Iatrogenic Terminal Hassling

If you're lucky enough to have a subscription to BMJ, you can read an essay by Carl May, Victor Montori, and Frances Mair entitled "We Need Minimally Disruptive Medicine." Since you are lucky enough to have a subscription to Stayin' Alive, and if I'd gotten around to it I could have written that essay myself, you can read my take on it here.

For those of us who are basically healthy, health care is -- or at least one would hope it would be -- a minor issue in our lives. Maybe we've had an episode here and there where we we suddenly found ourselves intensely interacting with doctors and health care systems, and then it was over and we were back to checking in once a year. But most of the medical enterprise, in terms of spending, personnel time, and the problems we worry about of cost and resource allocation, obviously concerns people with chronic disease.

There was really only a brief period, from the early 20th Century until maybe the 1960s or thereabouts, when medicine was mostly about acute diseases and curing people. Once we stopped getting carried off by common microbes and conditions that could be corrected by sterile surgery, doctors found themselves dealing more and more with long-term management of incurable conditions such as heart disease, diabetes, and chronic kidney disease. Quite often these conditions occur together and with other conditions such as osteoarthritis, depression, chronic pain syndromes, and on and on.

It is an incredible amount of work to comply with everything the doctors demand of people in these situations. A colleague of mine recently interviewed people with chronic kidney disease and they quite typically had ten or a dozen prescriptions, coming from 3 or 4 different doctors who as likely as not were not talking with each other. Each of these has to be taken according to its own schedule, with or without food, etc. Obviously, nobody actually does this, because it is nearly impossible. The people pick the ones they think are important and forget about the rest. And of course they don't tell their doctors because they'll just get scolded and who needs that?

And then they have to keep multiple appointments at various places, go through diagnostic procedures involving everything from painful needle jabs to barium enemas, follow diets and physical therapy regimens, while coping with the normal demands of life in the face of whatever functional and financial limitations they endure. This is not helping. It is making things worse.

As May and colleagues write, "We need to think about the burdens of treatment. These are different from the burdens of illness." They recommend that we put in place efforts to keep track of the burdens of treatment for patients; coordinate care much better among various clinicians; recognize that clinical evidence and resulting guidelines often do not take into account comorbidity; and ask patients to establish their own priorities and deal only with the problems they find it worth their effort and discomfort to handle at any particular time.

They might have done more to acknowledge the frequently highly detrimental effects of polypharmacy -- drugs that do good on their own may do harm when combined with others -- and of overtreatment in general. It's not just the burden of treatment, but its often directly harmful biological effects, that are insufficiently recognized.

Should I one day enter decrepitude, I am definitely not inclined to spend all my time worrying about my diseases and my pills. How incredibly tiresome. It's far more important to try to enjoy what life we've got. However, this isn't just a matter of personal initiative, it's a fundamental problem with the organization and culture of medicine. Again, we can save money and do better by people by doing less. Call it rationing if you will.