Once in a while I run across the writings of courageous and cutting edge doctors who dare question our chaotic Health Scare system. Dr. Palfrey revisits the old myth of Vulcan, the God of Technology, raping Minerva, Mother Earth quite well, as the movie AVATAR also does. But, let me get out of the way for you to read his wise advice:
I’ve grown worried that the practice of medicine has tipped out of balance.Recent advances in scientific knowledge and technology have resulted in the development of a vast array of new tests, new pharmacologic agents, and new diagnostic and therapeutic procedures. These are so accessible to us in the United States that few of us can resist using them at every opportunity. By being impatient, by mistrusting our hard-earned clinical skills and knowledge, and by giving in to the pressures and opportunities to test too much and treat too aggressively, we are bankrupting our health care system. Ironically, by practicing this way, we are perpetuating serious economic and racial disparities and have built a health care system that rates in the bottom tier among all developed countries in many categories of children’s health outcomes.
Most doctors are intensely risk-averse. We don’t tolerate uncertainty. Not wanting anything bad to happen, we reflexively overtest and overtreat in order to protect our patients – and ourselves. We feel judged by everyone – ourselves, our colleagues, our patients, the health care system, and the lawyers. The meaning of “first do no harm” has changed for us. We feel that “doing everything” is the best practice and the way to prevent harm, and we believe that it will shelter us from blame. We order tests and treatments because they are available to us, well before their importance has been established, their safety has been determined, and their cost-benefit ratio has been calculated.
The evaluation of a child with fever and cough is a good example. There are many possible causes, and we have a huge battery of available tests that might give us potentially relevant information. But why should we no longer trust our physical exam, our knowledge of the possible causes and their usual courses, and our clinical judgment? How much will we gain by seeing an x-ray, now, and how likely is it that the result will necessitate a change in our management? How dangerous would it be if we chose to perform certain tests later or not at all? Might our residents not learn more by thinking, waiting, and watching? Who is actually benefiting when we order a test – the patient, the laboratory, the drug company, the health plan administrators, or their investors? And who is losing health care as we spend these dollars? We need to ask these questions of ourselves and our residents at every step of the clinical process.
I believe that we must rediscover the value of clinical judgment and relearn the importance of the personal, intellectual, scientific, and administrative thought that is central to the best practice of medicine. We need comparative-effectiveness research, as well as cost-benefit and long-term-benefit analyses, to inform us how to integrate traditional clinical skills with the use of new tests and therapies. Our time and attention have been diverted to the task of sorting out data instead of sorting out what is important to our patients, their families, and the community at large. This new style of test-avid, cover-all-possibilities practice is bankrupting our health care system and depriving many families of access to health care and a medical home.
We as clinicians must change our practice patterns, but first the medical community, through standard-of-practice guidelines, must give us permission (or better yet, encourage us) to practice in a less costly way, so we don’t feel we are expected and incentivized to order expensive tests or treatments. Similarly, clinician-teachers must develop the confidence (or be given the imperative) to teach students, residents, and fellows how to practice in the most knowledge-based, least invasive, most frugal fashion possible and to seek input from physicians with more clinical experience when they feel the urge to order a test or initiate a treatment.
Education of the public is also critically important. We need to admit to our fellow citizens that the United States, despite its wealth, technology, and research expertise, is 21st in the world in terms of many indicators of health, and we must convince them that population-wide changes designed to improve health outcomes would be in everyone’s best interest. We need to teach our patients that more medicine is not better medicine, that it is poor health care for doctors to order too many tests or too many interventions, and that costly efforts do not equal better health care. As we address their personal needs, we need to explain to our patients that we have to use new medical technology with care and wisdom. Indiscriminate health care spending is not fiscally sustainable at a national level and actually hampers the achievement of many universal health benefits.
Every participant in our health care system must focus on ways to optimize health while decreasing cost, at every step of the process. We need to change the financial incentives currently embedded in health care reimbursement systems that reward the use of tests, procedures, consultations, and high-cost therapies. And finally, the legal system needs to be more restrained about pursuing lawsuits when a difficult diagnosis is missed or a treatment fails, to diminish the pressure on health care providers to practice expensive, defensive medicine at every turn.
These are major changes, but today we are far from providing good care for all our citizens and far from achieving health care equal to that in many other countries. We need to incorporate more realistic clinical, scientific, and financial information into practice in order to bring our health care practices, and our health care system, back into balance.[1
The good doctor’s advice is backed by research that many of the nifty tests we have relied on, like CAT scans, are not as harmless as we have been told by the industry.[2] As he suggests, we need to educate our doctors and the public about these issues; it all boils down to education. Unfortunately, medical education is in the hands of the very industry that pushes for a fancy pharmaceutical-technological approach:
The extent of industry support of continuing medical education (CME) has prompted concern that the medical profession has lost control over its own continuing education. In response, some academic medical centers, such as MemorialSloan-Kettering Cancer Center, have stopped accepting support for CME from pharmaceutical and medical device companies; others, such as the University of Michigan, are planning to do so. Although the role of industry-sponsoredCME remains controversial, there are proposals to either ban direct or indirect commercial support of CME or to otherwise reform the funding system. At present, a national ban on industry support is unlikely. The Accreditation Council for Continuing Medical Education (ACCME) has considered and rejected ending commercial support.[3]
So, what can we do? Spread the word; slowly, we, the people, will change the system. Be patient and see these problems as an opportunity for growth and change. We have the “True Grit”[4] necessary to overcome the greed and materialism that infects all areas of our society.
Hugo Rodier, MD
The Man in the Mirror
We need to work on the spiritual issues that plague our society, including our national addiction to refined foods, especially sugar. If we were to do this, we would immediately cut our health care expenses by 80%.[5] Of course, most dietitians will disagree that the problem is an addiction. The article “The Emerging Link Between Alcoholism Risk and Obesity in the United States“[6] leaves little doubt that we need to address obesity the same way we do alcoholism, smoking and any other addiction fueled by physiologic and emotional issues.To ignore this cutting edge research, in view of the tsunami of health problems obesity brings, is not wise:
We are in trouble. Effective strategies for preventing and treating obesity require a commitment to addressing its causes and consequences at multiple levels-from basic research through community and policy interventions.[7]
Pediatric update
The ones most affected by the bad foods we eat are our children (see blog “Reversing my Vote on Trixx.”) Here are the most recent articles I have read that apply to our beleaguered children:
“Caffeine Consumption in Young Children” triggers insomnia.[8] Cola drinks included, especially while watching TV and playing video games.
Bad foods trigger reflux that may lead to ear infections in kids.[9] Instead of treating the reflux with the purple pill, may be an elimination diet could reveal the offending food. (milk for sure.)
An elimination diet can help kids with ADD.[10] The main problem is processed food full of preservatives, pesticides, trans fats and refines sugars.
Vitamin A helps boost the immune system in intestinal infections.[11] Eating more fruits and veggies can prevent and treat most infections.
Low vitamin D levels increase allergies, asthma and pre diabetes.[12] Kids should be taking from 800-2,000 IU, but it is best to keep their blood levels around 75.
Acupuncture better than eye patching for “lazy eye.”[13] Avoiding surgery would be cheaper
Passive smoking raises kids’ blood pressure.[14] And we thought that the only problem with this was allergies, ear infections and asthma.
Low normal thyroid function increases the risk of heart problems in teens.[15] Give them iodine.
Benzene products increase the risk of neural tube defects in newborns.[16] Take folic acid.
[1] “Daring to Practice Low-Cost Medicine in a High-Tech Era,” N Engl J Med 2011; 364:e21March 17, 2011
[2] “Second Thoughts About CT Imaging,” J. Science 25 February 2011: p1002
[3] “Future Directions in Industry Funding of Continuing Medical Education,” J. Arch Intern Med. 2011;171(3):257
[4] “The Neuroscience of True Grit,” J. Scientific American, March 1st 2011, p 6
[5] Book “Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating” by Walter Willet, MD;
Fireside Press, 2001
[6] J. Arch Gen Psychiatry 2010;67(12):1301
[7] “Obesity Prevalence in the United States,” NEJM 2011;364:987
[8] J. Pediatrics 2011;158:508
[9] “A Prospective Study of the Effect of Gastrointestinal Reflux Disease Treatment on Children with Otitis Media,”
J. Archives of Otoralyngology-Head and Neck Surgery 2011;137:35
[10] “Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder
(INCA study): a randomised controlled trial.” J. Lancet 2011;337:494
[11] Vitamin A supplementation modifies the association between mucosal innate and adaptive immune responses andresolution of enteric pathogen infections,”
Am J Clin Nutr 2011;93: 3 578
[12] “Vitamin D Serum Levels and Markers of Asthma Control in Italian Children,” J. Pediatrics 2011;158:437&
“Low vitamin D linked to higher risk of allergies in kids,” J. Allergy Clinical Imm Feb 17th 2011 online &
“Associations Between Concentrations of Vitamin D and Concentrations of Insulin, Glucose, and HbA1c
Among Adolescents in the United States,” J. Diabetes Care March 2011 34:646
[13] “Patching vs Acupuncture for Anisometropic Amblyopia,” J. Arch Ophthalm 2010;128:1510.
[14] J. Circulation Jan 25th 2011 On line
[15] J. Fam Prac News, Feb 2011. p23
[16] “Maternal Exposure to Ambient Levels of Benzene and Neural Tube Defects among Offspring,”
J. Environ Health Perspect 2011;119:397
