Truth or Consequences in American Medicine, 21st Century Version

The New York Times has been a source of wonder and amusement to the Phantom lately, with regard to medical stories:
1. November 23:  Dr. Elizabeth Stier, a faculty member of the division of Obstetrics and Gynecology at Boston Medical Center, who is doing research on anal carcinoma, a disease which affects both men and women,  was recently notified by the American Board of Obstetrics and Gynecology they will decertify her as a board certified gynecologist if she persists in treating men,  as part of her research study. In explaining the board's stance, Dr. Kenneth Noller, the board's director of evaluation, provided a stunning explanation: "There were plenty of other doctors available to provide the HIV-related procedures that some gynecologists had been performing on men." If Dr. Stier persists treating patients regardless of their gender,  she will be defrocked, excommunicated from the club of certified gynecologists and possibly condemned to wander for all eternity in darkness. The board has not decided about wandering in the darkness yet.

2.November 24:  In the business section of the NY Times an article about the marketing of testosterone therapy directly to the public. Pictured and quoted in the story is Dr. Harry Fisch, a urologist, "who likes to say a man's testosterone level is 'the dipstick' of his health," and being a urologist, one might expect he might know about dipsticks, but he clearly does not know about testosterone.

  Fortunately, the Times has found someone to quote who may actually know of what she speaks, from  Georgetown School of Medicine, who, commenting on the advertising blitz said, "Do you feel tired after dinner?  Depends on how long after dinner. We all do eventually. It's called sleep."  

The article focused not on the truths we think we know about testosterone deficit as a disease in men, but on the marketing, the income derived--$2 billion dollars  in 2012, up from $324 million ten years earlier, after a $107 advertizing blitz by the drug makers, a nice return on investment. Of course the business types at the Times were either not interested or not qualified to judge anything about the basic truth of whether or not men are being treated for a real disease, i.e., for a true deficiency state,  or simply being sold snake oil. All that matters to the drug makers and the MBA types is the game: The FDA forbids the drug companies from trying to sell testosterone to men who are not truly deficient, but it does not forbid medical doctors like Dr. Fisch from becoming the pitch men for the product. If Dr. Fisch or a whole legion of like minded doctors want to prescribe Androgel, well, that's not the drug company's fault. They can't stop people from wanting their product. They just collect the money.

Any doctor can say anything he wants about testosterone, unless of course he is a board certified gynecologist, in which case he (or she) may be de certified and condemned to wander in darkness for all eternity.

3.November 24:  Mary Lou Jepsen, writing in the NYT Review, tells her harrowing tale of having a pituitary tumor which was misdiagnosed and mistreated, "only partly because of the shortage of endocrinologists, doctors who specialize in the hormonal systems." 

She tells us, "Without the ability to fine-tune my hormones and neurochemicals I believe I would have been trapped as a near-imbecile, wheelchair-bound, in my mother's basement for an abbreviated and miserable adult life. But with this ability, I have reached the top of my field. Still, the health care system hinders my acces to the chemicals I need to live. I am far from alone in this situation. It's time we changed the system."

Now, the Phantom has a special affection for endocrinologists, but he was disquieted when he got to the part where Ms. Jepsen says, "This all changed when I finally found a doctor to work with me to reconstruct my personality and my health by tuning combinations and doses of these powerful chemicals." 

Oh, oh, oh. And what kind of "endocrinologist" could do this? The Phantom lives in New Hampshire, where there are things called "naturopaths" who live under bridges and prescribe all sorts of things--eye of newt, testosterone, clomiphene--and they usually sell these out of the snake oil chest in their offices at substantial profit, and oh, my, my.  If truth is the first casualty of war, then truth is also the first casualty of the desire for financial profit.

The editors of the NY Times, did not call the Phantom for his opinion about the medical history Ms. Jepsen provided. The Phantom would have said, "Whatever this unfortunate lady had, it is dead certain what made her better was not any fine tuning of hormones and neurotransmitters."

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Here's a truth for the blogging public: There is, in fact, a huge revolution in American medicine and it has nothing to do with endocrinology, or testosterone or urology or gynecologists treating males with anal cancer, or with any science at all. It is contained in the observation that somewhere north of 90% of American doctors are now employees, file W-2 forms, and work for large corporations, "voluntary" hospitals, incorporated medical groups, the government or academic institutions. 

That, more than any scientific breakthrough, more than unraveling the human genome, more than any drug, more than startling advances in surgery (like laporoscopy) or in imaging (MRI's, ultrasounds) or in "personalized medicine," and certainly that, more than Obamacare,  has in fact, "depersonalized" medicine.

If your doctor is an employee, he likely has in his (or her) contract a clause which explicitly states that any patient he sees, (i.e., you) is the property of the corporation/ employer,  not the physician. That means, among other things, if the doctor leaves the practice he may be forbidden from "soliciting" you to be his patient.  He may run away from you in terror, should you track him down and show up in his new waiting room, for fear his former employers will direct their large in house corporate lawyers to drag him into court for "solicitation."  (And we are not talking about a misdemeanor, and a quick mug shot here.) He can only treat you if you manage to track him down all by yourself, which, given restrictive "non compete" clauses in his contract,  may mean he cannot practice any where within 20 miles of his current location. 

Think about that a little. 
Your doctor and you are not in the room alone.