Friday, November 20, 2009

Screening guidelines in healthcare

If you lived in Maine and told the local animal control group that you were concerned about cobras in the area, it would be foolish and a waste of money to begin a program to search for cobras.

If, on the other hand, the local zoo had reported that their snake exhibit had escaped in the middle of summer, you reported seeing a large snake that reared up and displayed a hood, and you had small children playing in the area, then money spent on a program to find and remove cobras in your area of Maine would be a good idea.

This example illustrates how decisions on health care screening should be made, although with more simplicity.  If a disease is extremely rare in your area and you have not had symptoms of that disease without another good explanation, it doesn't really make a lot of sense to screen you for that disease.

Remember that any screening test may give a false result.  In other words, that polyp they took a biopsy of from your colon may come back with a result of cancer.  You may undergo surgery and you may even suffer complications such as infection, or scarring that blocks your intestines, among others.  It would then be frustrating to find out that the original biopsy result was incorrect and that you do not have colon cancer.

This might not even be a case of malpractice.  Sometimes it is not clear what the result of a test or biopsy is, and an informed "best decision" has to be made, often with the consultation of several experts and hopefully inclusion of the patient.  Complications of treatment can occur even when nothing is done wrong.  Infections occur.  Scarring occurs. 

I think that the public reads about disease screening recommendations and fears that health care is being taken away.  It is important to understand the difference between routing screening and good health care.

So, if you are young, and colon cancer is rare, screening for it may not be a great idea.  On the other hand, even if you are young and it is a rare disease, if you describe symptoms such as a change in bowel habits, blood in your stool and weight loss, then screening would be a good idea, even though you might not fit into the group of people that should receive "routine" screening.

That is called the good practice (or the art) of medicine, not dictated by the base of evidence guidelines, but by the patient's symptoms and the doctor's judgment.

Evidence based guidelines can be helpful to make broad decisions that might save a population money that would otherwise be wasted, and allow it to be used for more fruitful endeavors, but they are not laws.  Part of what makes all those years of  a physician's training valuable is the ability to think without a rule book, and to use judgment that may go against what is traditionally thought.

Guidelines are just suggestions for groups of patients.  I would hope that they are never used to deny care that is proposed by a physician based on a patient's symptoms.  Guidelines are not intended to be used as such.  This is further reason why it is important that patients have relationships with their physicians and the ability to be seen without a long wait when necessary.  A physician who knows you can deliver better care because he or she knows your history and the way you have presented symptoms of disease in the past. 

Systems that apply to everyone are not interchangeable.  For instance, pain scales are OK for following the course of pain in an individual, but do not give an absolute measure of pain.  One patient may have a hangnail and call the pain 8 out of 10.  Another patient may have broken a finger and call the pain 3 out of 10.  That's because a 10 is the worst pain "imaginable" by that patient and is affected by personality and experience.  A physician who knows you is better able to take your personality and experience into account when treating you.

As guidelines for health care screening evolve and recommendations are changed, it is important to remember that all bets are off when a  patient has symptoms consistent with a disease.  Sometimes adults get "children's" diseases, and children get "adult" diseases.  We need to maintain the autonomy of physicians as well as their relationships with patients to provide the best health care, if that's what we want.  Otherwise patients will need "health care providers", insurance, and "health care advocates" to help them understand the decisions and make sure the correct ones are made.

In a recent New York Times article  Louse B. Russell, a research professor at the Rutgers University Institute of Health who has studied whether prevention necessarily saves money (and found that it does not always do so) said  "It's going to take time in part because too many people in this country have had a health insurer say no, and it's not for a good reason.  So they're not used to having a group come out and say that we ought to do less, and it's because it's best for you."

Sunday, November 1, 2009


Six months ago I was married.  Tonight I went trick-or-treating with my ex-wife, her new husband, and our two children.  Life changes quickly.

In past years we had Halloween parties that the children still remember although they are only four and six years old.  No party this year that I know of.  Of the three of us, I was the only adult in costume.

I joined the kids and greeted my ex and her husband pleasantly.  The things we'll do for our children.  For the rest of the evening I just pretended that my ex and her husband were casual acquaintances, easy to do as I have no feelings of lost love.

I focused on the kids and joined them as they approached each house eagerly.  I made small talk with the people who had decorated their homes.  My son wanted to give me all of his candy.  My ex-wife made sure to call from the curb for the kids to say thank you at each house.  I wondered where the Unicef boxes were.

My ex-wife and her husband walked along together and I heard a familiar tone and pattern of conversation that I found artificial and an unpleasant reminder of what I had once bought into.  I worried that she doesn't have what it takes to find herself.  I worried for the kids.

It was raining hard and my daughter became cold and I gave her my Marlon Brando jacket, part of my biker costume.  She looked cute in her fancy dress and too-large motorcycle jacket.

How strange it must be for a child to have two homes.  Not uncommon, but strange, especially to someone like me who grew up confident in his family's unity. 

As we walked my son mostly stayed with me, his current alliance.  My daughter is having a harder time and went back and forth, telling her mom and me both that she loved us.  Reciting the mantra, "I love daddy and I also love mommy".  A seemingly unnecessary burden for a small child to carry.

We arrived back at my ex-wife's home.  I was not invited inside, and I got my jacket back from my daughter and dripped my way to my truck.  I drove home in rain blown horizontal by the wind. 

I had a feeling of sadness.  I wanted to be there to review the loot.  To sort out the good candy from the undesirable stuff.

I took a candy bar that my son had given me and ate it.  I hope they had fun tonight.