Overdosed America (29 page)

On the day of surgery, Mr. Paul was lying on a stretcher, about to be brought into the operating room, when the neurosurgeon came by to ask him how he was feeling. Mr. Paul said that his pain had actually improved considerably in the previous few days. The neurosurgeon recommended that he get up off the stretcher and go home without surgery. He did. That was several years ago. When last I saw Mr. Paul he was almost completely pain free. The nonsurgery was a great success.

The saddest aspect of our excess spending occurs with end-of-life care, when people are most vulnerable and excess care can cause the most suffering. Unfortunately, this may also be the time when people are also most vulnerable to having supply-side care foisted upon them. Most of the terminally ill patients in my practice were elderly and ready to pass on when their time came. (The two most common fears, being alone and suffering, could usually be allayed by supportive families and good hospice care.) Often, however, the children of elderly dying patients were far less able to accept the inevitability of death—looking at the situation, as they must, through their own eyes and from their own station in life. Yet when seniors are actually given the opportunity to express their end-of-life preferences,
71 percent say they would rather die at home than in a hospital
, and 86 percent express the opinion that people with a terminal illness would prefer to be cared for at home.

Despite these clear preferences for less invasive and less hospital-based care,
people’s end-of-life wishes are usually ignored
. Sadly, even those people who have expressed a clear preference not to die in a hospital are no less likely than others to die in a hospital after all. The primary variable determining where and how people die is not their expressed preferences but the availability of hospital beds in their area. One of the most disturbing findings from the Dartmouth study of variations in Medicare spending was that people in the high-spending regions were almost three times as likely to receive “invasive life support,” meaning intensive care, emergency intubation, use of a ventilator, and feeding tubes, without any demonstrable benefit.

It behooves all of us to make our wishes known to our loved ones and especially to a person designated to speak on our behalf (a health care proxy) and to empower them to stand up, if necessary, to unwanted treatment at the end of our lives.

The cost of the oversupply of medical services to our nation’s pocketbook is staggering. Fisher and his colleagues estimate that 30 to 33 percent of Medicare expenditures could be saved nationally without compromising the quality of medical care. The goal of achieving these savings, they conclude, is “not unreasonable; after all, large metropolitan areas such as Minneapolis and Portland [Oregon] are getting along just fine with relatively modest Medicare expenditures.”

The comparison of health care expenditures among the OECD countries presented in
Chapter 4
comes to almost exactly the same conclusion. Whether we say we could spend 30 percent less on health care or we say we are spending 42 percent extra, the bottom line is that excess health care expenditures in the United States in 2004 will amount to about
$530 billion
(based on estimated total health care
expenditures of $1.8 trillion
).

The 2002 Annual Report of the White House’s Council of Economic Advisers (among them, Dr. Mark McClellan, before being appointed commissioner of the FDA and then Administrator of the Centers for Medicare and Medicaid Services) articulated the council’s general approach to health care: “
Markets respond more rapidly
than bureaucracies to the changing technology and new innovations in products and services that characterize the American Health Care System.” Markets do indeed respond quickly to changes in health care technology, but these responses do not necessarily lead to better health. Using the field of neonatology as an example, it’s easy to see that market-based solutions provide about twice the level of costly intensive care hospital services as other comparable countries—with no discernible health benefit. An article in
Health Affairs
, “Hooked on Neonatology,” suggests a different solution to improving the health of newborns: “Data from here and abroad suggest that some
combination of comprehensive social support
, preventive health care for women, comprehensive prenatal care, and easy access to family planning services may be far more cost-effective than neonatal intensive care.” Though the preventive approach is more likely to lead to healthier newborns, the market—left to its own devices—will not direct health care in that direction. Preventive medicine does not bring in the big bucks.

It is easy to understand why those profiting from this monumentally lucrative system want us to believe that market-driven health care is the best of all possible health care worlds. It is much harder to understand why doctors who have been trained to base their decisions on the best available evidence go along so willingly with health care American-style. That is the subject of the next chapter.

Even acknowledging the
medical industry’s exquisitely honed ability to shape our medical knowledge, it is still hard to understand why doctors—who are almost universally committed to providing the best care possible for their patients—are such willing participants in this overly commercialized dysfunctional system. Why don’t doctors just say no to providing medical care that is not supported by evidence that meets the highest standards of medical science?

Part of the problem is that professionals on the front lines of medicine have no reliable way to differentiate between care that is necessary and beneficial and care that has been pushed into use by financial incentives and will not stand the test of time. Much more important, however, is the template of “good medicine” that is permanently imprinted on doctors during their long years of training. Ever since Louis Pasteur discovered that bacteria cause disease, doctors have been committed to the biomedical approach to medicine: the idea that the cause and cure of every symptom and every disease can, with enough research, be understood and successfully treated at its most basic biological level. Modern scientists and doctors find this idea enormously appealing—identify the biological process that has gone awry, and fix it.

Consider the case of Mrs. Martin, a woman in her late fifties who had been my patient for many years. She always arrived for her appointments with her hair and makeup carefully attended to, and her greeting was always friendly and respectful—if a bit overly enthusiastic. At the beginning of one typical appointment, I walked into exam room 8 and found her sitting on the examination table with her feet, clad in the usual sneakers, swinging back and forth nervously.

When I asked how she was doing, she wasted no time getting right to the point. She said that her right knee had been hurting for about two weeks and had been swollen for several days. Tylenol hadn’t helped at all. She couldn’t remember any injury, hadn’t had a fever or a tick bite that would raise suspicion about infection (Lyme disease is common north of Boston), and no other joints were bothering her to suggest a systemic problem. She said she was particularly frustrated because her knee pain was interrupting her walking routine. Mrs. Martin had always been proud about keeping up her exercise—walking three to five miles at least five days each week.

As I finished my questions and was getting up off the stool to examine her knee, she made her expectations clear. She asked if I thought she needed an x-ray or MRI, and if one of the new drugs for arthritis might help. I said that those might be helpful, but asked if we could postpone a decision until I had a chance to examine her knee; then we could figure it out together. She agreed. I was relieved that the visit could proceed without becoming a contest of wills at the outset.

I started the exam by asking her to take a few steps across the room. She was favoring her right leg. On exam, her right knee was slightly warmer than the left, indicating the presence of inflammation. There was no redness that would have meant more intense inflammation or possibly even infection. With firm pressure I slid my hand down toward the upper part of her kneecap, and I could feel fluid inside her knee joint being pushed toward my other hand, which was cupped around the bottom of her kneecap. Full bending of her knee was restricted because the fluid inside the joint was acting like a water balloon, with the pressure increasing the more the knee was bent. On the positive side, there was no unusual looseness in the joint, ruling out a ligament injury. And there was no “catch” in the knee, which is sometimes, but not always, detectable when the meniscal cartilage is torn or frayed.

Mrs. Martin’s knee pain and swelling were almost certainly due to an acute flare-up of osteoarthritis, a weakening and erosion of the tough “articular cartilage” that covers the ends of the bones in our joints. When functioning normally, cartilage allows the joint to function with remarkably little friction—even with weight on the knee, there is only
one-fifteenth the amount of friction
between healthy cartilage-covered bones as there is when two smooth ice cubes are rubbed together. In osteoarthritis, however, the small fibers of the cartilage break down, disrupting the smooth surfaces and making the ends of the bones look moth-eaten. This is by far the most common kind of arthritis.

The fundamental cause of osteoarthritis is still not entirely clear. It appears that excess wear and tear somehow leads cells within the tough cartilage to
release enzymes that destroy the fibers
that make healthy cartilage so resilient. Unfortunately, there are no medications available that inhibit the intracellular process that is responsible for osteoarthritis; yet modern medicine does offer several remedies, mostly to relieve the pain. The first line of defense is weight loss, exercise, and, occasionally, physical therapy. Tylenol (acetaminophen) is the initial drug recommended for pain relief. If this doesn’t work, the
American College of Rheumatology’s
guidelines for the treatment of osteoarthritis recommend a “COX-2-specific inhibitor,” meaning Celebrex or Vioxx, to decrease the local inflammatory response (the biochemistry of which is quite well understood).

This is what doctors are trained to do: learn about the underlying biochemical and microscopic pathology that produces a problem such as osteoarthritis of the knee. Then we keep up to date with the best ways to intervene in this pathological process to help the tissues return to normal or at least control the symptoms—which, in this case, involved suggesting that Mrs. Martin cut back on her walking, lose a few pounds, and take expensive, long-term drug therapy.

Understand, diagnose, and treat, if possible, the local body part that is causing symptoms. This is the essence of the biomedical model.

But no knee is an island. Even if the biological process of cartilage destruction were completely understood, the biomedical explanation of osteoarthritis would still provide a grossly inadequate understanding of the inflammation in Mrs. Martin’s knee and would, by itself, still lead to minimally effective medical care. Mrs. Martin’s problem cannot be reduced to a description, even a perfect description, of the pathology in her knee. Of course there is pathology within these cells and the surrounding tissues, but it is impossible to understand the knee problem separated from the rest of her body and the rest of her life.

As her primary care doctor for many years, I knew that Mrs. Martin needed more than what the clinical guidelines advised. The cells in Mrs. Martin’s knee were malfunctioning because her walking was causing more wear and tear than Mother Nature had designed her knee to withstand. But I understood Mrs. Martin well enough to know that simply suggesting that she reduce her walking, as common sense would dictate, would have been very bad advice for her.

I first met Mrs. Martin about 15 years before this visit, when I was taking care of her husband, who was dying of lung cancer. Through the sadness and stress of her husband’s illness, I got to know her quite well. She is what you would call a worrier. Over the years, she had come to me seeking relief from panic attacks and insomnia. I referred her for psychotherapy, but it didn’t help, and she had no interest in trying counseling again. I prescribed several different medications, trying to ease her symptoms, but none provided enough relief to make the side effects worth putting up with. No doubt a combination of her genetic makeup, her formative childhood experiences, and her current life situation contributed to the chronic anxiety that plagued her. My job was to help her maintain her psychological equilibrium in ways that were not harmful to her health or, better yet, promoted it.

Mrs. Martin had learned over the years that the best medicine to keep the anxiety at bay was exercise, and her exercise of choice was walking. She knew all too well that the unpleasant fight-or-flight sensation would come roaring back as soon as she slacked off. Walking was a positive coping mechanism, especially compared with self-destructive alternatives such as smoking or alcohol abuse, but her knees weren’t designed to withstand the amount of walking required to control her anxiety. In fact, one could argue that the primary cause of Mrs. Martin’s osteoarthritis was her anxiety. And therein lies the problem with the biomedical approach. When we focus exclusively on the local cellular and biochemical pathology as the cause of disease, we often overlook other important sources of the problem and forgo opportunities to provide cure and relief.

Through the downs and ups of her life over the past 15 years, Mrs. Martin had come to trust that I understood that her walking was essential to keeping her anxiety and panic attacks under control. Walking meant the difference between a tortured life and a fulfilling life. Because she knew that I knew this, she was able to consider my suggestions. That is where we started our discussion.