Health

People often ask me, as a healthcare professional, what I think about "the healthcare system". I'm not sure how to encompass all of my thoughts in a succinct answer, but a medical student asked me about it a few weeks ago, and I realized that a lot of my ranting could potentially be quelled with a change in the philosophy of medical education (which in my mind, is much more doable than, say, getting Medicaid to change their reimbursement policies). I'm too lazy to look up the research behind this, though I'm pretty sure it would support me--but I'm convinced that if we took a giant step backwards in history, we would actually come out ahead.

In 1946, the World Health Organization published a document that stated, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

In 1946! Pretty sure we've long been ignoring that truth.

I would posit that if we, as doctors--and with the support of the rest of the healthcare system, including insurance reimbursement--could focus on promoting physical, mental and social well-being, rather than trying to "cure" disease or infirmity, we could make great strides in healthcare costs, patient satisfaction, and overall health outcomes.

Let me give you a few examples. In residency, we dealt a lot with what I called the bane of my existence, but what ICD-9 calls functional abdominal pain. Usually preteen girls with Type-A moms who manifest stress in their GI track, and despite 100% normal workups have disruption of their daily activities due to pain. If there was such a ratio as healthcare dollars spent per improvement in quality of life, functional abdominal pain would be among the highest. We did literally million dollar workups on these patients--sometimes including surgeries like gall-bladder removal, central line placement, and gastric tube insertion--all to prove to the parents and patient what we knew from spending 5 minutes in the room: they needed a therapist and patience, not a hospital. Rather than trying to find a physiologic cause for functional pain (which doesn't exist), if we had spent our efforts to promote overall well-being (ie: managing stress, teaching coping skills, reassuring the family, identifying and removing triggers), I'm convinced we would have been much more successful. But it's easier to "consult surgery" than to spend an hour with the family telling them what they don't want to hear: that there is no quick fix and that it's going to take time and effort rather than a simple prescription.

A much more common example is the plethora of viruses for which parents want a cure. While I do my best to reassure parents and rely on a thorough history and physical exam rather than tests, there are inevitably dozens of strep tests, urine tests, chest x-rays, lab draws, viral swabs, and--gasp--antibiotic prescriptions every week ordered because the parents and patients expect a quick fix. How about instead we focus public health efforts on hand-washing, hydration, symptom care, and keeping immune systems healthy by proper nutrition, vaccination, and not creating super bugs by overusing antibiotics? Not a quick fix, but ultimately better. Think of how many kids we could save from radiation, swabs, blood draws, catheters, and antibiotic-induced diarrhea! Take it a step further to incorporate the social well-being mentioned above--what if workplaces allowed parents of sick kids to work from home a handful of days a year rather than taking sick leave, or if schools didn't require antibiotics or negative tests to allow kids back in school, or if you could use HSA money for pedialyte and hand sanitizer and fresh produce (not saying that's the right answer, but just imagine if society could support well-being from the front end like this).

The adult world has even more examples--throwing expensive imaging tests and narcotics at chronic pain instead of teaching meditation or coping skills; using antacids and antianxiety meds to mask symptoms instead of dealing with stress; knee replacements and bariatric surgery years later instead of addressing childhood obesity.

It's a big system to change overnight, but if medical students and doctors had more training in talking with patients about overall wellness and felt equipped to resist unnecessary and even harmful interventions, then maybe patients would stop expecting a strep test every time they had a sore throat, or a narcotic every time they had pain. And then maybe insurance companies, hospitals, therapists, pharmacies, lawyers, policy-makers, etc. would get on board as well, promoting well-being instead of simply trying to cure disease.