Wednesday, September 21, 2011

Americans, death, and the health care system

This short commentary touches on one of the major problems that we have in the health care system: unrealistic expectations. Really, having great expectations is something that is almost quintessentially American. We generally aren't good at waiting for things or taking "no" for an answer. Health care is no different.

I sometimes get the impression that patients think we (physicians) can do just about anything for them, reverse any condition, and make them feel like brand new. In clinic, if you tell a patient that their condition may not improve, or that there isn't much we can do to help them, they almost always look at you like you're crazy. People tend to have very unrealistic expectations as to what we are capable of.

This especially becomes obvious at the end of life. As patients get closer and closer to death, some people still refuse to believe that we can't completely reverse everything. Even if you tell them as much, its almost as if they don't understand what they are being told. Their baseline perception of the world can be very mixed-up too. To some people, withdrawing care, IE letting the natural course of things proceed, is tantamount to killing the patient. Ceaseless medical intervention for some people is the natural course of things.

Its really very bizarre to me sometimes. Especially compared to other industrialized nations, America is a very religious place. Many if not most Americans profess strong belief in God. And yet, the inability of many people to accept death as a natural course of things, as a legitimate outcome, is just something I still never ceased to be amazed by. South Park made fun of the Terry Schiavo case years ago, but they also were on point in their underlying message. In that case, the Republicans were screaming that we were playing God by removing the feeding tube. Well, no - actually, we were playing God when we put the feeding tube in.

End of life care is enormously expensive. Arranging panels to help patients decide what their end-of-life objectives were was one of Obamacare's greatest pushes. It had the potential to save money AND to improve patient's quality of life (I don't consider prolongued and pointless hospital stays to be improvements in quality of life). Unfortunately, the idea was demagogued to death by members of the opposition political party. Very frustrating, but its something we need to start thinking about as a nation.

Wednesday, September 07, 2011

Herein lies the problem [with our health care system]

A forthcoming study shows that stents put into narrowed arteries in the brain actually increase the risk of stroke.  They are also enormously expensive.  Now that they are proven to not work, we will save money and make patients healthier by not implanting them in the first place.  Check out this quote from the NYT article about the study:
"Quite frankly, the results were a surprise," said Dr. Joseph Broderick, chairman of the department of neurology at the University of Cincinnati College of Medicine.  Without the study, he said, there was no doubt that the stents would have become even more widely used and that the willingness to conduct such a clinical trial would have waned. "Once things get into practice, the genie is out of the bottle, and it is very hard to put it back," Dr. Broderick said.

Herein lies a major problem with our health care system:  Its hard to put the genie back in the bottle.  It shouldn't be!  I have no doubt that there are tons of things that physicians do to patients, expensive things that have never been rigorously studied, that actually hurt patients more than help.  Very few physicians have the courage (or the funding) to look for them.

To be fair, docs aren't the only cause of this problem.  I am not sure we are completely protected (legally) if we want to carry out some of these studies.  Also in America we have a very demanding culture of consumption.  People always want their doctors to "do something!"  to fix their ailments.  A classic example are patients with viral infections who insist on antibiotics.  The physicians finally just get sick of hearing about it, stop fighting, and write the script.  And now we have antibiotic resistance.

If we can't even talk patients out of antibiotics for a cold, are we going to be able convince them to forego a surgery or some other major treatment that has been standard of care for decades for the sake of proving that it actually helps?