Saturday, October 31, 2009

Dr Rahul Parikh: Health Reform Should Be About More Than Money

Health Reform Should Be About More Than Money

Dr Rahul K. Parikh
OCTOBER 7, 2009 10:00AM

There is plenty to criticize in our bungling trek toward health reform.  Leaders on the right, left and at 1600 Pennsylvania Avenue  have sidestepped the crucial conversation of controlling the cost of care, in favor of partisan rhetoric about "death panels" and  "rationing care."  Worse, the entire focus of reform has centered on spending billions of dollars on technology solutions that will only make marginal changes in the cost and quality of care Americans get.

I want to refocus the debate on what matters most: relationships.  Let's reinvest in the sitting down with, listening to, empathizing with and touching patients.

America has the most advanced healthcare system in the world. But in our haste to research, develop and invest in high-tech medicine, we have lost sight of the very basics of good doctoring. The first things we learn in medical school are: ask, listen and touch. Doctors do not do enough of this any more.

As has been made painfully clear, most doctors are rewarded for doing all manner of procedures.  This is true from the earliest moments of our career. As a resident, even when faced with the most basic medical problems,  I was grilled by my attending when I didn't order the full battery of tests, or contact all the specialists available to consult on a patient. Thus, over-testing and over-treating becomes a knee-jerk response from the get go.

This is how doctors practice medicine today. Some of us do it this way because it's how we get paid. Some of us refer our patients to specialists because we don't have time to sit down with them ourselves. Some of us rely on tests and procedures because we're fearful of malpractice lawsuits. And most of us have just lost sight of the most powerful tools in the doctor's arsenal: our hands and our minds.

I'll illustrate this with an example. Once while still a medical student, author Dr. Sandeep Jauhar evaluated a man with chest pain whose lab tests and EKG suggested he was having a heart attack. The patient was admitted to the ICU. Hours later, the patient was in severe pain and his blood pressure had dropped. The resident in charge ordered another EKG and prepared to intubate and place a central line in the patient.

In the midst of this, Jauhar took the patient's blood pressure. For reasons then unclear to him, the resident instructed Jauhar to repeat the exercise -- on the patient's other arm. Jauhar tried, but above the din of beeping monitors and barking doctors, he couldn't hear the pulsing sounds through his stethoscope. Jauhar "shrugged and let it go."

Sometime in the night, the patient underwent a CT scan. The next morning Jauhar learned his patient hadn't suffered a heart attack, after all. Instead, it was an aortic dissection - a tear in the wall of his aorta, leading to severe internal bleeding. Worse, with the time lost to the misdiagnosis, the dissection was now inoperable. The patient died later that day.

I use this example because the diagnosis ultimately confirmed by a $1,000 high-tech CT scan would have been evident from the low-tech hands-on procedure Jauhar  shrugged-off. A discrepancy in blood pressures between the right and left arm is a classic indicator of aortic dissection, and easily distinguishes the condition from a heart attack.

Consider that a blood pressure cuff costs just a few dollars, compared with the hundreds of thousands of dollars in sophisticated ICU and ER equipment that the medical team employed trying to solve the riddle of the patient's condition. These same high tech tests and procedures also led the medical team down the wrong path. So much for the certainty we believe technology gives us.

If Jauhar had employed the basics of physical exam might the patient have lived? Possibly. In my own recent experience, I saw a young boy whose mother told me he seemed to be clumsier than other children his age. She had mentioned this to previous doctors, as well. When I examined him, I noted very brisk reflexes and an unusual flapping motion in his feet. This is called ankle clonus. I referred the mother to a pediatric neurologist. I learned shortly thereafter that her son wasn't just clumsy. He has cerebral palsy. This is a diagnosis that must be made clinically; oftentimes an MRI or a CT scan cannot detect CP because there are no discrete visible findings. The happy ending is that physical and occupational therapy can ameliorate the boy's symptoms.

My point is that not all of the system's ills can be solved with high technology - nor should they be. If you believe that reforming health care is essential for our country's future - and if you're at all mindful of our fiscal state -- then you've got to be open to other strategies besides throwing billions of dollars at the problem.

We can start by leveraging the basics. For doctors like me, this means re-learning value of the patient history and the head to toe physical exam. It means weaning ourselves off our dependence on technology, tests and procedures.

In a better system, doctors won't be rewarded for doing everything.  Instead, they will be rewarded for doing the right things. They'll use their heads and hands to decide how to spend our healthcare dollars - and I can promise you they'll spend less of them in the process.

This is how we could do it. This is how we should do it. Simply by re-prioritizing medicine's hands-on basics we can make great strides toward improving healthcare, without spending a dime on more technology.

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My Comments:
I have been very vocal about this for a long time. In this day and age of high-powered diagnostic tools and advanced technical instruments/skills, our growing dependence on these have crippled our clinical acumen. 

We are giving less and less time to our patients and allowing techniques and technology to replace our professional skills. Partly because, doing more tests or procedures means more reimbursement, so that we cannot be truly objective about our conflict of interests, our moral hazard. 

Perhaps, it is time to reward good clinical medical practice while saving some costs, and perhaps help reducing the risks and discomfort of some procedures which may be redundant or superfluous...




Breast Cancer
Today, one of my patients who is a  very health conscious woman, returned for her BP review after she had lumpectomy for breast cancer. Her cytochemical HER3 was positive, but oestrogen and progestin markers were negative.


This cancer was discovered on routine mammography about a few weeks ago; she had been faithfully having mammography annually for more than 15 years. Her late mother had breast cancer at 80 years, and she was worried that she could inherit this risk. 


She also had a CT angiogram done at another centre because a friend recommended this, because she was worried about her atypical chest pains. A few years ago she had a total body CT scan, again for health screening purposes--found some cervical and lumbo-sacral spondylosis, which made her nearly worried to death about her possible limp and neck/back ache. 

Since menopause, she was on hormone replacement therapy for 5 years, stopped for a year or two and then restarted on MHT/HRT for a further few years, only to stop when she developed hypertension about 4 years ago. She is now just 66 years old. Now she is contemplating further chemotherapy...


I just wonder if her breast cancer could have been the result of all her radiological exposure (MSCT thorax has been calculated to increase cancer risk in women in some recent studies), her hormone replacement therapy (WHI, NEJM), her stress levels, a multiplicity of risk factors, just enough to tweak her small genetic risk a little to manifest earlier, as potential co-carcinogens. I wonder...

Perhaps. less done might have been less harm...

1 comment:

Daniel said...
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