More Medicine Less Health | Less Medicine More Health
Majid Ali, M.D.
Updated March 19, 2015
There are two articles of note here. The first is from today
Medical expansion has led people worldwide to feel less healthy
The second from last month
Doctors Strive to Do Less Harm by Inattentive Care
Medical expansion has led people worldwide to feel less healthy
Across much of the Western world, 25 years of expansion of the medical system has actually led to people feeling less healthy over time, a new study has found.
A researcher at The Ohio State University used several large multinational datasets to examine changes in how people rated their health between 1981 and 2007 and compared that to medical expansion in 28 countries that are members of the Organization for Economic Co-operation and Development.
During that time, the medical industry expanded dramatically in many of those countries, which you might expect would lead to people who felt healthier.
But that’s not what Hui Zheng, assistant professor of sociology at Ohio State, found.
“Access to more medicine and medical care doesn’t really improve our subjective health. For example, in the United States, the percentage of Americans reporting very good health decreased from 39 percent to 28 percent from 1982 to 2006,” Zheng said.
In fact, Zheng conducted what is called a “counterfactual analysis” using the data to see what would have happened if the medical industry hadn’t expanded at all in these countries since 1982. In this analysis, other factors that are generally linked to improved health, such as economic development, were left unchanged.
Under this scenario, the analysis predicted that self-rated health would have increased in these 28 countries. For example, the percentage of Americans reporting very good health could have increased by about 10 percent.
“It seems counterintuitive, but that’s what the evidence shows. More medicine doesn’t lead to citizens feeling better about their health – it actually hurts,” Zheng said.
The study appears in the July 2015 issue of the journal Social Science Research.
“All of the improvements we might expect to see in subjective health as economies grow and citizens become richer seem to be offset by medical expansion,” he said.
Zheng said there are several reasons why medical expansion may actually lead people to feel less healthy. For one, more diseases are discovered or “created,” which increases the risk of being diagnosed with “new” diseases. Three examples, he said, include the rise in diagnoses of attention deficit hyperactivity disorder (ADHD), depression and autism.
In addition, there is more aggressive screening, which turns up more diseases in people. Overdiagnosis can potentially cause harm to perfectly healthy people, he said.
As more medical care becomes more widely available, people may expect better health, perhaps to an unrealistic degree, Zheng said.
“Consumers begin demanding more medical treatment because of the declines in subjective health and the increasing expectations of good health, and medical expansion continues. It is a cycle,” Zheng said.
In a separate but related study published online in Social Science Research, Zheng found that Americans’ confidence in medicine has declined over the last three decades, again at the same time as medical expansion.
“The decline in confidence has occurred at the same rate, regardless of gender, age, income or any other factor,” Zheng said.
This decline occurs even after taking into account many of the same factors used in the other study that may affect confidence in medicine. Related to the other study, the decline in confidence in medicine may be partly due to the adverse effect of medical expansion on individual subjective health. People with worse subjective health generally have lower confidence in medicine.
The study, based on data from the General Social Survey from 1972 to 2008, showed that people’s declining confidence in medicine could also be linked to declining trust in doctors’ ethics.
“We don’t know for sure, but one reason consumers may have less trust in the ethics of their doctors is because of the introduction of managed care in the medical market,” Zheng said.
“People may feel that doctors work more for these managed care companies than they do for the patients.”
Now from the New York Times
“Doctors Strive to Do Less Harm by Inattentive Care” published in The New York Times on February 18, 2015 (reproduced in full after my commentary on it).
There is a rage among doctors to reduce the suffering of patients in hospitals. What could be nobler? Let us consider how the top doctors in America’s top hospital are making most admirable efforts to reduce patient suffering. Here is what comes to my mind:
- They will focus on healing understand (healing literacy), not on disease literacy, drug literacy, device literacy.
- They will learn how to use time-tested natural remedies to prevent and reverse diseases.
- They will become well-educated and experienced clinical nutritionists.
- They will become thoughtful clinical ecologists and teach their patients how to prevent or reverse environmental illness.
- They will learn and then teach their patients about how oxygen-driven healing pathways preserve health and reverse chronic diseases.
- They will learn and then teach their patients about how excess insulin fattens, ferments, and inflames the body.
- They will learn and then teach their patients the difference between insulin-wise and insulin-unwise eating to prevent and reverse diabetes, heart disease, memory loss, strokes, and other disorders.
I am moved to offer this short article by a front page article on the subject entitled “Doctors Strive to Do Less Harm by Inattentive Care” published in The New York Times on February 18, 2015. I include below the text of that article for readers’ interest. They can then marvel at the efforts being made by our top doctors.
Doctors Strive to Do Less Harm by Inattentive Care
The New York Times February 18, 2015
Suffering. The very word made doctors uncomfortable. Medical journals avoided it, instructing authors to say that patients “ ‘have’ a disease or complications or side effects rather than ‘suffer’ or ‘suffer from’ them,” said Dr. Thomas H. Lee, the chief medical officer of Press Ganey, a company that surveys hospital patients.
But now, reducing patient suffering — the kind caused not by disease but by medical care itself — has become a medical goal. The effort is driven partly by competition and partly by a realization that suffering, whether from long waits, inadequate explanations or feeling lost in the shuffle, is a real and pressing issue. It is as important, says Dr. Kenneth Sands, the chief quality officer at Harvard’s Beth Israel Deaconess Medical Center in Boston, as injuries, like medication errors or falls, or infections acquired in a hospital.
The problem is how to measure it and what to do about it.
Dr. Sands and his colleagues decided to start by asking their own patients what made them suffer.
They found several categories. Communications — for example, a doctor blurting out, “Oh, it looks like you have cancer.” Or losing a valuable, like a wedding ring. Or loss of privacy — a doctor discussing a patient’s medical condition where an adjacent patient could hear.
“These are harms,” Dr. Sands said. “They elicit suffering. They can be long lasting, and they currently are largely unquantified, uncounted, unrecorded.”
One way to quantify these harms is to observe and note them, which is part of what Beth Israel Deaconess is doing. Another is to supplement efforts with patient surveys. Patient surveys, of course, have been around for decades. And since 2007, Medicare has required short surveys after discharge.
But patient surveys were usually not used by hospitals to measure suffering. Now they are. And even when a survey question does not directly ask about suffering, sharp-eyed administrators are seeing a suffering component.
That is how Dr. Michael Bennick, the medical director for patient experience at Yale-New Haven Hospital, solved a problem. He noticed a question on a Medicare survey asking, Is it quiet in your room at night?
Maybe, Dr. Bennick thought, what is really being asked is: Can you get a good night’s sleep without interruption? Is it really necessary to wake patients again and again to take blood pressure and pulse rates, to draw blood, to give medications?
He issued instructions for his unit. No more routinely awakening patients for vital signs. And plan the timing of medications; outside intensive care units, three-quarters of drugs can be given before patients go to sleep and again in the morning.
Then there were the blood tests. “Doctors love blood tests,” Dr. Bennick said, and want results first thing in the morning when they make rounds. That meant waking patients in the wee hours.
“I told the resident doctors in training: ‘If you are waking patients at 4 in the morning for a blood test, there obviously is a clinical need. So I want to be woken, too, so I can find out what it is.’ ” No one, he said, ever called him. Those middle-of-the-night blood draws vanished.
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Without anything else being done about noise in the halls, the medical unit’s score on that question rose from the 16th percentile to the 47th nationally in the Medicare survey. Now the entire hospital follows that plan.
“And it did not cost a penny,” Dr. Bennick said. “The only cost was thinking not from our perspective but from a patient’s perspective.”
Dr. Lee says he joined Press Ganey — he had been network president for Partners HealthCare System, a Harvard-affiliated hospital system — because one of its goals was to reduce suffering. At first, he said, he was a bit uncomfortable with the concept.
“I wondered whether it was a tad sensational, a bit too emotional,” he wrote in The New England Journal of Medicine. Then he realized reducing suffering was one of the most important challenges in health care.
Press Ganey administers detailed surveys to discharged patients, asking things like how well the medical staff responded to them and their emotional needs, and how well the doctors and nurses informed and educated them. The company also encourages hospitals to let doctors know the results.
Surveys can be misleading, though, cautions Dr. Scott Ramsey, a health care economist ann cancer researcher at the Fred Hutchinson Cancer Research Center in Seattle. Patients, worried about saying something bad about a hospital they depend on, may not reveal what they really experienced. Or they may look back and, not wanting to live a life of regrets, excuse a doctor who seemed not to listen.
On the other hand, Dr. Ramsey said, the suffering issues are real, and if survey answers can get doctors and hospitals to change their ways, “that is great.”
Although half the nation’s hospitals use Press Ganey surveys, it is not clear what many do with the data. But at some places, like the University of Utah, the survey and other efforts prompted significant change. One Utah doctor said he was stunned when his patients rated him in the first percentile nationally, about as low as a score can go. “I was thinking: That’s just crazy. Something wasn’t entered right,” said the doctor, James Ashworth. Then he decided to take the criticisms to heart.
The next quarter, he was rated in the upper 90s. The big difference was slowing down and listening to patients, answering their questions.
Utah began its program a few years ago by showing its 1,200 doctors, nurses and other workers their scores. Next, said Dr. Vivian S. Lee, the hospital system’s chief executive, they showed them how colleagues did. Then they posted individuals’ scores and patient comments online.
There was an immediate and noticeable change. When the university began, it was in about the 30th percentile nationally on the Press Ganey survey. Now, half its providers are in the 90th percentile and 26 percent are in the 99th percentile.
“It’s unbelievable,” Dr. Lee, the chief executive, said. “We were not like that before, I can tell you.”
“People wanted to improve,” she added.