March 2, 2015
By Margie Coloian
Allen Frances, MD, is a professor emeritus of psychiatry and the former chair at Duke University. He blogs regularly, including on Huffington Post, Psychiatric Times, and Psychology Today. He is the author of Saving Normal and Essentials of Psychiatric Diagnosis. Frances is a co-presenter for the RightCare in Psychiatry and Behavioral Health workshop at the third annual conference, Road to RightCare: Engage, Organize, Transform.
What is your overall impression of the health care system in the United States?
We have the worst organized system in the world. In fact, you can’t invent a worse medical system. We waste hundreds of billions of dollars on unnecessary testing and treatments, at the same time that we neglect those who are truly sick. All of this while we spend twice as much per capita as any only developed nation. And we achieve lousy outcomes.
What are some examples of this dysfunction?
We treat lab results instead of patients. We’ve substituted expensive high-tech care that does more harm than good for patients and lost is the human aspect of patient care. We have too much medicine performed in uncoordinated ways. Some high-tech, high revenue-generating specialists are primarily concerned with their specialized organ system, not the whole patient. Our reward system is screwed up, too. When medical students get out of school having $200,000 in debt, they are incentivized to go into a high-paying specialties and to perform high-generating procedures. It would be better if we had more PCPs and fewer specialists.
Why is that?
PCPs now get seven minutes with each patients. You can just about only order a test or prescribe a drug in seven minutes. It takes longer, much longer to do good medicine. Good medicine is doing less medicine. It’s important to explain to a patient why a procedure shouldn’t be done, instead of just doing it. Here’s the formula: Put more physicians into primary care and pay them better so that they spend more time with patients.
What other ways can we advance good health?
We know that 80 percent of healthy outcomes come from social aspects—not medicine. We have issues regarding inequality and access; we are not investing in social determinants. Instead, we are over-investing in medical care. In other nations, there is a balance between medical and social investments, but not here.
What else would you like to see reformed?
We have to fight against profit-making pharmaceutical companies and device makers. There is a vested interest of billions of dollars in profit-driven rushes toward excessive medicine. These folks include politicians and the FDA. Drug makers don’t have to negotiate their prices and so their industry is involved in price gouging. Look at cancer drugs. They’re out of control. Look at hospital costs; they’re opaque to patients. Drug and device makers have control over the institutions that regulate them. Did you know that drug companies spend twice as much on lobbying than on research? It’s outrageous how much is gouged out of the system.
Is there hope?
Yes, look at the model of big tobacco. Tobacco was able to distort the facts about the consequences of tobacco use. They were able to bribe politicians. When the public rose up after educational campaigns, politicians followed. Smoking cessation efforts have been the greatest development for public health in the last 100 years. No one could have predicted that this change would happen.
Who will lead the charge to transform health care?
The Lown Institute, along with Choosing Wisely, the BMJ, the “true believers.” They’re all taking the lead on this. The Lown Institute, in particular, is terrific. But I think the main hope for change won’t come from the true believers like Lown. It’s the public. The public needs to know that going to the doctor might not be helpful. They should be aware of the misleading information and incentives of doctors, drug and device makers. We all must play a crucial role in providing good information to the public.
Can the media help?
During the past 40 years, there has been an enterprise-wide bias in media reporting: negative study results are ignored because positive stories—about “breakthroughs”—sell newspapers. Lately though the media have been great in exposing hype, not promoting it.
Would you want your grandchildren to choose medicine as a career?
No. Medicine has lost its focus on healing and has become mindlessly and harmfully high-tech.