By Dr. Paul Ehrlich and Henry Ehrlich
(This piece comes from an intense discussion of the mentioned article, which captured both our imaginations so we decided to sign it jointly.)
An article in the New England Journal of Medicine “The Whole Ball Game — Overcoming the Blind Spots in Health Care Reform” by cardiologist Dr. Lisa Rosenbaum looks at the complexity of trying to extract value from efforts to change our health care system. Expressing it as simply as we can, she argues that the doctor’s goal of achieving better outcomes by practicing evidence-based medicine may not be reconcilable with the goal of achieving patient satisfaction because it doesn’t fit into the patient’s preconceptions about what he needs. This shows all that’s wrong about viewing health care as just another consumer marketplace. To the “satisfied customer” good medicine is often based on doing things that, medically speaking, are either pointless, misleading, or even harmful, and all of them cost money. To many, a trip to the doctor for a sore throat isn’t complete without a prescription for antibiotics, even if the cause is a virus. It used to be that such a prescription could be viewed as merely pointless. Today in the era of antibiotic resistant microbes and concern for the bacterial environment of the gut, it could be judged harmful. But that kind of logic often doesn’t register.
Dr. Rosenbaum tells about a patient she saw as a fellow at a cardiology clinic where patients often came seeking a second opinion. “Usually, such patients would hand me a stack of records describing previous care. But in attempting to satisfy their expectations of better care, I faced a frequent challenge: the previous cardiologist had not done anything wrong.” Rosenbaum asked why he wanted a second opinion. He said, “My other cardiologist just doesn’t seem to be doing anything to keep me from having a heart attack.”
The patient was preoccupied if not obsessed from the sound it. He had curtailed his life to lower the risks, cutting out playing hockey and also worried about working as hard as he did. “Though he had no symptoms, his fears were not unfounded. He was overweight and had poorly controlled hypertension, and his diet was riddled with salt. Most troubling to him, both his father and brother had had heart attacks at a young age. But as we began to discuss risk-factor modification, he raised a common question: ‘Isn’t there some test you could do?’” He had already had thousands of dollars worth of tests. To cut a long story short, Dr. Rosenbaum’s preceptor sat down with the patient and explained that further tests wouldn’t reveal anything they didn’t know and that blood pressure medication and a change in diet would help. The patient said no one had ever explained this before.
Never explained it? We were reminded of the scene in “My Cousin Vinny” in which the title character, watching a short-order cook put a vast dollop of lard onto the griddle, asks if he has never heard of the ongoing cholesterol problem in the country. More likely, following Dr. Rosenbaum’s thesis, the patient just hadn’t previously been prepared to comprehend this information.
A year ago, nine specialty groups, including allergists, published lists of five tests or procedures that should be eliminated or curtailed. Looking back on the list for allergists, elements of the dilemma posed by Dr. Rosenbaum are present on both sides.
People do want tests, and many doctors oblige, even if they reveal little or nothing meaningful. As with Rosenbaum’s patient allergies and asthma are frequently uncontrolled because patients don’t want to do the hard behavioral work that really makes a difference. Sometimes, however, a well-timed test can make the difference, such as testing breath for exhaled nitric oxide [eNO], which is a marker for asthmatic inflammation, or an oral food challenge if the doctor is fairly sure that a patient is not allergic. Unlike CT scans, which have been so casually prescribed for cardiac patients, the technology and expertise for these tests aren’t widely available. If they required huge capital investment and could be booked over and over again every day, like CT, they might done in strip malls everywhere.
An additional problem for aligning evidence-based physicians with patients who have been informed (and often misinformed) by the Internet is the dilemma presented by complementary and alternative medicine [CAM]. This is a particular challenge for allergists since all allergic and immune disorders are kind of mysterious and frequently manageable at best, not curable, so patients grow very frustrated. In these instances, they ask not for one more test, as in Dr. Rosenbaum’s case, but inquire about treatments they have read about. Others may have embarked on an “alternative” treatment without telling their doctor, which may compromise or conflict with their mainstream treatment. Colonel Renata Engler, MD*, and several co-authors have written, “Allergy-immunology specialists are faced with the challenge of how to respond practically to the evolving information presented by the expanding world of CAM.” Considering the fact that about a third of patients have tried some of these things and 50% would consider such avenues, Renata, et al, think much more must be done to address this challenge.
So, Dr. Ehrlich, what is an allergist to do?
Personally, I have learned not be dismissive of ideas brought to me by patients about alternatives. If nothing else, I have to learn enough about the therapy to argue against it, or, as in one case, to administer a treatment brought to me in desperation by a mother who had so thoroughly researched it that I was convinced, first that it would do no harm and second that it might work. So far so good. In other cases, I have referred eczema patients to Dr. Xiu-Min Li because after reviewing their full histories I was persuaded there was nothing else good-old American medicine could do for them—also with good results. When it comes to managing chronic illness, I am sometimes reminded of Woody Allen who told Annie Hall that after 15 years of psychoanalysis, “I’m giving it one more year and then I’m going to Lourdes.”
*Dr. Engler is an old Army buddy of Dr. Ehrlich’s. He did his allergy fellowship while in the service at Walter Reed, where Dr. Engler still works.
Photo by www.sportsbikeshop.co.uk