\”Your system is perfectly designed to yield the outcome you are presently getting.\”  – Not sure who said it, but dang, were they smart.

A patient was recently recounting some of her bad experiences with her health care.  I shot back with some of my frustrations with this system that seems hell-bent on making me give worse care to my patients.  We both paused and shook our heads.

\”It\’s a mess,\” she said.

At first I agreed with this simple assessment.  The system that is not a system is disjointed, disorganized, dysfunctional, and frequently makes me dyspeptic.  It seems like a bunch of disparate groups each fighting for its own place at the front of the money line, with patients suffering for this chaotic thing we call a system.  But the cynical, conspiracy theory wielding part of me buried deep within my people-pleasing primary care mind suddenly grabbed control.

\”No, it\’s not a mess,\” I said, getting a surprised expression from my patient.  \”It\’s malignant.\”

Her surprise turned to curiosity, and she tilted her head, urging me to expound on this idea.

\”The problems we\’ve got are not problems that exist simply because of a lack of organization; there are people, institutions, and corporations that make lots and lots of money because of that chaos.  There are forces out there who want the system to stay just like it is.  There are lots of people who would lose their jobs, and companies that would go out of business if health care became efficient.  That seeming chaos,\” I concluded, \”is job security for an awful lot of people.  I don\’t think it\’s accidental that things are the way they are.\”

She nodded at me as I got up to close the visit.  Conversations like this can get me really far behind in my schedule, so I had to stop while there was still a chance.

\”Is there anything that can be done about that?\”  she asked as she walked into the hallway.

I shrugged.  \”I am sure there is, but I also think any effort at doing so will be met with very stiff resistance.  People may want the system to change, but it\’s too big of a cash-cow to go down easily – regardless of what the politicians say.\”


There is something about the word I used: malignant, that seems a perfect adjective for the American health care system.  A malignant tumor is a group of a person\’s cells that no longer acts in the interest of the whole body, putting its own growth as top priority.  The body possibly can handle a single malignant growth, like a single skin cancer, but when the cancer becomes widespread it is a threat to the survival of the body.  The tumor\’s desire for it\’s own growth eventually causes its own death, as it kills off the body it once was part of.

Our system has multiple metastases that feed off of the money meant to fund care for people\’s health.  These consuming entities will, if left untreated, kill the system entirely.  They don\’t want to kill off the system that feeds them, but they can\’t see beyond their own profits or political agendas.  Taken individually, they may not bring down the system; but as the overall burden of malignancy grows, the true purpose of the system – caring for patients\’ health – becomes increasingly difficult, if not impossible.

I know this sounds harsh, but the reality I\’ve seen growing before me over the past 18 years in the exam room is becoming increasingly dire.  People are dying from our system.  Others see this, but offer solutions aimed at the external symptoms instead of facing the cancer that will take all of us down eventually.

The cancer?  The hospitals, lawyers, politicians, drug companies, lobbyists, insurance companies, device manufacturers, and yes, the doctors who continue to plunder a system that is struggling to keep standing.  There are huge profits in ordering unnecessary tests, doing unnecessary procedures, admitting people who should stay home, making a payment system that is intentionally incomprehensible, and paying politicians to see only a small part of the story.

So what\’s the solution?  Do we expose the bad people who make money?  Do we get corporations to stop wanting to make a profit?  It\’s far more complicated than just pointing at greed and getting on a pious pulpit pretending that we would do differently.  If we\’ve left the meat out in our back yard, we can\’t blame hungry wolves for coming and eating it.  If our system keeps holding out fists full of cash, we are foolish to act surprised that there are people willing to take it.



Just as chemotherapy is the horrible price to pay for a cell gone rogue, the cure for our system may seem worse than the problems.  It will be a bitter political pill to swallow for anyone brave enough to take it.  The sad fact about health care reform is this: lots of people will lose their jobs, and lots of companies will go bankrupt.  There are far too many companies dependent on a system willing to waste money.  There are far too many jobs that exist because of a payment system that is mind-bogglingly complex.  There are far too few people in the position to start the cure who are willing to face the firestorm that will follow.

It\’s going to be hard, folks.  Hospitals will close, people will lose their homes, and the political voices will become increasingly shrill.  I truly doubt that we as a country will have the courage to stick out the long, hard therapy we need to survive.  Can we really become efficient and conscientious if those good qualities bring ruin on an entire industry built on inefficient and haphazard care?

If we don\’t, the malignancy will kill us – both figuratively and literally.

2 thoughts on “Malignant”

  1. Your lead quote comes from Dr. Paul Batalden and was popularized by Dr. Berwick.  It is one of my favorites. Here is an editorial comment about it:

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