Doctor sees the system's strengths

CHAPEL HILL -- Editor's note: This fall, The N&O is talking to people about the nation's health-care system: what works, what doesn't and what should be done to fix it.

As a surgeon and academic leader at the UNC-Chapel Hill School of Medicine, Dr. George Sheldon often sees the U.S. medical system at its best.

Patients have ready access to specialists. They are treated with sophisticated technologies. As a result, they are living longer than ever before.

"The best parts of our system are by far the best in the world," says Sheldon, chairman emeritus of the surgery department at UNC-CH. "Saying it's broken is overstating it."

And while Sheldon agrees that reforming the system is a good idea, he has become a powerful voice for a measured and tactical approach to a fix. He has testified before Congress as past president of the American College of Surgeons and is one of the authors of a health-care roadmap presented last week to Congress and President Barack Obama from a national coalition of doctors called The Physicians Foundation.

What he would like to see is reform that expands access to health care for more Americans without pinching the system's assets to patch its weakness.

And that, he says, may require more money, not less.

"When I started my training [in the 1960s], the responsibility for people without health insurance was at the county level," Sheldon says. "Things were Spartan. You had big wards -- 30-person wards. Now they're more like hotel rooms. This is what people want and what they deserve, but it's expensive."

Sheldon says it's unrealistic to ratchet back care to save costs, particularly without working definitions of what constitutes good, basic medical treatment.

Patients who have kidney failure, for instance, might assume that a transplant should be covered by insurance or a taxpayer-funded program. Others may argue that dialysis is sufficient and that coverage for transplants should be part of an optional, more expensive insurance plan.

Projecting the savings in such scenarios, Sheldon says, is difficult. Dialysis is a treatment, not a cure, so those patients could cost the system much more over the long haul than if they had a successful transplant.

Sheldon also worries that a singular focus on bolstering the number of general practice doctors may erode specialty care, which he says is one of the brightest spots of the current system.

Instead, he says, more needs to be done to increase the ranks of all doctors -- plus other front-line caregivers such as physician assistants and nurse practitioners. He advocates a shorter, streamlined medical education for doctors in training, and more government money for medical schools to train doctors who have the increasingly complex skills needed for today's sophisticated medicine.

"In the 1950s, advanced coronary care was blood thinner, strict bed rest and you watch for arrhythmia," he says, referring to the irregular heartbeat that can signal problems.

Now, he says, people are treated with any number of different drugs, depending on their problem. They can undergo a balloon catheter procedure to unclog blockages, get stents installed to prop open the artery and might even have bypass surgery.

"The mortality rate is half what it was in the 1950s for heart attack," Sheldon says. "But it costs more."

He says the economic impact of the health industry is huge and isn't fully appreciated.

"Health care is the only part of the industrial economy that hasn't lost jobs during the recession," he says. "You have to make a value judgment about how much we spend on health care and what we get for it."

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