The author is vague with all the studies and theories. It comes down to training. I was trained its about time, if you fail you move on and keep with your basics. Unfortunately even with that training, my fellow medics, still stay on seen and try the et three, four five times, ivs the same.... Then bring back some one they no longer should. If you examine high training areas such as medic one in Seattle they out perform any of those studies that take in whole all of ems..... If they want to als to be something they need to improve the training and emphasize timing, they used to have the seven minute rule. Seven minutes to call, seven minutes on scene, seven minutes enroute. They don't have the same outcomes as the author sites. He needs to look outside of the box and find where it does work and that's what we need to do. Als does work when it is used right same with any skill. Such as CPR, it needed to change also recently and not be taken out or done less, just be more effective in a time frame.
Ok, a lot of politics and economics on the comments, but, why ALS is actually worse? is it that the procedures are outdated? are inherently more dangerous? I could understand if ALS would not make no difference, how come is it worse!?
The author's thesis is that Advanced Life Support delays transport to definitive care (an emergency room) therefore negating any benefit and indeed causing overall statistical detriment. Not saying I necessary agree, but that's the logic proposed. That being said, I wouldn't automatically dismiss it either. It warrants more research.
1
I'm a professional ALS Paramedic, and I will happily tell you that this is 100% a political article and 0% a medical one.
This "author" is basically saying "You have a greater chance of surviving a visit to your Primary Care Physician than an ICU, therefore we can clearly get rid of those useless ICU's." Well, no we can't. I worked as an EMT for years, and the patients that EMT ambulances are dispatched on are an entirely different class of patient than a paramedic would be dispatched on. Nearly every modern 911 system has what is called a tiered dispatch system. Those that don't generally dispatch BLS first and then the BLS providers decide on scene whether ALS is required (the ALS rig will then continue or be canceled).
Additionally if a BLS provider found themselves on scene with an ALS patient, they upgrade to that level and we are dispatched. So it would be pretty rare for a BLS ambulance to ever bring an unstable PT to the ER. This means all the unstable PT's are coming in via ALS ambulance. Then they have the nerve to say we are useless because more people who were only on BLS ambulances survive? There is literally no internal logic to the thought process and the entire article, and first major study mentioned are predicated entierly on false assumptions of EMS operations. Instead of "calling state offices to ask" perhaps the authors should have included some ALS agencies in their planning. I've worked in several ALS prehospital studies.
This "author" is basically saying "You have a greater chance of surviving a visit to your Primary Care Physician than an ICU, therefore we can clearly get rid of those useless ICU's." Well, no we can't. I worked as an EMT for years, and the patients that EMT ambulances are dispatched on are an entirely different class of patient than a paramedic would be dispatched on. Nearly every modern 911 system has what is called a tiered dispatch system. Those that don't generally dispatch BLS first and then the BLS providers decide on scene whether ALS is required (the ALS rig will then continue or be canceled).
Additionally if a BLS provider found themselves on scene with an ALS patient, they upgrade to that level and we are dispatched. So it would be pretty rare for a BLS ambulance to ever bring an unstable PT to the ER. This means all the unstable PT's are coming in via ALS ambulance. Then they have the nerve to say we are useless because more people who were only on BLS ambulances survive? There is literally no internal logic to the thought process and the entire article, and first major study mentioned are predicated entierly on false assumptions of EMS operations. Instead of "calling state offices to ask" perhaps the authors should have included some ALS agencies in their planning. I've worked in several ALS prehospital studies.
Here is an easy fix- patients and/or their family and/or estate must pay for 20% of all expenses incurred in the last 6 months of life. Everyone has a little skin in the game. If you want to have a pacemaker or dialysis in your 90's so be it but not without some expense to you.
2
That sounds perfectly acceptable to me, especially in socialized medicine where I live, work and pay taxes to support. Fully agree.
There's a lot of brain damage in many cases after CPR has been done on them -- usually not because of the CPR but because of the shortage of oxygen to the brain . At 86, I would prefer to not endure CPR.
As a CPR instructor I feel it is important that as many people learn basic CPR skills as possible. We can't have ICU on every corner, but we can have large number of people who can call 911, initiate high quality compression and use an AED.
Over many year of teaching students I have seen many cases where bystanders made a real difference.
http://sanmateocprcertificationclasses.com/
Over many year of teaching students I have seen many cases where bystanders made a real difference.
http://sanmateocprcertificationclasses.com/
1
Unfortunately, the standard of care, once there is been a bad outcome is: was Everthing and Anything, that in retrospect might have helped, done. If not it is malpractice. "Doctor at this point might ABC have prevented this death?" If this answer is maybe then it is considered to be bad care. That is why we do so much potentially futile care.
1
The Taiwan article cited here actually does show that advanced life support helped. However, the difference between 7% survival and 5% survival was not "statistically significant". The probability that the 7:5 odds ratio benefit could have been coincidence was "0.17", or 17%.
Would you pay for an i.v. and a couple of doses of adrenaline to improve your odds of survival from 5% to 7%?
Would you pay for an i.v. and a couple of doses of adrenaline to improve your odds of survival from 5% to 7%?
1
My oncologist knowns when to treat me and when not to treat me. She is incredible wise.
2
Rather then looking at the uselessness of ALS vs BLS they should look at the awful state of end-of-life care.
6
Yesterday, my husband and I had an elderly pet "put down." He had heart and lung issues, and has not been getting enough oxygen to the brain and was falling and having stroke like symptoms as a result.
Today, my daughter called to tell me that her husband and his sister were called to the hospital where there 80 + year old father was taken for dehydration and a kidney infection. He has not been at home since before Thanksgiving but has been back and forth from a stroke rehab facility and the hospital. Today, the medical team wants to discuss palliative care.
Reading this article on the heels of these two family events highlights the difficulty so many have in talking about end of life matters and making decisions. As a now retired person who served for several years as a hospital chaplain, I would encourage any one, patient or family member, who is facing major end of life decisions and encountering difficulties to involve health care chaplains! Many are gifted at cutting through the crap, the red tape and supporting decision making that is truly in the patient's best interest. As previously noted, often more treatment means a longer dying process without quality of life. And there is a vast difference between euthanasia and palliative care!
Today, my daughter called to tell me that her husband and his sister were called to the hospital where there 80 + year old father was taken for dehydration and a kidney infection. He has not been at home since before Thanksgiving but has been back and forth from a stroke rehab facility and the hospital. Today, the medical team wants to discuss palliative care.
Reading this article on the heels of these two family events highlights the difficulty so many have in talking about end of life matters and making decisions. As a now retired person who served for several years as a hospital chaplain, I would encourage any one, patient or family member, who is facing major end of life decisions and encountering difficulties to involve health care chaplains! Many are gifted at cutting through the crap, the red tape and supporting decision making that is truly in the patient's best interest. As previously noted, often more treatment means a longer dying process without quality of life. And there is a vast difference between euthanasia and palliative care!
21
I also put a dog down after almost 17 years but sometimes I still sit in the dark and visit with him. Those moments yield a powerful, inexplicable comfort. God knows it helps.
2
Good for you! The medicalisation of old age and especially the end of life has reached its logical, but insane, zenith. TIme to return it to family, friends, chaplains and any other human(e) but non-medical case managers! All the ethical dilemmas of unnatural acts of euthanasia will be suddenly non-issues. A life spent upright deserves death with dignity.
10
The authors of the JAMA article have made false conclusions that are not supported by their hypothesis or study methods. The only conclusion one can make is that billing for BLS results in better outcomes for MEDICARE patients than billing for ALS level care in urban areas. We know nothing about the billing in rural areas from this article and we know nothing about the actual care that was provided.
5
In US, one other factor plays out in the decision called “fear of a lawsuit” when “not doing enough” gets converted to “the negligible act of a medical professional”, as the lawyers get involved.
2
So, considering the source of the study is Canadian, is the conclusion that advanced life support should only be considered in exceptional cases? Did they provide the anticipated cost savings? Is there a plan to push the use of DNR authorizations with an eye to controlling costs? While that seems chilling, if I live to be elderly and end up in that situation, I might chose to avoid the consequences of so much life support as the quality of my life after such would likely be nil.
6
Am I the only person who is uncomfortable with the use of the Cross to make what is essentially a secular interpretation of a bad political consequence.
1
This is a cross small c meant to be a neutral symbol, not the religious Cross capital C. That should be obvious from the appearance of it. See: http://en.wikipedia.org/wiki/Emblems_of_the_International_Red_Cross_and_...
1
Sorry, Charlie. There are no small 'c' Crosses with which the faithfully departed are memorialized. In my opinion, this is another example of an unnecessary exploitation. The intention perversion of specific sacred religious content, to illustrate a political narrative. I am against the exercise of such universally less useful liberties and am tired of reading about otherwise disinterested innocent parties having to protect themselves from its consequences.
1
Charlie? As in Charlie Hebdo?
As a doctor with 30 years of practice, the biggest problem I see in health care is the conflict between the availability of tools to preserve live, and the growing mass of the very elderly population. This leads to huge dollars spent on "futile care". Is ACLS effective or not? If it preserves life, what kind of life?
I see 96 year old demented patients started on hemodialysis by the agreement of enabling doctors and families who've been led to believe that they must do everything to keep Mom alive at all costs. To add "only in America" seems superfluous. Doctors who imagine that they'll be blamed if Mom dies at age 96 lend a further sense of unreality to this equation, of how far our behavior has drifted from a common sensical way of understanding things. I should add that a lot of doctors treat this situation with understanding and perspective, but some do not.
Despite everything, the death rate is still 100% according to the latest data. We must improve and examine how we handle the inevitable in the USA.
I see 96 year old demented patients started on hemodialysis by the agreement of enabling doctors and families who've been led to believe that they must do everything to keep Mom alive at all costs. To add "only in America" seems superfluous. Doctors who imagine that they'll be blamed if Mom dies at age 96 lend a further sense of unreality to this equation, of how far our behavior has drifted from a common sensical way of understanding things. I should add that a lot of doctors treat this situation with understanding and perspective, but some do not.
Despite everything, the death rate is still 100% according to the latest data. We must improve and examine how we handle the inevitable in the USA.
31
One line of thought on preventing painful and futile care is to change the economics so that patients and doctors have more "skin in the game" Essentially making medical care less affordable for the patient and family, and unprofitable for the doctor.
For those of us who value doctors mainly for their expertise, however, adding a monetary conflict of interest doesn't improve the wisdom of the patient nor the trustworthiness of the doctor.
A better plan might be to increase the reimbursement for actual time spent with the patient over the lifespan, so that the doctor's advice would be better grounded in an individual patient-doctor relationship.
In short, familiarity breeds respect.
For those of us who value doctors mainly for their expertise, however, adding a monetary conflict of interest doesn't improve the wisdom of the patient nor the trustworthiness of the doctor.
A better plan might be to increase the reimbursement for actual time spent with the patient over the lifespan, so that the doctor's advice would be better grounded in an individual patient-doctor relationship.
In short, familiarity breeds respect.
2
As a volunteer EMT (BLS), the study results do not surprise me. When confronted with a heart attack, BLS providers know we can't do much, so we move -- fast -- to get the patient to a hospital. ALS providers are able to do much more for a patient and all that intervention takes time.
9
Wow! I read these statistics in the reverse:
“87 percent of patients who received basic life support DID NOT SURVIVE to be discharged, versus 91 percent of patients who received advanced life support. And 92 percent of patients who received basic life support DID NOT LIVE for 90 days after discharge, compared to 95 percent who received advanced life support.” So most patients died, and fairly quickly. And of those who survived, it’s not clear what their “neurological outcome” was.
So, yes, I agree: Less is More. And I’m going to hazard a guess that this conclusion applies to many, many medical treatments today. We seem to have totally lost track of “First do no harm.” To what end are we inflicting all this harm that painful, debilitating, and oftentimes dangerous treatments cause?
“87 percent of patients who received basic life support DID NOT SURVIVE to be discharged, versus 91 percent of patients who received advanced life support. And 92 percent of patients who received basic life support DID NOT LIVE for 90 days after discharge, compared to 95 percent who received advanced life support.” So most patients died, and fairly quickly. And of those who survived, it’s not clear what their “neurological outcome” was.
So, yes, I agree: Less is More. And I’m going to hazard a guess that this conclusion applies to many, many medical treatments today. We seem to have totally lost track of “First do no harm.” To what end are we inflicting all this harm that painful, debilitating, and oftentimes dangerous treatments cause?
12
Another in a long line of articles indicating that the medical profession often knows less than it thinks it does. It's not alone in this, for instance mutual fund management is no better- statistically speaking- than random stock picking, political punditry is less reliable than simple opinion polls, economics is not called the 'dismal science' for nothing etc. Decision making under uncertainty is hard.
What makes medicine seem different is that doctors are so valued by us, and rightly so, that their expertise is not evaluated rationally. In particular they are equated to scientists, people who, to a lesser or greater degree, follow a set of rules to establish what they know. Whether because of tradition, difficulty in applying those rules, or simple hubris, medicine routinely lacks that rigor. I constantly have to explain this to my 15 year old daughter, who is convinced doctors must be *better* than scientists! And maybe, in some respects they are, but not in reliability of what they believe is known. And don't even get me started on nutritionists!
What makes medicine seem different is that doctors are so valued by us, and rightly so, that their expertise is not evaluated rationally. In particular they are equated to scientists, people who, to a lesser or greater degree, follow a set of rules to establish what they know. Whether because of tradition, difficulty in applying those rules, or simple hubris, medicine routinely lacks that rigor. I constantly have to explain this to my 15 year old daughter, who is convinced doctors must be *better* than scientists! And maybe, in some respects they are, but not in reliability of what they believe is known. And don't even get me started on nutritionists!
6
Explain one recurring observation: ill doctors themselves are much less likely to accept many of the extreme things that their patients get to do. This could be because doctors deliberately push such treatments for gain (not really commonplace based on personal observations over 30+ years), fear of consequences of not visibly doing everything in our litiginous world, or patients have unrealistic expectations that make them demand even the demonstrably useless. So it is not necessarily that doctors lack rigor or do not know that they don't know all that much, it is convincing the desperate patient of that deficiency that is often difficult.
2
More isn't necessarily better and the question of quality of life needs to be considered. Problem is that the current medical system takes on a blank, empty stare, as do the majority of physicians inhabiting the system, when it comes to the quality of life question. In the past three years I've had four physicians unable to diagnose what seems to be a systemic issue in my body...unfortunately it seems that they've only been trained to come up with fixes. One of them said, "Maybe this is your new normal" but sat there and offered no solutions, nor any referrals to figure out HOW to live as fully as possible with this "new normal." For those answers I was on my own baby and it was necessary to become my own "doctor."
Six months later, in looking/pursuing my own answers to having some semblance of quality of life, it was then too ironically funny to walk in to a medically sponsored meditation group (which the doctor could have referred me to, but didn't) and lo and behold, the good doctor was herself in that group! Apparently that group and quality of life solution was good enough for her but not her patient?! Fix as much as possible and cut patients loose to fend for themselves when there's no more to be done.
E-gads, what's the point of having a doctor when they themselves are unable to identify one of the reasons for having medicine in the first place: to make the life each of us has left, worth the living of it.
Six months later, in looking/pursuing my own answers to having some semblance of quality of life, it was then too ironically funny to walk in to a medically sponsored meditation group (which the doctor could have referred me to, but didn't) and lo and behold, the good doctor was herself in that group! Apparently that group and quality of life solution was good enough for her but not her patient?! Fix as much as possible and cut patients loose to fend for themselves when there's no more to be done.
E-gads, what's the point of having a doctor when they themselves are unable to identify one of the reasons for having medicine in the first place: to make the life each of us has left, worth the living of it.
9
Thomas Jefferson supposedly said that when two or more physicians gather, buzzards can't be far. The urge to do more is ingrained in all of us, not just physicians. "Don't just stand there, do something!" Well, maybe not. Health care is a good/service the less consumed, the better. Yet, we measure the level of development of a country in part by how much health care is consumed. In the U.S. a large part of health care spending is on diagnostics, which reflects both our wealth and our fear of the future. Yet, diagnostic errors occur frequently, and contribute to substantially higher health care costs. What's next: telemedicine/monitoring. Soon enough, grandma and grandpa will wear monitors so that they have 24/7 health care. Not.
5
Have not read all 126 comments, but the ones I have read seem to have left out the entire question of Quality of Life. Sad but true, people and their bodies do wear out. The last thing I look forward to is being bedridden with an acute and razor sharp mind. No, I don't want to run a 4 min mile, but I would like my body to function half as well as my mind. And if my mind gives up and departs, I would want my viable body parts to go to others. Lets face it, we all start to die as soon as we are born. Too often we are taught to view death as some kind of failure on our part. Instead it should be talked about and looked at as the logical progression of our life.
I do worry that in our rush to keep people alive and "living" we too often forget that we radically change what we mean by " alive and living.' We are not alive and living in the same manner as a 25, 35 or 55 year old.
We do need to make allowances for the decisions of the individual. I'm not here to say you have to die when you get sick. I'm trying to strike a balance. We are discovering that many juvenile cancer treatments can lead to serious problem in later life. We need to improve treatments so they do not become a Trojan Horse.
Kind of confusing, but I hope the read will understand the point/s I am trying to make. Just a layman's observations and thoughts.
kapm
PS We need to make sure the results of the cure aren't as bad or worse than the disease.
I do worry that in our rush to keep people alive and "living" we too often forget that we radically change what we mean by " alive and living.' We are not alive and living in the same manner as a 25, 35 or 55 year old.
We do need to make allowances for the decisions of the individual. I'm not here to say you have to die when you get sick. I'm trying to strike a balance. We are discovering that many juvenile cancer treatments can lead to serious problem in later life. We need to improve treatments so they do not become a Trojan Horse.
Kind of confusing, but I hope the read will understand the point/s I am trying to make. Just a layman's observations and thoughts.
kapm
PS We need to make sure the results of the cure aren't as bad or worse than the disease.
13
Sometimes it actually feels that it doesn't really matter if the patient lives or dies.
What this country needs is a comprehensive insurance coverage single payer not just for profit, just like most of the citizens of the developed countries in the world possess. The ACA is flawed, probably the worst health care system in all our peer countries, but it is better than the de facto criminal health plan of the Republicans. I don't like their plan either - be rich or don't have a bad life event.
Millions more people are now insured, the worst criminal aspects of the Republican plan like pre-conditions, dropping you if you get sick are gone, thanks God.
What this country needs is a comprehensive insurance coverage single payer not just for profit, just like most of the citizens of the developed countries in the world possess. The ACA is flawed, probably the worst health care system in all our peer countries, but it is better than the de facto criminal health plan of the Republicans. I don't like their plan either - be rich or don't have a bad life event.
Millions more people are now insured, the worst criminal aspects of the Republican plan like pre-conditions, dropping you if you get sick are gone, thanks God.
15
Sensible assessment for a sensitive subject. More is not necessarily better, and the best is, in most cases, worse than the good. And with finite resources, if financial conflicts of interest, and fear of malpractice, can be eliminated, a more rational system may emerge, as it should. Anecdotal 'savings' will always intrude in our thinking,,,but critical recommendations based on good logic and experience, and, yes, statistics, must prevail.
4
My mother, 91, dementia, recently fell. Her PT A(six weeks) is complete. I'm now scrambling to find a nursing home The body has healed, the mind cannot. Anyone dealing with this knows the difficulty and pain in finding a good nursing home and in watching a loved one go through the loss of independence.
This past decade - 2006: Open Heart Surgery; 2009: removal of skin cancer, removal of nipple w/recommendation of radiation, which I refused. Meds for kidney failure, heart failure, insulin for diabetes, pills for Macular Degeneration, she can hear.
2012- non compliance with meds; 2013:geriatric psyche unit 5 wks, paranoia/delusional thinking. Nursing home recommended but I knew better. I took her home, where nothing could convince her that it was 3 am not 3 pm. Ever seen a person sundown?
2014: Rehab for fall because of her focus to an examining table for a possible UTI, where she fell, fractured her pubic bone/smacked her head, She sees/talks with dead relatives.
We learned how to fix the heart, replace the joints, lift our faces to look younger. The list goes on. What we've never learned is how to accept we are mortal and when to stop.
Excellent book/Gawande/Mortality. Also, for those caring for or those who don't believe how stressful all this can be for all, I suggest AgingCare website, real stories about real people suffering from this horrendous disease.
I'm Christian, I now see prolonged medical intervention as playing God.
This past decade - 2006: Open Heart Surgery; 2009: removal of skin cancer, removal of nipple w/recommendation of radiation, which I refused. Meds for kidney failure, heart failure, insulin for diabetes, pills for Macular Degeneration, she can hear.
2012- non compliance with meds; 2013:geriatric psyche unit 5 wks, paranoia/delusional thinking. Nursing home recommended but I knew better. I took her home, where nothing could convince her that it was 3 am not 3 pm. Ever seen a person sundown?
2014: Rehab for fall because of her focus to an examining table for a possible UTI, where she fell, fractured her pubic bone/smacked her head, She sees/talks with dead relatives.
We learned how to fix the heart, replace the joints, lift our faces to look younger. The list goes on. What we've never learned is how to accept we are mortal and when to stop.
Excellent book/Gawande/Mortality. Also, for those caring for or those who don't believe how stressful all this can be for all, I suggest AgingCare website, real stories about real people suffering from this horrendous disease.
I'm Christian, I now see prolonged medical intervention as playing God.
26
In 2003, my mother presented with abnormal nipple discharge. She had a negative mammogram. A ductal (galactogram) study of the breast was abnormal and path was malignant.
Still in medical training she, received a breast MRI to assess both the affected and opposite breast. Both breasts had significant carcinoma in situ.
After meeting with all the experts, Mom chose a bilateral mastectomy.
Though this may seem like a case where advanced, expensive care was taken at the front end, my Mom is cancer free more than a decade later.
Moreover, she has never had to undergo anxiety provoking medical oncology, radiation oncology or medical imaging followup. I'm quite sure her tough personal decision has resulted in less net overall medical cost and less personal stress.
Stephen Zink, MD
@harlemrad
harlemradiologist.com
Still in medical training she, received a breast MRI to assess both the affected and opposite breast. Both breasts had significant carcinoma in situ.
After meeting with all the experts, Mom chose a bilateral mastectomy.
Though this may seem like a case where advanced, expensive care was taken at the front end, my Mom is cancer free more than a decade later.
Moreover, she has never had to undergo anxiety provoking medical oncology, radiation oncology or medical imaging followup. I'm quite sure her tough personal decision has resulted in less net overall medical cost and less personal stress.
Stephen Zink, MD
@harlemrad
harlemradiologist.com
8
Do not forget: there are many times that doing more does more. It's too bad the Times never highlights these stories, but maybe it's not news anymore that healthcare is delivered everyday in lifesaving and routine ways that benefit people's health. The only articles the Times ever publishes are anti-doctor/RN/EMT/clinical personnel and anti-biomedical healthcare system. Don't drink the kool aid--it's bad for your health.
Patients and doctors have to weigh the risks and benefits of every intervention, including doing nothing, and then take the risk that their choice may have unintended side effects, unexpected or known complications.
If a patient cannot decide for herself due to incapacity, it is up to the family delegate to decide within cultural customary measures. If we as a society want to define differently what are customary measures, that's another discussion altogether, and one that will evolve over time naturally.
Patients and doctors have to weigh the risks and benefits of every intervention, including doing nothing, and then take the risk that their choice may have unintended side effects, unexpected or known complications.
If a patient cannot decide for herself due to incapacity, it is up to the family delegate to decide within cultural customary measures. If we as a society want to define differently what are customary measures, that's another discussion altogether, and one that will evolve over time naturally.
10
The other thing the Times and other media don't report is who paid for the studies. There are a series of studies that promote minimal treatment that may be paid for by interests that are conflicted, insurance companies for example. It would be helpful to know.
10
ACLS is a longstanding failure surrounded by multi-million dollar industry supporting ACLS education, which is useless. Doctors and nurses must re-do ACLS every two years, a forever annuity to the American Heart Association. Its anothe scam.
9
The oath that I took when I graduated medical school said 'First do no harm' and often that means do nothing. Patients still don't always get that especially here in New York City where they often want EVERYTHING done. Even when the data is not supportive of that paradigm. Part of the issue is the discomfort of other physicians with standing down, the financial incentive to do anything, and the family wanting care even if futile. Another issue is we continually read about miraculous advances in medicine - we hold out hope that it will apply in THIS case. The result is that we lose confidence in the body's ability to heal itself if we get out of the way.
I grew up in medicine in an exciting time with many advances and yet in so many areas it is the simple things that make the biggest differences. It is why I am such a proponent of preventive medicine - it is still the biggest game changer. You want to prevent disease? Exercise.
I grew up in medicine in an exciting time with many advances and yet in so many areas it is the simple things that make the biggest differences. It is why I am such a proponent of preventive medicine - it is still the biggest game changer. You want to prevent disease? Exercise.
15
Not really sure what the takeaway is here. A more focused look at the pre-hospital issue, without all the tangents, might have been more clear. Regardless, BLS vs ACLS in the field is not a useful study - they have to do everything in the absence of full history, etc. The real question is why are we doing an hour of ACLS on dying patients in the ICU? Because families insist and doctors don't want to give up - and of course because residents need to practice placing lines while compressions are underway (it's tricky!)
5
I'm uncomfortable basing recommendations for everyone based on Medicare patients. Did they perhaps use as a control the number of Medicare patients who died in that time period who did NOT have emergency admissions to the hospital? I'm sure there were a "statistically significant" number. Perhaps you could do a study showing that hospital admission is strongly correlated with increased mortality too. We shouldn't project these figures to deny aggressive emergency treatment for younger people, for whom accidents are a leading cause of death.
2
Statistical results show the effectiveness of a procedure for the 80% in the results that create the 'norm'. The outliers, are just that, outside the norm. And there are of course, those who are helped enormously by the procedure, just as there are those for whom it provides no help, and the few who are harmed.
How hard for those who FIND breast cancer from mammograms, or serious prostate problems from the prostate screening to think they would have never had the life saving test if the 'standards' were applied.
How hard for those who FIND breast cancer from mammograms, or serious prostate problems from the prostate screening to think they would have never had the life saving test if the 'standards' were applied.
1
Some of those women getting mastectomies rather than breast-conserving surgery are no doubt demanding the mastectomy. Some women -- not all, of course, once they hear they have breast cancer, want the breast removed out of a fear the cancer will return.
2
The problem is that in a certain population of women that is not an informed decision to have a mastectomy or it at be an unrealistic one.
This is another attempt by the corrupt insurance industry to continue their endless crusade for coverage cuts. The tone of the article is misguided because treatments MUST BE INDIVIDUALIZED. These are statistics, frequently used by third party payers to DENY medical coverage. Patients characteristics determine whether a total mastectomy may, in a particular circumstance, be potentially more beneficial than a lumpectomy. The same applies to advanced cardiac life support in certain settings. M. Pappolla, MD, PhD
9
Keeping biomass alive for fun and profit.
1
Denial of care is what's known in Obamacare as the Death Panels. Designed to withhold care to redice cost.
1
Obamacare is going to solve some of the overuse problem. With a bronze level plan, my insurance doesn't kick in until I hit $10K of expenses. If I go to the ER, it costs me a $850 co-pay that does not count against my deductible. I'm going to have be pretty sick before going to a doctor and it will take a lot of convincing to ever get me in the door of an ER.
3
When you're "pretty sick" enough to see a doctor, will you accept "no treatment" in exchange for your $? That's the gist of the author's message.
The answer is not so simple. It is not just tort reform or universal insurance. It is a more nuanced collaboration between the patient the physician and society. We need to have discussions on expectations while the patient is well so we don’t fall down the rabbit hole of doing everything in an emergency because we don’t know what else to do.
It is the discussion of what are the consequences of various choice – say uncontrolled diabetes or hypertension – or for that matter smoking, drugs or alcohol.
It is the realistic expectations of the results of the intervention. How often have I heard my patient say ‘I dont mind dying, I just don’t want to have a stroke,’ and I have to explain to them that they might not have the choice if they choose surgery. Then I say what do you want us to do if you have that stroke, and their response ‘I don’t want to think about it.’
It is looking at health in a vacuum instead of the reality that it is part of everything we do. Do we pay for that marginal treatment and raid the kid’s college fund.
Until we act like adults and put all aspects of healthcare - including natural limits, the discussion will degenerate to the greedy insurance or the greedy doc or the victimized patient instead of real answers.
It is the discussion of what are the consequences of various choice – say uncontrolled diabetes or hypertension – or for that matter smoking, drugs or alcohol.
It is the realistic expectations of the results of the intervention. How often have I heard my patient say ‘I dont mind dying, I just don’t want to have a stroke,’ and I have to explain to them that they might not have the choice if they choose surgery. Then I say what do you want us to do if you have that stroke, and their response ‘I don’t want to think about it.’
It is looking at health in a vacuum instead of the reality that it is part of everything we do. Do we pay for that marginal treatment and raid the kid’s college fund.
Until we act like adults and put all aspects of healthcare - including natural limits, the discussion will degenerate to the greedy insurance or the greedy doc or the victimized patient instead of real answers.
6
The hardest thing when faced by a suffering/dying patients -"Don't just do something , stand there". "Standing there" to witness, comfort, observe, or wait is often the best we can do for the patient.
4
Sometimes it is not even the patient who "wants more" - frequently it is the family.
Having case managed ICU's, time and time again, I saw patients who would have gladly shied away from further more extensive, more expensive treatment.
However to please their loved ones, they endured, they succumbed, they suffered. And why? To provide biding "more time" and/or "wait and see time" as they say in ICU llingo.
Having case managed ICU's, time and time again, I saw patients who would have gladly shied away from further more extensive, more expensive treatment.
However to please their loved ones, they endured, they succumbed, they suffered. And why? To provide biding "more time" and/or "wait and see time" as they say in ICU llingo.
8
Amen to that. Worked EMS for almost 30 yrs. So many times we knew an older person (above 90) was dead and wouldn't be brought back with any quality of life but the family demanded we do everything possible. People need to talk to their family members BEFORE they "die"--not have the family fight afterwards in the heat of the moment.
1
" it’s hard not to lay some of the blame on economics. After all, in a fee-for-service system, more visits and more treatments mean more money."
How often do doctors recommend a more expensive procedure when less invasive, equally effective, and, yes, cheaper alternatives work just as well.
Case in point, treatments for the chronic regional pain syndrome that developed in my hand after a wrist fracture and surgery to repair the break. Everyone agreed that physical therapy was the key to my recovery. In spite of the fact that there were medications to control pain and allow me to benefit more from the exercises, and that I experienced significant improvement after a month of this regimen, one pain specialist insisted that I needed a nerve blocking procedure. One of his arguments was that my insurance ( Medicare) would pay for it. Luckily, I got a second opinion.
Until we get rid of fee- for- service, profit will continue to result in more treatments that mean more money.
How often do doctors recommend a more expensive procedure when less invasive, equally effective, and, yes, cheaper alternatives work just as well.
Case in point, treatments for the chronic regional pain syndrome that developed in my hand after a wrist fracture and surgery to repair the break. Everyone agreed that physical therapy was the key to my recovery. In spite of the fact that there were medications to control pain and allow me to benefit more from the exercises, and that I experienced significant improvement after a month of this regimen, one pain specialist insisted that I needed a nerve blocking procedure. One of his arguments was that my insurance ( Medicare) would pay for it. Luckily, I got a second opinion.
Until we get rid of fee- for- service, profit will continue to result in more treatments that mean more money.
4
Value = Quality/Cost
Most of us understand this relationship when we comparison shop for clothes, cars, schools, etc. But when it comes to healthcare, we remain blissfully ignorant. The sad reality is that the quality of our care is below average compared to the top developed countries but costs 2x as much. We get 50% of the value compared to the UK, Canada, Australia, etc.
Most of us are now insured. But since insurance pays for most of our care, we rarely see the full cost. Hospital bills don't reflect the true costs either. The average hospital stay costs $500/d (as much as $2000/d in an ICU) - more than a luxury hotel! I'll bet if given the choice, most people would rather use this money now to take their family on a vacation than stay in a hospital during the remaining days/weeks of their lives.
I am a critical care doctor. I treat the sickest of the sick daily. Families always ask, "will my loved one live?" I never tell them statistics because people don't understand them, especially when stressed. The odds of winning the Powerball are 1:175 million = statistically 0. Yet millions of people keep playing. Statistics won't convince critics.
Providers need clear, evidence-based guidelines that also incorporate value. Doctors and patients/families need to regularly reevaluate the situation to decide when enough is enough. We need to reward providers for improving heath, not just for providing care. This is what the ACA was designed to do.
Most of us understand this relationship when we comparison shop for clothes, cars, schools, etc. But when it comes to healthcare, we remain blissfully ignorant. The sad reality is that the quality of our care is below average compared to the top developed countries but costs 2x as much. We get 50% of the value compared to the UK, Canada, Australia, etc.
Most of us are now insured. But since insurance pays for most of our care, we rarely see the full cost. Hospital bills don't reflect the true costs either. The average hospital stay costs $500/d (as much as $2000/d in an ICU) - more than a luxury hotel! I'll bet if given the choice, most people would rather use this money now to take their family on a vacation than stay in a hospital during the remaining days/weeks of their lives.
I am a critical care doctor. I treat the sickest of the sick daily. Families always ask, "will my loved one live?" I never tell them statistics because people don't understand them, especially when stressed. The odds of winning the Powerball are 1:175 million = statistically 0. Yet millions of people keep playing. Statistics won't convince critics.
Providers need clear, evidence-based guidelines that also incorporate value. Doctors and patients/families need to regularly reevaluate the situation to decide when enough is enough. We need to reward providers for improving heath, not just for providing care. This is what the ACA was designed to do.
11
NYC Commuter
You are the doctor I would want to work with in the ICU's.
You are correct about how many people never see a bill - or pay attention to what it entails. After being eligible for Medicare, our whole mindset towards cost has changed. When we see how little Medicare reimburses, then throw in the cost of secondary premiums, the whole healthcare insurance world after 65 has taken on a different meaning.
I cannot imagine those ICU bills and reimbursement values, (considering many ICU patients are of Medicare eligible age) especially when we see many patient outcomes that are not what patients/families hope for - through no fault of the health care providers.
You get the ACA and advocate for it. Good for you. President Obama needs more of you and should be aware of who you are and what you stand for.
Patients and their families need to appreciate your mind set. It is for real.
Thank you.
You are the doctor I would want to work with in the ICU's.
You are correct about how many people never see a bill - or pay attention to what it entails. After being eligible for Medicare, our whole mindset towards cost has changed. When we see how little Medicare reimburses, then throw in the cost of secondary premiums, the whole healthcare insurance world after 65 has taken on a different meaning.
I cannot imagine those ICU bills and reimbursement values, (considering many ICU patients are of Medicare eligible age) especially when we see many patient outcomes that are not what patients/families hope for - through no fault of the health care providers.
You get the ACA and advocate for it. Good for you. President Obama needs more of you and should be aware of who you are and what you stand for.
Patients and their families need to appreciate your mind set. It is for real.
Thank you.
4
Dr.you have explained it well.
1
The Institute of Medicine did a study several years ago where they analyzed the root causes of death in the United States. They found that the third leading cause of death was medical care. Do no harm is a motto still worth following.
4
to revive a heart with chest compression causes broken ribs in the elderly and I was told as a nurse that hardly any time does cardiac compression actually result in a revived heart in the elderly- although it is a lifesaver for the middle age.
On the other side, old people deserve good care to simply live-- I have a 102 year old friend and I so enjoy her - she reads the new Yorker Magazine and tomorrow we are meeting at the nursing home to watch her Amaryllis bloom-
On the other side, old people deserve good care to simply live-- I have a 102 year old friend and I so enjoy her - she reads the new Yorker Magazine and tomorrow we are meeting at the nursing home to watch her Amaryllis bloom-
3
Here's yet another doctor arguing for death panels. No wonder the public has lost trust in their physicians. That's especially true because the doctors who make these arguments all complain about how dumb other doctors are. So how are we to know who the smart ones are -- who to believe? Decisions about life and death are too important to be left to the doctors.
1
The article cites two areas of medicine: out of hospital cardiac arrests which have been known for decades to have low success rates. We cannot fail to do CPR because of this. Several studies indicate that advanced life support is less effective than basic life support. Good. Let the evidence accumulate and treatment may change. In breast cancer treatment women often dictate the form of treatment when several approaches are available. We, as a society, are not going to deny them that. But these two examples cannot lead us to the conclusion that less in medicine is more. The case for evidence-based medicine is compelling whether it is less or more and the illnesses that afflict us are legion. Each must be considered on its own merits.
Please don't use the pronoun "we" in this. The preaching should be done to medical providers at all levels who initiate - generally automatically - excessive responses. And then claim it is all what the patient wants, and file claims for payment. I am tired of hearing how fear of malpractice is a reasonable justification for hospital and Dr. decisions, as if there can be no professional obligation to try to do the correct thing, and to explain why. Some patients and families want extreme measures; but increasingly many better informed ones do not, and have to work at convincing health care providers that they are serious.
4
I've been reading (and hearing, mainly on NPR) this very same garbage since Obamacare was a fevered dream of the democrats 7 years ago. I recognized instantly what this propaganda was, an apparently thought up on the fly, second grade type argument to get the average american to accept less health care because Obama and the democrats intended to give another something for free (healthcare) to millions that they knew would subsequently become democrat voters. After all who can resist Santa Claus in the guise of Pelosi, Reid and Obama. it is the same as insulting me with the promise of my healthcare choices not eroding even though there were going to be millions more people competing for the same finite set of healthcare resources, or even insulting me with the lie that if I liked my current healthcare policy I could keep it. Democrats: trying to talk me out of radiation therapy IS death panels, in another guise, so sell your ridiculous arguments to the Canadians or the British, they have already drank the Kool aid.
4
You express yourself in a way that will not find much support amongst readers of this newspaper, and it is anti-scientific to blindly claim that more health care is always better. Better health care is better.
But you are correct that, when the same entity pays AND decides what care to dispense, there is a definite conflict of interest. This is a terrible ethical problem in single-payer systems such as the UK's.
But you are correct that, when the same entity pays AND decides what care to dispense, there is a definite conflict of interest. This is a terrible ethical problem in single-payer systems such as the UK's.
2
I want you to take an elderly dementia patient into your home. Give them the meds that are keeping their bodies intact. Take them to their medical appointment while listening to the doctors tell you how 'wonderfully they are doing'. Keep it up! Smile. Prepare their diets, wash their sheets umpteenth times a day, take the diapers they're wearing off the floor because they've pulled them down, 'just because'. After you've washed the floor, make sure they've bathed (oh, I forgot, you can't wash the floor because you have to watch the patient to make sure they don't leave the house). Now you have to try to get them to rinse themselves off (not easy, they don't like bathing).
I don't believe in Euthanasia. I also don't believe in keeping people alive artificially when God is trying to tell us to let them die naturally. We don't want to witness death. But many of us are now doing just that. With no help from people who haven't done it yet.
This is why I believe in Hospice Care, palliative care, not medical intervention. Medical intervention can only take one so far. Then it's God's turn (or whomever you believe).
I don't believe in Euthanasia. I also don't believe in keeping people alive artificially when God is trying to tell us to let them die naturally. We don't want to witness death. But many of us are now doing just that. With no help from people who haven't done it yet.
This is why I believe in Hospice Care, palliative care, not medical intervention. Medical intervention can only take one so far. Then it's God's turn (or whomever you believe).
8
Jordan, I find your attitude troubling: "insulting me with the promise of my healthcare choices not eroding even though there were going to be millions more people competing for the same finite set of healthcare resources" So you are OK with not sharing? Even more than OK: You support actively not sharing. As long as you have yours, anyone else -- millions of anyone elses -- can go without? Where did you learn this?
4
For those of you responding to this pice by resorting to the tired trope about the need for 'tort reform' I would direct you to statistics generated by the Director General of Health and Human Services which reported in 2010 that Medicare records reveal that medical malpractice caused or contributed to the deaths of 180,000 Americans over the age of 65 in that year alone. Medical malpractice is the third leading cause of death in America.
So please, stop blurting out the dogma fed to us by politicians whose pockets are lined by the medical industrial complex and repeated ad nauseum by the media about the need for 'tort reform'.
We need to cleanup medicine; not the tort system that makes some meager attempt to compensate victims of the system.
So please, stop blurting out the dogma fed to us by politicians whose pockets are lined by the medical industrial complex and repeated ad nauseum by the media about the need for 'tort reform'.
We need to cleanup medicine; not the tort system that makes some meager attempt to compensate victims of the system.
22
After 35 years of observation, my data is purely anecdotal. I usually note that the best care can be delivered with basic procedures coupled with a total lack of screwup. Zero mistakes will always maximize outcome over more complex, invasive, or innovative approaches. Complex, invasive, and innovative are the breeding ground of errors. As in all things; Keep It Simple, Stupid.
37
Thyroid problems might also be over-treated.
Most thyroid cancers are tiny and very slow-growing. Yet a total thyroidectomy is the standard treatment, and is often used even if the thyroid merely has nodules, and no cancer was found on biopsy or the biopsy results are equivocal. It seems easier (more profitable?) just to excise the thyroid rather than repeat the biopsy.
Although the thyroid gland is a major player in the body's metabolism, and is part of the very delicately balanced hypothalamic-pituitary-thyroid (HPT) axis, many surgeons regard it as an optional organ, like the appendix.
Just take one Synthroid tablet per day forever, all will be well...
Tell me: If there's no need for the continual micro-adjustments of the HPA axis, why did the body bother to make them? Why would replacing the HPA with a steady dose of thyroid hormone with a long half-life make no difference to the body?
One of my adult daughters has thyroid nodules, and a biopsy coming right up. When we asked the endocrinologist about Memorial Sloan-Kettering research that advises repeated ultrasounds rather than a rush to thyroidectomy, he literally shouted us down. Yet thyroid surgery can damage the vocal cords and/or parathyroid glands.
Travel and self-pay for a NYC second opinion are beyond our means, so we must make do with what's available. It's wearying to face an entrenched local medical establishment at the very start of a new era.
Most thyroid cancers are tiny and very slow-growing. Yet a total thyroidectomy is the standard treatment, and is often used even if the thyroid merely has nodules, and no cancer was found on biopsy or the biopsy results are equivocal. It seems easier (more profitable?) just to excise the thyroid rather than repeat the biopsy.
Although the thyroid gland is a major player in the body's metabolism, and is part of the very delicately balanced hypothalamic-pituitary-thyroid (HPT) axis, many surgeons regard it as an optional organ, like the appendix.
Just take one Synthroid tablet per day forever, all will be well...
Tell me: If there's no need for the continual micro-adjustments of the HPA axis, why did the body bother to make them? Why would replacing the HPA with a steady dose of thyroid hormone with a long half-life make no difference to the body?
One of my adult daughters has thyroid nodules, and a biopsy coming right up. When we asked the endocrinologist about Memorial Sloan-Kettering research that advises repeated ultrasounds rather than a rush to thyroidectomy, he literally shouted us down. Yet thyroid surgery can damage the vocal cords and/or parathyroid glands.
Travel and self-pay for a NYC second opinion are beyond our means, so we must make do with what's available. It's wearying to face an entrenched local medical establishment at the very start of a new era.
22
M.L. Chadwick, I'm so sorry that you feel stuck with your local health care provider. But can you fashion another care plan with him or her, one more tailored to and in line with recent research? I remember one little old lady telling me that when discussing treatment options for dealing with a new breast cancer in her late 70s (after a double mastectomy in her mid 30s), she declined radiation therapy -- and the radiation oncologist stomped out of the room. This was 12 years ago. Recent research supports the little old lady's position. But this story had a happier ending: The RO came back and apologized to her. And the little old lady patient is still with us. So have the courage of your convictions: You have the right to decide on your treatment.
1
Thank you, Dr. J.
As I noted, my attempt to negotiate was met by the physician shouting at me. He did this twice. Quite stern and patronizing. I'm mild-mannered.
Unless the physician changes his mind and apologizes, our only option is to seek a second opinion... maybe a third or fourth. I've been through this literally dozens of times, as my husband and I have two daughters with birth defects, one of whom--in her mid-30s--is under our guardianship.
Maine is one city's worth of people scattered over a vast geographic area. Our previous searches for quality care have taken from 4 to 20 years. We're now old and tired. Yes, thank you for your encouragement, we will keep trying to "negotiate."
I've now done intensive study and written a 30-page literature review on thyroid nodules and controversies in their treatment. Not being listened to while female... well, there was a great NYT article about that the other day. My husband has studied my little tome, and this time HE will talk to the doctor.
As I noted, my attempt to negotiate was met by the physician shouting at me. He did this twice. Quite stern and patronizing. I'm mild-mannered.
Unless the physician changes his mind and apologizes, our only option is to seek a second opinion... maybe a third or fourth. I've been through this literally dozens of times, as my husband and I have two daughters with birth defects, one of whom--in her mid-30s--is under our guardianship.
Maine is one city's worth of people scattered over a vast geographic area. Our previous searches for quality care have taken from 4 to 20 years. We're now old and tired. Yes, thank you for your encouragement, we will keep trying to "negotiate."
I've now done intensive study and written a 30-page literature review on thyroid nodules and controversies in their treatment. Not being listened to while female... well, there was a great NYT article about that the other day. My husband has studied my little tome, and this time HE will talk to the doctor.
4
General studies (at Dartmouth) have shown 25-30% of medical bills are for overdiagnosis as well as overtreatment.
Patients as well as doctors want everything possible done because it might help. Few consider it might be worse.
Added to the 25% overhead for most private insurance (Medicare and Medicaid have 3% overhead). America could cut its medical cost In half, but that would cause much unemployment and lobbying dollars.
Patients as well as doctors want everything possible done because it might help. Few consider it might be worse.
Added to the 25% overhead for most private insurance (Medicare and Medicaid have 3% overhead). America could cut its medical cost In half, but that would cause much unemployment and lobbying dollars.
9
We love to vilify the healthacre and pharmaceutical industries - yet we have the indisuptably best healthcare in the world. Perhaps the real issue is the "research" industry holed up in academia.
Researches live by the motto "publish or perish". They need to publish in order to attract grants that reinforce their income as well as enhance their prestige and position within their respective institutions.
We should be more cynical of "research". There are so many extraneous variables that can skew the results of any findings. Moreover, we need to be equally aware of the economic motivations behind the research before we jump to conclusions.
Researches live by the motto "publish or perish". They need to publish in order to attract grants that reinforce their income as well as enhance their prestige and position within their respective institutions.
We should be more cynical of "research". There are so many extraneous variables that can skew the results of any findings. Moreover, we need to be equally aware of the economic motivations behind the research before we jump to conclusions.
2
Actually, I think it's highly disputable that the U.S. has the "best" healthcare in the world--certainly if you look at outcomes, we do not. What we have, indisputably, is the most expensive healthcare in the world--but much of that money is wasted and--worse--spent on treatments that erode quality of life with no, or only trivial, extensions of disease-free life.
45
Bob, name one measure by which we have the best healthcare in the world.
9
At one time I would not have agreed with you but I've changed after seeing the 'quality of care' given in some of the best hospitals in this country.
Now I just don't know what to think anymore.
Now I just don't know what to think anymore.
4
I was good with this article until they started beating the dead horse about lumpectomy vs mastectomy for women.
Health writers/policy analysts just don't get why a woman might prefer total removal to being left with a malformed body that will continue to require yearly monitoring.
Health writers/policy analysts just don't get why a woman might prefer total removal to being left with a malformed body that will continue to require yearly monitoring.
9
You're probably right about some of them. But - I imagine even a man could see that it gives greater peace of mind to put the problem behind you. No one can calculate the individually-varying cost/risk/impact of instead carrying that monkey-on your-back with you day after day after day after day. It's hard for any of us to entirely see all the factors and understand their true potential impact. Unfortunately this is a choice between the lesser of two evils. Try to take an clear view of the risks unclouded by unreasoning fear. On the other hand, I don't think intuition is superstition.
Another possibility it seems is that when the advance life support teams arrive, if the patient seems relatively strong, that they only do the basic life support procedures. So, even if the dispatcher sends teams out randomly, this could effect the statistics.
7
Dr Carroll, talks about the worse outcomes and then shies away from exploring it.
Assuming the medical care of an individual patient on record is different than talking on the TV show or writing a general article.
In USA, worse outcome in a patient or their next of kin, who does not believe that they are getting every possible, not just probable shot at getting better is a death sentence to the practicing physician. Try the randomized controlled data on the jury in the death of a thirty year old mother of two whose cancer came back. Please reform the Tort law protecting physicians dignity and license when in spite of treating as per the Guidelines, a bad out come occurs and not left to the mercy of non medical peer's interpretation of the randomized controlled trials.
The Monday morning quarterbacks from the academic pedestals always talk retrospectively about how less care is better. It is the priming of the non medical intellectuals to accept the "less" is the new substitute for "right" care.
Assuming the medical care of an individual patient on record is different than talking on the TV show or writing a general article.
In USA, worse outcome in a patient or their next of kin, who does not believe that they are getting every possible, not just probable shot at getting better is a death sentence to the practicing physician. Try the randomized controlled data on the jury in the death of a thirty year old mother of two whose cancer came back. Please reform the Tort law protecting physicians dignity and license when in spite of treating as per the Guidelines, a bad out come occurs and not left to the mercy of non medical peer's interpretation of the randomized controlled trials.
The Monday morning quarterbacks from the academic pedestals always talk retrospectively about how less care is better. It is the priming of the non medical intellectuals to accept the "less" is the new substitute for "right" care.
11
"Do not go gentle into that good night. Rage, rage against the dying of the light.” Dylan Thomas must have had America, 2014, in mind when he wrote those words. Americans have this idea that they never should get old and wear out, let alone die. Those from the "greatest generation", that are still with us, bemoan government debt and its affects on their grandchildren, but have no concept of how they, themselves, are running up this debt using every available test and treatment as they head out the door. As for the boomers, the "botox" generation, they are even worse; grasping at the straws offered by medical science, no matter the cost, to try and fend off what is to every other species an act of nature, but to the boomers seems like an affront. I am of that boomer generation and I have worked in the medical field for almost 40 years, witnessing the astounding waste of resources on train-wrecks that aren't repairable. It's shameful. As citizens, our selfishness to claw for one more day, instead of pausing and accepting our circumstance, is the American Way. The Republicans knew just how to play to our fears by speaking of "death panels" in the early days of the ACA. Yet, truth be told, most of us cannot be trusted to make wise decisions with health care, especially in old age. Rationing may be a bad word, but it is a necessary consequence of our lack of wisdom. The boomers should start the conversation going.
31
judgeroybean - yes trust is the key. In general, we each are the most qualified to look out for our own best interests - the person most worthy of our own trust. As we get older and our mental agility declines, the strengths and abilities of others may result in the most worthy placement of trust shifting.
Recognize however, that it is very frequently lesser worthiness. Even family members have their own wellbeing to consider over ours. And governments and payors and physicians (in no particular order) are even farther down the scale.
Recognize however, that it is very frequently lesser worthiness. Even family members have their own wellbeing to consider over ours. And governments and payors and physicians (in no particular order) are even farther down the scale.
2
As a long-time ICU nurse, I have observed that the people who push on with more and more invasive treatment for desperately sick patients are about equally divided between physicians who feel they must do every last possible thing and families who feel that they must agree to every possible last thing. There's also a smaller group of patients whose families cannot agree on whether to add treatment, or not. There is nothing like an estranged and guilt-laden adult child to step forward and insist on "everything" being done. The default is always, always, to do more. Doctors are rarely sued for doing "everything".
Personal feelings and family dynamics will always cloud the data.
Personal feelings and family dynamics will always cloud the data.
To my mind, the purpose of medicine is to help the sick body heal itself. And this requires observing, listening, and knowing when to intervene and how.
I don't find the author's criticisms of "more" treatment to be helpful or insightful. "More" is vague, it can mean almost anything. I think it would better to discuss what constitutes "appropriate" and "effective" treatment. General measurements of "less" and "more" are immaterial.
I don't find the author's criticisms of "more" treatment to be helpful or insightful. "More" is vague, it can mean almost anything. I think it would better to discuss what constitutes "appropriate" and "effective" treatment. General measurements of "less" and "more" are immaterial.
10
TL - Yup - as mentioned earlier, Facts Matter.
1
This is one of those cases where what is true in a factual/data sense will probably make no difference in a practical sense. Science and medicine are done by human beings who respond to trends and fads just like every other area of society. If it makes the practitioners feel better to use a more thorough treatment method, that is probably what they are going to do. Medical care isn't just about what helps the patient. It is also about what makes the practitioner feel better about helping the patient.
If you really want to be surprised about medical care, read up on the real and lasting effects that double-blind placebos have in helping people get better. If these cures are 'all in their heads', they are a pretty powerful set of effects.
Scientists are convinced the entire field of homeopathic medicine is nothing but placebo cures, and people spend a lot of money on homeopathic medicine. Facts and beliefs are often on opposite ends of the rational scale of thinking, but both work and both are necessary. Human beings are not only rational actors, or even primarily rational actors, even if a lot of scientists and atheists wish they were.
11
Based on my well-considered and long-established religious and philosophical beliefs, I feel that my health would be radically improved by ten million dollars, tax-free, placed delicately in the trunk of a Rolls Royce Silver Ghost and presented to me for my birthday, and you have no right whatsoever to claim otherwise.
9
Robert - But I do have a right to claim otherwise, and I feel your health would be radically improved if the Rolls and contents were instead delivered to ME.
4
Lets call it greed. It's like going to an "all you can eat" establishment and you fill your plate to the brim even though you know that you cannot eat all and even if you can, it's bad for you. No patient wants less than "everything possible", whatever that means, treatment. The patients want to live as long as possible, as well as possible, regardless of the cost to the society. After me, the flood, is the prevailing attitude. Money do play a role in clinical decision. If a physician has to choose between an expensive and mutilating treatment and a safer, less invasive one, its no surprise that the more expensive one will be proposed. This happens as long as the government is willing to pay the higher price. Some can go as far as suppressing clinical trial completion and suppression of unfavorable results. Some invasive and expensive treatments are promoted by experts as superior, in spite of lack of scientific evidence. It becomes impossible to conduct proper research because it would be perceived as unethical. Where there is doubt, one has the liberty of doing anything. And then there is the fear of lawyers. Few doctors risk to be perceived as not doing "everything" for their patients, because it doesn't matter if they are right or not. What matters in litigation is the perception. The more aggressive the patient is, the worse the treatment. Greed is good, but not for everyone.
4
I don't think this is true. There are more than enough patients to keep almost all doctors very busy, and I have never encountered a doctor who chose a therapy only on the basis of reimbursement. (I am a retired physician). Moreover, many physicians are salaried, and do not profit from recommending costly treatments. I have yet to meet any physician who would propose a "mutilating" treatment without a compelling medical reason. Surgeries and other hospital-based procedures are reviewed by other physicians and often must be authorized by insurers, or sent for second opinions. A physician who advised an inappropriate treatment would be subject to peer review, which could lead to discipline.
I acknowledge that there are exceptions; the NYT recently cited the example of a plastic surgeon whose billing was outrageous. But it was as outrageous to the medical community as it was to the general public.
I think the great majority of physicians try to act in the best interests of their patients.
I acknowledge that there are exceptions; the NYT recently cited the example of a plastic surgeon whose billing was outrageous. But it was as outrageous to the medical community as it was to the general public.
I think the great majority of physicians try to act in the best interests of their patients.
7
Thank you jaime, and I agree. There is such a thing called medical ethics, which most physicians follow. The outragoeous costs are often devised by MBA administrators playing reimbursement games. As you point out, most physicians don't benefit from "more tests" anyway, unless they own labs.
Yeti says: "Money do play a role in clinical decision" but than says "It becomes impossible to conduct proper research because it would be perceived as unethical", which makes no sense.
Yeti says: "Money do play a role in clinical decision" but than says "It becomes impossible to conduct proper research because it would be perceived as unethical", which makes no sense.
2
The problem with basing care on the averages in studies is that there is no way to know if you are an average person or an exceptional person who actually benefits from the care. People are willing to bet other people's money that they are the exception and the studies are meaningless to them. You then are left with either letting each person make a choice for themselves or allowing others to make it for them. Few people prefer the latter, which is why meaningful cost control is virtually unattainable.
12
I am a retired physician. One of the retired nurses from our department, was diagnosed 6 months ago with a terminal illness. She did elect to undergo chemotherapy, which had devasating side effects. It took her several months to partially recover from the worst of these, during which time she was treated as an inpatient, and then in a rehabilitation center. She finally elected, to stop all treatment, other than paliative treatment to only control distressing symptoms, and was managed at home by a local hospice organization. Her final month at home under hospice care was the most peaceful time she had from the moment she received her chemotherapy. It was a blessing to see her peaceful and happy. She certainly realized when it was time to stop. I hope that we can all recognize that time when it arrives.
55
Once a person is 80 or 90 yrs old if they have serious health issues a DNR should be in effect for them. Giving elderly patients statins is harmful. Giving 90 yr old women Calcium can also be harmful. Many treatment practices are still "old school" and presribing such medications and supplements should be discontinued as they are of little value and do nothing to improve the quality of life.
11
my father was in his nineties when he broke his shoulder in a pedestrian/automobile interaction. The doctors advised to do nothing. He had splinters of bone poking his skin for several years and pain--I regretted that we did not guide him thru surgery- he would have done whatever was recommended- having been a test pilot - he was unaffraid. I regret that family did not urge him to do the surgery and everybody is an individual no matter what age..
12
Your father's injuries were quite awful and only surgery would have corrected the alignment of the bones. Surgery is a huge risk for anyone in their nineties. Sorry that he suffered the pain but I believe you would have lost him sooner than necessary.
5
Have to disagree with you there - logically surgery was the only way of improving/restoring his quality of life; the anticipated quantity of life vis a vis surgery would require more knowledge of his overall condition/comorbidities and "lost him sooner than necessary" is an entirely speculative construct on your part.
2
If I wanted speculative observations I would go to the comic sections of the paper. I wonder who paid for this piece, the Insurance lobby?
11
Wait a minute! The 3 month survival rate of these patients was terrible. The 3 month survival rate of those receiving basic life support was 0.0104 (one in a hundred) and for those receiving advanced life support 0.0045 (half of one in a hundred. These were all medicare patients, therefore over 65 who got basic or advanced life support because their hearts stopped. My conclusion would be that patients with such poor chances of survival aren't a good test case. Also we weren't given the statistics - were the survival rates statistically different from zero?.
22
I think there may be some confusion. Both sets of statistics refer to the total patients meaning 8% of all patients who received basic care survived for 90 days, not 8% of the 13% who were discharged. When read this way the long term survival rates, while still low, are 3% above those who received advanced life support and that is statistically significant.
One thing the article fails to mention is the sample size in each pool. Over those 3 years there were 31,000 people who received advanced support, where as there were only 1,600 who received basic support.
One thing the article fails to mention is the sample size in each pool. Over those 3 years there were 31,000 people who received advanced support, where as there were only 1,600 who received basic support.
7
Thanks for the information. At those rates I wouldn't bet my house on it.
3
Josh is right - 8% of all the patients given basic life support survived 90 days, not 8% of the survivors. Similarly, 3% of all the patients given advanced life support survived 90 days. Sorry!
The percentages are low, lower than I'd have guessed from reading/hearing about those who were saved and went on to do newsworthy things. But nowhere near zero statistically. Due to the difference in numbers of patients the percentage for advanced life support patients is more reliable.
The percentages are low, lower than I'd have guessed from reading/hearing about those who were saved and went on to do newsworthy things. But nowhere near zero statistically. Due to the difference in numbers of patients the percentage for advanced life support patients is more reliable.
There's no secret to some of the major problems with our so-called health care system. It's for-profit (with CEOs of "non-profit" hospitals making millions), and puts making money above providing good care. Hospitals and doctors (or their corporate employers) make money by doing more procedures, regardless of their benefit. I'm sure fear of malpractice suits adds to the p unnecessary procedures. The costs of everything from a band-aid to open heart surgery varies widely, with no rhyme or reason, and doesn't correspond to outcome. Charges for everything are often wildly expensive and out of line with what they should be. And the existence of insurance companies, which provide nothing of benefit and sucks a huge amount of money from health care into the pockets of middlemen, is a complete waste.
The interesting thing is there are solutions to our health care mess, but we ignore them. Every advanced country provides universal health care based on one of a few models at less cost and with better results than we do. Using their examples, we could do the same. It would look nothing like the ACA, and it would require a complete overhaul of our current system. It would be painful, many people and interest groups wouldn't like it, and it would have to be phased in carefully to minimize the disruption. But the end result could be a health care system that is fair, that we could be proud of, and works for all Americans.
The interesting thing is there are solutions to our health care mess, but we ignore them. Every advanced country provides universal health care based on one of a few models at less cost and with better results than we do. Using their examples, we could do the same. It would look nothing like the ACA, and it would require a complete overhaul of our current system. It would be painful, many people and interest groups wouldn't like it, and it would have to be phased in carefully to minimize the disruption. But the end result could be a health care system that is fair, that we could be proud of, and works for all Americans.
42
You imply that national health care systems around the world are simple. But, they have all struggled since WWII with rationing, cost, tough choices. The successful versions share several characteristics.
First, they are highly decentralized and community based. (ACA is the largest centrally controlled system in the world.)
Second, the populations they treat tend to be less than 80 million people. US is looking at 325 million and up.
Third, they do not have a government-sponsored for-profit third-party "malpractice" lawsuit industry which is also a major funder of lawmakers. They resolve issues at local levels, often with the patient and doctor talking to each other directly. In the US one can see lawyer "trolling" billboards in every city.
If we got rid of the state-by-state local regulatory boards, and then established local health care "communities" of perhaps 100,000 individuals, we would have much better health care.
The "for profit" thing is a red herring. The problem is central state-supported near monopoly control by government-supported big pharma, devices, malpractice, insurance, etc.
This article reveals how hard it is for people to "choose less" intervention, invasion, second-guessing, and administrative cost (which is profit to the administrators).
First, they are highly decentralized and community based. (ACA is the largest centrally controlled system in the world.)
Second, the populations they treat tend to be less than 80 million people. US is looking at 325 million and up.
Third, they do not have a government-sponsored for-profit third-party "malpractice" lawsuit industry which is also a major funder of lawmakers. They resolve issues at local levels, often with the patient and doctor talking to each other directly. In the US one can see lawyer "trolling" billboards in every city.
If we got rid of the state-by-state local regulatory boards, and then established local health care "communities" of perhaps 100,000 individuals, we would have much better health care.
The "for profit" thing is a red herring. The problem is central state-supported near monopoly control by government-supported big pharma, devices, malpractice, insurance, etc.
This article reveals how hard it is for people to "choose less" intervention, invasion, second-guessing, and administrative cost (which is profit to the administrators).
13
Marty, re the second characteristic, what dynamic comes into play as the covered population rises above 80 million?
The PPACA is "centrally controlled," only in sense that there are rules, and was always designed so that individual states would run their own delivery systems.
2
We here in the United States really need to learn when to say no to advanced medical treatment. We need to stop spending soooo much money on aggressive treatments for people who would clearly benefit more from end of life care. None of us is getting out of this world alive. We need to accept that fact and help our terminally ill loved ones die in peace and with dignity. Of course that idea doesn't generate as much money for the greedy, money grubbing for profit medical community so it is unlikely to be implemented.
28
A big limitation to evidence based practice is the tort system. The tort system punishes you anytime there is a bad outcome, whether or not you followed the evidence base. There really is not option but to pile on extras, in case there is a bad outcome. Reform the tort system, and we can practice less expensive medicine. I would like nothing more than do just about everything based on history and physical examination with minimal testing.
10
The so-called tort system does not punish "bad outcomes." It punishes wrongdoing, malpractice and incompetence.
6
SML, that is what we wish the tort system did, but this isn't really true in reality. I can tell you from experience that physicians face lawsuits for plain old "bad outcomes" quite frequently. Even when there is clearly no wrongdoing, malpractice insurers and counsel will often recommend settling for some modest amount, perhaps $100K - $500K instead of risking the expense, time, and uncertainty of a jury trial. The experience of being sued, sometimes frequently, truly does influence physicians to over-treat and over-test, in order to avoid future lawsuits and have better "I-did-everything-possible" defense when they are inevitably sued at some point in their career.
9
Paul Michael, that happened to my father, a physician with a patient with so many co-morbidities and multiple specialists care (think neurologists, cardiologist, pulmonologists, etc.), and her kids, one of which was a nurse, dared have the audacity to sue my father for malpractice. When her multiple 3-inch thick files were reviewed by the physician of the insurance company, he said "This doctor did everything possible to save this patient." She was dead because she continued to do the one thing my father said was making her chronic conditions worse: living with her dysfunctional kids. He told her they were killing her; but she, being a mother, still wanted to live with her adult dysfunctional kids. After her death, the family realized how good a doctor my father was, and even became his patients. Their problem was not accepting that they were the problem and not accepting that despite doing everything right, bad outcomes can happen.
3
Good point, but pre-hospital ACLS is a minuscule sliver compared with the money spent on unnecessary CT scans, MRIs and bogus surgeries for knee pain and back pain. 1 year of ACLS across the country probably pays for 1 day of unnecessary tests and procedures. Target a really big target like that, and I think you will actually make a dent.
16
This article highlights how important shared decision making is in deciding the right care for patients. It should ultimately be up to the patient to decide how much or how little healthcare they want, after they have been fully informed about the pros and cons of any medical care. Unfortunately, default care is often the most intensive care, whether or not the patient is on board. Primary care providers, when they develop a trusting relationship with their patients, can help navigate the ever-expanding menu of options afforded by modern medicine.
3
I agree with your point for many medical decisions, but your comment does not address the issues raised by the article. If you need urgent life-saving care, you are unlikely to be in a position to evaluate the best option. You will be getting treatment from a paramedic or EMT who is following the policy of his or her agency or company. This is a situation in which a sound public policy is needed.
Beyond that, there are significant reasons that shared decision-making may lead to bad decisions. It is often in doctors' interests to provide more care, not only financially and legally, but emotionally. Even if doctors accept the results of studies like those cited, they are only human and many have trouble facing the emotion-laden demands of many patients and family members who want more care in life-threatening situations if it is available.
Why is it my business what care you choose to get? Because society is paying for most of it, either through government programs or insurance. I believe that rationality and science should determine the limits of what gets paid for. If you can pay for not-science-based care, go ahead. But for most of us, science-based care is all we are entitled to receive, and it is usually the best available care as well.
Beyond that, there are significant reasons that shared decision-making may lead to bad decisions. It is often in doctors' interests to provide more care, not only financially and legally, but emotionally. Even if doctors accept the results of studies like those cited, they are only human and many have trouble facing the emotion-laden demands of many patients and family members who want more care in life-threatening situations if it is available.
Why is it my business what care you choose to get? Because society is paying for most of it, either through government programs or insurance. I believe that rationality and science should determine the limits of what gets paid for. If you can pay for not-science-based care, go ahead. But for most of us, science-based care is all we are entitled to receive, and it is usually the best available care as well.
8
NeilG1217 - That's the challenge - determining science-based care.
As we have seen, there is frequently more to the story, and the various participants each have their own biases or limitations, conscious or unconscious. The best decisions are based on the most facts, but few have all the facts, and fewer weight them accurately. So getting to "science-based" isn't trivial.
As we have seen, there is frequently more to the story, and the various participants each have their own biases or limitations, conscious or unconscious. The best decisions are based on the most facts, but few have all the facts, and fewer weight them accurately. So getting to "science-based" isn't trivial.
1
Thank you for your response.
To your first point, one goal is to make patient preferences clear with advance care directives for all adults when they are well and clear-minded so that patient preferences are carried out if and when the time comes that one may need urgent life-saving care. For example, a Physician Order for Life Sustaining Treatment (POLST) is a medical order that is a directive to emergency medical personnel to not perform CPR for patients who have a do-not-resuscitate order.
To your second point, I think you misunderstand the true meaning of shared decision making. If done correctly, debiasing both the provider and patient from preconceived notions about what is "right care" is part of the process. Agree with you that it is often hard for physicians to do this in the wake of emotions, financial incentives, etc., and the medical community is slowly coming around to reclaiming the ethical fiduciary responsibility to our patients by respecting patients' preferences, and the concept that often times "less is more."
Ideally, rationality and science should determine the limits of what should get paid, but if you've ever practiced medicine, you know that there are so many gray areas where the evidence is not clear and that we need to respect patient preferences and values in light of the limitations of the state of current science.
To your first point, one goal is to make patient preferences clear with advance care directives for all adults when they are well and clear-minded so that patient preferences are carried out if and when the time comes that one may need urgent life-saving care. For example, a Physician Order for Life Sustaining Treatment (POLST) is a medical order that is a directive to emergency medical personnel to not perform CPR for patients who have a do-not-resuscitate order.
To your second point, I think you misunderstand the true meaning of shared decision making. If done correctly, debiasing both the provider and patient from preconceived notions about what is "right care" is part of the process. Agree with you that it is often hard for physicians to do this in the wake of emotions, financial incentives, etc., and the medical community is slowly coming around to reclaiming the ethical fiduciary responsibility to our patients by respecting patients' preferences, and the concept that often times "less is more."
Ideally, rationality and science should determine the limits of what should get paid, but if you've ever practiced medicine, you know that there are so many gray areas where the evidence is not clear and that we need to respect patient preferences and values in light of the limitations of the state of current science.
A wise doctor once told me when i was a resident, "Don't just stand there, do nothing." Sometimes the hardest thing to do in medicine is nothing. Interesting studies. It is easy to confuse motion for progress and hard to dial back dogma.
37
You stole my line! Every time I'm asked what I'm doing, I say I'm substituting motion for progress. The wise doctor probably said "Don't just do something, stand there". At least that's the way I say it (even if I'm not wise).
1
skalramd - the meaning of your words is that you're engaging in motion instead of progress. You're saying progress was there already, and you came along and put motion in its place. You substituted motion where progress was. Is that what you meant to say?
This article makes one fundamental mistake. 911 dispatchers, while without medical training, are trained in classifying calls in categories. An abdominal pain call is not the same as a trauma or a cardiac arrest. Most 911 systems dispatch ALS to highly critical jobs, such as heart attacks, traumas, and cardiac arrests, while dispatching basic units to minor injuries, sick calls, asthma attacks, and other conditions appropriate to BLS's more limited scope of care. It's no surprise that patients who received advanced life support die more - they are much much sicker!
34
I agree with this comment. Although the article states that the dispatcher can't tell if it is a mild or severe attack based on a phone call, I would contest that. Even if a third party lay person calls, dispatchers are likely trained well enough (or learn through experience) that they can get an idea from the third party how sick the person is, even if they have a cardiac arrest. For example, they could ask if the person is breathing, are they alert, able to talk,etc. From my time answering phone calls on-call, I often can get an idea not just from the content of the call but the tone, speed, breathlessness, etc. of the caller how serious a medical situation might be.
5
I worked EMS. I never worked out the stats but can say that for the ten yrs we were basic we had one save from CPR - due to the person lying in a snow bank for ten minutes would be my guess. The next ten we had a defibrillator and had about 1 save a yr. For the next ten we were full out ACLS and had about 5 saves a yrs. This is in a town of 20,000. When I say "save" I mean going on to lead a productive life. For a little one who drowned that meant another 90 yrs of productivity. Getting to an ED fast does what? ACLS. Small town EDs do VERY little in the ACLS dept that a medic crew can't do--only the medics do it 10-20 minutes earlier. This study may be applicable in an urban area but doubtful it is in a rural one.
You'll never convince Americans that more is not more. This is why we can't have socialized medicine. Statistics and better outcomes and lower costs and any other metric you want to throw at us just rolls off like a duck's back. We seem hard-wired not to believe. All I can hope for is the crippling, crushing burden of the baby boomers on younger generations. Maybe then we'll get it.
15
We're in an era that has elevated 'common sense' to exalted status. That's a result of deeply conservative or religious people feeling slighted and marginalized by intellectual elites who upturned the traditional social order in the 60's culture war. Elevating "common sense' above academic learning returns their sense of dignity and worth. But that comes at a price, one being inefficiencies in healthcare because "common sense" dictates escalating medical interventions to the maximum.
7
Lives_Lightly - I don't feel you've supported your argument.
I get the issue with trying to save money, but I think there is a risk saying not to bother with certain procedures in the name of cost saving. Then again, I sort of have my own anecdotal story that supports case brought up in this article. When I was diagnosed with ulcerative colitis the doctor wanted to cut to the point and take out the colon. I saw someone else who prescribed a steroid (forget the name of the prescription) and asacol with enemas. I've been in remission for about a year now, no colon having to be removed etc. Another anecdotal story, but not relating to me but a friend, had sleep apnea..did the surgery that removed uvula. He was dead in 2 days. Sleep apnea is a real problem, but eh..considering the risk I rather just use the oxygen tank over that of dealing with uvula removal and it's risks. So I don't think there is really a solid black and white area and more grey than anything else.
Certainly if someone needs open heart surgery or whatever else, these need to be addressed. But for moderate UC, a colon removal might not be needed immediately.
As for containing costs, I'm a big supporter in giving RNs and Nurse Practitioners more tasks that currently physicians do. Nurse Practitioner Specialists can take over many tasks that in-office physicians of dermatology, gastrointestinal specialties. RNs could be given the tasks of physicals, other basics and perhaps even basic script writing (excluding antibiotics, opium based products.)
Certainly if someone needs open heart surgery or whatever else, these need to be addressed. But for moderate UC, a colon removal might not be needed immediately.
As for containing costs, I'm a big supporter in giving RNs and Nurse Practitioners more tasks that currently physicians do. Nurse Practitioner Specialists can take over many tasks that in-office physicians of dermatology, gastrointestinal specialties. RNs could be given the tasks of physicals, other basics and perhaps even basic script writing (excluding antibiotics, opium based products.)
6
I've seen a study showing that while primary care nurse practitioners earn less, due to their lower education, they refer more patients to specialists, thus increasing the total cost of care.
1
I agree with the article in that we have a for profit health system that gets paid more for doing more. We also have earnest health care workers who honestly hope to beat death, and that hope pushes the envelope. I read the comments and I detected a lot of bias against doing more than what works.
I do ICU care and this what happens in an "Arrest". The heart stops either electrically or mechanically and blood stops flowing. If it is an electrical arrest, the best that can be done is to reset the pacemaker with a defibrillator. If there is a clot it may dislodge or not. If the heart is damaged nothing in the field will help. If you do the numbers, perhaps 80-90% of true Arrests cannot be fixed in any event. so the 15 or so that may be helped can be helped with simple life support or luck. Neither of these items are unique advanced life support. Still, this is an earnest effort. If there is no statistical worsening, it may be reasonable to push the envelope until we prove we cannot save more people.
I have had 3 close people die suddenly. Their lives ended, period. Awake before, gone after. I have had 3 close people linger on ventilators for longer periods, awake during the ordeal, still they died. I have take care of hundreds I didn't know. I don't think there is much wisdom we learn from this. It would nice to give one 24 hrs to see if they can go on, but I would prefer sudden demise for myself.
I do ICU care and this what happens in an "Arrest". The heart stops either electrically or mechanically and blood stops flowing. If it is an electrical arrest, the best that can be done is to reset the pacemaker with a defibrillator. If there is a clot it may dislodge or not. If the heart is damaged nothing in the field will help. If you do the numbers, perhaps 80-90% of true Arrests cannot be fixed in any event. so the 15 or so that may be helped can be helped with simple life support or luck. Neither of these items are unique advanced life support. Still, this is an earnest effort. If there is no statistical worsening, it may be reasonable to push the envelope until we prove we cannot save more people.
I have had 3 close people die suddenly. Their lives ended, period. Awake before, gone after. I have had 3 close people linger on ventilators for longer periods, awake during the ordeal, still they died. I have take care of hundreds I didn't know. I don't think there is much wisdom we learn from this. It would nice to give one 24 hrs to see if they can go on, but I would prefer sudden demise for myself.
17
We've ample evidence to prove that more ain't necessarily better when it comes to medical care and that there's much overconsumption. Might be worth paying some attention to identifying those institutions that chronically deliver more so that patients in non-emergency circumstances would have a better idea of what environment they were getting into. Knowing that an alternative institution does fewer invasive procedures and gets equally good results would be a useful thing to know. And while some practitioners are aware of this disparity, few patients are.
4
The institution to check out is the pharmaceutical industry. Prescription drugs are the 3rd leading cause of DEATH. Research is generally funded by Big Pharma; pharma sales reps inundate our doctors' offices; drugs are advertised on TV and everywhere else. The situation is so bad that so-called research by Big Pharma results in the raw date being called "proprietary": others get to see the conclusions, but not the raw data they're based upon.
I'm one of those who've been trashed by a statin drug. Most of you don't believe that muscle and nerve damage from statins can be permanent. I envy you profoundly. Check out Spacedoc if you want more confirmation of drug overprescription madness.
I'm one of those who've been trashed by a statin drug. Most of you don't believe that muscle and nerve damage from statins can be permanent. I envy you profoundly. Check out Spacedoc if you want more confirmation of drug overprescription madness.
17
And yet, they are pushing high dose statins in ANYBODY who is pre-diabetic/Type 2 diabetic, even if they have absolutely no issues with cholesterol. A local hospital was tweeting about this, telling patients to see their doctors & make appointments, come to a education session on the new guidelines. I asked why, given the issues with statins, they would want to encourage this in patients who are already high risk if they do not have cholesterol issues. The response was "its just good medicine". No, its BAD medicine! The guidelines are 70-189, you give statins. So, basically, you're going to give statins to a huge portion of the population.
7
"Given the remarkable advances that have been made in the last 50 or so years in pharmaceuticals, medical devices...."
Advances? At this moment, as the most prominent example, statin drugs are "appropriate" for all males from 66-75. 100%. Every single one. The majority of the panel that set these "expert" guidelines has ties to the pharmaceutical industry.
The largest benefit I've seen is about a 2% reduction in cardiovascular disease over 10 years. That takes us guys to 76-85. The adverse effects are generally suppressed (Google the BMJ article on statin adverse effects, and add Rory Collins; or the ABC statin program in Australia, also censored).
This massive overprescription of drugs, like the massive prescription of amphetamine-like drugs to so many of our children, is the most blatant "doing more does harm" in our healthcare system.
Advances? At this moment, as the most prominent example, statin drugs are "appropriate" for all males from 66-75. 100%. Every single one. The majority of the panel that set these "expert" guidelines has ties to the pharmaceutical industry.
The largest benefit I've seen is about a 2% reduction in cardiovascular disease over 10 years. That takes us guys to 76-85. The adverse effects are generally suppressed (Google the BMJ article on statin adverse effects, and add Rory Collins; or the ABC statin program in Australia, also censored).
This massive overprescription of drugs, like the massive prescription of amphetamine-like drugs to so many of our children, is the most blatant "doing more does harm" in our healthcare system.
37
" Over Dosed America, the Broken Promise of American Medicine" by John Abramson MD
5
in Australia at a presentation about seniors health care costs I heard that 80% of costs to government was end-of-life, typically the last 3 months, in things like intensive care interventions with intubation and life support, emergency operations which were finally fruitless.
when surveyed, most seniors said they did NOT want this - embarrassing attempts to intervene in a natural decline - they did not want to be seen/remembered by visiting friends and relatives with tubes up their nose connected to beeping life support machines - and wanted only pain relief - which I believe doctors can easily do for minimal cost.
So whose fault is the ridiculous overcharging (people in Australia can't believe $80-250,000 bills for minor operations - we get most operations free paid for from our taxes thank you !) - is it the hospital/business seeking profit - way to treat the vulnerable in your society - or is it a hangover from slavery days - best treatment for rich white folks, crumbs for the poor ?
when surveyed, most seniors said they did NOT want this - embarrassing attempts to intervene in a natural decline - they did not want to be seen/remembered by visiting friends and relatives with tubes up their nose connected to beeping life support machines - and wanted only pain relief - which I believe doctors can easily do for minimal cost.
So whose fault is the ridiculous overcharging (people in Australia can't believe $80-250,000 bills for minor operations - we get most operations free paid for from our taxes thank you !) - is it the hospital/business seeking profit - way to treat the vulnerable in your society - or is it a hangover from slavery days - best treatment for rich white folks, crumbs for the poor ?
22
This article points up the proper place of the new push for Evidence Based Medicine.
Evidence Based Medicine, you may say? Isn't all medicine already evidence based?
I'm afraid not, as Dr. Carroll's essay illustrates.
There are a lot of points of modern everyday clinical practice (what one's family doctor or specialist recommends and prescribes) that is contrary to the best evidence available about what is most effective and what is safest for the patient.
The Center for EBM [ http://www.cebm.net/ ] at Oxford University is a good place to start to find out more.
Evidence Based Medicine, you may say? Isn't all medicine already evidence based?
I'm afraid not, as Dr. Carroll's essay illustrates.
There are a lot of points of modern everyday clinical practice (what one's family doctor or specialist recommends and prescribes) that is contrary to the best evidence available about what is most effective and what is safest for the patient.
The Center for EBM [ http://www.cebm.net/ ] at Oxford University is a good place to start to find out more.
8
There's a need for a lot more evidence-based medicine, but this piece reminds us that evidence doesn't automatically translate into behavioral change. Getting more evidence is a useless exercise if it doesn't change practice patterns.
6
Evidence medicine uses reasonable statistics and confidence intervals. If you sue them, and miss something, some slick plaintiff's attorney can sue you, and it doesn't matter how much evidence you have on your side.
2
The problem is we need to separate procedures that are life saving from those that merely delay death. An ICU was developed to manage an acute event so the patient could ultimately fully recover. Now they are used for patients with little to no hope of a complete recovery, and thus serve only to forestall death by a few days, weeks, or months. Death is frightening and sad but in the end, the one certainty is we each will die. Nothing can stop that. During my husband's final hospital stay for terminal cancer, our doctor told us that if his heart were to stop from the chemotherapy, they could resuscitate him by shocking his heart, possibly breaking his ribs and intubating him. He would be transferred to the ICU. Of course, none of this would stop his cancer. Though he was young, we declined and he died. To fix our broken medical system, we need to look at costs, both economic and human, and rely on data, not emotional arguments.
105
I think you identified the fundamental emotional problem, death is frightening and sad. The way we, as a society, have chosen to deal with that is to use the medical system as a scapegoat to exonerate ourselves from any responsibility for frightening or saddening a dying person. "We did everything we could" are the only words that are acceptable in connection with a death. Anything else is heard as an incrimination of moral failing.
14
From my discussions with practitioners within the medical community (I am a researcher in the medical field and my wife is a physician), I have often heard that doctors' decisions for treatment usually hinge on two things: what the insurance company covers in this situation and what course of treatment is least likely to lead to getting sued. The doctor's judgement about what is actually "best" generally takes a back seat to those considerations in our medical system.
54
Absolutely, the standard of you can never miss anything yields ever increasing expenses. The first thing they ask in a deposition is "why didn't you order more tests, Doctor?" Make the standard for malpractice evidence based medicine and not hired guns who will say anything the plaintiff's attorney pays them to say, no matter how ridiculous and non-evidence based it is.
8
I don't think your experience is generally true. Especially not in HMO's like Kaiser Permanante.
4
No, the first question is Doctor, how could you read the results of the tests you ordered so wrong. How did you miss the flags? Did you even read the test results before you misdiagnosed x as y? The evidence is in black and white in the medical record.
3
It's great to read about an effectiveness study where care was taken to make sure the criteria are actually relevant/applicable to all people. But even here, in the case of the breast radiation, a 10 year equal survival rate means something very different to somebody who relatively young, versus someone older. If radiation treatment increases the likeihood for another cancer, such as lymphoma, 30 years down the road, would it still be preferable for someone in their 30s?
Other studies we've heard about seem to give more weight to negative outcomes such as the stress of a false positive, or an unnecessary biopsy than maybe some people feel is necessary.
Other studies we've heard about seem to give more weight to negative outcomes such as the stress of a false positive, or an unnecessary biopsy than maybe some people feel is necessary.
8
Interesting data but truthfully dont we already know that "more" healthcare for a particular illness is often a crapshoot whether that extra care helps or not? Not entirely because of poor care, but because of the complexities of how different patients respond to different treatments.
9
All these anecdotes are basically aimed toward saving money, no matter if the patient lives or dies. I am a physician who owes his life to the prompt use of very expensive diagnostic modalities, which has enabled me to live 17 years after emergency open heart surgery, and 11 years after discovery of bladder cancer.
What this country needs is comprehensive insurance coverage single payor not for profit, as most of the citizens of the major countries in the world possess.
What this country needs is comprehensive insurance coverage single payor not for profit, as most of the citizens of the major countries in the world possess.
155
I am very glad that you had a great outcome from a life threatening situation.
But I disagree that it's all about saving money although I too would like a single payer plan.
I want evidence based medicine to inform the decisions I and my doctors make. I really like Cochrane.org for their methodology, but I wish it wasn't so difficult to get data on the efficacy of treatments in comparison to doing nothing or to watchful waiting.
But I disagree that it's all about saving money although I too would like a single payer plan.
I want evidence based medicine to inform the decisions I and my doctors make. I really like Cochrane.org for their methodology, but I wish it wasn't so difficult to get data on the efficacy of treatments in comparison to doing nothing or to watchful waiting.
1
think there's a big difference between anecdotes and evidence. the piece we're commenting here deals with the latter -- what most helps most people most of the time. that doesn't ignore outliers who are helped by extraordinary procedures. one could argue that we'd all live somewhat longer if we had daily physicals, also, but that misses the policy issue.
1
I "recommended" what you wrote, but....
Overprescription of drugs does not save money. You were saved by "expensive diagnostic modalities", but my health was destroyed by a statin drug. The prescribing cardiologist is a true believer: his group had received hundreds of thousands of dollars from Merck and Pfizer.
He gave me misinformation about DNA tests for predisposition to damage from simvastatin. He told me that "Some people think statins should be in the water supply." He said that "Statins are the reason Americans live longer now."
If you want to know how much damage can be done, write [email protected]
Overprescription of drugs does not save money. You were saved by "expensive diagnostic modalities", but my health was destroyed by a statin drug. The prescribing cardiologist is a true believer: his group had received hundreds of thousands of dollars from Merck and Pfizer.
He gave me misinformation about DNA tests for predisposition to damage from simvastatin. He told me that "Some people think statins should be in the water supply." He said that "Statins are the reason Americans live longer now."
If you want to know how much damage can be done, write [email protected]
12
AS we are learning what actually causes disease we are waking up to the fact that much of medicine is based on beliefs,not science. Dioctors fall into the trap of making up their own ideas of what works and what does not. Once they do these actions that now have to find "proof' that they work. They do this by ignoring the statistics and rely on "gut" feelings.
This is why clinical efficient medicine is necessary. It shows what works and what does not. We need to enforce the actual facts of treatment not the belief systems. Also, once a doctor is taught something it is difficult to have them change to a new perhaps more complicated method. Many surgeons once they learn a procedure will not take the time to learn a new one even tho the literature shows it to be better.
This is why clinical efficient medicine is necessary. It shows what works and what does not. We need to enforce the actual facts of treatment not the belief systems. Also, once a doctor is taught something it is difficult to have them change to a new perhaps more complicated method. Many surgeons once they learn a procedure will not take the time to learn a new one even tho the literature shows it to be better.
17
This is a very poorly written piece. The main story is that patients, usually very elderly, frequently demented, and likely in their last months of life without an acute event (becasue advacned dementia is as deadly as metstatic cacner), are then subject to the most aggressive care imaginable, inclduing repirators, dialysis, surgery, CT/MRI scans etc. usually at the family's behest, for the 1-2% chance that there will be some preservation of life but most commonly extends the dying processs by weeks at the cost of several $100,000.
41
I really thought we had all this worked out long ago. The same logic applies to most everything we do in life.
Salt is essential to life. The first empires and first wealth was built on finding and moving large quantities of salt from 'mines' to where it could be used to preserve food. But too much salt leads to significant physical problems and the more wealthy city dwellers went from dying of salt deficiency to dying of high blood pressure and heart disease.
So to with sugar. From periodic famine to diabetes.
Everything in moderation means that it is not pleasant to die of thirst but dying by drowning isn't a good way to go either.
Salt is essential to life. The first empires and first wealth was built on finding and moving large quantities of salt from 'mines' to where it could be used to preserve food. But too much salt leads to significant physical problems and the more wealthy city dwellers went from dying of salt deficiency to dying of high blood pressure and heart disease.
So to with sugar. From periodic famine to diabetes.
Everything in moderation means that it is not pleasant to die of thirst but dying by drowning isn't a good way to go either.
7
As an RN and both a former Emergency nurse and Hospice nurse I can assure you that often more is not better! However, I do disagree with the bit about the breast cancer treatments. If a woman has breast cancer in one breast she is highly likely to develop it in the other breast at some time (I believe it is about 30% more likely but not sure about the actual figure). Believe me, if I had breast cancer I'd want them both off NOW! Why go through the stress of watching and wondering and waiting for the other shoe to drop for the rest of your life? Breasts are just cutaneous tissue and fat--big whoop-de-do! Get falsies or have implants if they are that important to you.
14
the reason is because the prophylactic contralateral mastectomy does not actually prevent cancer. That's why it is not recommended
2
Km, if prohylactic surgery never prevented cancer, why would it be recommended for women with gene mutations that predispose them to cancer?
Is a study that looks at 10 year survival rates predictive of 20 or 30 year survival rates? And do the survival rates include people who may in fact have been successfully treated for a 2nd cancer? What if not having to go through the process again is more important to you than losing your breast - even if it could be treated?
Is a study that looks at 10 year survival rates predictive of 20 or 30 year survival rates? And do the survival rates include people who may in fact have been successfully treated for a 2nd cancer? What if not having to go through the process again is more important to you than losing your breast - even if it could be treated?
1
Having had bilateral with the second prophylactic, let me tell you that it is a bit whoop-de-do if you are the person undergoing the surgery.
I had solid reasons for the prophylactic surgery, at least part of which was the lifetime of close monitoring that would have been required had I not had it done. However, it was less a question of convenience than the high likelihood of both recurrence and missing the recurrence that drove the decision.
I had solid reasons for the prophylactic surgery, at least part of which was the lifetime of close monitoring that would have been required had I not had it done. However, it was less a question of convenience than the high likelihood of both recurrence and missing the recurrence that drove the decision.
3
The title is inaccurate. As the article briefly mentions, doing more for patients may not help them but it sure helps the wallets of doctors and hospitals.
Although I frequently hear how it is fear of not doing enough and perhaps being sued that is the reason for patients receiving too many unnecessary tests and treatments, as a physician I can tell you that the major reason is money. Studies have shown that when Medicare and private insurance reduce payments for procedures, their frequency markedly declines.
Although I frequently hear how it is fear of not doing enough and perhaps being sued that is the reason for patients receiving too many unnecessary tests and treatments, as a physician I can tell you that the major reason is money. Studies have shown that when Medicare and private insurance reduce payments for procedures, their frequency markedly declines.
76
Bingo Steve...yes there are ambulance chasers...there always will be...but the criminal republican system of letting hospitals/doctors etc charge obscene amounts of money for useless tests 90% of the time is a national disgrace.
31
Both Steve and Paul are right on. Having spent over 30 years calling on larger hospitals, I have personally seen physicians go wild with tests and needless and sometimes dangerous procedures when they get a patient with the best health insurance.
I will tell this again - when my brother was admitted to a local 200 bed hospital, he was immediately intubated and when i was able to see him in the ICU - someone had kicked the connection loose to the machine pumping oxygen into him. His blood was fully saturated while breathing through a tube of almost 6' long. I raised hell immediately and demanded they get him off that useless and dangerous intubation. When a patient is intubated, they gradually loose their lung functionality and it is a one way trip. I had to get a show cause order from very good lawyers to get him out of there.
Lesson is this - if you have a loved one in hospital, if it is a serious case - get to a teaching university hospital and still have family members monitor what is going on with the patient. Nurses have so little time - some are caring for over 10 patients and another set of eyes on the patient is good.
Remember hospitals are a business and some of them do their best to fill their pockets with the physicians only concern is how long will the insurance last.
I will tell this again - when my brother was admitted to a local 200 bed hospital, he was immediately intubated and when i was able to see him in the ICU - someone had kicked the connection loose to the machine pumping oxygen into him. His blood was fully saturated while breathing through a tube of almost 6' long. I raised hell immediately and demanded they get him off that useless and dangerous intubation. When a patient is intubated, they gradually loose their lung functionality and it is a one way trip. I had to get a show cause order from very good lawyers to get him out of there.
Lesson is this - if you have a loved one in hospital, if it is a serious case - get to a teaching university hospital and still have family members monitor what is going on with the patient. Nurses have so little time - some are caring for over 10 patients and another set of eyes on the patient is good.
Remember hospitals are a business and some of them do their best to fill their pockets with the physicians only concern is how long will the insurance last.
58
Doctors and hospitals "charge" whatever they want but insurance companies decide what they will pay. Because many forbid balance-billing that's all the doctors/hospitals pay anyway.
This is partly an "out-of-network" thing becuase the insurance companies insist on having narrow networks.
This is partly an "out-of-network" thing becuase the insurance companies insist on having narrow networks.
2
Another documentation of America's de facto criminal health care system (especially pre ACA), ie...be rich or don't have a bad life event while HMO.drug execs make billions off of the sickness and suffering of Americans.
Another downside of our system... Many people are so turned off by it and/or can't afford it, they don't go to doctors in the few cases where they can really save a life or be of help.
Another downside of our system... Many people are so turned off by it and/or can't afford it, they don't go to doctors in the few cases where they can really save a life or be of help.
14
And that is something that the ACA does not even address (along with cost controls) but actually worsens -- high deductible "insurance" means that ordinary people must make a dreadful calculation every time they feel sick, as to whether it is "worth" risking the huge deductible ($6300 per year on a Bronze policy) for something that might be....indigestion.
In a real life example, my best friend's mother DIED at only 59 (this was about 12 years ago). She was returning home on a long drive after visiting her grandkids. She felt terrible "indigestion" -- gas, burping, heartburn. She stopped several times along the way to get Pepto Bismal, Rolaids -- to no avail. Her husband was alarmed enough that he wanted to stop at a hospital emergency room along the route; she refused.
She had no insurance. (He did; he was older and on Medicare.) Just a visit to the ER for a brief consultation with a doctor could mean a $2000 bill -- rack rate -- or worse. What if they did a CAT scan, god forbid? What if she incurred all that cost, and it was indigestion? They were not wealthy people and this would be a HUGE financial blow to them.
So she waited and kept popping antacids. 10 hours later, they arrived home and she went upstairs to rest. Her husband checked on her 20 minutes later, after unloading the luggage -- and she was dead of a massive coronary. (For the record, she was very slender and fit, and a non-smoker.)
Folks, that's "having skin the game" for you.
In a real life example, my best friend's mother DIED at only 59 (this was about 12 years ago). She was returning home on a long drive after visiting her grandkids. She felt terrible "indigestion" -- gas, burping, heartburn. She stopped several times along the way to get Pepto Bismal, Rolaids -- to no avail. Her husband was alarmed enough that he wanted to stop at a hospital emergency room along the route; she refused.
She had no insurance. (He did; he was older and on Medicare.) Just a visit to the ER for a brief consultation with a doctor could mean a $2000 bill -- rack rate -- or worse. What if they did a CAT scan, god forbid? What if she incurred all that cost, and it was indigestion? They were not wealthy people and this would be a HUGE financial blow to them.
So she waited and kept popping antacids. 10 hours later, they arrived home and she went upstairs to rest. Her husband checked on her 20 minutes later, after unloading the luggage -- and she was dead of a massive coronary. (For the record, she was very slender and fit, and a non-smoker.)
Folks, that's "having skin the game" for you.
70
The ACA is flawed, probably the worst health care system in all our peer countries but it is better than the de facto criminal health plan of the Republicans...ie..be rich or don't have a bad life event.
Millions more people are now insured, the worst criminal aspects of the Republican plan like pre conditions, dropping you if you get sick are gone.
Millions more people are now insured, the worst criminal aspects of the Republican plan like pre conditions, dropping you if you get sick are gone.
80
But before the ACA mandate requirement, people with no insurance could still go to ER and receive care as required by law. It wasn't the tooth fairy who paid for us but rather the rest of us through higher insurance payments.
And if we like virtually every other industrialized country recognized healthcare as a right and not a luxury, no one would have any of the problems you describe.
And if we like virtually every other industrialized country recognized healthcare as a right and not a luxury, no one would have any of the problems you describe.
23
This is the kind of story that makes me go "Hmmm" when I then read about the 17-year-old in Connecticut who has lymphoma being handcuffed to a hospital bed and forced to undergo chemotherapy against her will. Doctors are so sure--until they're not.
26
Let's be accurate. The 17 year old patient in question is a minor and therefore cannot make legal decisions for herself. In this case the mother (her legal guardian) refused to have her treated. The patient in question was suffering from Hodgkins lymphoma which is successfully treated in 85% of cases - successful as in the patient survives and goes on to have a normal life; whereas absent treatment the death rate is essentially 100%. The mother in refusing treatment is guilt of child abuse; and if her daughter were to die, reckless homicide. Facts matter.
44
This article, which talks about a number of studies showing less treatment is better for heart attacks and some breast cancers, and the girl in Connecticut who refused proven, lifesaving treatment, have nothing to do with each other. Doctors don't know everything, and are constantly finding out what works, but your comparison is nonsensical.
6
A child in state custody gets medical care. A child dependent on their parent may not. For sheer efficacy, better the child be in state custody.
http://inhomecpr.com