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PostPosted: Wed Apr 21, 2010 7:54 am 
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What's wrong with American medicine? Continuing a discussion with JungleDoc from a different subject thread.


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PostPosted: Wed Apr 21, 2010 7:55 am 
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Jungledoc wrote:
ApolytonGP wrote:
I'm a belt and suspenders type. Physical exam, MRI, X-ray. Multiple diagnostic tools.
This is exactly the problem with American healthcare. The majority of people demand this sort of standard. The best example I've seen lately is the cartoon of the guy sitting on the exam table with an arrow through his head. The doctor says, "Right off I'd say you have an arrow through your head, but just to be sure I'm going to order a bunch of tests." Technology is overused to a horrible degree. Canada has a fraction of the CT and MRI scanners that we do, and their outcomes are at least as good as ours. I'm pretty sure that the same could be said for most of the developed countries in the world. It's MRIs, PET scans, nuclear scans, exotic serologies, and on and on. Chemistry profiles...don't let me get started on chemistry profiles, those panels of 20 or 25 tests that are so often merely as screening tests, despite the fact that it's been shown that they are MORE likely to show normal people who are merely outliers than to reveal unexpected pathology, and thousands and thousands are done every day. And on and on.


1. It is a GENERAL problem-solving trait that having multiple independend indications for a diagnosis (particularly when multple problems can be the cause) is helpful. Thus MRI is not perfect. Neither is X ray. Neithe is examination. TOGETHER, they are more powerful than on their own.

2. Of course, irellevant tests do NOT help the diagnosis (blood tests for an arrow through the head). MRI, X-ray and physical exam, for a musuloskelatal issue sure don't seem like blood tests for an arrow through the head to me. For TWO reasons.
A. The tests are not unlikely to give helpful related information.
B. We often do NOT have a conclusive indication of what the problem is by visual examination.

3. "gold standard" This is a better point. Sure...there are cases where we have to make economic tradeoffs and basically decide that a lower standard of care is worht the tradeoff. Of course even if we make these kinds of decisions, I want the doc at least
A. thinking logically. IOW, he may say, not worth the money to do test X, because of the cost versus the information. But I don't want him just putting his brain on hold and not even thinking in the manner of corrrelating information.
B. I want to know about these tradeoffs. Maybe I would pay for it. And I sure as heck don't want the guy incentivized by my insurance company to get little kickbacks for not ordering tests.

4. Gold standard continued: this is why I really hope/think/pray/want MRIs to come down in price. I want them to become like X-rays. There is SOOOOO much information available from them that is very pertinent to ortho diagnosis. You are getting me motivated to go invent a room temperature superconductor and then go after GEs ass with a doctor's office MRI!

5. "Technology is overused." It's a general statement and hard to evaluate. I've heard it, for decades now. I really haven't studied it or done the work to look at social science studies of it. At least in my personal experience (admittedly healthy young male) have not had this experience....really more the opposite of going decades without seeing a doc and of not having them push tests at me when I had athletic injuries. I wonder if this is more of an issue with other patient populations or internal medicine issues and not really related to the ortho type conditions we are discussing here?

6. "Technology is overused." My doc had a little placard on the wall talking about over-ordered imaging. And I've heard the colloquial comments. However, my experience is that the MRI changed the diagnosis twice. Both times, I had to insist on it. First time, we discovered grade 4 chondro (loss of cartilage down to the bone), when ortho diagnosed tendonitis. Second time, surgeon and primary care doc said my already operated shoulder had tendonitis and the labrum was fine, would not authorize a contrast agent MRI...I had to find a doc to order it. Did so. And it successfully resolved the labrum (which a non-contrast agent had not) and showed the anterior labrum "missing".

7. It's not like I think technology shows us everything. that's why I said, multiple tests. I want to put it all together. But I sure as heck don't want to rely on the "white labcoat appeal to authority". Sorry. The mechanic explains the car problems to me. Same with dishwasher repair. Same with my freaking body.

8. Canada outcomes: Outcome is a broad brush. Are ALL outcomes the same or better up there? Also, the patient populations are not identical.

9. If a test has a higher false positive reading, then we should just take that into account with a Bayesian consideration of the results. I can handle the if-then statistics logic. Can the docs? :wink:

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More later.


Last edited by ApolytonGP on Wed Apr 21, 2010 8:31 am, edited 3 times in total.

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PostPosted: Wed Apr 21, 2010 8:04 am 
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I think its sorta like the nature vs nurture argument- its sorta both, and in some cases one more than the other.


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PostPosted: Wed Apr 21, 2010 8:35 am 
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Rucifer wrote:
I think its sorta like the nature vs nurture argument- its sorta both, and in some cases one more than the other.


(I posit) It's more one in OB-GYN and more the other in Ortho. :twisted:


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PostPosted: Wed Apr 21, 2010 9:02 am 
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In general, I think that a lot of the tests being done are cover your ass type tests, that aren't really required but if not done, could leave the doctor open to liability. If the insurance company will pay, the test gets done even if it's not needed. The answer here is that it should be a medical team that decides if a test is warrented, not the legal or insurance system.

Too many tests can have negative consequences. False positives can lead down rabbit holes that detract from the main issues and can cause stress and complications on their own. Too many tests can also lead to information overload where the real issue is obscured in all the data.


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PostPosted: Wed Apr 21, 2010 9:11 am 
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our problem with medical care (at least as it pertains to this discussion) is a the general sense of entitlement. As soon as someone makes a mistake, be it medical or otherwise, a lawyer gets called to see if they can get some money out of it.


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PostPosted: Wed Apr 21, 2010 1:54 pm 
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I have never had CYA tests. Well perhaps I did and didn't notice it! But at least it doesn't happen to the extent that I noticed it on myself. I've been hearing about this CYA test stuff for 30+ years...but never really seen it up close and personal. I have had tests NOT DONE, that when later done, showed different diagnoses and changed the treatment path.

What's the cost of months of physical therapy for a problem that will not respond to PT? And it's not just the PT itself but the value of the patient's time in non-responsive PT and loss of function while waiting for correct treatment.


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PostPosted: Wed Apr 21, 2010 1:56 pm 
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frigginwizard wrote:
our problem with medical care (at least as it pertains to this discussion) is a the general sense of entitlement. As soon as someone makes a mistake, be it medical or otherwise, a lawyer gets called to see if they can get some money out of it.


Could be. I'm not sure it is the only problem. Think there is a lack of evidence-based medicine as well. Look how long the damn docs hunkered down and refused to admit that stomach ulcers came from bugs not stress.


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PostPosted: Wed Apr 21, 2010 2:17 pm 
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ApolytonGP wrote:
frigginwizard wrote:
our problem with medical care (at least as it pertains to this discussion) is a the general sense of entitlement. As soon as someone makes a mistake, be it medical or otherwise, a lawyer gets called to see if they can get some money out of it.


Could be. I'm not sure it is the only problem. Think there is a lack of evidence-based medicine as well. Look how long the damn docs hunkered down and refused to admit that stomach ulcers came from bugs not stress.


I would contest that issues like that are global, and have nothing to do with the country the doctor is based in.


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PostPosted: Wed Apr 21, 2010 2:56 pm 
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frigginwizard wrote:
ApolytonGP wrote:
frigginwizard wrote:
our problem with medical care (at least as it pertains to this discussion) is a the general sense of entitlement. As soon as someone makes a mistake, be it medical or otherwise, a lawyer gets called to see if they can get some money out of it.


Could be. I'm not sure it is the only problem. Think there is a lack of evidence-based medicine as well. Look how long the damn docs hunkered down and refused to admit that stomach ulcers came from bugs not stress.


I would contest that issues like that are global, and have nothing to do with the country the doctor is based in.


Good catch. I agree.


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PostPosted: Thu Apr 22, 2010 3:31 am 
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I think there is plenty of blame to go around.

Paying higher costs because of all the services never payed for by low income people is probably the biggest. All that other stuff sure doesn't help though.


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PostPosted: Thu Apr 22, 2010 4:43 am 
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I'll play but only really want to comment on muscle/joint injuries as this is the only thing I have an opinion (and passion) about. Other stuff I just don't know much about and wouldn't like to get into it without knowing more.

ApolytonGP wrote:
1. It is a GENERAL problem-solving trait that having multiple independend indications for a diagnosis (particularly when multple problems can be the cause) is helpful. Thus MRI is not perfect. Neither is X ray. Neithe is examination. TOGETHER, they are more powerful than on their own.


It would be great to get a good examination, X-Ray, and MRI everytime you had some joint pain. It would also be good if I could just employ a full time chef to live in my house and prepare all my meals for me, especially if they also had a passion for cleaning. However, some things just aren't practical.

ApolytonGP wrote:
2. Of course, irellevant tests do NOT help the diagnosis (blood tests for an arrow through the head). MRI, X-ray and physical exam, for a musuloskelatal issue sure don't seem like blood tests for an arrow through the head to me. For TWO reasons.
A. The tests are not unlikely to give helpful related information.
B. We often do NOT have a conclusive indication of what the problem is by visual examination.


What if simply having a diagnosis is irrelevant? This is really my whole point. In the other thread I posted a study which looked at MRI's done on the lower back for people who had no complaints of any problems. The majority had 'something' wrong with their spine. So what use is the MRI to those people? If I can have 2 people with a disc bulge in the lower back and, one is in pain and the other feels fighting fit then, what's the difference? The difference can be found by looking at the work of people liek Sahrmann, Cook, McGill, etc.

To put it another way - I've got shoulder pain and eventually I get a diagnosis of a partial tear in the supraspinatus and some 'labral fraying' (damage to cartilage). How does that help me? The only way that helps is that I now have something to tell people when they ask what's wrong with my shoulder. It literally does nothing in terms of getting to the cause of the problem. Symptom and Source are often very different things. The joint that shows the symptom is not commonly the joint(s) that caused the problem. No X-Ray, MRI, or whatever will tell me that my shoulder blades and upper spine suck and that's why my shoulder joint got sore. All they tell me is that "ah, yes, you have a sore shoulder and, our MRI shows that you should infact, have a sore shoulder". Well thanks. I'll take my anti inflammotries now and look forward to my bouts of 'ultrasound therapy'.

Loads of things can cause cartilage to get damaged, tendons to tear, or whatever. A diagnosis tells you nothing about the cause. I think the only value is in the cases where you may need surgery. However, I believe a movement based approach should be done first, since it's the least expensive and has a lot of potential to solve the problem without surgery. Surgery still doesn't 'solve' the problem btw, it only reduces symptoms. You still have some underlying reason why the problem happened in the first place.

KPj


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PostPosted: Thu Apr 22, 2010 4:53 am 
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frigginwizard wrote:
our problem with medical care (at least as it pertains to this discussion) is a the general sense of entitlement. As soon as someone makes a mistake, be it medical or otherwise, a lawyer gets called to see if they can get some money out of it.


I agree with this but also want to piggy back on it. I think that 'sense of entitlement' is a big issue in general. Someone who is overweight, does no exercise, spends the majority of their life sitting down in horrible positions will develop some kind of joint pain. It'll be persistance because they never actually change anything. They just hope for some magic pill that will solve the problem. When it keeps coming back they start to blame doctors for their joint pain - as if the Doctor is providing poor service and that's why he keeps having joint problems. Never mind the fact that his nutrition is terrible and he's extremely sedentary. It would be too difficult to make any changes here.

In short, I think people need to take ownership of their health and stop relying 'as much' on other people. Just moving around more and learning how to cook real food would be huge steps. Both of these entail taking things into your own hands - My joints suck because they don't do anything, i'll start doing something. My diet sucks because all I eat is processed foods, ready meals, fastfood, etc. You know what, it's about time I learned to cook, you never know, I might actually enjoy it.

KPj


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PostPosted: Thu Apr 22, 2010 8:24 am 
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Kpj:

Literal LOL on the MRI chef! Extra points if she looks good in a skirt too...:)

Yes, I agree that it is not cost-reasonable to have every joint twinge recieve an MRI. That's why I think JD's "gold standard" comment was good (we still ahve to quantify the cost/benefit). But really, this is very different from ordering blood work for a guy who has an arrow through his head. Remember that docs can do things like diagnose GI distress or patellofemoral syndrome...which aren't really even diagnoses, but fancy words to cover up that the problem could be a lot of different things.

On the "info might not help". Sure, it's POSSIBLE that knowing the exact mechanical issue might not help treatment of the injury and prevention of recurrence. I guess that's like not drilling for oil, since you only "might" strike it. I find generally in life (cars, appliances, business, etc.) that understanding things enables better responses.

Remember the NASA middle manager shmuckette who got 7 Shuttle astronauts killed because "photos wouldn't help since we can't do anything anyway" (which was untrue...she had not really examined rescue or damage control options which the USN-led investigation sadly showed existed and would have changed probability of survival significantly.)


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PostPosted: Thu Apr 22, 2010 8:30 am 
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KPj wrote:
frigginwizard wrote:
our problem with medical care (at least as it pertains to this discussion) is a the general sense of entitlement. As soon as someone makes a mistake, be it medical or otherwise, a lawyer gets called to see if they can get some money out of it.


I agree with this but also want to piggy back on it. I think that 'sense of entitlement' is a big issue in general. Someone who is overweight, does no exercise, spends the majority of their life sitting down in horrible positions will develop some kind of joint pain. It'll be persistance because they never actually change anything. They just hope for some magic pill that will solve the problem. When it keeps coming back they start to blame doctors for their joint pain - as if the Doctor is providing poor service and that's why he keeps having joint problems. Never mind the fact that his nutrition is terrible and he's extremely sedentary. It would be too difficult to make any changes here.

In short, I think people need to take ownership of their health and stop relying 'as much' on other people. Just moving around more and learning how to cook real food would be huge steps. Both of these entail taking things into your own hands - My joints suck because they don't do anything, i'll start doing something. My diet sucks because all I eat is processed foods, ready meals, fastfood, etc. You know what, it's about time I learned to cook, you never know, I might actually enjoy it.

KPj


This is sort of tangential. But it is one reason why I wanted to change my fatness and weakness. I wanted to A. see if losing weight and getting strong would help the joints and B. even if it didn't, be treated as an athlete by docs when consulted (and they sure treat me more like an athlete now, then when I was 50% weaker and had 70 pounds more fat.)

And it's not the docs fault that my body is falling apart. God didn't build it to last forever. :(


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