What do we want and (how) can we have it?

In "A Calculus of Suffering" Martin Pernick describes the introduction of general anesthesia

into surgery. There were dilemmas in trying to understand what gains and losses would

accrue. Anaesthesia certainly appeared dramatically effective in reducing indeed abolishing

the extreme distress patients experienced during surgery. But was it safe? How many

patients might die as a consequence of this novelty? How many deaths might be accepted in

the interests of massive relief for the many? Would even those who survived have worse

outcomes attributable to anaesthesia? It is fascinating study which might  serve as a model

for a new, urgent analysis,  in this case pitting the concerns over cost against the assorted

dimensions of benefit which stem from modern healthcare. If we are uncomfortable paying

as much as we do today, ( and perhaps we needn’t be*) where are the savings to be made?

Conventional writing on the topic tends to stick with looking at efficiency, "eliminating

waste" which is uncontroversial (though  harder to assess and pursue) and thereafter

discreet mumbling about general affordability much of cloaked in the unstated view that

those who can pay will receive and the rest will ....... trailing off into unstated detail. This

will not do. We need an adult approach based on the foundation that effective healthcare

should be available to all however resourced.

To begin we need a clear eyed view of what issues are up for debate, what dimensions might

we trim in pursuit of savings.

Any respectable Healthcare system has to attend to the following:

Equity of access

Capability/ Efficacy

Safety

Comfort (being both comforting, and providing comfort)

Convenience

Confidentiality

- in an efficient economical manner.

You mean we might spend less on safety? Yes we might. But clearly there is a hierarchy of

potential here. Safety might not be first - but it might not be last!

* How much should or can we pay for healthcare? As much as we choose, recognising that

the more we spend here the less we have to spend on everything else which might

collectively be regarded as health promotion or protection activities devoted to preventing

illness rather the necessarily narrower focus of healthcare on correction of established

disorder.

Healthcare makes only a small contribution to Health

  WHO  in 1948 defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
This is the hardest concept and possibly the least important to  discussions of healthcare. We should probably leave this to last but let's get the hardest word out of the way first. What is health? Am I healthy?  I think so. Do you?  Health is essential to us all but is essentially undefinable. Much work has been done and definitions  abound but they all feel unsatisfactory and are often violently contested. Individuals believe they know when they feel healthy or otherwise and worrying over the definition is unproductive. There is much confusion in the writing about healthcare, illness and disease caused by associating these with health. Health is peripheral to the concerns of healthcare. It is not the prime concern of healthcare. Whatever health is its main determinants lie well away from healthcare. Healthcare does of course seek to help people who are ill to regain their health but this is a small effect compared to the many influences which affect health.. The core activities of healthcare can all be described, comprehended and improved with little or no concern for the meaning of  health. Healthcare must stick closely to its task of relieving current distress and improving lifetime outlook. The companion disciplines of Health Promotion and Health Protection have closer involvement with health.

The changing nature of the doctor.

Created a century ago, far from perfect and yet the most successful model yet.  The model is however now increasingly inappropriate. It is costly, it is ill adapted to the current environment and crucially its current practitioners are at best ill at ease and at worst extremely unhappy.

Why?

A century ago medicine was largely ineffective. A few innovations which survive had made some impact - anaesthesia dating from mid 19th century had expanded the possibilities of surgery including importantly caesarean section. Medicine was worse off and dominated by a range of unsubstantiated theories and systems. Flexner's notion was that progress in medicine could only be made by the application of science. He wanted doctors trained in the methods of science and in command of the best available knowledge of bodily structure, function and pathology.  He was correct in his assessment and the last century has seen the fruits of his vision in ways he may not have imagined. (He died in 1959.)

This was a reasonable approach given one startling fact - at the time, and for many decades thereafter there was little or no certainty on what was the best advice or treatment to give in a wide range of clinical disorders.

The implicit idea was that the best chance of useful outcomes would come if   the doctor, educated and trained and carrying this knowledge with him would confront a variety of patients' problems and using a combination of his teachers views, rationale and an ever growing personal experience and would,  by and large, make helpful suggestions, decisions and interventions. Was that the best that could have been achieved? Probably. The outcome of this more generally was the notion of the doctor as we have come to know her - educated, knowledgeable , skilful, thoughtful, independent, reliable, available and affordable.

Hold on to "independent" . For as long as there was little systematic evidence of what was best in any given situation doctors could and did take a variety of courses and within very broad limits each was as acceptable as the other. The patient may have had little insight into this variability but it was until recently the defining feature of medical practice. Doctors were educated and trained to accept the responsibility this uncertainty placed on them and to enjoy the status, the respect and the rewards which came with it.

Over the years scientific research expanded and clinical knowledge grew. As part of this there was a more concerted focus on establishing precisely what might be the best way to assist patients in a given situation. The tools needed to do this were also developing with a growing understanding and application of statistics and the arrival of the computer to handle the numbers. By the 1980s medicine had increased its understanding, its options and crucially its costs. Governments and others were increasingly asking questions on how these costs might be contained and one conclusion was that if there were a range of ways of dealing with a particular illness or disease and if there were no differences in the success rate then we might as well concentrate on the cheapest option. Similarly if there were differences in the success rate we should ensure that all patients had access to that best available treatment. One of the main consequences of those developments was the notion that individual doctors could no longer exercise wide ranging unquestioned autonomy in making decisions, perhaps denying patients access to best treatments or incurring costs above those which would deliver  best outcomes. None of this happened overnight but these last 25 years that has been the direction of travel and it has had as they say "mixed reviews". Some doctors have welcomed the change, relishing the notion that for the first time in history we knew with some confidence what was the best way to help patients with a given disease or illness. Success of course was gradual and patchy and there remained plenty of scope for the traditional autonomous doctor to practice. But change was progressive and irreversible and many traditionally trained doctors, sensing what was afoot hated the very idea. It must surely be right that any doctor should be left to come to his own conclusions on what would be best for "his" patient. There is still talk today of the "sanctity" of the doctor patient relationship. Along this path there were assorted surveys of doctors' attitudes to their profession and a recurring theme was - unhappiness.

So where are we now and where are we going?

We have seen a stupendous growth of reliable knowledge on how best to deal with an increasing number of illnesses. The evidence is well supported, clearly set out, accessible to all and capable of being enacted by a growing range of clinicians most of who have not had the extensive, thorough, bioscientific education and training which Abraham Flexner correctly saw as essential 100 years ago. For an ever increasing number of clinical consultations we no longer require the presence of a traditionally conceived doctor and that trend still has a long way to go.  We already have increasing numbers of patients being seen and managed by a growing range of non medically qualified professionals from nurses and physician assistants to physiotherapists and radiographers. We shall see more of this and fewer consultations with the traditional doctor.  We shall of course continue to need some bioscientifically trained doctors at the front end, seeing patients whose ailments are atypical or  unclear,  conceiving and carrying out clinical trials of new approaches, performing complex physical interventions such as surgery where instant decision making requires a detailed knowledge of the underlying biology though even here there is scope for newer types of clinicians who have not had the extensive detail of the traditional model in their training.

Here we might note the use of the word training as opposed to education. Education, the developing of an individual's potential, is of the essence in preparing an autonomous practitioner capable of safe and effective management of uncertainty. For the newer model of clinician the organisation wishes her  to deliver a structured series of exchanges with the patient along lines selected and approved by the organisation. Autonomy is limited and at the margin. Training the individual to do as the organisation bids is the new imperative.

So the Flexner model is in decline and though it will not become extinct its passing from universality will be resisted screaming and kicking by its current adherents. 

A Good News Story

A small child got flu and was seriously ill. She recovered. Geneticists studied both her and her parents DNA. They discovered that she had a genetic mutation whereby she failed to make quantities of Interferon in response to infection. In this regard both  her parents were genetically normal. The genetic finding has been confirmed by testing blood samples from the clild and her parents with influenza virus. Interferon is readily available to treat patients. How many more people are at risk of serious illnes from flu due to this mechanism and how many might be helped if they got flu by giving them Interferon.? Time will tell but the news is good.

Unnecessary Deaths

The UK health secretary says 1000 people are dying unnecessarily each week in Britain's NHS hospitals. Aside from the fact that this is intended to drive people in greater numbers to the (no more safer or efficient) private sector he is of course wrong. but then politicians often are and on healthcare issues they have a noble tradition of being wrong!
but he must have got this number form somewhere! Indeed he did. And the source was wrong as well.
How come?
Its easy to be wrong. There are lots of ways of being wrong but usually only one way of being right!

Hospitals make records of all the patients they see. The amount of information on each patient is quite small - typically it would include age, sex, times and dates of admissions and discharges, whether the patient died in hospital  and a list of the diagnoses reached by the doctors. This sounds fairly straightforward but recording the diagnoses is often wrong. The doctors may not have made the correct diagnoses(or indeed any at all), they may not have recorded their findings properly and what they have recorded is not correctly transmitted to the hospitals information system - this is done by applying a code to each diagnosis reached (and each major procedure carried out). This coding is done by hospital staff reading the doctors diagnoses and converting this into an agreed code. Sounds easy? It does -but it is not. There a re many reasons for it being wrong!  However let us assume all that is correct. What about the 1000 deaths?

Each hospital makes its records available to a central system, often a private company who analyses the information and compares hospitals one against the others.
For each diagnosis there will be a death rate for every hospital that had patients with that diagnosis. Sort these hospitals in order and one hospital will have the lowest death rate. Every other hospital will have higher death rates and if the lowest hospital is doing everything right why can't all the others. By this test all the deaths in all the hospitals apart from the lowest that are above the lowest rate are "avoidable". Do this for hundreds of diagnoses and in no time you have hundreds of "avoidable" deaths. Except you don't.  No one hospital will have the lowest rate for everything - indeed it is entirely possible that every hospital might have the lowest death rate for something!
Why? Things vary in ways the numbers collected cannot explain. Sure they can allow for the fact that one hospital might on average treat older or younger patient, more men or more women, more patients with multiple diagnoses and so on and this does help to make the information more understandable. But the collected information leaves out far more than it contains. it does not tell much about the patients' past lives, how fit they were before coming ill and crucially how ill they were on this occasion. Not all heart attacks are of the same severity, Not all bouts of pneumonia make the patient as unwell.  Not all patients with a given diagnoses come to hospital - some die at home - and so on.
There are not 1000 avoidable deaths each week. There are od course avoidable deaths - no system is perfect - but for now we do not know how many or indeed which deaths are avoidable. One day information gathering will improve and we may know the answer to that question. But not yey.

A Surprising Fact about Alternative Medicine

Suppose you had an ailment and were inclined to seek help from an alternative medicine practitioner. Many do. Who should you go to? Should you consult an osteopath, a chiropracter, a homoeopathist, an acupunturist or a herbalist or one of many more alternative medicine specialists? I imagine you might like to choose the one most likely to help your particular problem. But which is that?

The answer - no-one knows! An extensive review of published literature turned up no trials where one form of alternative medicine was compared with another. Whatever ails you will be treated exclusively by the method of the specialist you go to. No acupunturist will ever tell you that for your complaint a herbalist might be better, no chiropracter will tell you that you would be better off seeing a homoeopathist for there is no known difference in the effectivenes of the different modalities of alternative medicine. That seems an unlikely situation, but it is true - and for a simple reason- they are all similarly effective for they all rely totally on what orthodox medicine describes as the placebo effect. We all, when afflicted by a wide variety of conditions can get a degree of relief when someone listens to us and shows some kindness and gives us something that they tell us confidently will help. And that is all that alternative medicine has to offer. It is no more than normal medicine can do - and with less fuss and less cost. Normal medicine can also help with ailments caused by much more serious disorders. Trust your normal doctor. She can help in most situations and will be honest enough to tell you when she can't. Good Luck and keep well.

Expensive Healthcare

American healthcare is the most expensive in the world. That seems to be established. Is it the best? Debatable. How would we know? By looking at specific aspects we as users would value - accessibility, timeliness, cost, effectiveness, kindness, safety confidentiality and so on.
A recent study by the Commonwealth Fund using such an approach suggests it is not the best - indeed it came last in study of a number of countries worldwide. Other studies have found similar results when looking at the health of the citizens but wrongly make the jump from healthcare to health. Expensive health care should mean a healthy populace they seem to expect. Wrong! Even excellent albeit costly healthcare cannot make a population healthy. It can help those whose ill  health becomes a major issue. It cannot beyond advice, education and exhortation make a society behave in a manner which will promote good health. And here is the kicker - if we live badly and make poor choices we will have poor health, we will make extra demands on healthcare which will in turn cost more!
Expensive healthcare is not just about inefficiency, profligacy or exploitation - it is also about levels of demand which in turn are driven by the health of the population.