“Silo medicine”. It’s an odd way to express it, “silo medicine”, but there have been articles written using just this phrase to express one of the most serious flaws in the health care system.
Picture an open field somewhere in the Midwest with a couple of dozen silos. “Cardiology”, “Rheumatology”, “General Surgery”, “Psychiatry”, and so forth, painted across each silo, maybe adding the logo of the hospital system, Northwestern, U. of C., Loyola. Each specialty gets its own Silo, some much larger than others. Each Silo is the Center for the hundreds of doctors in that specialty. Lined up outside waiting to get in, sometimes weeks or months, is “you” with your “mysterious symptom”.
Your appointment to the Silo had been based on a quick evaluation at an emergency room or urgent care visit owned by the same (not for profit!) company that owns the Silo. Maybe you’d been sent there by someone reasonably skilled at diagnosis, like your primary care doctor (PCP), likely on the payroll of the Silo company as well. It’s certainly possible your PCP didn’t think you needed a “silo-specialist” but felt pressure from you for the referral. In fact, admit it, this may be your second or third Silo company altogether. “I’ve been to Loyola, I’ve been to U. of C., now I’m going to try the biggest Silos of them all, Rochester, Minnesota and the Mayo Clinic!”
Once within the hallowed silo you’ll be whacked about like the silver ball in a pinball game. Each time you’re hit by the flipper and bang against a bumper, it lights up and you’ll find yourself attached to a machine that hums and whirs. You may get nervous but don’t worry, you’ll be glanced over by nurses, students, and maybe even an actual physician. They’ll know virtually nothing about you as a person or anything else about your health and well-being. Once your test is over, they’ll never know anything about you again. “Procedures”, whether for biopsies, repairs, scoping, are always encouraged by physicians. Since the system is seriously inefficient, days and weeks go by between flipper “hits” and bumper ‘”bumps”. “We need to follow up on that abnormality on your mammogram with an ultrasound, but we’re booked up eight weeks.” You ask for some Klonopin to sleep, but this is refused to prevent you from becoming a drug addict.
By the time you’ve exhausted all that Silo #1 has to offer, and you’re bordering on PTSD from the health care system, they admit they couldn’t find anything except one tiny abnormal blood test which needs a follow up by a doctor at Silo #2, and the whole process starts all over again. Although Silo #1 records are available, you notice that the Silo #2 doctor doesn’t even glance at them but does suggest a biopsy. Also, since your blood pressure is “a bit high” you need to see a “hypertension specialist” in Silo #7 who happens to be on maternity leave.
In her recent book, “The Invisible Kingdom: Reimagining Chronic Illness”, Meghan O’Rourke describes the helplessness of having a chronic illness and being shuttled from silo to silo with perpetually “negative” tests. She had an almost physical longing for someone to just tie everything together and be in charge of the pieces of her care.
This very same topic has been taken up by primary care doctors themselves. The most detailed paper, “The Problem of Fragmentation and the Need for Integrative Solutions”, by Kurt Stange, M.D., addresses cases exactly like Ms. O’Rourke’s, but adds comments about overutilization and duplication of services, incredible cost overruns, and poor health outcomes. The U.S. ranks 37th in quality in regard to health care, and this is not necessarily lack of access but rather too much of the wrong kind.
There are several takeaways from this somewhat cheerless Health Tip:
- With so many Silos, so many doctors, and so much equipment, errors are always possible. It is well known that medical errors are the third leading cause of death in the U.S.
- Side effects of prescription drugs are the fourth leading cause of death.
- The likelihood of the presence of the new symptom being caused by a disease is far less than the source of that new symptom being caused by an unhealthy lifestyle choice or simply something not functioning just right in your body. These are actually called functional symptoms, diagnosed by integrative physicians, chiropractors, and nurse practitioners, with the help of your input. I have written in detail about this here . Functional symptoms are quite real, are notorious for endlessly “negative tests”, and almost always respond to lifestyle changes.
You might ask, “Why does this inefficient fragmentation of health care continue? Why do the silos keep getting larger and larger?”.
This is fairly easy to answer. Reimbursement in the U.S. healthcare system is based on procedures, all sorts of stuff done to your body. The lowest payment is given to practitioners who simply sit down and talk to you, review your records, go over your life. There are about 900 physicians on the payroll at both Northwestern and University of Chicago, the highest earners being the ones who do the most procedures. To meet their needs, the hospitals fill their silos with the finest equipment their donors can buy.
…And wait for you to show up.
David Edelberg, MD