Archive for July, 2011

Tuesday, July 26th 2011

Primary Care And ‘Health’

Much has been made of the lack of tertiarization (I’ll pretend that is a word) in American health care. The U.S. has a proportion of specialists to primary care physicians greater than any other western nation. Just over a third of U.S. physicians practice primary care.

Ratios of primary care physicians to specialists that more strongly favor primary care have, in the past [doc], to be strongly associated with lower mortality, higher compliance with health care and other positive outcomes.

But flipping through a Dartmouth Health Atlas project shows even amongst this long tenent there is a lack of consensus,

Rates of leg amputation, a serious complication of diabetes and peripheral vascular disease, also had no relationship with having at least one annual visit with a primary care clinician. And patients’ risk of leg amputation varied dramatically depending upon where they lived – there was a tenfold difference in the rate of leg amputation, ranging from 0.33 per 1,000 beneficiaries in Provo, Utah to 3.29 per 1,000 in McAllen, Texas.

The report also found that having an annual primary care visit did not keep patients out of the hospital for ambulatory care-sensitive conditions such as diabetes and congestive heart failure. There was a more than fourfold difference in the rate of ambulatory care-sensitive discharges among Medicare beneficiaries, ranging from 30.7 per 1,000 in Honolulu to 135.0 per 1,000 in Monroe, La.

It’s a complex issue for sure and certainly the sum of evidence seems to support benefits for more primary care physicians (even at the expense of specialists) but I thought the write up on the Dartmouth Atlas data was interesting.

Monday, July 25th 2011

Informed Consent

I’ve been thinking a lot of late about informed consent. I mean the ethics of trying to explain, in sufficient detail, what exactly you propose to do to a patient, what the potential benefits of such are, what the potential risks of such are, what the potential alternatives are.

Excuse me rehashing; I know it isn’t a new topic.

But I think often we fall far short of informed consent, at least what I was taught informed consent encompassed in medical school. And I’m not sure it is a fault of our own.

Medicine, more than any other consumer transaction (and I use that term loosely) has an informational imbalance. It is a situation wherein the physician has a much greater level of knowledge than the patient can often ever hope to. And often, with the nuances of and individuality befit every separate case, the majority of the patient’s knowledge must come from the physician.

If I take my car in and the mechanic hands over a bill for $700 for a new altinator I can research the symptoms of a failing altinator and compare them to my car’s own and if I want I can research the step by step specifics of how to replace an altinator and probably, if I was so inclined, manage it myself.

Facing the description of a medical procedure, the risks of it, the description of the pain and what to expect in recovery however is something else. There is a final step to reality that often times, if the patients and families lack a comparable experience to draw on, cannot be made.

I can try to convey the pain I’ve seen other patients go through after a surgery but without previous experience it often seems meaningless to patients. I can try to explain exactly what I propose to do to a patient step by step with models and diaphragms but the brutal reality of surgery is often somewhere lost between the clinic and the operating room. I can try to explain the plethora of risks I’m instructed to list out to the most dramatic, but quoting 1 in 1 million chance of contracting HIV with this transfusion is almost meaningless. 1 in 1 million, what does that even mean? How to comprehend that? What to compare it to? How to weigh it against the alternative?

Supposedly those are the questions informed consent is supposed to put into perspective. But in patients with limited education, limited health literacy, with no comparable experiences within the health care system, it sometimes seems no amount of time spent on consent will leave them informed.

Quizzical looks fading into resignation and repeated, non-sequitor questions I don’t think are always a symptom of my performance in trying to obtain informed consent. I think they’re just the nature of the situation sometimes.

I certainly have never thought my views on medicine, on the patient-physician relationship paternalistic but sometimes; sometimes it feels the best informed consent is to lay out, as best you can, why a procedure needs to be done, in very basic terms what the procedure is, your experience with the procedure, the fact that bad things can happen and let the minutiae stay aside. Maybe informed consent is something different for each patient, for each situation.

I know that isn’t reality and there are medicolegal and other aspects to consider but that feels ethical to me.