Economists, Doctors, and Homeostasis

Dr Alper is Clinical Professor of Medicine, University of California, San Francisco, Visiting Scholar, Hoover Institution, Stanford University, and practices internal medicine in Burlingame, Calif.

Wall Street Journal

The lead article on page 1 of the on March 28, 2007, "Job Prospects: Pain From Free Trade Spurs Second Thoughts," describes how Princeton economist Alan S. Blinder, PhD, broke ranks with the conventional wisdom of his profession and with his own previous advocacy and is having second thoughts about unfettered free trade and globalization. The column, written by David Wessel and Bob Davis, is subtitled, "Mr Blinder's Shift Spotlights Warnings of Deeper Downside." The take-home message, as Dr Blinder himself put it, is that the harm done when some lose jobs and others get them will be far more painful and disruptive than trade advocates acknowledge.

So what does this have to do with us? Maybe radiologists will have to compete for readings with competitors in English-speaking Third World countries. Surgeons and hospitals are already losing business to physicians in well-equipped and well-staffed facilities abroad. Cosmetic surgery initially, and now even advanced cardiac surgery, are offered at far lower cost than in the United States.

Internists are not in the front lines of this battle. But we are familiar with the steamroller impact of economic theories linked to political influence. Like unrestricted free trade?managed care, managed competition, pay for performance, pay for quality and for the adoption of technology (which is often thought to be synonymous with quality)?have all been designed with the loftiest motives in mind: better and more cost-effective patient care. However, the abuses, chaos, and sometimes devastation that have resulted are the underemphasized "downsides" that strong proponents of economic policies are loath to consider, let alone warn about in public.

Those who actually do the work suffer less from this kind of selective blindness. Dr Blinder notes that the job instability that is affecting millions of Americans because of the ready availability of outsourcing is "something factory workers have understood for a generation." Many more millions will be affected as a result of "the cheap and easy flow of information around the globe." And that's where we come in. Physicians already in practice labor on. But those who are in training understand the lowered value of cognitive medicine in the current marketplace. They are voting with their feet, with a 50% drop in the number choosing primary care careers in the last 5 years alone. Curiously, the leading economists who were so vocal about the value of primary care?directed medicine only a few years ago, are largely silent about this.

Maybe this is because of too much zero-sum, I-win?you-lose thinking. Are globalization and free trade really bad things? Probably not, at least in the long run, if implemented intelligently. Are giving greater structure to healthcare, incorporating quality standards, and rewarding performance really bad ideas? Again, probably not. But everything depends on implementation and the rate of change. Our biggest challenge is the maintenance of homeostasis while undergoing change.

Consider that society resembles a living organism in many ways. I've told patients, "We hang by a thread?but it's a very strong thread." By this I mean that years in medicine have impressed me with the vulnerability of the human body. But I've been more impressed with the body's amazing resilience, provided it is not overly destabilized by change that is too rapid or that exceeds the capacity of the system to adapt. In the latter case, even correction of perceived deficits can be dangerous—electrolyte imbalance, for example, that is reversed either too rapidly or without adequate allowance for the effect of comorbidities and unanticipated problems. The sardonic joke that, "the patient died in perfect electrolyte balance" mocks treatment that is cosmetic, but futile. It also includes instances in which the treatment contributes to the demise of the patient.

This unfortunate situation occurs all too often in medicine. Refeeding patients who are starving can be fatal when done too zealously. The same is true with the correction of diabetic ketoacidosis. Administration of oxygen, which is generally more benign, can also be harmful in certain circumstances. High concentrations may induce retrolental fibroplasia in premature infants, for example. In every instance, the goal is worthy, but the execution is flawed.

I see an important parallel between medicine and the rest of society. Dr Blinder has estimated that somewhere between 30 million and 56 million American jobs are "offshoreable," largely as the result of advances in communications and free trade. He warns that destabilizing displacements that were once limited to factory workers are "now coming down on the heads of highly educated, politically vocal people, and they're not going to take it."

In the long run, it may indeed all be for the best, as uncritical believers in free markets claim. The trouble is that people live in the short run, as well as in the long run. Few people are able to retrain for jobs better than the ones they lost. Blind faith in ultimate benefits resembles the attitude of "cowboy" physicians, who consistently underestimate the downside of treatments. Blind faith also leads to blind eyes. Risks and opportunities to minimize consequences may never even be perceived, and if they are, may not get the interest and attention they deserve.

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The lay press often presents upsides and downsides in a clearer way than professional literature, in which intellectual jousting is more the rule. A new book I am currently reviewing (?? by Jonathan Cohn) poignantly portrays the personal impact of job loss on people who are sick with a chronic illness, or those who get sick once they have also lost their job-related health insurance. That insurance is far more difficult to replace than the job itself. In fact, it's often irreplaceable, leading to, "what's your insurance?" confrontations with the front offices of doctors and hospitals.

The pressure this creates is destabilizing for both patients and doctors. It is painful enough for many in healthcare (as in the economic community) to turn a blind eye to it, because there seems to be so little we can do about it. True, it affects the minority of people, but medicine has always been about the minority of people who are sick at any given time: the current insurance situation short-shrifts them. And should their number dramatically increase, as Dr Blinder believes, their plight will further destabilize their lives, our lives, and the provision of healthcare.

Constructive change is rarely pain free. In medicine its impact extends outward, because medicine, although not entirely a zero-sum game, does have limits on available resources at any given time. In addition, such things as cries for "not wasting money on futile care for the elderly, and putting it to better use by improving prenatal care" leave us with no way to effect such transfers, let alone decide how long each patient has to live, and when to switch to only minimal care.

The introduction of evidence-based medicine (at least in the way it is currently understood and applied) is a change that also threatens medicine's homeostasis. Emphasis on "right ways" and "wrong ways" to treat leads to abrupt transformations in practice that have preempted the historic gradual evolution of new therapies and technologies. While some patients lost out in the process, there was a measure of safety in gradualness that currently flip-flopping recommendations (eg, hormone replacement therapy, coronary stents) ignore.

Washington Post

And then there is the cost. Strong lobbies recommend annual magnetic resonance imaging (MRI) for breast cancer detection, and the American Cancer Society has recently signed on for high-risk patients (for an interesting discussion, see "Annual Breast MRIs Urged For Women at Cancer Risk," , March 28, 2007). There is also lively debate over the value of serial CT to detect lung cancer in smokers. Although these are discussed in terms of quality of care, taking us wherever the evidence goes, adoption destabilizes the rest of medicine, with a negative impact on primary care virtually certain. The trade-offs are ignored.

Homeostasis remains crucial for the body, medical practice, and the economy.

e-mail: philipa@ucsf.edu