Doing “Everything”

Family docs tend to be medically “conservative”. This means we don’t like to intervene with medical tests and treatments unless we have to. Actually, the better way to describe it is that when there are two reasonable approaches to a patient’s illness, FP’s are more likely to make the less-invasive choice.

The fact is that the whole idea of doing “everything you can” for a patient is a bit of a myth. Often this, in practical terms, is doing everything you can TO the patient, not for him/her. CPR – although practiced even by the most conservative hospitals – is a good example. Did you know that over 80% of CPR “codes” result in no change in the patient’s condition? This is, we initiate the code because the patient is dead. Eventually, the end result is the same…dead. It doesn’t do anything. But when the family comes to see their now-deceased loved one, they find someone who looks like they just lost a fight in the Octagon. I won’t go into the bloody details, but it’s often a grisly scene. One example: by state law (having to do with lawyers, as usual), nobody is allowed to remove the endotracheal tube used to deliver oxygen to the patient. So, when the family comes to see the patient, even if we’ve cleaned him/her up a bit, we have to leave this big plastic tube sticking uselessly out of their mouth. Imagine that being the last image of your Dad.

I should mention that occasionally we do bring people back, but most people don’t know that a good majority of them will have been without oxygen for so long that they will have permanent mental disabilities. Often severe disabilities.

And this is considered conservative care.

Contrary to impressions, medicine rarely presents clear cases with absolute interventions. So many nuances exist in each case that doctors really do make many choices based on their experience and judgment. But often, it isn’t the individual doctors who make those treatment choices. These days, hospital committees (comprised of senior doctors and others) decide how to treat anyone coming in with specific symptoms. Chest pain, for example, often requires a “rule out” of a heart attack. What needs to be done is all laid out on a pre-printed order sheet. The doc just checks a few boxes and the patient is whisked off to the floor. Those order sheets can vary widely between hospitals depending upon how “aggressive” they are. Some hospitals may require significant interventions with fluids and pre-treatment for catheterization, telemetry monitoring and more than 3 sets of cardiac enzymes. They may want chest CT’s to rule out aortic dissection. Other hospitals tone it way down, just following the patient in an ER bed with enzymes and an occasional EKG, sending patients home that in some hospitals would be required to stay overnight.

You might think that the more aggressive hospitals – using all the latest technology, tests and interventions – would be the best place to go if you’re REALLY sick. I mean, if it’s your mom, wouldn’t you do “everything you could” to save her life? Sure you would. But excellent research disputes this thinking. Often, outcomes are no better at either type of hospital. But if you’re looking for aggressive hospitals, you’d want to go to the downtown hospitals in America’s big cities like NY, and LA. They have recently been ranked by Consumer Reports, based on this study by the public health school at Dartmouth. The site has a tool that allows you to compare the aggressiveness of most hospitals in the U.S. Mine comes out as one of the least aggressive in the country. Being a family doc, I’m perfectly fine with that.

There are lots of reasons why more aggressive hospitals don’t help you, and spend much more money in the process. But the bigger issue is that any hospital – and the care they provide – can hurt you. More aggressive care leads to more infections, poorer coordination of care, medical errors, and – my personal favorite – higher rates of false-positive tests. For example, digital prostate exams will be falsely positive more than 40% of the time. From there, further evaluations also have a high false-positive rate, and many people end up getting a harrowing surgery that usually leaves them unable to get erections (even with viagra) for the rest of their lives. And they never had prostate cancer.

Medical interventions are not safe. They never are. Even the ones that are totally justified by medical literature. No medicine, no intervention, no test. For that reason, never be afraid to ask what someone is doing to you and why before you let it happen.

Life is best outside hospitals. You never know what will happen inside them.

2 thoughts on “Doing “Everything”

  1. batguano101

    There is a difference between conservative and aggressive beyond what you point out: practicing defensive medicine laying down a groundwork for legal defense and simple greed.

    This issue is complex, but the starting point to outlining it fully is to acknowledge the strong financial motivations sometimes only pay lip service to the clinical situation and more importantly to the patient.

    To the exact degree standards of treatment (diagnostic procedures) have a set point higher than indicated for good patient care (complications, morbidity and death outweigh value to the patient) the factors of defensive and income enhancement (greed) are counter productive.


  2. secretwave101

    I can’t agree more, and I wish I’d thought to add this element into the post. I think you just gave me my next topic, in fact.

    CYA (Cover Your A**) medicine is a huge problem. I suspect it nearly doubles the cost of medicine in America.


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