From: nyeda@cnsvax.uwec.edu (David Nye)
Newsgroups: talk.politics.medicine
Subject: Re: The future of medicine
Date: 11 Jan 93 02:19:22 -0600
Organization: University of Wisconsin Eau Claire

[reply to jlove@ivrit.ra.itd.umich.edu]
 
>I found this to a remarkably well-reasoned brief article
 
Gee, thanks. :)
 
>>When the inevitable rationing begins, we are going to have many
>>dissatisfied customers.
 
>My quibble here is that I think we already have rationing.
 
True, but I think it is going to become much more overt.  Few carriers
now deny treatment unless it is experimental or of no proven utility.
What I meant by rationing is what was attempted in Oregon, or the rules
in the Brittish system that no one over a certain age is eligible for a
transplant or gets recussitated after an arrest.
 
>I have read a number of articles which claims that this argument is
>exaggerated; that much of this "defensive medicine" constitutes good
>medical practice. Perhaps someone else might want to provide competent
>literature on this subject.
 
This figure seems about right to me from watching the behavior of some
of my colleagues.  The necessary studies have not to my knowledge been
done.  To answer the question of what constitutes good medical care, one
needs to know the cost-benefit ratio of a given test in a given
situation and agree on some number above which a test is not worth
ordering.  For example, say it costs 10 million dollars to find one
brain tumor in an adolescent without focal neurologic signs or symptoms
presenting with a first seizure.  Waiting until focal neurologic signs
and symptoms have developed might mean a wait of a couple of months, but
this rarely will mean the difference between a cure and death.  Is it
"good medicine" to get a routine CT?  Is it necessary instead to get an
MRI at 3-4 times the cost of the CT because a CT will on rare occasions
miss a very small tumor that the MRI will catch?
 
The most common situation in which an unnecessary test is ordered is
when the physician is confident that he can exclude some diagnosis based
on his history and examination, but knows that a negative test will
carry more weight in court than his own observations.  This is the
rational behind ordering a brain imaging study in a patient with a
migraine.  If the patient's headaches are not present every day, they
can't be due to a brain tumor (the tumor doesn't come and go once a week
or month).  What happens if the patient is found to have an unrelated
brain tumor or a ruptured aneurysm 5 years later?  I've seen physicians
successfully sued in this situation.  Most physicians just figure they
will avoid the potential hassle and get the study, even if it isn't
indicated.  Some physicians will get any study a patient asks for, even
when they know it isn't indicated, just to avoid antagonizing the
patient.
 
>While my suggestions are not quite as radical as shooting all the
>lawyers and destroying all the insurance companies, they would result
>in some additional unemployment in both professions. :-)
 
If they contribute nothing to the quality of health care, they have no
right a slice of the pie.  The ability to choose between different
insurance plans or to play "medical malpractice lotto" is undoubtedly of
some value to patients, but I wonder if people would consider them worth
the price if they knew how much they cost.
 
>>quality control maintained by professional societies, not the
>>courts.  I won't hold my breath waiting for this to happen, though.
 
>For one reason or another, the members are never held to appropriate
>standards.
 
True.  Well, perhaps a panel of experts, physicians employed by the
state?

David Nye
nyeda@cnsvax.uwec.edu
Newsgroups: talk.politics.medicine