One Doc's Thoughts on Why Americans Pay so Much for Health Care for so Little Benefit
The March 2013 AARP Bulletin reported on a study of 17 developed nations that showed the US to be at the bottom among them in life expectancy. Yet Americans spend nearly twice as much per person on health care.
I have seen a pattern of testing and treatment that makes me understand how we could be spending so much more without reaping benefits. I get my recommendations for screenings from Harvard Women's Health Watch and Journal Watch General Medicine as well as my own medical training. If the details in this article seem overwhelming, skip to the last paragraph.
Let's start with routine screenings. EKG's with yearly physicals are a waste. The only time EKG's are useful is when there are symptoms of heart problems. The only routine blood work that is necessary for outwardly healthy people is a cholesterol check every once every five years. Of course, if this test reveals a problem, it has to be done more often. Blood pressure checks are good, but you can get them for free in many pharmacies. Screening Prostate Specific Antigen (PSA) tests create unnecessary biopsies and surgeries and aren't recommended at all by the US Preventive Services Task Force. Same with glaucoma checks. Yearly physicals don't reveal much. One thing you might want to have done yearly is a test for blood in stool. Depression, tiredness, loss of appetite, unexplained weight gain or loss, pain or other symptoms, however, are good reasons for a physical and blood work, perhaps even an EKG. You should have a colonoscopy at age 50, earlier if someone in your family has had colon cancer. I was trained to do yearly physicals and blood work panels. I did hundreds and never found any abnormalities in a person with no symptoms. I'm sure some doctor somewhere has found something in an asymptomatic person, but I'm sure symptoms would have cropped up shortly. Personal experience is not evidence, just illustration.
If you have urinary tract infection (UTI) symptoms, which are burning when you void, voiding frequently, and having to get to the bathroom very quickly, you have a UTI. There is no need for a urinalysis, though I let my doctor do this as it is a non-invasive and inexpensive test. Pick your battles.
If you've had several normal pap smears, you only need to have them repeated once every three years. There is much talk of reducing the mammogram interval to every two years from every year to reduce the number of unnecessary biopsies without significantly cutting down on dangerous cancers discovered.
EEG's in folks who have their seizures well-controlled are of limited value according to the British Medical Journal. I have convinced my husband to change neurologists because of the unnecessary yearly EEG's by a doctor who owns the EEG lab.
The only folks who need abdominal aortic ultrasounds are elderly male smokers. Carotid ultrasounds should not be done unless there is a TIA or stroke. Repairing narrow carotids can result in stroke and will only be of benefit if the person has symptoms.
I've learned some other things from me or my family living through the illness.
I had endometriosis. I was scheduled to have the lesions zapped by laser.When I went for my pre-op tests, they wanted to do a pregnancy test, though I wasn't sexually active. I refused. Also I noted on the paperwork that they planned to scrape out the lining of my uterus while I was anesthetized. The doctor couldn't give me a good reason for this procedure, so I refused. The laser surgery cured my problem. Sometimes the "standard of care" doesn't make sense.
My father went through a several month's long process for diagnosis of liver cancer. The specialty hospital could have avoided a $6000 PET scan if they had bothered to look at the abdominal CT his family doctor had ordered months earlier. Communication is so important.
My sister had a $50,000 coronary catheterization which carries a 1% risk of death - all unnecessary. She had kidney failure and the build-up of fluids had caused her heart to fail. If the cardiologists had just waited past a few dialysis sessions, they would have noted that her heart failure resolved itself.
My husband used to have sleep apnea. He lost weight, which is known to improve the disorder. One night I couldn't sleep. My husband wasn't wearing his CPAP machine. I noticed that he didn't stop breathing all night long. On his next visit to his doctor, my husband revealed my observation. The doctor said, "There is no home test for sleep apnea." So my husband had a sleep study. Guess what. No sleep apnea, unnecessary expensive test.
And meds- Zetia lowers cholesterol but doesn't prevent blood vessel disease. I had my mother stop it. Statins are the only cholesterol lowering drugs to date that have been shown to prevent heart attack. Be wary of treating a meaningless number with other drugs. I had my husband stop Lopid for that reason. The combination of two types of high blood pressure drugs called ARB's and ACEI's gives no added benefit over just one of them, just extra side effects. With two studies in hand, I had my mom's cardiologist stop her ARB.
A person who has heart chest pain with exercise that isn't getting worse or occurring at rest needs only medicine, not any procedure.
The new, expensive, obesity-and-diabetes-generating antipsychotics overall are no more effective than their older much cheaper cousins. The newer ones are less likely to cause movement disorders. Let's see, diabetes kills you, while tremors are inconvenient. I take an older antipsychotic. This should be an individual choice made by the informed patient, not a mandate from the doctor, who is likely too much influenced by drug marketing.
There are no current drugs for Alzheimer's that offer more than marginal benefit. These drugs have many side effects and high cost. At best, they can delay nursing home placement by two months. Desperation to be able to offer anything contributes to doctors prescribing these frequently instead of discussing the risks, costs and benefits with the patient and family, then going with their informed decision. I got the information for this paragraph from the package inserts for these drugs.
One of my patients needed a cataract operation. I did a pre-operative EKG. It showed an old heart attack. The surgeon wanted a stress test. I explained to the patient and her surgeon that her single-handedly taking care of her farm without chest pain was stress test enough. She refused the test and had a successful cataract operation. Common sense is often thrown out the window over fear of malpractice suits. That didn't happen this time.
You can imagine that with my attitude, I wasn't horribly popular with my fellow physicians and lasted nine years before I got booted from the field.
I'm no longer licensed, so don't consider this article medical advice. Use it as food for thought and perhaps to begin a dialogue with your doctor, who doesn't have as much time to keep up with new guidelines for testing as I do. Informed patients who advocate for themselves tend to be healthier than those who don't. Never be timid about asking for a second opinion. Research online at sites ending in .org, .edu, or .gov, not .com. .com sites are usually trying to sell you something, so are biased. My favorite site is the national library of medicine at nlm.nih.gov.
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