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Strange Medicine






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Not since Herman's Hermits plugged in their first Stratocasters have we had so much to fear from our friends across the sea as we do now. Incredibly, through a combination of hype, hysteria, and the purple haze of Bubba's Chelsea morning memories, the bewildering British health care system has been pushed forward as a model for our own. God save the Queen, indeed! God save us all!

Before we allow American medicine to be Anglicized or Canadized or, more generally, Rodhamized we might want to look a tad more closely at, say, one given surgical procedure and compare the social-cultural vibes it gives off both hither and yon.

Allow me to submit as evidence in this comparison--and forgive my temerity for so doing-- Document A, an ad I wrote for a hospital in a mid-size Mid-America town. The copy quoted below describes endoscopy--more specifically, laparoscopy--the procedure in question:


Imagine a slender fiber-optic tube inserted deep in the body. Imagine-- inside of the tube--a tiny telescopic lens, a miniature light source, and the snippers, staplers, and graspers that the surgeons manipulate. Meanwhile a palm-size camera records the action within. And a surgeon uses a TV monitor to guide his work. Ten years ago, this seemed like the stuff of science fiction. Today, these are the tools of the surgeon's trade.


Sound pretty cool? Not necessarily. Let me also submit as evidence, Document B, a recent article concerning the very same procedure in The London Times, England's most prestigious newspaper. What we call endoscopic (or "minimally invasive") surgery, the Brits call "keyhole surgery." The British sentiments about this kind of surgery are pretty well summed up in The Times scary headline: "Keyhole surgery could double the risk of damage to patients."

Why, you ask, would someone willingly submit to an operation that is alternately "revolutionary" (Document A) or "dangerous" (Document B)? The ad copy goes right to the point:


A surgeon can now spare the scalpel and remove a gall bladder through a tiny incision. The patient may spend a day in the hospital now, not a week as he might before. He could be back to work in a week now, not six. And he would experience far, far less pain.


Powerful incentiives to be sure, fairly stated. The London Times, however, puts a different slant on the motives behind the popularity of this surgery. "The trend," the authors write with gloomy Luddite assurance, "is encouraged by political pressure from the department of health to cut the time patients spend in the hospital." And that's about it.

Which source is to be believed, you ask? A paid advertisement in a small town paper or an in-depth article in the lofty London Times? Paradoxically, both are. That each is credible in context says volumes about the whole weary Gestalt of British medicine. Please allow me to explain.

By nature, surgeons are no more inclined to seek out new technology than longshoremen. Who can blame them? In most countries, they invest a ton of time, and money too, in a given skill and get it down to a science. They can play God in the morning, play golf in the afternoon, and put some real money in the bank. It's hell of a life. Why jack with a good gig?

Why? In America, at least, the physics of modern medicine compels them to. Inevitably, some young buck of a surgeon, driven by dreams of glory and riches untold, will push himself to perfect a new surgical technique. The same dream will inspire the hustling CEO of a teaching hospital to adapt the new technique and publicize it. A more bankable version of the glory and riches dream will goad ambitious surgeons to learn the technique and become its gurus in their own burgs. Stirred by humbler dreams of glory, and a healthy dose of competitive anxiety, local medical centers will recruit and equip these new gurus and hire people like myself to promote their skills. Moved by fear of pain and/or death, savvy consumers will then seek out those surgeons who can spare them both or either.

Finally, driven by worry of economic obsolescence, the remaining surgeons will abandon their old ways and perfect the new technique. Forget compassion. If every person on the chain had a heart of surgical steel--and some may--it wouldn't matter. The system would still produce the world's best care. (With a little reform, the most efficient as well.) "The law of unintended consequences," Adam Smight reminded us, is that strong. Inertia will yield to the superior force of profit every time. That's how the world turns, Bubba! Even in Arkansas.

In Britian, where profit is as unseemly as the Prince's love life, inertia rules. With but few exceptions, surgeons are government employees. Like Postal workers, they get pretty much the same pay regardless of how hard or how skillfully they labor. Hospitals don't publicize physician talents or promote their services. Patients--In Britian, they are not yet "consumers"--have little knowledge of a surgeon's skills and little choice among them even if they did know.

As a consequence, progress is painfully slow , with an accent on the pain. British medical schools, for instance, still do not teach endoscopic, or "keyhole," procedures--even though they have been routine in the US for a decade. The Royal College of Surgeons does not test for the procedure in any fashion even on its higher exams. At its annual conference in June, a patients' pressure group, Action for Victims of Medical Accidents--Does this name tell you something about British medicine?--will conspire to check the spread of keyhole surgery as if it were a disease.

And if all else fails, Britian's stunningly absurd animal rights activists can be counted on to sacrifice every man, jack, and gall bladder in the kingdom to save the mother-loving lab rat. Pulling together, these anti-forces can suck even an ambitious physician into their black hole of alleged "caring." As a result, British surgeons embrace a radical change in job technology only a shade more eagerly than would the elevator operators at the County Courthouse.

If all this weren't disincentive enough, there is still another anti-force at work in Britian, one that's more subversive than even the animal yahoos. And that is the press itself. Although their facts are true enough, and their tone appropriately defeatist,The Times' writers--much like their American counterparts--refuse to ask the basic questions: Why is laproscopy more risky in Britian than in America? After the learning curve, might not minimally invasive surgery be even less risky than traditional sugery? What impact does nationalized medicine have on a surgeon's willingness to learn?

And most fundamentally, how is that virtually all new procedures come to Britian not through internal research but by Fed Ex? Clearly, without the incentives of American medicine, and the imperatives of American consumer choice, keyhole surgery would not exist at all. For that matter, British surgeons might still be cutting hair--they've done it before. And the British press would probably be happier for it.

All of this British brouhaha would be academic, of course, were it not for our media-driven enthusiasm for any health care system other than our own. In America, too, the media's instinct is to champion those who kvetch about progress not those who create it. A recent media survey, for instance, asked folks on the street how much surgeons should make. The consensus was about $80,000. Da noive! No one has ever asked how much Tom Brokaw should make or Connie Chung. Hell, based on a 40 hour week, Oprah would make her $80 Grand in just two hours. Literally.

To be sure, our mixed-bag health care system needs a little surgery. But I would argue for the minimally invasive kind: suck out a little government fat; develop a little more real consumer control in its place. And to perform this surgery , I would much prefer a skilled young buck with some shiny new micro snippers than a barber-surgeon with a chainsaw.



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