The Discussion About Medicine We Should Be Having

November 8, 2013

More healthcare isn't better -- a conversation about smarter healthcare is needed.

A former radiology partner of mine who is always good for an outspoken opinion on everything recently observed that there has been a dramatic increase in thyroid biopsies compared to just a few years ago. Not one to accept the status quo, he asked one of the staff pathologists if there had been a corresponding, unpublicized increase in thyroid cancer of which he was unaware. The reply was “No.” So, why so many biopsies?

Clearly there have been dramatic changes in the practice of radiology over the past 30 years. Fluoroscopy and angiography have given way to cross-sectional imaging.  I get this.

What I don’t get are some of the current imaging patterns or lack thereof. For example, patients with extensive deep vein thrombosis on ultrasound followed automatically by a CTA of the chest, routine CT scanning of straightforward extremity fractures and every kidney stone, routine pre-operative chest radiographs, plain films of the abdomen following abdominal CTs, and on and on.

One possible explanation has been referred to as “the impossible quest for medical certainty.” Another explanation is the ever increasing role of physician extenders and the increased time pressures that result in ordering tests and imaging rather than careful clinical assessment. Pressures to minimize hospital stays seem to have led to an “order everything and sort it out later” style of medicine.

It seems medicine has also become subject to “algorithmizing.” As a radiologist, I know that there is a list of fetal body parts that have to be mentioned in the report if I want to be paid for a complete obstetrical ultrasound. So, I follow that algorithm. I imagine referring physicians have similar pressures when they are evaluating patients.

With all the furor over Obamacare and the government telling us what constitutes good healthcare, we need to step back, re-evaluate, and start talking about the real issues concerning healthcare in America.

The United States spends twice as much per capita on healthcare as any other country but only rates at the top in one metric- availability. Americans want healthcare and want it now. The Canadian model limits availability of many services, such as MRI, by limiting the number of MRI scanners in the country. The proliferation of MRI scanners in this country means same-day service is usually available. No need to wait and see if the condition resolves on its own or responds to conservative treatment.

We need to use common sense. Healthcare should be between a patient and a doctor-not a patient, a doctor, and a bureaucrat or insurance company. Each healthcare decision is unique and should not be forced into an algorithm. Just because we have the technology to do something does not mean it should be done. Prolonging life at all costs because it is technically possible is neither good healthcare nor is it the best use of our limited resources. It is frequently not the best thing for the patient either.

Many factors should be considered when making medical decisions, including the patient’s wishes, overall health and age of the patient, the likelihood of restoring the patient to reasonable health and, yes, the cost. For instance, long-term dialysis of elderly patients with dementia is probably not the best use of our limited resources. More healthcare is not necessarily better healthcare. It is, however, more expensive. It is time to address the real issues in medicine, not just the politically correct ones.