By: Les Ruthven, Ph.D. clinical psychology/health consultant
Email: dr.les.ruthven@gmail.com
Blog: www.ruthvenassessments.com
In my recent book on healthcare, “Much of U.S. Healthcare is Broken—How to Fix it?, perhaps my number one criticism of current healthcare is (1) we have a disease conception of health problems when the vast majority of health problems are caused by non-organic factors and (2) the 10 minute physician office visit is the result of number 1. The diseasing of healthcare promotes a strong bias for physicians to look for bio physical treatments such as drugs while the vast majority of health problems (see below) according to sound health research arise from non-organic problems including our self-injurious health behaviors. The above shapes the 10 minute office visit and typically ends with the doctor’s prescription for one or more pharmaceuticals, many of which do not address any of the patient’s important non-organic factors operating in their impaired health. I assure the reader that I am not anti-medication; I applaud drugs that cure diseases, drugs that remit serious health problems or substantially reduce distressing symptoms. However, I am opposed to medications that have no or a little more than placebo value (perhaps the majority of those prescribed), drugs that do not treat the health problem directly but many times impair the brain to distract one from the adverse symptom (e.g., antidepressants), or a medication that “treats” by partly making the patient feel better (e.g., opioids).
The pluses and minuses of physician training
Physician training at the undergraduate and graduate or MD level are basically in the physical and biological sciences which I feel is as it should be even though I have said it leads to the 10 minute office visit. Consistent with the 10 minute office visit how can we insure that bio physical diseases in a health plan are treated by those best trained to treat then, i.e., physicians, and for the critical non-organic health problems how can we insure that these health problems are treated by those best trained to treat them and not general physicians? Since there is not one non-physician health profession which has all the expertise needed to competently treat all the critical non-organic health problems these referrals should be referred to a carve out rather than the patient’s primary care physician. Some readers might say at this point “What about diseases and chronic health problems with significant non-organic factors (e.g. a Type 2 diabetic who is overweight and depressed?). Shouldn’t these cases be treated both by a physician and in the example just cited a psychologist? In the health plan envisioned there would be an automatic referral to the carve out for patients with high blood pressure, heart disease, cancer, asthma, chronic pain, and cognitive impairment among others to be sure that critical non-organic factors in the patient’s health problems are properly diagnosed and treated by those best trained.
The following health problems should be diagnosed and treated by a psychologist and not the patient’s primary care physician.
- Sleep problems: Psychologists are the best trained professional rather than physicians to treat these disorders and also without the side effects of drugs. According to research a sleep-hygiene approach, which requires changes in sleep behaviors, is often very effective even if the sleep impaired person has a diagnosable depressive disorder. A psychologist rather than a general physician is better trained to diagnose depression and to treat the associated depression rather than the patient’s physician.
- Overweight/Obesity: Despite 75 years or more of treating this critical health problem, which is involved in several diseases, physicians continue to treat over eating with drugs while overweight/obesity is reaching 40% of all Americans. The latest self-injected medication for weight loss requires life time treatment at a cost of $15,000.00 a year for about a 20% weight reduction. One study found that if the patient stops the injections two-thirds of the patients regain their lost weight! I know we have been told that obesity, as well as several other health problems, is a “disease” but many overweight/obese people including the writer gained normal weight without professional help. Overweight/obesity was unheard of in the human race until the beginning of the age of affluence and limited activity. Manipulating brain chemistry has not worked and it’s time to try something else, perhaps to treat the health problem as a self-injurious behavior and to turn it over to psychologists to treat the eating behavior and often the associated psychosocial contributing causes of the behavior.
- ADD and ADHD: Except for the mental disorders I can think of no other area of healthcare which is so badly diagnosed and treated because medical professionals as a group are ill-trained to treat this important health problem. I happen to believe that a correctly diagnosed case of ADD should be on an appropriate dose of Ritalin daily but in my experience in diagnosing and treating ADD, the disorder is often underdiagnosed and many persons given the label ADHD are misdiagnosed. These disorders are diagnosed exclusively on the patient’s behavior and a medically trained professional is ill equipped in making a diagnosis by counting the patient’s symptoms in the current DSM! The psychologist and not the Pediatrician or other medical professional should make the diagnosis and recommend appropriate treatment.
- Preventable diseases and certain health problems with critical non-organic and psychosocial factors: All of the diseases, the largely preventable diseases such as Type 2 diabetes, heart disease and many health problems such as hypertension should be treated by physicians and other medical professionals because the bio physical causes of the disease require important bio physical solutions by those who are best trained to treat to treat these disorders with important bio physical causes. When receiving such a diagnosis these patients, in addition to the label, also have major anxiety and non-organic or psychosocial difficulties associated with the diagnosis and these should be treated by psychologists, for example, and not the medically trained. Some readers will say at this point something like “Don’t psychiatric drugs effectively treat anxiety and other psychosocial factors? I know that’s the propaganda from psychiatry and Big Pharma but no proof is offered and sound health research finds no support for such a view.
What would it take to change in a major way the current healthcare system which is basically created by and delivered by the medical profession and which is extremely shaped by and reflects the physician’s training at the undergraduate, medical school, and internship in the bio physical sciences.
The only current health entity open to implementing any of the above recommended changes would be the employer sponsored self-insured employee health plans but these parties will need to be educated in ways that are necessary to improve the quality and cost of care. We have a healthcare system that is largely based on physician clinical opinion and physician-patient satisfaction rather than the available research which I have been seriously reviewing for the past 22 years. I use the term sound research because in reviewing it I find more than half of the published research is unsound (see “Much of US Healthcare is broken: How to Fix it” by this author, 217 pages, 155 references, 2023). For 3000 years healthcare was largely based on clinical opinion and it was replete with unproven treatments such as bloodletting to cure dozens of health problem including the black plague. I have noticed that many physicians are attacking randomized therapy-placebo controlled FDA clinical trials because many trials find the drug has little more than mild clinical value. In order to improve the quality and cost of healthcare we have to base clinical practice on proven efficacy and turn away from physician clinical opinion and anecdotal “proof”. Those patients referred to the carve outs would have their care managed by non-physician health professionals with referral to physicians when needed. In this revised health plan general physicians would have no responsibility for the diagnosis of patients with suspected cognitive impairment (Ci) or the diagnosis and treatment of the mental disorders or the other non-organic health problems noted above.
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