Map of life expectancy at birth from Global Education Project.

Monday, August 31, 2009

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.


Anonymous said...

Can’t resist this example. I have a friend who is 87, and the older brother of her ex-boyfriend (long dead) is 103.

This gentleman is handicapped, has a gamey left leg, does not walk well or much. He is also blind. Sharp in the top storey, he chuckles about his five ladies, and enjoys life, Music!, braille books (brought to his door), radio reportage, old friends, who are the children of his old friends, etc.

Lady no 1. is a nurses aide on a motorcycle. She gets him up, washes him and helps him dress, lays out breakfast. Sometimes she has a mate with her to do bigger jobs (cutting toenails and so on.)

Lady number 2 is meals on wheels and social assistance. (lunch, laundry, paperwork..)

Lady no 3 is a fully qualified nurse and physical therapist, that’s the leg taken care of. He is made to walk about, and exercise, stretching, yoga, that kind of thing. She has a small car.

All of them visit every day except Sunday.

No 4. is a Doctoresse who only checks in say every two weeks. She walks to him.

No. 5 is his grand daughter - quite doddery and fed up with it - she does a cold supper and company.

Cost: zero (France.)

Of course he lives very modestly, in two rooms, doesn’t even own a TV (duh)

In the village, they plan a big party for him when he hits 105.

Heh. Isn’t that grand?


Cervantes said...

In the U.S., he'd be in a nursing home -- they won't pay for all those home-based services. And he'd be all drugged up. And he'd probably be dead.

Anonymous said...

I don’t know C that it costs so much ...No. 1. would I imagine work from 6 to 12..zipping around on her motor bike...and do how many ppl? With only ‘aide’ qualifications her salary would be higher than (french) minimum wage but not much. If she lives alone, without another job, she lives in a one room flat and shops at the discount supermarket. No. 2. is in the same position, and the gent pays for the food (not the service.) No. 3 costs, for sure, but she does several ppl with minimum trips in between. Another client of hers lives 3 doors down, this gent is bedridden since 5 years, Alzheimers, no bed sores, he’s quite fit actually, but mentally completely out of it. He’s a tough old coot and just won’t die, his wife says. He survived both WWs and 5 years as a prisoner of war. He used to wear a beret and loved to dance the tango.

There are no infrastructure costs. Of course the families contribute a lot, directly and indirectly.


Bix said...

Good post.

There does seem to be a culture of medicine in this country. So many in the healthcare industry emphasize and reward their own efforts, patients are just a means to that end.

Victor Montori said...

Thanks a million for quoting our paper in the BMJ. We have a blog on this topic at and would love to have comments from folks about the meaning that this proposal has for them. Thanks a million!