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Emergency Medicine News:
doi: 10.1097/01.EEM.0000451586.71378.d9
Viewpoint

Viewpoint: 1910 Again

Mosley, Mark MD

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Dr. Mosleyis the medical director of the emergency department and residency education, the director of quality improvement, and the director of operations management at Wesley Medical Center in Wichita, KS.

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Abraham Flexner was not a physician, but he transformed the practice of medicine. He was an educator who demanded that medical education conform strictly to the scientific method, and he published his findings in the Flexner Report in 1910. Almost half of all medical schools closed within a few years of that report, and the remaining ones changed dramatically. The professionalization of medicine for American physicians had been restructured on a foundation of scientific integrity.

What was the condition of American medicine prior to 1910 that necessitated such a cataclysmic change? Medical education and physicians used the field primarily as a financial enterprise without regard to valid science. “Proof” was provided by the testimonials of patients who had been miraculously cured or by physicians claiming their personal experience. This approach in its worst form was epitomized by the medicine show selling snake oil. What were these questionable therapies used to dupe the American public for personal financial gain? Chiropractry, massage therapy, natural herbal therapy, homeopathy, electromagnetic therapy, and probiotics, to name a few. The scientific legitimacy of American medicine required the denial of these unproven therapies. This is well documented in the book Nature Cures: The History of Alternative Medicine in America.

The 1960s saw a resurrection of these alternative medicines into mainstream culture. The scientific medical community countered in the late 1980s and early '90s with evidenced-based medicine. The NIH concurrently established the office of alternative medicine to see if these popular therapies could be scientifically validated. Almost none of these has shown much benefit, including a huge database of vitamin and mineral supplements. Well-respected scientific medical journals regularly report on their lack of value and danger. Yet, they have become a massive financial industry every bit as popular as they were in the late 1800s.

“Dwell on the past and you'll lose an eye. Forget the past and you'll lose both eyes,” Aleksandr Solzhenitsyn wrote in The Gulag Archipelago, recounting the Russian proverb. Today, the American medical profession is still placing profit before professionalism and business strategy ahead of scientific integrity. Many “providers” have adopted vitamins, minerals, herbs, massage, chiropractry, homeopathy, and other alternative approaches into some aspects of their practice to satisfy the cultural and personal beliefs of patients. These include Dr. Oz, Dr. Andrew Weil, and other popular TV show personalities. Alternative medicine is less about medicine and more about alternative income.

Others are using their professional licenses and cultural status to become expensive beauticians, offering surgery, lasers, creams, and potions for ailments like cellulite, crow's feet, varicose veins, love handles, sagging buttocks, and small breasts. No serious person would consider these illnesses (except in the more extreme examples of disfigurement from trauma or cancer), but we have all convinced ourselves that if people want something and are willing to pay for it, why not have a medical doctor practice cosmetology? We should be reminded that capitalism has no sacred oath to “first, do no harm.”

Many physicians are practicing alternative medicine and boutique cosmetology on the side to increase their profits, and mainstream physicians have their own versions of making extra money by making people happy. Physicians, now called “providers,” see patients, who are now called “health care consumers,” and they are given completely unnecessary and expensive (and often dangerous) medicine for little reason other than the “provider” believes it will make the patient happy. This is done perhaps out of ignorance (not knowing, for example, that science does not support antibiotics for a routine sinus infection), and other times out of laziness (it takes too long to explain to the patient why an MRI of the back may be harmful).

My generation of physicians has done much harm by putting “selling” before proper science: Zithromax for all things respiratory, Prilosec for all things gastrointestinal, Neurontin for chronic pain, COX-2 inhibitors, Tamiflu, EPO, hormone replacement therapy, steroids for spinal cord injury, hypothermic therapy, antidepressants and antipsychotics for everything psychiatric, and, I fear, IV tPA for stroke. These valueless therapies are the proverbial tips of the iceberg that don't even take into account medical devices and surgeries. It is not that these therapies are completely without scientific merit, but they essentially have no value, especially when applied to a much larger population than is necessary and when the small magnitude of benefit is weighed against potential harm and cost.

One more layer of this professional denigration dates back to the 1800s. Patient-centered care is being redefined and reimbursed according to a patient-defined experience. Satisfaction scores are the updated version of testimonials. Quality is not a scientific outcome but a metric of reimbursement based on nonscientific support. “Make me happy quickly” is now what makes the money, regardless of the science. The consumer's personal experience, not the allocation of proper science by a trained professional, determines the stamp of “top quality” on a website or billboard. The hands of philanthropy now wear the gloves of narcissistic consumerism.

A business-driven wagon has overtaken the American medical profession. Whether the medicine show is alternative medicine, medicalized cosmetology, an alliance with what Big Pharma promotes, or gaming CMS metrics for customer satisfaction, we are strangely similar to that pre-1910 era. We need another Flexner Report. Until then, the only power real physicians have is our duty to say, “First, prove it.” And if it cannot be consistently proven, we must have the moral courage to say, “No, this is not legitimate medicine.” We can only hope that physicians and patients will be able to learn the difference between professional ethos and a medicine show.

Wolters Kluwer Health | Lippincott Williams & Wilkins

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