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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Tuesday, April 17, 2007

    Demographic Storm Thoughts: Looking back on the comments on this post about the coming demographic storm, someone asked "What would you suggest?" What can we do, if anything, to handle the surge in patients that will come as the baby boomers age. We can't expect the supply of doctors to surge. They have their own boomer dempgraphic, too, so we can expect an uptick in physician retirements at the same time.

    So, how do we make it possible for fewer doctors to see more patients? Some people say technology will make it feasible. Automate, automate, automate. But I'm not so sure. You still need a physician to look at results, correlate them with the patient and that patient's history and then make a decision. And one of the problems with modern medicine is that doctors are compelled to do a lot of testing and interpretation of those tests for marginal gains. A physician used to be judged on his diagnostic acumen, or surgical skills, or ability to communicate with his patients, but now he is judged on how well he tracks lab values and brings them into acceptable ranges.

    A good example of this is cholesterol screening. The older a population, the higher the cholesterol, in general. We've cultivated cholesterol levels into a "quality" marker for the practice of medicine. Insurance companies look at LDL levels as a measure of how well a doctor is managing his high risk patients. When a person is identified as having a high LDL, therapy must be initiated and subsequent levels must be measured every six months. The doctor has to review these results and make treatment decisions each time. That takes up a lot of time, believe me. Most of my after hours paper work is devoted to this. It's easy when everything is normal and nothing has to change, but that's rarely the way the results come back. It also translates into more doctor visits for the patient.

    Modern medicine has entered an era of Uber-prevention in which we are constantly pushing the envelope of diagnosing and intervening in diseases. There's a move afoot to relabel hypertension to lower parameters than it has ever been defined before. Ditto with diabetes. All of that puts an additional strain on an already overburdened system. And it does it at a marginal benefit to the greater public health.

    As a profession we need to step back and ask ourselves how much of this kind of thing we can continue to do as the population ages. Will the acutely ill go without treatment because we are so pre-occupied with managing the minutiae of chronic disease that we don't have time to see them?

    posted by Sydney on 4/17/2007 08:31:00 AM 4 comments


    The short answer is yes, and it is already happening in doctor's offices today. The twist is doctors are using insurance coverage to populate their practices with relatively healthy people whom they repeatedly test. This fills their time slots with quick appointments and limits liability.

    On more than one occasion I have had doctors and nurses physically block the door insisting I needed extensive testing to treat symptomless and yet to be diagnosed problems. After some debate I am always left with some variation of the same quote "but, you have insurance."

    My last blood work showed allowable blood sugar levels to be 70 - 105, BP must be under 120/80 even in the most stressful situations. One doctor told me my LDL levels did not matter, since with multiple medications, they would bottom out at the lowest number possible. Any variation demands medication and additional testing. One doctor informed me that a BMI of over 20 made a person obese and a cardiac/diabetic patient with immediate weight loss a priority. Lipo being one solution.

    This has left the truly ill searching for caring medical care and the few doctors still willing to treat the seriously ill patient overworked and burnt out. I am afraid this situation will only get worse.

    Steve Lucas

    By Anonymous Anonymous, at 2:44 PM  

    Steve, I love your posts. As usual, I agree.

    In addition, many employers bought into the idea of the magic of prevention. Ours gives us two rebates - $150 for saying we are exercising and $150 for filling up some web questionnaire asking us about our cholesterol, sugar, BP, and our screening history. If we say we did all of the tests and promise to take care of bad numbers, we get this rebate. I take the former and refuse the latter out of principle. It is all voluntary and trust-based, but it still bothers me. It's not like these measures are even cost-saving, but the bureacrats who came up with the idea don't understand.

    By Anonymous Diora, at 9:48 PM  

    just import them from the Philippines. There are so many docs here that can't find work that pays well that some docs retrain to work in the US as nurses...

    By Blogger boinky, at 7:27 AM  

    The down-definition of disease is mind boggling. I just did one of those online cardiac risk assessment thingies and it defined a BP of 120/80 as "pre-hypertension" and raised my risk a certain (small) percentage. The drug compaines are clearly winning in the short term (but when everyone is on medication after the age of 20 the drugs will be nationalized IMO).

    By Blogger William, at 8:57 AM  

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