The Old Man Versus the Medical-Industrial Complex
By J. Winakur, MD;; 7/9/14

A 90-year-old man falls down the stairs and breaks his neck. He is whisked into the modern er of his hometown clinic, where he suffers respiratory arrest. He is quickly diagnosed, plus a tracheostomy saves him. But many other life-threatening complications occur. He spends 8 weeks altogether in the hospital after which a rehabilitation center. Then the man returns to his home.

All this costs well over $300,000, however the man is in charge of paying only some hundred dollars. In the end, he's highly critical of some areas of his medical care. This happens every single day in America. Granted, sometimes the outcomes are not happy ones, but not for deficiency of trying.

The writer of the autobiographical narrative is Dr. Arnold Relman, professor emeritus at Harvard Medical School, an old editor of The New England Journal of Medicine, and an oft- quoted health policy guru. The story is produced by his article “On Breaking One’s Neck” (New York Rev. Books 2014; 61(2):26-29).

Since 1980, Dr. Relman has railed against the rise of the “medical-industrial complex,” warning against its attendant problems of “overuse and fragmentation of services, overemphasis on technology” and ”undue influence on national health policy.”

Yet he heaps praise around the famous academic hospital where he received acute care, Massachusetts General Hospital, (the “Mecca” Big Medicine in America) and it is staff of quick-acting specialists, intensivists, proceduralists, and hospitalists. On the other hand, she has only disdain for your Spaulding Rehabilitation Hospital where he recovered. He writes:

“No physician seemed to be actually accountable for my care, or spent long at my bedside beyond the thing that was required for a cursory physical exam. They did, however, leave lengthy notes within the computerized record, full of repetitious boilerplate language and lab data, but low in coherent descriptions of my medical progress, or my complaints and state of mind.”

One understands from your description of his ordeal until this was a rude awakening for Dr. Relman. Where was the physician – his medical doctor – who cared about him as being a person, who knew him just as one individual, who knew his family, his life circumstances? Someone to whom he might turn and say, “What is occurring here?” or “No one seems to hear me!”?

This is the place where medicine is practiced in America currently, as Dr. Relman has learned. After Big Medicine stabilizes a frail, elderly man, the painful transitions begin: on the ward, to rehab, to long-term care. Different doctors and “teams” take charge at each place. From one place towards the next, diagnoses are forgotten, medications missed, dosages changed, or drugs added to treat the complications brought on by drugs still given for past problems now resolved.

Reams of information accompany the patient but are unfocused and redundant because no-one has taken some time to prepare a coherent summary. The patient is reduced to specimen: a list of problems and meds, algorithm-guided checklists. Who is there to ask, “How will be your level of pain? Are you sleeping? Have you been moving your bowels? Are you having your concerns addressed? Are you feeling depressed? What kind of assistance do you consider you will need when you're home?”

With few exceptions, the attending physician who once asked questions such as these is no longer present with the bedside. Dr. Relman has always proposed that what ails primary care could be fixed by causing these doctors salaried employees of giant multispecialty groups. And now, most doctors in America are employed by the major players in the medical -industrial complex: hospital systems, insurance agencies, other corporate medical enterprises, and government entities.

These doctors are but tiny cogs in someone else’s giant wheel; their long-term allegiance is inside the process of shifting from other patients to their employers. How this will alter the physician-patient relationship and medical practice is often a work in progress.

Meanwhile, the role of primary attending physician may be denigrated from the academic medical establishment and undervalued and poorly remunerated by Medicare, Medicaid, and personal health insurance companies. So far, the Affordable Care Act pays only lip service on the dwindling amounts of primary care doctors in America and has only hastened their exodus into retirement or salaried employment. If one speaks to young doctors practicing primary care today – or reads their blog articles – one knows that they are equally as demoralized by how forces beyond their control dictate their practice of drugs as Dr. Relman is through the care he received.

Geriatricians, not motivated by money or power, only shrug looking at Dr. Relman’s saga. We’re the docs whom the medical-industrial complex forgotten. But we, no less than, comprehend the importance of coordinated care, a concept that Dr. Relman seems unaware of when he writes: “I had nothing you've seen prior understood how much good nursing care contributes to patients’ safety and comfort, especially when they may be sick or disabled. This is often a lesson all physicians and hospital administrators should learn. When nursing is just not optimal, patient care is never good.”

One can only ask: Where has this doctor been every one of these years?

Having survived a mauling with the medical-industrial complex, Dr. Relman writes he wants “to stay around as long as possible to view what is likely to happen…towards the health care system I was studying so closely.”

May turned be a strong advocate for elevating the status of primary care doctors. Make them the lynchpins in our medical system. Pay them to get the real doctors they need to, once more, be trained being: skilled clinicians, empathic caregivers, judicious arbiters products their patients need. Each and every patient really should have a pediatrician, a family physician, a broad internist, or even a geriatrician: somebody that should be generously remunerated for caring across all sites of our own sprawling medical-industrial complex.

As Dr. William Osler, the “father of internal medicine,” once wrote: “The good physician treats the condition; the truly amazing physician treats the patient who has the sickness.” The power brokers of our medical-industrial complex need to become reminded of the. Let’s hope it doesn't take devastating injury or illness for others to see the light.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


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by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication