without any insistence future doctors learn anything about how to manage pain. This is a victory for the pharmaceutical industry. Through a variety of different means, it has convinced the medical profession all it needs to know about pain management is which pills to prescribe.

Now let's get these doctors out into the real world. All the most ambitious and best qualified go where they will make the most money. This means they specialize in the forms of treatment with the highest profit margins. So long as their billing numbers are high, they will do very well. Now ask yourselves how for-profit hospitals and clinics make the most money. The answer, of course, is to treat as many people as possible in the shortest period of time. There's no time to think. Everyone is treated the same and given standard treatment. Now comes the second problem. The insurance industry has been pressuring doctors to join networks in which they have to meet performance targets. This maximizes the profit for the insurers and even further reduces the face-to-face time available for individual patients. That's why, if you are lucky enough to see one of the doctors treating you, it will be a five minute appointment with an emphasis on either referring you for more tests or giving you a prescription.

The IOM is calling for reform of the insurance framework for funding treatment, allowing for more consultation time and greater flexibility in the range of treatments that can be included. As it stands, hospitals and clinics are discouraged from offering one-to-one therapy because this is an inefficient use of labor. So in other countries you would see a physical therapist or go for cognitive behavioral therapy. We are told this is too expensive to be included in the health plan. You can pay for it yourself, of course, or there's the always reliable Tramadol. We take more painkillers than any other country in the world. The answer is always a pill like Tramadol instead of actual treatment designed to reduce the pain. And our healthcare services will stay this way until the politics are resolved.