Have you read the best medical paper of the year?

Rinckside 2014; 25,7: 13-14.

his year's best medical paper so far appeared at the end of January. It wasn't published in Radiology or another leading medical journal, but in the New York Review of Books. The author is Dr. Arnold S. Relman, a succinctly articulate man and leading figure in U.S.-American internal and social medicine. In his paper, he revealed the final realization of his life. He learned the hard way about the deficits of modern medicine.

I have dealt with this topic over the years, but Relman was perhaps more suitable and qualified than me to reach a wide public and make a major impact on health politics. In this column, I will try to give a glimpse into his latest articles.

From 1977 to 1991, Relman was the editor of the New England Journal of Medicine. In the autumn of 1980, he introduced the term "medical-industrial complex" — coined from Dwight D. Eisenhower's "military-industrial complex."

The most important healthcare development of the day is the recent, relatively unheralded rise of a huge new industry that supplies healthcare services for profit.

"The most important health­care de­velop­ment of the day is the recent, rela­tively un­herald­ed rise of a huge new industry that supp­lies health­care ser­vi­ces for profit. Pro­prie­tary hospitals and nursing homes, diagnostic labora­tories, home-care and emer­gency-room services, hemo­dia­lysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to $40 billion. This new 'medical-industrial complex' may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and 'cream-skimming,' and it may also exercise undue influence on national health policy [1]."

In an interview some years later, he went against vested interests and profiteering by colleagues:

"Many people think that doctors make their recommendations from a basis of scientific certainty, that the facts are very clear and there's only one way to diagnose or treat an illness. In reality, that's not always the case. Many things are a matter of conjecture, tradition, convenience, habit. In this gray area, where the facts are not clear and one has to make certain assumptions, it is unfortunately very easy to do things primarily because they are economically attractive [2]."

He took the topic up again several times, and gave an excellent overview of it in his Shellock Lecture in 1991 [3].

Last year, shortly after his 90th birth­day, he fell down the stairs in his home, broke his neck, and spent weeks in the sur­gi­cal in­ten­sive care unit (ICU) of the Massa­chusetts Ge­ne­ral Hos­pital, as well as other hos­pitals in Boston. When in inten­sive care, he started scribbling — and this finally turned into one of the best articles I have read about hospitals and our health system, both in North America and in Europe. The article begins like this:

"I am a senior phy­si­cian with over six de­ca­des of ex­peri­ence who has ob­serv­ed his share of critical illness — but only from the doctor's perspective."

This thought is resumed further down:

"Despite all [my] ailments, I had never needed more than a brief hospitalization [4]."

In his article, he stated that he learned about some aspects of the U.S. health system he had never thought of before: intensive care treat­ment and re­habi­li­tation seen through the eyes of a patient.

"What did this experience teach me about the current state of medical care in the U.S.? Quite a lot, as it turns out. I always knew that the treatment of the critically ill in our best teaching hospitals was excellent. That was certainly confirmed by the life-saving treatment I received in the Massa­chu­setts General emer­gency room … But what I hadn't appre­ciat­ed was the extent to which, when there is no emer­gency, new tech­no­logies and elec­tronic record-keep­ing affect how doctors do their work. Atten­tion to the masses of data ge­nerat­ed by labo­ra­tory and imaging studies has shifted their focus away from the patient. Doctors now spend more time with their com­puters than at the bed­side …

"What personal care hospitalized patients now get is mostly from nurses … I had never before understood how much good nursing care contributes to patients' safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.

"Even in the best of hospitals, with the best of medical and nursing care, the ICU can be a devastating psycho­logical experience for patients — as it was for me. Totally help­less, deprived of control over one's body, ICU patients despe­ra­tely need the com­fort­ing pre­sence of family and loved ones. I was for­tu­nate to have that support, but some others in the MGH ICU were not. I can only hope they re­ceived extra atten­tion from their nurses."

Applied to radiology, human quality in this discipline climbs and falls not only with a personal contact between physician and patient, but — perhaps even more so — with the guidance, information, and care given by radiographers. In radiology, maybe more than in other disciplines, old medical skills have turned into electronic habits. Art and crafts­man­ship have been replaced by reli­ance on machines. And the more we rely on machines, the more we cede control of our craft to them, to those who manu­facture them, and to those who ad­mini­ster us. Do we want to become puppets of the "medical-industrial complex"? Or are we already puppets on their strings?

Relman died on his 91st birthday of causes unrelated to his accident.

I highly recommend that you read this article.

References

1. Relman AS. The new medical-industrial complex. N Engl J Med. 1980; 303(17): 963-970.
2. Confronting the crisis in health care: An interview with Arnold Relman. (MIT) Technology Review. 1989; 92(5): 30.
3. Relman AS. The health care industry: where is it taking us? N Engl J Med 1991; 325: 854-859
4. Relman AS. On breaking one's neck. The New York Review of Books. 2014; 61(2): 26-29.

Citation: Rinck PA. Have you read the best medical paper of the year? Rinckside 2014; 25,7: 13-14.

A digest version of this column was published as:
Rinck PA. Have you read the best medical paper of the year?
Aunt Minnie Europe. Maverinck. 24 September 2014.