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Is U.S. cancer care “in crisis,” as the Institute of Medicine proclaims?

Americans love to fight, traditionally. All real Americans love the sting and clash of battle…When you, here, everyone of you, were kids, you all admired the champion marble player, the fastest runner, the toughest boxer, the big league ball players, and the All-American football players. Americans love a winner. Americans will not tolerate a loser.

General George S. Patton, Jr. was famous for his flamboyance and aggressiveness going on the attack, among other things. He was also known for a number of pithy quotes made throughout his lifetime, particularly during World War II, such as the one above in which he declared how much Americans love to fight. I sometimes wonder whether he was more correct in that assessment than he knew in that we seem to view almost everything through the lens of war and a crisis that calls for a war. In medicine, for instance, we have the “war on cancer” and the “war on obesity.” We have a propensity for likening problems and their solutions to war, where the goal is to destroy the enemy.

Similarly, but less dramatic (although only slightly so), we have various crises. Indeed, Americans seem to love to compare problems to crises as much as they love to compare them to war. Of course, the two are closely related, as a crisis of some sort is a necessary prelude to a war. We can argue about the definition of a “crisis,” but one thing is certain. No matter how one defines it the word “crisis” implies an urgent problem and further implies that something must be done now—or at least very soon—to prevent the catastrophic consequences of that problem, which usually involve a breakdown of a current system. It was with these thoughts in mind that I approached the Institute of Medicine (IOM) consensus report released last week, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. It’s a behemoth of a report, weighing in at 360 pages, and it does indeed paint a picture of some very serious problems in cancer care that should be addressed. It is subdued in that it doesn’t engage in that oh-so-American tendency to declare “war” on every problem, but is cancer care “in crisis”? Of that, I’m not so sure, but it’s definitely got problems. But, as I’ve said, the system’s had problems for a long time, as the IOM itself documented in its 1999 report Ensuring Quality of Cancer Care, which concluded that “for many Americans with cancer, there is a wide gulf between what could be construed as the ideal and the reality of their experience with cancer care.” The report also recommended steps to improve cancer care and the evidence base for cancer care, and to overcome barriers of access to high-quality cancer care. As the introduction to the current report states:
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Posted in: Cancer

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Dr. Donald Berwick and “patient-centered” medicine: Letting the woo into the new health care law?

There’s been a bit of buzz in the health blogs over President Obama’s decision last week to use the mechanism of a recess appointment to be the director of the Centers for Medicare and Medicaid Services (CMS). Recess appointments, for those who may not be aware, allow a President to put a nominee in place when Congress is in recess in order to have him in place without the messy process of having him approved by the Senate. True, the Senate still has to approve a recess appointment by the end of its term, or the seat goes vacant again, but it’s an excellent way to avoid having nasty confirmation fights during election years. Of course, both parties do it, and the reaction of pundits, bloggers, and politicians tend to fall strictly along partisan lines. If you support the President, then a recess appointment is a way to get around the obstructionism of the other party. If you don’t support the President, it’s a horrific abuse of Presidential power. And so it goes. Either way, I don’t really care much about the politics of how such officials are appointed so much as who is being appointed.

The man who was appointed last week to head CMS is Donald Berwick, M.D., CEO of the Institute for Healthcare Improvement. His being placed in charge of CMS will likely have profound consequences not just for how the recent health care/insurance reform law is implemented but for how the government applies science-based medicine to the administration of the this massive bill. Most of the criticism of his views that I’ve seen thus far comes from conservatives, who do not like Berwick’s apparent penchant for health care systems like the British NHS. Ironically, it’s views held by Berwick that will likely come into direct conflict with his mandate to hold down costs that are the problem with Dr. Berwick, at least to me. It is in these views where there is much that is admirable. Unfortunately, I also fear that there is much about Berwick’s views that are very friendly to the possibility of allowing the infiltration of woo into the U.S. health care system as well, and these fears begin with what Berwick is most known for, a term he calls “patient empowerment.”

What a grand word! After all, who doesn’t want to be “empowered”? Certainly not me. Perhaps that’s the reason why it’s become the new buzzword in a movement known as “patient-centered” care. Old fart that I am, when I first encountered the term I was a bit puzzled by exactly what “patient empowerment” means. After all, I’ve always thought I have been practicing patient-centered care, ever since my first days in medical school. Apparently these days it means something different, at least if this article from about a year ago in the New York Times is any indication. It’s an interview with Dr. Donald Berwick, who advocates what he himself calls a “radical” patient-centered care, having at the time recently published an article in Health Affairs entitled What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist. It was unclear to me then and it’s unclear to me now whether Berwick was being sarcastic or flippant in his characterization of himself as an “extremist.”
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Posted in: Politics and Regulation, Public Health, Science and the Media

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