Thursday, September 3, 2009

Rational vs rationing medicine


This morning on NPR's Morning Edition, Atul Gawande was interviewed to explain the difference between Rationing Care and Rational Care. He gave a nice, clear, straightforward explanation that Health Reform will never be about rationing. Rather, providers and patients need to make educated, joint decisions (the art of medicine) regarding rational care. He proceeded to explain that Health Reform is necessary. That continuing 'as is' will lead us to an essential meltdown with Medicare going bankrupt very shortly. He also spoke of our country's need for more Geriatricians and Gerontologic Nurses--that regardless of the 4-5 year expected time to transition our current uninsured patients into the new health system, that our elderly population (most of whom will have Medicare) is expected to double and we don't have the existing capacity in workforce to accomodate everyone.
What I always find remarkable about Gawande's writing and interviews is his ability to translate issues into easily-understood language. He helps to clear the air of the voluminous mis-applied, mis-defined, mis-used language that is out in the public and press.

7 comments:

Eric WIdera said...

Atul Gawande likes us, he really, really likes us!

I was extatic when I listened to this piece on the way to work today, especially when he said we need more Geriatricians and Gerontologic nurses. I couldn't agree more that we are coming to a crossroads where the population is getting older but the number of health care providers who have a focus on aging is decreasing.

I also found the idea of rational vs rationing health care to be a clear and useful way to phrase the arguement for health care reform. I know far too many people who recieve unessesary and likely harmful diagnostic tests. CT scans for simple headaches, coronary calcium scores in healthy 50 year olds, whole body scans, or screening mammograms in 20 and 30 year-olds (or 90 year-olds). There is an increasing amount of evidence that radiologic procedures such as CT scans may increase (although only slightly) ones risk for cancer. Why take the risk for something that is unlikely to help?

Paige Moorhouse said...

I agree. So often there is the misconception by the public that although the aging population has more comorbidities, that parsing off each issue to a specialist is still a feasible approach, when in fact, what we really need is more health care professionals that are able to take a step back from the trees to see the forest, and help make medical decisions that are best for the forest, not just for each tree. PS I'm new here, have metaphors been blackballed?

elderlaw said...

I recently discovered what I suppose one might call a "lump" in my breast, but I was not really concerned, since I was breastfeeding at the time. Like a good patient, I nevertheless went to the doctor. To be safe, she ordered a sonogram (+/- mammogram, if sonogram showed a problem), and sent me to the breast imaging center that day. Then a nightmare unfolded. To make a long story short, I did not think there was anything wrong, my doctor did not think there was anything wrong, but the imaging center insisted that everyone gets a full mammogram first, then the sonogram too, and fought with me about it IN THE WAITING ROOM, IN FRONT OF OTHER PATIENTS HOOKED UP TO CHEMO IVs. I insisted on the sonogram only, and can happily report that it showed nothing of concern. I heard later from my doctor that the radiologist had called her to yell at her about my refusal to get the mammogram too, and to insist that she make me another appointment. I'm 35, well below the age at which even the aggressive American guidelines call for mammograms, and as Eric mentioned, there is growing concern that the scan itself is unreasonably carcinogenic. Now, I can only assume that this all happened this way because I am well and fully insured. I read in the paper soon after that there is growing outrage because the wait to get a mammogram at the county hospital nearby, even when a lump has been found, is 6 to 9 months.

Umanohone said...

Okay, so I sent the NY Times comment on the recent NEJM article on the radiation that testing is causing in this country. I'll post it here for those of you who didn't get it. It's a pet interest of mine. I think it is hard to see the connection of events distant in time and space. The chest CT or mammogram I order today may or may not be the cause of the lung CA my pt gets 30 yrs from now. AND I may not even be seeing the patient any more.

For the NY Times Article see:

Study Finds Radiation Risk for Patients .

With the push for CT colonography, cardiography, etc. these numbers are just going to continue to rise.

-Chrissy Kistler

Eric Widera said...

I think we should be clear that CT scans, mammograms, and the like can save lives if used rationally. There comes a point though where the risks of exposure outweigh any benefit. I don't want someone to think that we are in favor of not recommending screening mammograms (call me paranoid but I just watched the following video.

----
Paige – here is our official stance on metaphors. You can use them if you are thinking outside the box, attempting to grab the bull by the horns, building bridges, or holding someone’s feet to the fire. [In truth, we don’t really care if you use metaphors. We are just happy you are commenting!!!]

Dan Matlock said...

Rational Care - no question we need to be more rational in our ordering of tests and procedures with no benefit.

Even when we become more "rational", there is still a high likelihood that our contry could "ration" care. Rationing defined as denying potentially beneficial but overly expensive therapies based on their cost. This is indeed the potential implication of cost effectiveness analysis. If society sets some threshold such as $100,000 per QALY for coverage decisions then we will indeed be "rationing." To be clear, physicians need to be involved in these discussions but at the policy level, not the patient level.

Cynthia said...

What an interesting blog! I've been looking elder and senior care and keep coming across issues involving denture creams and neurological problems. It seems that some popular creams are involved and lawsuits are beginning to be filed. I found a site that is sponsored, I believe, by an attorney group, but that has some good health and legal information: http://www.denturecreamlawyer.com/ I hope this is of help to your readership.