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Thursday, March 22, 2012

Why are patients becoming so much more complicated?

When I was in medical school, lo those many years ago, patients used to come in with diagnoses like pyelonephritis or cellulitis or pneumonia or myocardial infarction or cirrhosis of the liver or heart failure. They were very sick, and I was very inexperienced, so it was always a challenge. I drew blood for various blood tests run by a lab, got a urine sample and looked at it under the microscope, got a chest x-ray and sometimes an EKG. I took a history and did a physical exam and wrote this all up on a piece of paper and made my conclusions and wrote orders and started an intravenous line for medications. A nurse would do vital signs, clean up messes, give medications and call me if something bad happened. Rarely had my patients had anything more complicated medically than a hernia operation and rarely did they take more than 6 medications. It was often perfectly adequate to get the entire medical history from the patient, which was good, because finding medical records was difficult.

After the initial head scratching, a patient would usually have 1 or 2 important things going on and I could focus my attention on curing those things. Abnormal lab tests were usually due to some immediate or far reaching effect of their primary problem.

In the ensuing years since my graduation, the numbers of tests and therapeutic procedures and medications that are commonly used has grown tremendously so that now it is unusual to admit someone to the hospital who has less than 10 distinct problems. Each of these problems has some sort of workup associated with it and often a medication, and has a significant implication for what treatments can be given for the current problem and what new testing needs to be done. There are so many more mistakes to be made than there used to be.

It seems likely that the fact that physicians and other healthcare suppliers are paid "fee for service" is directly responsible for the fact that patients have gotten more complicated. People haven't fundamentally changed, but the numbers of tests we do on them has, and our concept of our patients as collections of measurable variables has lead to an appearance of complexity. But they really are more complicated, even outside of our improved ability to peer into their inner selves. They are more complicated because of what we do to them.

A diabetic patient now may easily be on 4 medications for blood sugar control, 2 for high blood pressure, one for cholesterol and an aspirin. Then, of course, they also take something for depression, pain, a sinus infection, a weak bladder, gout...All of these drugs are incredibly powerful and can lead to death or dire illness alone or much more commonly in combination. Side effects are difficult to identify. In a fee for service world, patients see many specialists and each one has his or her own set of medications to offer, which balloons the numbers of drugs taken and geometrically increases the chance of side effects and drug interactions. Every time we do a procedure to a patient, we beget more diagnoses--at the very least a "status post" diagnosis, but often failure of the procedure results in further disability. Imaging, such as CT scans and MRI scans, has increased steeply in the last 10 years, leading to discovery of mostly irrelevant anatomic anomalies which frighten patients and confuse physicians and require repeated and more focused imaging for clarification.

Long lists of diagnoses clutter the mind with irrelevant data, but are the way we get paid for what we do. A person with a simple pneumonia will warrant a low level service code, but if I mention that they have heart disease (be it distant) and high blood pressure and borderline glucose intolerance and flat feet and piles and wens and and and and... the level of complexity and thus the billable amount goes up. But, having enumerated all of these ills, I now need to think about them and comment upon them and then I am paying less attention to the sick patients' immediate needs, and am much more likely not to notice a wrong drug dose or a lab test that implies a complication.

It's not entirely clear how to get back from here. Having insurance companies (including Medicare) pay for whole person care, by the person and not by the procedure, will begin to lead us back to where we need to be. Providing good competent primary care which can reduce reliance on specialists can help. Deliberately limiting the number of prescriptions taken by patients, realizing that taking a large number of good drugs is a bad thing ( should reduce the harm we do with the best of intentions.


Ed Rodgers said...

Since I work in Cancer, I always like to scale some of my cancer thoughts to population medicine because it often touches many corners of a care ecosystem. Today what came to mind when I read your post was "prevention"

Cancer would be better served with more prevention. Ban cigarettes already. HPV vaccines are going to lower cervical, anal, and head and neck cancers. and then reduce environmental exposures to other carcinogens AND eat better... which leads me to say:

General health would be better served with less additives, less use of high fructose corn syrup, MSG (natural flavors...yum). Stop partially hydrogenating everything. Stop using so much growth hormone and dont have a constant drip of antibiotics attached to other livestock. Teach people how to eat better. Probably could prevent quite a few type II diabetes patients this way. Probably could prevent some colorectal cancers this way, maybe other endocrine tumors as well - thyroid, pancreas, gastroesophageal.

You are what you eat and people could prevent the need to have 7 different medications if they would address the problem of bad nutrition. Toss in some consistent exercise and watch out!

We need to start promoting healthy lifestyles as more than just a thing that maybe 10 or 20% of the population subscribes to.

...but there's not much money to be made in prevention until whole-person care is rewarded when healthcare reform takes deeper root.

Then maybe physicians could go back to treating pyelonephritis or cellulitis or pneumonia or myocardial infarction or cirrhosis of the liver or heart failure.

Dr. Kevin said...

So well said...

I work with hypothyroidism and the first thing I do is address food sensitivities and stabilizing blood sugar. It's amazing how people after just doing this. But then again, I'm not an MD, I'm a doctor of natural medicine.

Dr. Kevin