Earlier this year, the Associated Press and other popular news agencies reported on the disturbing results of a study published in the March 16, 2006 issue of the New England Journal of Medicine that concluded that Americans receive, on average, only 55% of the care that they should receive at any given time 1,2. This study evaluated the care that individuals, from a wide variety of ethnic and economic backgrounds, receive in a variety of different healthcare settings (clinic, hospital, etc.) here in the U.S. The authors came to a conclusion that was, to me, very startling; but, as it turns out, this is not really new information.

With some minor variation across the boards, people were either under or over treated, for a variety of conditions ranging from alcohol dependence to urinary tract infection. This means that, although we have very well defined screening, diagnostic, and treatment protocols, nearly half of the time these protocols were not followed by physicians, other health care personnel, or the institutions in which they work.

While the Associated Press story decried this as “woefully mediocre… care,” and the New England Journal authors concluded that the “problems with the quality of [health] care,” are “widespread and systemic,” I personally see this as an outright tragedy. Although we spend more money on health care than any other nation, and our massive research efforts have well defined the ideal mechanisms to prevent, diagnose, and treat disease, we are still unable to provide our mothers and fathers, sisters and brothers, husbands and wives, with the care that they all pay for, deserve, and that is available. I find the idea repellant that people’s quality and duration of life is routinely compromised in this manner.

Although this is profoundly disturbing, this is also not a new problem by any means, but instead is simply another aspect of an inadequate and dysfunctional health care system. In 1999, the Institute of Medicine (http://www.iom.edu/), a private, non-profit research arm of the National Academy of Sciences, published “To Err is Human,” which reported that somewhere between 44,000 and 98,000 individuals die annually, and that “hundreds of thousands” of others are injured or narrowly escape injury, as a result of avoidable medical errors (also available free on-line at http://www.nap.edu/books/0309068371/html/) 3.

While hospital systems and healthcare providers attempt to begin the lengthy process of remediating this situation by initiating a number of changes across the country (including,as oneexample,instituting an electronic, all-inclusive medical record accessible from any clinic, hospital, or emergency department, among other changes), one area has yet to be addressed - patients are far too often unaware and uninformed about their diagnoses and treatments, and as such, are unable to make informed decisions about their healthcare. Although we are far past the days of following the “doctor’s orders,” and “the doctor knows best,” we have yet to provide patients with one of the best protections available -a thorough understanding of their health and the knowledge to be actively and effectively involved with its maintenance and restoration.

There are a few barriers to this process, however, in the current system. It is not uncommon today that a physician has far less time to examine, diagnose, prescribe and counsel to a patient than the time that it takes to change the oil in your car, or get a haircut, etc. Some physicians, in fact, have to average less than ten minutes per patient! It is impossible to expect that any physician, even the most caring and dedicated, could adequately explain to a patient their diagnosis, treatment, and prognosis within that time frame, and answer questions as necessary. Furthermore, some providers are worse than others at this skill, and the current system most certainly does not encourage or help them in this regard.

The current system does not really value, then, an informed patient. While we are taught in medical school that patients need to be properly “informed” in order to make “competent” medical decisions, the system currently in place clearly does not encourage this sort of activity. If anything, in fact, it discourages it.

The time has come for external systems to try and pick up this role, and to help patients and their families understand any and all aspects of their health. It is unlikely that any time soon physicians will have more time to help better educate patients (new cuts in Medicare reimbursement, as a matter of fact, just approved in July of 2006, will, if anything, make it even harder for physicians to spend time educating their patients). Services must be established (some are already in place) that can help patients answer questions that they might have about their diagnosis or treatment options. Unfortunately, at present many of these services are offered with little oversight as to the quality of information that is provided.

Without the help of a professional, patients often try and find answers for themselves to their health-related questions. While there are many valuable internet resources that are available (WebMD., etc.), there are many more available that offer inaccurate, incomplete, or incorrect information. If taken at face-value by a patient, this can present a profound problem as patients can then base potentially life-threatening or life-changing decisions on this information. So a guide, in many respects, is really necessary to provide accurate information, and then to make sure that the patient understands it.

Improvements like the electronic medical record will most certainly help reduce the incidence of medical errors, and should also help ensure that patients receive care up to the current standard. But improvements must also be made in other areas as well, including patient education, because patients can most often provide far better oversight of their own care than any pre-designed system, no matter how “high tech” it might be. It seems that patients have already realized this, and are seeking out information from any available source. Hopefully hospital and insurance administrators, and government officials and healthcare providers will also realize this, and dedicate funding and efforts to fill this substantial, but presently ignored, gap in the provision of healthcare.

- Jonathan Fay, M.D., August 14, 2006.

References

1. Asch SM, Kerr EA, Keesey J, et al. “Who is at greatest risk for receiving poor-quality health care?” N Engl J Med. 2006 Mar 16;354(11):1147-1156.

2. “Study Says Americans Get Equally Mediocre Health Care” - Jeff Donn, Associated Press, 3/15/2006.

3. To Err Is Human: Building a Safer Health System. Institute of Medicine, Committee on Quality of Health Care in America. National Academy Press, Washington, D.C. 2000.

Copyright © 2006 Jonathan Fay, M.D.

Dr. Fay is a personal medical consultant, providing answers to patients’ questions about their health, diagnosis, and well-being (available on the internet at http://www.doctorfay.com). He has helped thousands to better understand their health, and to be in a far better position to be highly involved in their own healthcare. As such, patients can make better decisions about treatment options, that better fit their own personal preferences (and not those of their physician, another provider, or anyone else).

Dr. Fay is also the author of numerous articles about the state of healthcare today in the United States, new developments in medicine, and articles to help explain medical treatments and diagnoses in terms that patients can easily understand.

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Dental practice in Ireland is of the highest standards in the world. That is also true of our medical practice. Our teachers at our hospitals are, in many ways, quite extraordinary. They have strong academic backgrounds and training, and are committed genuine and passionate people. These people are given the job of training undergraduate and graduate students to the highest possible standards of knowledge and practice and that is what they give their all to accomplish. When students qualify they are committed first class graduates for the most part. This is all great news. So where is the problem?

The ideal versus the ‘real’ world

Many medical and dental graduates will tell you about the culture shock that they experience when they come out into what is called the “real” world. We have been trained to provide the Gold Standard in treatment but suddenly we are expected to do our work ‘under pressure’. The cruel task-master going by the name ‘economics’ but better known simply as ‘money’ comes in to take control all of our activities and this is where our problems really begin. The exacting and exhaustive precision with which we were trained to provide excellence of service comes into clear and sharp conflict with the constraints of ‘money’ and the other well known lord of economics ‘time’. These omnipotent dictators are of course related to each other. How often is the dictum proclaimed, sometimes with a sigh, sometimes triumphantly, sometimes almost reverently, but always with faith and conviction. “Time Is Money” we are assured.

Is this the same job I learned in the hospital?

To give you all some idea of the size of this culture shock that I refer to, consider this. A job which would take up to two hours as a student under supervision is now afforded maybe 15 - 20 minutes. This is a speed up factor of 4-6 times the taught rate in the Teaching Clinic. This jump in speed is expected to be accomplished immediately and is experienced as real pressure by the new graduate. Yet in this ‘real’ world it is Time and Money which must have pride of place.

We must now speed up so that we can be “acceptable” in the market place in terms of how long the job takes and how much the job costs. We are still expected to produce the Gold Standard which we were trained to provide in the hospital situation, yet the conditions in which these standards were obtained are now drastically different. The pressure has begun.

Government and politicians will safeguard the sanctity of the healing arts?

As if all that was not bad enough, we now allow/decide that authority in healthcare is the business of politicians and government. They become the paymasters and who pays the piper calls the tune. Suddenly, what we do and how we do it is being evaluated by people who know nothing of the burden of duty and responsibility that comes with the allegiance to Hippocrates.

Next comes our dealing with Government Departments. Remember that I am not talking about the people in these departments. They are merely trying to do the job that they were asked to do. I am talking about the systems. So the Department is going to provide Treatment for workers but it has limited resources. So it “negotiates” a deal to have work done by dentists/doctors at reduced cost. This is not a real negotiation because dentists are made to feel that unless they give in, they will lose their livelihood. So they ‘agree’ to reduced fees. Now the pressure intensifies because the required standard remains the same but the ‘time allowed’ to achieve it is reduced.

All decisions have consequences?

Needless to say the increasing strain puts pressure on all the components of the system. The practitioner is under pressure in many ways. The cost of being in practice, wages, insurances, rents, rates, materials, laboratory are high to begin with. These increase year on year but the pressure is always intense to keep fees down. The first pressure is self-induced. This stems from the perception that people will not come to the practice if the prices are too high and so fear of the loss of business rules. State funded schemes are always at very reduced fees and so are a burden to the practice anyway. The solution to the problem is to either increase fees (and the fear of loss that comes with this is very strong) or do more work. Doing more work will involve either longer hours or working faster to get more done. Maybe it will involve a bit of both.

Look in honesty and without defensiveness.
There are many consequences to the decision which many have to work longer and/or faster. The study of these consequences reveals the very origins of the hazards that have come to be associated with modern general practice. While I can appreciate that it may be difficult to look upon these truths, surely it must be good news to find the origin of the problem. For only in identifying the cause of a problem can a solution becomes possible. The alternative is to continue with the same methods which are bringing as much pain and suffering to the practitioners as they are to the people that they purport to serve. How ironic and indeed unbelievable that we have not noticed that our ‘healthcare’ system as it is currently constructed is causing the sickness and pain that it was set up to eliminate?

Is this really what we want?

As we look honestly at our methods and the results they bring, how can we say that we are satisfied that we are going in the right direction. As we analyse the consequences of how we operate our systems and see how one things leads to another, it must become obvious that the most radical change is needed. When will we bring some light to the hell that we have created and continue mindlessly and blindly to support? We like to think of ourselves as scientists but since what we do and continue to do is totally illogical we cannot apply the term meaningfully.

Science must be logical to be itself and a lack of logic is a lack of science. To continue to use something which brings the opposite of what it was designed for, speaks volumes about the blindness that operates in healthcare. What hope could there be in asking blindness for direction? What can we deliver from blindness but chaos and confusion.

My name is Philip Christie. I qualified as a Dental Surgeon at Trinity College, Dublin (Ireland) in 1980 and completed a Master’s Programme in Dental Science, again at Trinity College Dublin, by research in 1995. I have been working full time in dental care either in general practice or specialist practice since qualification. My main interest is and always has been prevention.

My real qualification is 23 years experience in dealing with real people and their problems face to face, as a clinical practitioner.

I am the author of “Something To Chew On: A Mouth Map To Health”. It is a Health Manual with a difference. Different because it is designed for the future and for success. It is different because it gives the power back where it belongs, to the person’s own self. Different because it prevents problems at source and saves on treatment and cost!

Philip.christie3@ntlworld.ie
http://www.peopleaspartnersinmedicine.com

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