Dr. Jeff Hersh: Changes and challenges in health care

In my 500th column today I want to look back on the changes in medicine since my first column more than 10 years ago.

Let's start with good news: Many treatments have improved, including treatments for heart disease and many cancers, the two most common causes of death in the U.S.

But many new challenges have arisen. For example, increased travel has made the world a smaller place, and infectious diseases (such as West Nile virus, Dengue fever and new strains of flu) have spread. Furthermore, inappropriate overuse of antibiotics has increased medication-resistant strains of many diseases (for example, methicillin resistant staph aureus).

However, the most significant challenge is the trend toward more, but not better, health care being delivered. A recent discussion I had about where to go out for dinner illustrates this point. "I think we should go to the place just off the highway," my buddy told me. "But the food there really isn't very good," I responded. "Yeah, but the portions are huge," he replied.

The problem of increased quantity but not quality of health care is multi-factorial, contributed to by the fear of malpractice litigation, the American attitude that new, fancy, high-tech is always better (driving patient expectations), as well as our compensation system that pays lots of money for testing and interventions and not so much for prevention and good old doctor-patient interactions.

Up to one in three of the tests and interventions we perform are not necessary. Let's look at some examples

- Inappropriate medication usage, strongly responsible for developing medication resistant diseases, is rampant. Three of every four ER patients receive medication, many for antibiotics, and many of these are unnecessary (for example, antibiotics are often inappropriately dispensed for certain ear infections, viral illnesses, etc.).

- Powerful anti-acid medications (proton pump inhibitors) are used two times more often than they are needed.

- Overall, studies have shown that PSA testing does not reduce prostate cancer deaths when done as a routine screen in certain patients. Yet the results of a positive PSA often lead to unneeded biopsies and interventions (along with their significant side effects).

- Fetal heart monitors used to track labor are overused. There is no evidence that they decrease cerebral palsy or death in low risk patients; however their overuse strongly contributes to the 1 in 3 caesarean section rate in the U.S.

- Half of all worldwide medical radiation is used on Americans, despite the U.S. being less than 5 percent of the world's population. For example, half of all emergency room patients get X-rays, often ignoring well documented algorithms as to when certain X-rays are needed. It is estimated that soon 2 of every 100 cancers in America will be linked to medical radiation.

- More complex back surgeries are often used when simpler interventions, including less complex surgeries and/or non-surgical interventions, would be sufficient.

- Many heart catheterizations are done despite the knowledge that they may not be indicated; one study noted that 1 in 4 cardiologists have ordered a catheterization out of fear of being sued.

- There is also a huge bolus of over-testing and over-treating (both with medications and other interventions) in patients as they approach the end of their lives. About one-third of Medicare dollars are spent on the last year of patient's lives.

All in all, the last 10 years have seen a worsening in the trend of "more, but not better" health care being delivered. So, what is the solution? We must:

- Address the fear of malpractice litigation that drives over-testing and over-treatment.

- Allow health care providers to spend more time examining, interacting with and teaching their patients. The trend is to have more primary care delivered by non-physician health care providers (the aging population and the complexity of their conditions added to the limited numbers of physicians ensures that this trend will continue), and this can become part of the solution if done correctly.

- Stop over-paying for testing and interventions and begin paying for improved outcomes.

- Stop spending twice as much on health care as other developed countries without reaping the benefit of improved health of our population. The inefficiency, waste and ineffectual (and sometimes harmful) care our present system has led to must be addressed.

I am hoping that 10 years from now my 1,000th column will celebrate the improvements we will soon make.

Massachusetts-based Jeff Hersh, Ph.D., M.D., F.A.A.P., F.A.C.P., F.A.A.E.P., can be reached at DrHersh@juno.com.