Still mining the BMJ

I love the BMJ for putting medicine in its social and economic context. If we had the same habit of reality based thinking here in the colonies I wouldn't have to spend so much time swatting away stupid ideas.

One of the most important, biggest, and stupidest ideas stalking our once-proud country is the neocon push for "consumer directed health care," which means everybody gets really crappy health insurance with at least a couple of thousand dollar annual deductible, and tax exempt savings accounts which wealthy people can use to subsidize their out of pocket expenses -- they being the ones who can afford them anyway. The idea is, since we're paying out of pocket, we're in "control" of our health care and we'll make sure we get what we pay for.

So, Mala Rao and some colleagues from hither and yon in Albion -- where the people are no stupider than they are here -- asked some people 65 and older to assess the technical quality of care provided by their GPs using a standard survey, and compared the results to information from their medical records.

Whaddya know. Very weak correlations with appropriate measures for blood pressure control, and no correlation at all with influenza immunization. Listen folks, this is a no-brainer. The reason we pay doctors at all is because they are supposed to be experts. They know more about medicine than we do. It is good for most people to be reasonably well informed about health and medicine, and if we're diagnosed with something specific most of us will benefit from finding out a good deal about it. But if we were qualified to make all the decisions about our own health care, we wouldn't need doctors at all. I don't tell my auto mechanic that I don't need a brake job, because I don't want to die. But some people decide they can't afford one right now, and whaddya know -- they die.

While we're on the subject of blood pressure, I've mentioned before that the Limeys have an agency called NICE, the National Insitute for Clinical [and Health] Excellence, which reviews evidence and establishes guidelines for cost-effective medicine. NICE has decided that beta blockers should no longer be a first-line treatment for hypertension -- they just don't work that well. If you're under 55, go with an ACE inhibitor, if that isn't enough add a calcium channel blocker. That accords with my personal experience perfectly. My doctor first tried a beta blocker, which didn't work. Now I'm on an ACE inhibitor and CCB, and it works great. All generic, cheap. (Thiazide diuretics, the cheapest of all, are appropriate for some people but didn't work for me because I do a lot of hard work in the hot sun and they made me faint if I got dehydrated.) But in the U.S., we don't have a NICE. That would be a violation of our religion, called the Free Market, i.e. the right of drug companies to push stuff that doesn't work.

As usual these days, no post on Saturday, back Sunday.