Miller philosophical, blunt, calls for systemic change
(05/10/2008)
While AATS President D. Craig Miller left off the signature Stetson for Monday’s Presidential Address, he didn’t forget the bullets. In his presentation “Anti-Memoirs of Rocinante,” Dr. Miller focused his sights, and a good helping of free-market philosophy, on the current ills infecting the health care system in the US, advocating a single-payer system, an overhaul of the current educational system for cardiothoracic surgeons and a move towards regionalization.
“Why is medicine no longer a noble profession?” he said to a capacity crowd. “If you don’t like what I have to say, you are welcome to leave, but … we must do this for our patients.” A self-described individualist with rightwing roots, Dr. Miller said a single-payer system, similar to that used in Great Britain, will force doctors to improve the quality of care they are providing their patients.“I started off as a far right-wing Goldwater supporter and I may leave this world a socialist,” he said. “It is the god damnedest thing I’ve ever seen. This is hard, …we don’t want regulations, but perhaps we need them.”
Dr. Miller said that the title of his speech paid homage to two influences — French writer André Malraux and Spanish author Miguel de Cervantes. He explained that the “Anti-Memoirs” portion was taken from the self-deprecating title of the French existentialist’s autobiography.
“I like to laugh at myself with some regularity,” Dr. Miller said. “Those that don’t are taking themselves too seriously. You should try it, it is a very therapeutic exercise.”
“Rocinante,” Dr. Miller said, is the name of Don Quixote’s horse.
“Cervantes played with the irony of how we look at ourselves and the world around us,” he said.
Dr. Miller said he first discovered Malraux when reading Man’s Fate, “a novel that outlined the essence of 20th century existentialism.”
“Existentialism posits that individuals create the meaning and essence of their own lives, as opposed to deities or authorities creating it for them,” he said. “Every person should choose his or her own meaning, free from any external forces.”
The inverted incentives that doom the current system to failure are a good example of external forces that need be eradicated, Dr. Miller said.
“They (incentives) are perverse and they are certainly not sustainable,” he said. “If we adopted best practices throughout the country, one-third of the health care practitioners in the country would be fired and would have to be retrained.”
Dr. Miller said that Roemer’s Law of Demand — supply may induce its own demand where a third-party practically guarantees reimbursement of usage — is playing out in the US, with physicians spending billions of dollars on unnecessary tools and procedures that do nothing to improve the lives of their patients post-op.
“Why is it so expensive to die in certain US regions?” he said. “Look at the cost difference between the Mayo and Cleveland Clinics and Cedars–Sinai in Los Angeles. There is a two-fold cost difference and you still end up dead anyway.”
And while those in favor of aggressive care say it is saving lives and worth it, Dr. Miller said he disagrees.
“I may save a life for two months, but it costs a lot of money and the end result is no better,” he said. “And more importantly, who knows what the operation does to the quality of life?
“How many of these patients will return home to their own zip code? That is not the way I want to spend the last few years of my life.”
Dr. Miller said one of the few bright spots in the battle to save medicine is the Joint Council on Thoracic Surgery Education (JCTSE), created by the leaders of the American Association for Thoracic Surgery (AATS), American Board of Thoracic Surgery (ABTS), Society of Thoracic Surgeons (STS), and Thoracic Surgery Foundation for Research and Education (TSFRE) to change the current training paradigm and to coordinate all thoracic surgery education in the United States.
“In order to live we need to dream big and dare to fail,” he said. “Surgeons tend to forget they are not masters but servants of the patient, and patients must come first,” he said.
(Source: AATS 88th Annual Meeting Daily News)
AATS President D. Craig Miller, MD, delivers his Presidential Address