Friday, December 28, 2012

What's Going On with Medicine in America?

Some claim that the United States has the best health care in the world, but do we? When compared to others countries, we fall short in many areas. What we do have is the most expensive health care in the world. In 2010 we spent over $8000 per person. That is 2.5 times more than other developed countries.

The Institute of Medicine says that 30% of health care spending is wasted on unnecessary procedures, excessive administration costs, and fraud or other problems.

Whistle-Blowing Doctors

When I decided to look into this, I discovered quite a few books written by "whistle-blowing" doctors. I was quite surprised by what I learned. Just the titles are enough to cause alarm:
  • How We Do Harm: a Doctor Breaks Ranks about Being sick in America, by Otis Webb Brawley, M.D., Chief Medical and Scientific Officer of the American Cancer Society, 2011
  • Overdiagnosed: Making People Sick in the Pursuit of Health, by H. Gilbert Welch, L. Schwartz, and S. Woloshin, 2012
  • Overtreated: Why too much Medicine is Making Us Sicker and Poorer, by Shannon Brownlee, 2007
  • Seeking Sickness: Medical Screening and the Misguided Hunt for Disease, by H. Gilbert Welch and Alan Cassels, 2012

What these books tell us, in a nutshell, is that some doctors base their treatment recommendations on the payments they will receive. Some hospitals and pharmacies actually seek out patients to test and treat, even when they are not actually ill, if they have good insurance that will pay.

One thing that's happening is that they are widening the definition of certain illnesses to expand the market for treatment, tests, and medications. This seems like a pretty outrageous claim, but just think about it:

What is "pre-hypertension"?  They used to have a set of numbers that were considered the line for high blood pressure. Later, they decided that maybe those numbers covered the worst but were missing a lot of people whose blood pressure level also wasn't safe, so they lowered the level of what was considered high blood pressure. So that should have been enough. But no - now we have "pre-hypertension." These are people whose blood pressure numbers are nearing, but not quite at, the level for high blood pressure. In other words, they are still in the normal range. But rather than just warning people and teaching them ways to prevent it from getting higher, they want to start medicating them - before they even have high blood pressure.

What is "pre-diabetes"?  Same idea here. These people are not sick. There is no evidence of actual disease. They don't need medication; they need to be taught to eat right and exercise so they don't develop diabetes in the future.

How about "at risk"?  Suddenly people whose tests show that they are near the levels for high cholesterol or osteoporosis are being treated for diseases that they may develop - or they may not. This is called "overdiagnosis." These people are still in the normal range, just at the high end of it.

Overdiagnosis

This is a huge problem! It is estimated that 20 to 35% of all money spent on health care goes to pay for unnecessary treatments, tests, medications, and devices. Just Google "overdiagnosis" and check out the huge list that comes up.

The Dartmouth Institute for Health Policy and Clinical Practice is organizing a conference, Preventing Overdiagnosis Conference 2013. I highly recommend that you watch the video on their web page.

An interesting op-ed piece in the New York Times last month, Cancer Survivor or Victim of Overdiagnosis? explains this better than I can, but I would be very upset to find this out now if I had ever gone through the horrible treatment for breast cancer. Here is another article in the New England Journal of Medicine about the same study.

Better Safe than Sorry?

It would seem, and indeed it is argued, that it is better to be over-diagnosed than under-diagnosed. We wouldn't want them to miss something.

Well, as it turns out, maybe we would. Two very good examples are with screening mammograms for breast cancer and PSA tests for prostate cancer. It turns out that we have these little cancers in our bodies that, if left alone, will never do anything to cause us any harm at all. We've probably always had them, but they never found them until they went looking.

Now it is estimated that 1.3 million women have undergone chemotherapy, radiation, and surgeries for nothing. The worst of it is probably the terrible fear that they have gone through.

This PBS Newshour article explains it much better than I can. And don't pass up the video explanation that is attached. This is about breast cancer, but the situation is very similar for prostate cancer and the PSA test.

Does the Advertising of Prescription Drugs Make Sense?

People who retire to Mexico learn quickly that they don't need many of the medications they are taking. The doctors here carefully wean them off, one at a time, until they get down to the few that they really do need for whatever reason. These books tell about the problems with pharmaceutical companies:
  • Selling Sickness: How the World's Biggest Pharmaceutical Companies are Turning Us all into Patients, by Ray Moynihan and Alan Cassels, 2005
  • Overdosed America: the Broken Promise of American Medicine, by John Abramson, M.D.
 When I worked in doctors' offices about 35 years ago, the drug companies had representatives who went around to all of the doctors offices and tried to convince them to prescribe their products. They left them with piles of samples that the physicians could give to their patients to see if they helped whatever the problem might be. The doctors I worked for gave out the samples but for the most part they went right on prescribing whatever they had already been using. Then the drug companies started advertising directly to the consumers.

These drug ads are everywhere we look; it is very hard to avoid them. The advertising companies that they've hired know how to do their job well. First they convince us with darkness and frowns and sad music that every little twinge or momentary feeling of sadness or frustration is a major problem that must be cured with medication. And they have just the right thing for that cure. As soon as you take it, all of your problems will go away, which you will be certain of because you will be surrounded by bright colors and flowers, singing birdies, and happy music.

And while your mind is busy thinking about whether that drug is the cure for all of your problems, you miss the huge long list of all the side effects, contraindications, and complications that go along with this medicine. And the list is read off so fast that you'd better give it 100% of your attention to get it all. They may tell you about tests that prove how wonderful their drug is, but they neglect to mention that they ran the tests and just may have fudged the results a wee bit.

Of course, you still need your doctor to prescribe the medicine, so you go into his or her office and ask for the prescription. And you'll probably get it, whether the doctor agrees that you need it or not. Why? We've backed our doctors into a corner. They are damned if they do and damned if they don't. If they don't prescribe it and something later comes up that shows it might have helped, they will probably be sued. So they are safer if they do give it to you, as long as it doesn't kill you or do any great harm.

So, in the meantime, their oath to "Do no harm" has become "Do no great harm."

Growing Older

Things get every worse as we age. Think of the old people you know. How often are they going to the doctor? How many medications are they taking?

The most interesting of the books I read was Rethinking Aging: Growing Old and Living Well in an Overtreated Society, by Nortin M. Hadler, M.D.  In addition to discussing everything I've already mentioned, this book focuses on tests and treatments for people who are too old to benefit from them.

Think about heart surgery on people in their nineties. Chances are real good that the surgery is more dangerous than the heart condition. Or how about cancer treatment for someone that age. Why? They would be so much better off enjoying the life they have left than making themselves miserable with treatment for their few remaining months or years.

This book can help us to help our parents make wise health care decisions, but it also addresses the problems of people just reaching retirement age. What we do now can make a big difference in our lives in the future. Who wants to live long if the life you live is filled with aches and pains and illness? It would be so much better to take care now and be happier and healthier later.

What Can We Do?

Doctors study hard for a lot of years to try to learn as much as possible about keeping us healthy. We certainly want to respect them for that and take advantage of the knowledge that they have worked so hard to attain. But somewhere along the way we've gotten lost.

Doctors are scared to death of malpractice lawsuits, and who can blame them? We want them to be gods and then turn on them when they aren't. This fact affects everything they do and say. It is time for change.

First, we have to take the responsibility for our own health in every way possible. We need to eat healthy food and not too much of it. We need to get out there and exercise. Don't drink too much. And we need to get enough sleep.  That's a start.

Next, we need to make an effort to inform ourselves about any health issue that comes up. Check it out on the Internet. Find out all you can from legitimate medical websites, not from Joe Blow giving his opinion. Learn about the possible treatments and potential harms. Make a list of questions that you want to discuss with your doctor.

Also, don't blindly accept everything you are told. If doctors don't agree with each other, find out why. Ask questions. Find out the pros and cons of a particular treatment. What can you expect? What if it doesn't work? What can go wrong? You cannot give "informed consent" to a treatment without knowing the answers to these questions.

Even better than "informed consent" is "shared decision making." This honors both your doctor's expert knowledge and your right to be fully informed of all your options. There may be some doctors out there who have lost sight of what is best for their patients, but most of them are great people who are doing the best they can to help us stay healthy. What are you doing to help them do their job?

5 comments:

  1. I agree with everything you've said! Here in Canada, there isn't quite the same culture of fear of being sued, and doctors don't earn more for ordering tests. My doctor is a bit of a rogue: he continually talks people out of prescriptions and tests (for example, he will not prescribe antibiotics for a cold unless there is a definite bacterial infection present). I just hate prescription drug advertising and think it should be banned.

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    1. I guess there's not much we can do except to take responsibility for our own health care. Ask questions and insist on explanations. Of course, this has to include eating right, exercising, etc.

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  2. I am very weary of all of the medical things in the life of the elderly. My mother was sentenced to a stress test- which she failed (duh- she is in her mid 80s). So she got to get one of the catheter ones. It stopped her heart AND the meds made her kidneys fail. When she came out of it she refused dialysis. My sister was horrified. I started up the cherry juice and a kidney friendly diet. Five months later she was fine - kidneys at 100%. Now her skin guy carves off spots like it is going out of style. My mother has poor circulation---always has. The deep gouges take months to heal. She won't stop him because they are cancer....AGGGG! Hate it!
    I take a daily vitamin at 56. I don't plan on getting more involved anytime soon.
    You HAVE to die of something!

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  3. I agree, Janette. It can be very difficult caring for the elderly because they grew up believing that doctors are like gods and don't want to believe otherwise. My boyfriend's doctor recently raised his blood pressure meds to one and a half pills a day. He started blacking out from low blood pressure. We've got it stable now at 1/4 of one pill a day. You just have to be sure to pay attention to what your body is telling you.

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  4. Doctor's need more precise medical prescription. Not all medicine are effective to same person and not all medicine have the same effect and side effect on each patient.

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