Poetry at the End of Life

shutterstock_215471662Poetry is when an emotion has found its thought and the thought has found words. – Robert Frost

The following excerpt is from a book in-progress about hope at the end of life. It exemplifies an unusual phenomenon, known as terminal lucidity, in which people, who have been incapable of meaningful conversation for a long period of time, inexplicably become lucid shortly before death.  

Though terminal lucidity has been the subject of ongoing scientific investigation for over a century, researchers are no closer to understanding how it arises…particularly in patients with overwhelming dementia or intractable mental illness.

For loved ones, the ability to have a final, coherent and moving conversation with a family member prior to their passing can bring hope and closure at the end-of-life. It suggests that perhaps not everything is reducible to what happens at a cellular level rather than at the level of our soul.

The summer of 1936 was stifling hot in the Midwest. Record temperatures had sent the thermometer soaring – reaching an unprecedented 113 degrees as far north as Michigan’s Upper Peninsula.  Thousands of people would ultimately succumb to the heat.

As the summer swelter reached its crescendo in late July, U.S. athletes prepared to compete in the Berlin Olympic Games. A scant two months earlier, legendary boxer, Joe Lewis had lost the title of heavyweight champion of the world to Germany’s Max Schmeling. It had been a stinging defeat, yet the Olympics represented a chance to regain nationalistic pride.

Two days into the Games, Jesse Owens would bring home a gold medal in the 100 meter run with a blistering time of 10.3 seconds. He would go on to win three more golds – a powerful affront to Hitler’s claim of Aryan supremacy. No imagined that, two years later, Germany would begin the systematic persecution and annihilation of Jews on Kristallnacht.

For an adventuresome young woman of sixteen, who was headed off to college, these events seemed a world away. What mattered most were school, boys, and her family. At sixteen, Shirley Tivol was among the youngest students matriculating to the University of Illinois (she had been allowed to “skip” a couple of grades of primary and secondary school). She couldn’t wait to get her books, pledge a sorority, and hopefully meet the love of her life.

Her parents, Charlie and Mollie, were excited, yet also a bit anxious about their daughter’s departure. As Russian émigrés, they had made a perilous journey early in life to escape the Czar’s pogroms. Hard work and perseverance had allowed them to not merely survive but thrive in their new home. Life was neat and tidy, and they wanted it to stay that way.

Kansas City’s Union Station was bustling as Shirley and her parents wove their way between the myriad of trains preparing for departure. After handing her bags to a waiting porter, Shirley gave a long hug to her folks and stepped onto the awaiting Pullman. She quickly found her seat, lowered, the window, and blew a final kiss with a wave.

My mother went on to do exceptionally well in college, which came as no surprise to anyone. She was enthralled by the opportunity to learn – whether it was a course in creative writing, comparative religion, or her major – teaching. And though she didn’t find the love of her life at school, she did shortly thereafter. She met and married my father, Jack Leifer, shortly after graduating college in 1940. Though they had known each other but a few months before marrying, it was a union that they would enjoy for more than 61 years.

Throughout her life, my mother’s love of learning continued. She read voraciously — at a pace that would have made Evelyn Woods look like a dullard.  Had she not passed her books on to friends, our house would likely have been transformed into a library!

As a result of her reading, my mother could speak authoritatively on a vast array of topics. But she was never bookish, quite the contrary…she was warm and effusive. That’s why it was all the more difficult to watch her decline in the latter years of her life.

My mother and father had been inseparable. A few months after they were married, Dad was shipped off to Europe. He would be among the first forces to land on Normandy Beach. It would be three, interminably long years before my folks saw one another again. After the war, the only thing that could separate them was death itself.

My father lived a great live and died at the age of 86.  We assumed that my mother, stripped of her life-companion, would quickly follow suit, but she surprised us and lived for another five plus years.

Yet, she changed during that time. Not the core of who she was as a human being – love and kindness always emanated from my mom – but she began to slowly lose the extraordinary mental acuity that had been her hallmark. It was as though a deep fog was settling in, obscuring her memories, and forcing her to search for words that once flowed so effortlessly from her lips.

By the time my mother was in hospice care, our conversations had become quite broken in nature.  Sure there were fragments of cohesive thought, but they were punctuated by inconsistencies, confusion, and ultimately fatigue. My wife  and I knew that death would reach out someday soon, take her from us, and return her to the warm embrace of my father. Oh how I wanted her to have that eternal peace and love, but how hard it would be to say good-bye!

 

Mom had begun to refuse not merely food, but even water. She knew exactly what she was doing, despite the outward appearance of dementia.

When I arrived at her condominium one morning, I knew that something had changed. I could read it on the face of her caregiver.

As I walked through the foyer into the living room, I found my mother perfectly dressed and sitting up in a chair – something I had not seen in a very long time. But it was more than her clothes or posture that caught my attention. It was a glow, an energy in my mother’s expression and eyes that I had not seen in decades. It was as though she had shed the burden of forty years of life and regained the spirit of that sixteen year-old girl about to go off on a grand adventure. She radiated warmth and love.

In a crystal clear voice, she told me to sit close…that she had some things she wanted to share with me. She took my hand, and began:

There are things that I want you to  know and always remember. Most importantly, I want you to know how much your father and I love you.  You have been a wonderful son, and we are so proud of you.

Though you will not be able to see me, I will always be with you. I will always be looking down upon you. You will carry me with you in your heart wherever you go.

I’ve had a wonderful life. I had the most wonderful husband and children I could ever ask for, and I am eternally grateful.

Don’t mourn my passing, but, rather, celebrate the gift I was given during this lifetime.

I love you more than you could ever imagine.

With that my mother squeezed my hand, before slowly letting it go. She was tired now, and it was time for her to rest.

It was the last talk we would ever have on this earth — my mother was saying goodbye to me.

How could she know that, like a train waiting to leave the station, the departed hour was at hand?  How could she have rallied and overcome the infirmities that had crippled her thinking so as to convey such unconditional love?

The next day, when I went to visit my mother, she was unresponsive. She would pass away that night with me holding her hand, and my wife holding mine.  It was a serenely peaceful, but profoundly sad moment…though softened by the act of grace I had witnessed the previous day.

As I looked upon her lifeless body, I knew that her spirit, which had once animated her body so vividly, had departed. She had gone to be with my Dad.

 

A great gift is bestowed upon those of us fortunate enough to experience such parting words.  And though researchers have bestowed a scientific term upon this phenomenon – referring to it as terminal lucidity, I prefer to call it grace.

 

 

[I would welcome your feedback. Are you interested in the topic of “hope at the end of life?” If so, what would you hope to find in a book on this issue? What questions would you want addressed?]

 

INTERVIEWING YOUR PCP

shutterstock_162343382(The following post is an excerpt from The Myths of Modern Medicine: The Alarming Truth About American Health Care by John Leifer and available at Amazon.com)

 

Imagine navigating the Amazon without a guide. Though the health care system isn’t rife with venomous snakes and flesh-eating fish, there are a great many hazards that can make the experience tortuous, expensive, and even deadly. Your tour guide, the one who keeps you out of harm’s way, is your primary care physician (PCP). He or she has drawn the map for your journey, enlisted others to help you surmount obstacles, and carefully tracked your progress. When you need someone with specialized knowledge, your PCP should know the best resources to call upon for help. When an unexpected complication arises, he knows how to course-correct.

It’s doubtful that you will find the Indiana Jones of primary care. What you will find, with a dedicated search, is a highly competent and compassionate physician who is dedicated to your family’s health. You can improve your odds of finding the right PCP through a well-organized search process that includes some or all of the following elements:

Your search starts here:

  • Decide whether it is important for your physician to adhere to a certain demographic profile:
    • Does it matter whether your physician is male or female?
    • Do you want your physician to fall within a certain age range?
    • Do you have any feelings relative to the ethnicity of your physician?
  • As we’ve discussed, physicians undergo varying levels and types of education and training. It is important to identify what level of training and credentials are important to you:
    • Are you seeking a physician who has trained at a traditional medical school, or are you equally comfortable with someone who has undergone osteopathic training? There are subtle philosophical differences between the traditions that still exist today. You may find one more appealing than the other.
    • How important is it that your physician be American trained? An increasing number of primary care physicians are foreign medical graduates. Their training may be impeccable, but it is a factor worthy of your consideration.
    • Will you be more comfortable with a family practice physician (who integrates care for patients of both genders and every age, and advocates for the patient in a complex health care system[i]) or with an internal medicine physician (who provides long-term, comprehensive care, managing both common and complex illness of adolescents, adults, and the elderly[ii])? If you select a family practice physician, what range of services are you comfortable receiving from this physician before being referred to a specialist (e.g., would you allow your FP to perform a colonoscopy or would you expect to be referred to a gastroenterologist? What about delivering your baby?)
    • Do you value certain training institutions more than others, be it for medical school, osteopathic school, or residency? Would you, for instance, have higher confidence in an internist who trained at the Mayo Clinic?
    • Is your physician board-certified or board-eligible by either the American Academy of Family Practice (AAFP) or the American Board of Internal Medicine?
  • How will you determine whether your physician possesses the requisite experience, knowledge, and wisdom to manage your care optimally?
    • How many years has your physician been in practice?
    • How long has he or she been in their current practice?
    • What does your physician do to stay current on medical advancements? Can you discern whether they are a “life-long learner?”
    • Can you obtain informed opinions from other physicians about your PCP?
    • Have you been introduced to any of your PCP’s partners—particularly the primary physician providing coverage when your physician is off or unavailable?
    • What have you heard from friends and family about this physician? They may have limited ability to discern his or her clinical skills, but they may provide wonderful insight into the physician’s bedside manner.
  • Your physician’s sphere of influence:
    • Are you comfortable with the hospital(s) with which your PCP is aligned? Since chances are you won’t see him or her if hospitalized (hospitalists increasingly act as the primary care provider within the confines of the hospital), you should give this issue serious consideration.
    • Is your physician independent or employed by the hospital? If they are employed, all the more reason to be comfortable with that facility or system, since it may pressure your physician to use the resources of that system.
    • Your PCP may have a relatively tight-knit group of referral sources who are also tied to one or more hospitals. Are you familiar with some of the key specialists upon whom your PCP relies, and are you comfortable with these groups based upon your limited knowledge about them?
  • Is the physician’s philosophy of care congruent with your beliefs and values?
    • Under what circumstances would your physician consider it essential to see you the same day?
    • Does the physician welcome you as a collaborator in your care or does he or she prefer that you defer to their judgment?
    • Is the physician relaxed and thorough when addressing your questions or concerns?
    • How does the physician manage your fear or anxiety? Is it with compassion or is he or she dismissive?
    • How will your physician actively coordinate your care when multiple specialists may be involved?
    • Does your physician have a particular bias toward medications in general or specific categories of drugs?
    • How much importance does your physician place on wellness and prevention versus intervention? How do they demonstrate their commitment to wellness?
    • How much importance does your physician place on well-being or emotional health? How do they demonstrate their commitment to this element of our lives?
    • Does your physician practice within a medical home?
    • Does your physician’s staff include advance practice nurses and nurse educators who can play an important role in your health?
    • What is your physician’s perspective on end-of-life care?
  • How confident are you that your physician will recommend treatment regimens based on the latest medical science?
    • Does he practice evidence-based medicine?
    • Does he utilize an electronic medical record?
    • Are there standard protocols of care integrated into the record that your doctor relies upon?
  • Can you discern any other important information about your physician from trustworthy third-party data sources?

You can glean some of this information by scheduling an appointment to meet your potential new PCP and conduct an “interview.”

With perseverance complemented with a little luck, you will end up with the guide you need. Remember, though, even the best of guides are human. Your job is not to place blind trust in any single individual within the health care system, but to use your discernment to know when to be deferential and when to seek more information. A good primary care physician will not be offended or threatened by your questions, but rather respect your stewardship of your own health.

If you are worried about asking your doctors tough questions, get over it. As Charles Inlander advises, “The bottom line is that you have to walk in with an arsenal of questions to be able to pick a primary care doctor or specialist.”[iii] When we began, I indicated that selecting the right PCP is a formidable task. If you’ve done the homework, you are in agreement that the effort is well worth the time.

Otis Brawley, MD, offered similar advice when I asked him how a consumer could find the “right” physician—be it a PCP or specialist: “I think that people should interview doctors. If someone has a chronic disease, this may be the most important interview of their life. Think of it as a hiring decision.”[iv]



[i] American Academy of Family Physicians, last modified 2013, http://www.aafp.org/home.html.

[ii] Intermountain Health Care, last modified 2013, http://intermountainhealthcare.org/providers/specialties.html.

[iii] Ibid.

[iv] Otis Brawley, MD (Chief Medical and Scientific Officer, American Cancer Society) in discussion with the author, August 16, 2013.

Taking Responsibility for Our Health

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Many of you have written to me stressing the importance of maximizing one’s health by engaging in appropriate lifestyle behaviors. I agree that this is a vitally important theme, and thus offer the following excerpt from The Myths of Modern Medicine for your consideration:

“I’m Just the Patient; I’m Not Part of the Problem”

Sarah Matthews had always struggled with her weight. Her life was a series of disappointing attempts to control her insatiable appetite. It came at a hefty price—to her self-esteem, her relationships, and ultimately to her health.

Though her physician had long counseled her to lose weight and begin to exercise, Sarah continued her habit of consuming more than four thousand calories a day. Her weight at age forty-two had swelled to more than 280 pounds, and her joints were showing the wear of carrying such a big burden.

But it was more than Sarah’s joints that were beginning to fail. Her annual physical revealed that she was perilously close to becoming a full-blown diabetic. Her blood pressure hovered at 160/100, which is very high, and the slightest exertion made her short of breath. At this pace, Sarah’s life would be dramatically shortened. As a diabetic, she would run the risk of blindness, loss of limbs, and eventually death. If her blood pressure remained high, coronary-artery disease would naturally follow—potentially precipitating a stroke or heart attack. Furthermore, recently published research suggested that the earlier one becomes obese, the greater the probability of developing atherosclerosis.

This time, her physician was unflinching in his strongly worded advice: “Lose the weight now. There are no more tomorrows.” Sarah broke down in tears. It was not a lack of desire to lose weight; she simply didn’t know how to win the battle against her lifelong demon. Fortunately, her physician had a dedicated nurse educator, who not only started Sarah on the path to recovery but enlisted the help of a counselor, a nutritionist, and an exercise coach.

Frightened by the prospect of a grim future, Sarah became compliant. Though it took more than a year, she successfully shed just shy of one hundred pounds through daily diet and exercise. Her lab values responded in tandem with her changes in lifestyle. After eighteen long, difficult months, Sarah was able to stop taking her medications. What appeared to be the beginning of a lifelong path of advancing chronic illness had been stopped in its tracks.

Taking Personal Responsibility for Our Behavior

The message emblazoned in every chapter of this book has been that our health-care system has gross deficiencies that can seriously affect your care. Numerous strategies have been outlined about how to increase the probability of receiving the “right” care for you and your family. Yet the best strategy of all is to simply not need care in the first place.

That means taking exquisitely good care of ourselves—a lesson that Sarah is learning late in life. Sarah was not merely the patient. She was also the problem. It was her eating behavior—not some random disease or virus—that was causing her to develop debilitating, chronic conditions. Had she maintained her current trajectory, these conditions could have robbed her of joy, health, and ultimately her life. In the process, Sarah would have required an increasing onslaught of medications and other interventions, all of which would have brought their own associated risks and contributed to feeding the national health-care bill.

Granted, not all of us seem to suffer the ill effects of an unhealthy lifestyle. Some people get away with murder when it comes to their bodies. My mother was such a person. Finding the best restaurants and bakeries was a lifelong passion for her, though she somehow stayed slim. Her idea of strenuous exercise was a full day of shopping. Her habits finally caught up with her at the age of sixty-five, though, when her severely blocked arteries necessitated quadruple-bypass surgery. Having her chest brutally cracked open slowed her down for a short time, but before long she was back to her diet of candy, cookies, fried chicken, and steaks.

My mother’s diet contributed to her development of cardiovascular disease (including a heart attack), transient-ischemic events (TIAs—or “mini-strokes”), and insulin-dependent diabetes. Despite her multiple comorbidities, she lived another twenty-two years and seemed to enjoy almost every minute.

There are always exceptions, but poor lifestyle choices eventually catch up with most of us, taking a major toll on our health and well-being. Whether it is smoking, overindulging in food or alcohol, or foolishly taking chances with drugs, promiscuous sexual behavior, or the need for speed when behind the wheel of an automobile, our choices often determine our fates.

Proof can be found in the data collected by the Centers for Disease Control, who keep close tabs on our nation’s health. The CDC’s website contains some startling illustrations of the impact of lifestyle choices on the health of the population:

  • Seven out of ten deaths among Americans each year are from chronic diseases. Heart disease, cancer, and stroke account for more than 50 percent of all deaths each year.
  • In 2005, 133 million Americans—almost one out of every two adults—had at least one chronic illness.
  • Obesity has become a major health concern. One in every three adults is obese, and almost one in five youths between the ages of six and nineteen is obese.
  • Diabetes continues to be the leading cause of kidney failure, nontraumatic lower-extremity amputations, and blindness among adults age twenty to seventy-four.
  • Excessive alcohol consumption is the third leading preventable cause of death in the United States behind diet, physical activity, and tobacco.[i]

The bottom line is that we are a chronically ill nation and our illnesses are not merely debilitating but also costly—resulting in hundreds of billions of dollars spent unnecessarily on health-care expenditures every year. And the situation is deteriorating!

It doesn’t have to be this way. We have the power to change our nation’s prognosis. Many of the chronic diseases we experience are either preventable or can be delayed until the latter stages of our life. This simple yet profound message was preached for more than thirty years by Dr. James Fries. The question is, Do we have the will to change?

Compression of Morbidity: A Fancy Term for a Simple Goal

The July 17, 1980, issue of the New England Journal of Medicine featured a landmark article by Jim Fries, MD, professor of medicine at Stanford University. The article became one of the most frequently cited scientific references in the emerging field of wellness. Fries focused on the impact of chronic disease, which he described as “responsible for more than 80 percent of all deaths and for an even higher fraction of cases of total disability. Arteriosclerosis (including coronary-artery disease and stroke), arthritis, adult-onset diabetes, chronic obstructive-pulmonary disease (including emphysema), cancer, and cirrhosis represent the overwhelming majority of our health problems. They are widespread conditions that originate in early life and develop insidiously; the probability of their occurrence increases with age.”[ii]

Fries’s contribution did not lie in describing the inescapable spiral of chronic disease into disability and death. Rather, it was his challenging theory of the “compression of morbidity” that suggested the progression of disease and infirmity could be forestalled. “Disability and lowered quality of life due to the most prevalent chronic diseases are thus inescapably linked with eventual mortality,” he wrote. “These chronic diseases are approached most effectively with a strategy of ‘postponement’ rather than cure. If the rate of progression is decreased, then the date of passage through the clinical threshold is postponed; if sufficiently postponed, the symptomatic threshold may not be crossed during a lifetime, and the disease is ‘prevented.’”[iii]

Fries is stating that, while we cannot escape the human condition, by taking care of ourselves we can stay vital, active, and healthy until the very twilight of our lives. In Fries’s mind, that would be living the good life. He even went so far as to point to behavior changes that would compress morbidity, saying that “some chronic illnesses definitely can be postponed; elimination of cigarette smoking greatly delays the date of onset of symptoms of emphysema and reduces the probability of lung cancer. Treatment of hypertension retards development of certain complications in the arteries. In other illnesses, circumstantial evidence of similar effects of postponement is strong, but proof is difficult: that arteriosclerosis is retarded by weight reduction or exercise is suggested by associative data but has not yet been proven.”[iv]

I was fortunate enough to meet Jim Fries when he was part of a panel assembled by my mentor, Martin Seligman, at the University of Pennsylvania. Seligman, who was working under a Robert Wood Johnson Foundation grant, had assembled some of the brightest minds in preventative medicine to define the emerging field of positive health, including Dr. Fries. Fries obviously lives by the tenets he preaches, for he appeared to be in great physical condition.

In the intervening three-plus decades since Fries published this article, our knowledge on wellness and prevention has expanded greatly. Thousands of researchers have built on Fries’s foundational research, and the accumulated knowledge provides us with powerful but disheartening information on the degree to which our population is managing their lifestyle behaviors to affect wellness:

  • More than one-third of all adults do not meet recommendations for aerobic physical activity based on the 2008 Physical Activity Guidelines for Americans, and 23 percent report no leisure-time physical activity at all in the preceding month.
  • More than forty-three million American adults smoke. Lung cancer is the leading cause of cancer death, and cigarette smoking causes almost all cases.
  • Excessive alcohol consumption contributes to over fifty-four different diseases and injuries.[v]

If you are wondering how that compares to other people in other nations, “in terms of individual behaviors, Americans are less likely to smoke and may drink less heavily than their counterparts in peer countries, but they consume the most calories per capita, abuse more prescription and illicit drugs, are less likely to fasten seatbelts, have more traffic accidents involving alcohol, and own more firearms than their peers in other countries.”[vi] As we saw in the opening chapter of this book, our nation pays dearly for its behavior as evidenced by our poor population health status relative to every other industrialized nations.

Regardless of one’s nationality, the trick is not in knowing merely what to modify but how to modify our behaviors so that we live longer, happier, healthier lives.

 

If you would like to learn more, please consider reading: The Myths of Modern Medicine: The Alarming Truth About American Health Care, John Leifer, 2014 (Rowman & Littlefield).

 

 

[i] Centers for Disease Control and Prevention, “Chronic Diseases and Health Promotion,” last modified August 13, 2012,http://www.cdc.gov/chronicdisease/overview/index.htm.

 

[ii] James F. Fries, “Aging, Natural Death, and the Compression of Morbidity,” New England Journal of Medicine 303 (July 7,1980):doi:10.1056/NEJM198007173030304.

 

[iii] Ibid., 248.

 

[iv] Ibid.

 

[v] Centers for Disease Control and Prevention, “Chronic Diseases and Health Promotion.”

 

[vi] Institute of Medicine of the National Academies, U.S. Health in International Perspective: Shorter Lives, Poorer Health (Washington, D.C.: National Academies Press, 2012),

 

What’s The Matter with Health Care? It All Comes Down to Money

 

Prepared to be shocked!

Prepared to be shocked!

The World’s Most Expensive Care

I remember when a bottle of soda pop cost a dime. It came in an icy cold glass bottle with a cork-lined cap. Over time, the bottle and cap gave way to a can, and the price rose to a quarter, then half a dollar, and even a buck. But what if that soda had risen to twenty dollars? Would there have been a public outcry? At what point do we decide that the rate of cost escalation for an item or an industry is absolutely out of control?

There’s a fitting irony to the fact that health care costs were first “officially” analyzed and recorded in 1929, [i] when the economy tumbled and the stock market crashed. Over the next two decades, prices remained relatively stable and consumed approximately four percent of the nation’s gross domestic product (GDP).[ii] Then all hell began to break lose. In 1950, health care costs were a “meager” $12.7 billion.[iii] Three generations later, in 2012, those costs had risen to $2.6 trillion. That’s more than a two-hundred fold increase in the nation’s health care bill! Based upon that same 20,000% increase in price, our proverbial bottle of Coca-Cola would now cost twenty bucks!

Today, health care purchases consume more and more of every dollar we spend. The nation’s health care bill has risen from 4.4% of GDP in 1950 to nearly 18% in 2012. If you are wondering how that compares to the spending levels of other industrialized nations, the next highest OECD country, the Netherlands, spent 12% of its GDP on health care.[iv]

Before you conclude that our spending levels are merely a reflection of the size of our population, take a look at average per capita spending. In the US in 2012, we spent $8,233 for each citizen. That’s approximately $5,000 more per capita than the average expenditures among all thirty OECD nations.[v]

The lowest spending OECD nations (New Zealand and Japan) consume approximately $3,000 per capita in health care services. Japan achieves this remarkably low level of spending despite the fact that it actually uses a tremendous amount of health care resources per capita. It simply manages costs far better than the US.[vi]

Americans are awakening to the fact that we have a system whose costs are out of control, and journalists are sounding the warning claxon. In an article published in the Atlantic in 2013, entitled “Why is American Health Care so Ridiculously Expensive,” author Derek Thompson opined: “The U.S. medical system is absurdly expensive. You know that already. But you probably didn’t realize just how absurdly expensive it is compared to other countries.”[vii]

While consumers’ overall confidence in US health care may be unfaltering, their growing awareness of its escalating costs is growing, as was revealed by a series of focus groups funded by the Robert Wood Johnson Foundation. The research, conducted in four major American cities, explored consumer sensitivity to health care costs.

The unambiguous conclusion drawn by the researchers was that “Universally, participants were aware of the effects the rising cost of care had on their pocketbooks and the accelerating speed at which costs have rising in recent years. That said, they didn’t know why costs are going up or how to decipher them.”[viii] Perhaps most alarming, based upon the respondents’ feedback, researchers further concluded, “Across the board, there was a sense that participants were nearing the breaking point.”[ix]

Even a cursory review of articles written about health care costs over the past forty years suggests that we’ve been at or near “the breaking point” for decades.[x] The term conjures powerful images of a runaway train, but will the train ever truly derail? More importantly, why is our nation’s health care bill so high, and what can we do about it?

Where Our Money Goes

Our astronomically high national tab for health care is driven by many factors, not the least of which is the high price we pay for health care products and services. Let’s begin by breaking down the bill.

For every health care dollar we spend, approximately 31% goes to hospital care. Twenty percent is spent on the professional services rendered by physicians and clinics, and 10% buys drugs. The remaining 30% is spread across a number of categories.[xi]

If we dig even deeper, it’s amazing what we uncover. Take hospital charges, for example. When compared to other developed nations, our hospital costs are almost 2.7 times greater ($19,319 versus OECD median costs of $7,180 per discharged patient). That helps explain why the US had 54% as many hospital discharges as Germany, and yet our health care tab was still 190% greater per capita than Germany’s.[xii]

We also hit pay dirt when we dig into the issue of pharmaceutical costs. US pharmaceutical spending per capita was nearly $1,000 in 2010—two times the OECD median.[xiii] That’s not terribly surprising in light of the fact that we pay more for the top 30 pharmaceuticals—nearly three times as much as New Zealanders and twice as much as people in the U.K.[xiv]

The sad fact is that the difference between US drug prices and the price for exactly the same drug in other countries can be staggering. In the US, the average cost of Lipitor, a commonly prescribed drug to treat high cholesterol, was approximately $100 in 2012. It was $6 in New Zealand.[xv]You don’t have to travel halfway around the world to experience this phenomenon. Anyone who has traveled across the border to Mexico has seen many of our prescription drugs sold over the counter for pennies on the proverbial dollar.

In essence, Americans are subsidizing lower drug prices in every other corner of the world, allowing pharmaceutical manufacturers to nonetheless maintain their historically high levels of profitability by charging us more.

Patients in Glass Houses Shouldn’t Cast Stones

The data proves irrefutably that most industrialized countries have healthier populations based upon numerous metrics, and they accomplish this feat while spending a mere fraction of the US health care bill.

There’s no greater illustration of this phenomenon than Japan, one of the most prolific consumers of health care services on the planet. Its population visits physicians with more than three times the frequency of Americans, yet Japan’s total health care bill, on a per capita basis, was only 37% of the US per capita spend.[xvi] As a country long enamored with technology, it is not surprising to learn that Japan has nearly five times as many MRI units as the average OECD country, yet the cost per scan, and thus overall contribution to the nation’s health care bill, is quite low.

Japan does a great job of controlling its costs—and often does so in innovative rather than Draconian ways. One example is its purchase of MRI units. Because this imaging modality is heavily utilized by its physicians, Japan’s health care providers need to be able to deliver MRI services cost-effectively. They accomplished this goal by working hand-in-hand with major Japanese technology firms, such as Toshiba, to develop far less expensive MRI units than those deployed in the US. Though somewhat less sophisticated, these units nonetheless provide clinically satisfactory images for physicians.[xvii]

Americans love to loath the British health care system. Yet, a side-by-side comparison of costs for common surgical procedures shows the U.K. to be far more cost-efficient: The average cost for an appendectomy in the US is $13,851 versus $3,408 in the U.K. A normal delivery in the US is $9,775 versus $2,641 in the UK.; and a C‑section costs in excess of $10,000 more in the US than in the UK. Finally, the total cost for bypass surgery averaged $73,420 in the US In the UK, it cost $14,117. In France, it cost $22,844.[xviii] Every time we say derisive things about socialized medicine, the Brits are laughing all the way to the bank.

Technologically advanced procedures may show an even greater difference in price. Fifty years ago, a Swiss physician performed the first percutaneous coronary angioplasty (a minimally invasive procedure for opening up clogged arteries). Today, the average cost of that procedure in Switzerland is $5,295. In the US, the average cost is more than five times as much—$28,182.[xix]

If you are wondering who’s making all the money, the answer is everyone associated with health care delivery in the US. I’m only being somewhat facetious, as we shall see in the remaining chapters of this book. For now, let’s take a look at just physician fees.

Professional or Profiteer?

Medicine may be recognized as a noble profession across the globe, but nowhere is it more remunerative than in the US, where physicians enjoy phenomenally strong earnings when compared to their international brethren, which translates into higher fees for American patients. Average physician fees in the US for a routine office visit in 2012 were $95 versus $30 in Canada and France.[xx]

Surgical specialists in the US fare particularly well. Surgeons in the US receive fees almost three times greater than their counterparts in Canada for hip replacement surgery.[xxi] US orthopedic surgeons make more than twice as much as their Canadian counterparts (with cost of living adjustments factored in). Most notably, American obstetricians were paid more than five times as much to deliver babies as their foreign counterparts in Canada and France in 2012.[xxii]

Most Americans don’t mind paying more for a measurably better product or service. The question, again, is: Are we getting value for each of the 2.6 trillion dollars we spend annually? Not according to global health researchers Docteur and Berenson, who state, “In the light of the fact that the United States spends twice as much per person on health care as its peers, those who question the value for money obtained in US health expenditures are on a firm footing.”[xxiii]

They are far from alone in their belief. Another powerful voice in this choir belongs to Arnold Relman, Editor Emeritus of the New England Journal of Medicine. Relman wrote: “Considering that we spend so much more on medical care than any other advanced country, we ought to expect health outcomes to be at least as good, and our citizens ought to be at least as satisfied with the system. But we can claim neither.”[xxiv]

[Excerpted from The Myths of Modern Medicine: The Alarming Truth About American Health Care, by John Leifer. Publisher: Rowman & Littlefield, 2014]



[i]George D.Lundberg, Severed Trust (New York: Basic Books/Perseus, 2000).

[ii] Ibid., 19.

[iii] Ibid.

[iv]“OECD Health Data 2012: How Does the United States Compare,” Organisation for Economic Cooperation and Development, http://www.oecd.org/unitedstates/BriefingNoteUSA2012.pdf.

[v] Davis et al., Mirror, Mirror on the Wall.

[vi]DavidSquires, Multinational Comparisons of Health Systems Data, 2010 (The Commonwealth Fund, 2012), http://www.commonwealthfund.org/Publications/Chartbooks/2011/Jul/Multinational-Comparisons-of-Health-Systems-Data-2010.aspx.

[vii]DerekThompson, “Why Is American Health Care So Ridiculously Expensive?,” Atlantic,March27, 2013, http://www.theatlantic.com/business/archive/2013/03/why-is-american-health-care-so-ridiculously-expensive/274425/.

[viii]Robert Wood Johnson Foundation, Consumer Attitudes on Health Care Costs: Insights from Focus Groups in Four U.S. Cities (January 2013), http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/01/consumer-attitudes-on-health-care-costs–insights-from-focus-gro.html.

[ix] Ibid.

[x] Ibid.

[xi]AnneMartin et al., “Growth in US Health Spending Remained Slow in 2010; Health Share of Gross Domestic Product Was Unchanged from 2009,” Health Affairs31, no. 1 (January 2012): 1-13, doi:10.1377/hlthaff.2011.1135.

[xii] Squires, Multinational Comparisons.

[xiii] Ibid.

[xiv] Ibid.

[xv]International Federation of Health Plans: 2012 Comparative Price Report(International Federation of Health Plans, 2012), http://hushp.harvard.edu/sites/default/files/downloadable_files/IFHP%202012%20Comparative%20Price%20Report.pdf.

[xvi] Squires, Multinational Comparisons.

[xvii]T. R.Reid, The Healing of America (New York: Penguin, 2010).

[xviii]International Federation of Health Plans.

[xix] Ibid.

[xx] Ibid.

[xxi] Squires, Multinational Comparisons.

[xxii] Ibid.

[xxiii] Docteur and Berenson, How Does the Quality.

[xxiv]Arnold S.Relman, A Second Opinion (Cambridge, MA: Public Affairs/Perseus Books Group, 2007), 48.

“Honor Amongst Thieves” — A Perspective on the Access to Medicine Index

iStock_000004475255MediumEach year, the Access to Medicine Foundation publishes a hierarchical list of pharmaceutical companies ranked on their efforts to improve access to medicine in developing countries.”  See: http://www.accesstomedicineindex.org/ranking. Without wanting to diminish the good intention of this group, the index, from my cynical perspective, may denote little more than the level of “honor” amongst thieves.

Gilead — the Poster Child:

 While seemingly noble on the surface, one does not need to dig deeply to discover the degree to which these companies are vastly more concerned with quarterly returns to shareholders than altruistic actions that benefit global health. Take Gilead Science, for instance, and the company’s perceived, initial reluctance to discount Sovaldi – a breakthrough drug in the treatment of Hepatitis C. The undiscounted cost for a course of treatment is approximately $85,000. According to a June article in Forbes, “Sovaldi costs about $130 to manufacture, reinforcing how outrageous its pricing is.”

Yet, it was only after being cast as the poster-child for egregious profiteering that Gilead reassessed its stance on the cost and availability of Sovaldi. The organizations that spoke out about Gilead’s pricing were formidable, as evidenced by an article appearing in the April 11, 2014 edition of Bloomberg News stating: “The WHO yesterday called for ‘‘a concerted effort’’ by various stakeholders to lower the cost of the drug.”

Implicit in the WHO comments was a threat that generic versions could be produced independently of Gilead: “In addition to tiered pricing, voluntary and compulsory licensing, where generic-drug makers are given permission to produce more affordable versions of a medicine, can also help achieve affordability, the WHO said.”

Bowing to Pressure:

In response to increasing public pressure and the potential loss of control of their golden goose, Gilead slashed the costs of Sovaldi to selective countries, such as Egypt and India, where there are large populations of infected individuals that lack the resources to pay for the drug. Yet, they did little to address the drug’s unaffordability to the myriad of indigent patients in economically developed countries.

It’s worth noting that Gilead acquired the ability to manufacture Sovaldi through the purchase of Pharmasset at the cost of $11 billion. Amazingly, “Gilead is on pace to recoup the full cost of its $11 billion investment in just over one year. That is unprecedented,” according to the Forbes article.

Deanna Beasley, writing for Reuters, quoted Brendan Buck, a spokesperson for America’ Health Insurance Plans, as stating: “The blank check mindset we’ve seen from Gilead is a threat to our entire health care system, and we hope they will pursue more sustainable pricing in the future.” Gilead ranks fifth from the top (out of twenty) on the Access to Medicine list.

18/20 Companies Guility

It is unfair to single-out Gilead as the greedy one amongst pharmaceutical and biotech firms. As a recent New York Times article pointed out, “Eighteen of the 20 companies in the index have settled or been convicted of unethical marketing, unfair competition or bribery in the last two years.”

Again, I applaud the foundation’s efforts. Whether its list  is a noble attempt to improve transparency within the pharmaceutical industry and catalyst for greater altruism or simply lipstick on the pig, I will leave up to you…my reader.