The Fault Lies Not in the Stars but in Ourselves: The Achilles Heal of a National Health System

I get ticked off every time I go to an airport. The security people that work there treat me like I'm a clean-shaven Osama Ben Ladden in Dockers. I've come to view the rituals of submission to authority - removing belts, shoes, etc., more as political indoctrination than actual security measures. Part of the problem is that preventative measures become more and more annoying the further removed they are from the triggering event particularly when one has no direct recollection or physical experience of these events. A challenge for TSA, if security is the motive, is that we don't know how many, if any, follow-on terrorist attacks were thwarted by these policies. We have no real sense of where these measures fit in the overall security plan although presumably they are last ditch point defense against plans not thwarted earlier by more sophisticated and surreptitious means. Prevention is not sexy - we only care about it when it fails, then we want someone's head. Presumably, all but the most rabid libertarians would prefer some intermittent inconvenience instead of another smoking hole in NYC, DC, or San Francisco.

The irony of course is the longer these measures are successful, the less the public 's interest will be in continuing them. Are these measures useful? I don't know (though the fact that cargo still isn't screened makes me wonder). I mention all of this because despite my contrarian disposition to the whole process it is possible that these security measure are ACTUALLY doing more than just making us all complacent Winston Smith clones. Blissfully unaware of the actual risk of terrorism today at the airport and lacking any knowledge of what success if any TSA has had in thwarting the bad guys all I can feel is irritation at the process and inconvenience.

There-in lies the metaphor for a potential Achilles heal of a national health system. In order to afford a sustainable system, we will have to shift the emphasis of care from today's acute or sick care, to prevention, wellness and a rationing of acute care. The burden of health must shift from the medical profession to the patient themselves - the essence of patient-centric care. A lot of patient advocacy groups talk up patient centric care models. They usually mean that the patient is the center of their own universe and everything needs to come to them at their convenience. That will not work here without some substantive shifts in perception and responsibility. There has to be a quid pro quo; greater convenience and control by the patient must come with greater individual responsibility or costs will spiral out of control. Keys to cost containment are prevention, early detection and diagnosis and compliance with therapy. The first and third are largely under the control of the patient though our current system still manages to shift the blame to the clinicians even there. Like the frequent traveler, patients are very vulnerable to confusion regarding association vs causation, or they become impatient with activities that don't seem to make them feel any better at the time. It's kind of like guard duty - after a while you get lax unless somebody tries coming through the wire. Successful prevention is anticlimatic. From experience though, the problem is that patients often want you to fix something when they come in. They want a pill. This is why pharma companies love being allowed to directly market to consumers - if your doctor would just give you this little pill you'd be so much better! They do this because they know it works.

Scientifically vetted best practices have demonstrated that the overwhelming majority of cases of sore throat are viral in origin, not bacterial. In other words we know without doubt that antibiotics will not affect the course of the disease one iota. Yet millions insist that they receive unnecessary antibiotics for their sore throats which adds to costs and contributes to antibiotic resistance. People refer to any case of pharyngitis (sore throat) as 'Strep throat' which is a bacterial infection requiring antibiotics. Doctors have tired of arguing the science or just want to get people out of their office. Further complicating this discussion are variant presentations of strep (only a few percent of actual cases) where the patient comes in after symptomatic treatments fail railing that they knew all along that the doctor was a quack. Defensive (lazy) medicine is very expensive. The national health system must be based upon science if it is to be a viable program. Judging by the reception evolution receives in this country (the evidence of which is far greater than almost all of our medical knowledge) , making a case for medical science is going to be a tough sell.

The ongoing battle over vaccination is another danger sign for the national health system. There is absolutely no doubt that vaccination programs have saved millions of lives that would have been lost to infectious diseases. There are the occasional bad reaction to them, which is understandable considering what they are. However there is absolutely no data that vaccinations cause or ever have caused autism despite what that paragon of medical expertise, Jim Carrey had to say. The big studies of the proposed phenomenon have shown no correlation. Of course, current vaccines themselves no longer contain the original agent of concern. It's been a long time since this country experienced a pandemic that killed or mained millions. Thank our vaccination programs. But now all these new smart people who never experienced the horrors of a plague have a hard time weighing the costs and dangers of having an increasing number of unvaccinated people out there and at some point, herd immunity (the benefit that you get from the fact that enough people are vaccinated to prevent the agent from easily spreading throughout the population) will fail. A lot more kids will suffer than have ever had a bad reaction from a vaccine. Prevention and science have to be a the forefront or this won't work. The science has to come from NEJM not Oprah. Unfortunately more people get their information from Oprah. Science and medicine is not a democracy where everyone's opinions count. It's hard enough for trained experts to keep up with new developments let alone the lay public getting just bits and pieces of their information from often unreliable sources.

One night, years ago, a patient with a known diagnosis of a congenital skin condition came in. to a doc-in-the-box (urgent care for you civilians ;)) The condition resulted in a life-long affliction of dry scaly skin and a lot of itching. This patient had 2 dermatologists and an internist for their primary. There wasn't much I could add to what they had already done but we did find out that the patient had never really payed much attention to the types of skin products they used. I called around town and got some good recommendations for products that would lesson the problems. I spent 45 minutes on these activities, assessment and education. When they went to check out the patient became livid when asked to pay the $25 fee. The patient said, "Why should I have to pay anything, you didn't even give me anything to take!". I asked the patient what was expected from an urgent care visit for a chronic problem for which --- was already being treated by 3 specialists? I didn't last too long in that job. Dealing with this mentality - if I don't get something for it, it's not important - is an important part of making a national health system work. The better the system the fewer times you'll actually get something for treatment!

Where does Woo fit into the picture? I know this part may irritate some but it has to be said. At the beginning of the 20th century a great war was fought and won - I'm not talking about WWI here. It was the battle amongst medical doctors, and everyone else. Prior to that time there was little to lead one to choose and vitalism in its many pseudoscientific forms was very popular. But science took hold in medicine and research, outcomes, professionalism, and data allowed MD's to pull away from the pack. Not bravado but actual history. Like all professions steeped in science MD's stopped looking over their shoulders and went about their business - not perfectly but pretty relentlessly. (An aside about medical progress: I was at a party some years ago and a drunk lawyer kept following me around insulting my profession. Being new to dating the future Mrs Pliny I was on good behavior. This guy would not let up. Finally I was talking to a group of his colleagues and this guy walks up and says: "When you doctors were bleeding George Washington to death lawyers were debating the Constitution and what did I think about that. " I looked at him and said, " True and in the interim we have developed hundreds of new procedures, eradicated diseases, developed vaccines, organ transplants and intrauterine surgeries to name just a few of the advances - and you lawyers are still f------ around with the Constitution..." Ah life's little victories....)

Unfortunately just like all other such areas, Woo returned with a vengeance fueled by a basic distrust of all things orthodox. In my area chiropractors outnumber MD's and naturopaths are springing up all over the place. This despite the fact that the effects of chiropracy can be harmful and any positive effects (beyond placebo) can be equaled by a physical therapist. But nobody cares. I think it's fairly obvious why that is - it's the same 'give me something' expectation. Let me illustrate it. I once did a survey of back injured patients who saw chiropractors vs an orthopedist. It was interesting. The orthopedists would examine the patient and tell them that there wasn't anything other than some PT and pain killers that would help. They were assured that in 6 weeks it should get better on its own. It usually did. But the ortho patients were less satisfied than the Chiropractor patients and here is why. The chiropractor would see the patient do their twisting stuff and then tell the patient that they would require weekly adjustment for about 6 weeks then it should be cured... The orthopedist told them the facts of the natural history of their injury which would take 6 weeks to heal. The other guys told them what they wanted to hear - I'll keep on treating you until you are better. There is nothing better than to get credit and cash for managing a largely self-limiting condition. Something that I as a surgeon could never get away with (nor should). The patients also had no sense of entitlement for chiropractic services but were irritated to have to pay for the orthopedist - is this a great country or what! This stuff is exactly like what happens between ID and evolution - no amount of science is ever enough to dispel religion or woo. Why the rant about this? These groups are pushing hard to get some of this national health system financing. MD's should go to the mattresses over this one - it is completely unfair and ridiculous to talk about physician accountability to best practices science if we are going to turn around and blindly pay for other services which are not based in any science what so ever. Incredibly few people see the irony.

Prevention is the key. It's also boring and hard. If you want to live longer then put away the bucket of lard you're eating from, turn off the TV, get some moderate exercise each day, don't contribute to your favorite fast food joints bottom line, sleep right, don't smoke, eat a lot of green things (assuming that they started out that color) and reduce your calories. There, free prevention and wellness advise...