Blood Clots or How Dr. House Breaks Down the United States

A recent study from Italy is making the media rounds indicating that doctors should screen more for blood clots in the lungs. Now that this is pushed by the media and the social media, there will be more pressure on doctors to screen for blood clots. More patients will come in to urgent care and emergency care about what they think represents blood clots. The cost will be enormous with little change in outcomes - a representation of much that is wrong with the most costly health care in the world.

And, by the way, doctors have long known about clots as a hidden cause of health problems inside and outside of formal health care. The truth is that the incidence of clots is actually much higher and the body handles these challenges well. And those that tend to have the worst symptoms (faints, falls) and worst clots are often closest to death.

Some reflections
  • Do we really want doctors pressured by the government and insurance companies to do less or by the media (academic media, news media, social media) or patients to do more?
  • Decades of manipulations have not resulted in improvements of care and have substantially worsened costs and have resulted in no improvements in health outcomes.

Review what NPR represents to the public, with my comments
  • "When A Fainting Spell Is Caused By A Serious Blood Clot" - The errors made by journalists start with the title. Elderly people averaging 76 years and with chronic conditions have many different reasons for fainting. This may or may not be due to a blood clot, even when a clot can be found. And it is possible for a clot to have already dissolved into smaller pieces such that the clot caused the "faint" but there is no evidence of a clot - such is the ability of the body to address clots although aging and other conditions can impact this ability.
  • "Blood clots are on the list of conditions that doctors are supposed to consider when figuring out the cause of a fainting spell, but physicians don't routinely do full work-ups to look for them....The doctors screened for blood clots among 560 elderly patients (average age 76). And they report in the latest issue of the New England Journal of Medicine that 17 percent of the patients with fainting spells also had blood clots in the lung."   Full work ups cost thousands of dollars. Excluding every condition on every list (The Dr. House Approach) would result in thousands more dollars in some fairly common presentations across emergency rooms, urgent cares, and primary care settings.
No Smoking Gun
  
It is well known that we throw blood clots throughout our lives. Some are too small to detect or are too small to cause problems. Some can be detected and cause problems. Some cause problems and cannot be detected. Other clots are just present when people faint but this was not the reason for the fainting.


No Baseline for Comparison

The research survey design has problems. The population that was surveyed was the most likely age of all to have conditions that lead to clots. There is not even a reference population to indicate how many have clots "normally" for the age and other conditions present (matched controls).  

Treatment Consequences

The treatment for clots involves anticoagulation. Thousands have complications from anticoagulation or die. This is the riskiest of all treatments which many should realize given the number of lawyer commercials. 

Government design made it more difficult to care for patients with clots. The government design for payment (Diagnosis Related Groups) has forced hospitals to send patients out of the hospital faster. The design has also made it more difficult to get follow up.

Does More Treatment in the Oldest of the Elderly Add to Life?

The study population is closest to the last year of life. This is the time period that results in 30% of Medicare costs and this proportion continues to increase - not surprising given journal, media, and other promotions. Having a fainting episode or a clot indicates patients even closer to death. The treatment adds to costs and results in some who die from complications.

Costly Training That Results in Higher Costs and Must Be Unlearned By Physicians

Doctors are taught by the Dr. House approach. In this approach, medical students are taught to form a differential diagnosis of every different condition that could cause the symptoms. They tend to think in organ systems (cardiac, respirator, GI) with one or more conditions reviewed for each organ system. This can result in 50 - 100 reasons for a patient's condition. Faculty have "pimped" students and residents to spout forth all of these different possibilities as a condition of "looking good" during medical rounds. 

A major reason given for the high cost of graduate medical education is the need for those in training to do more testing. But as we are learning more and more, the higher costs are more about the patients and their conditions and how they present than what is done by physicians impacting a few minutes of the life of a patient.

Many require expensive tests or technologies that may or may not identify the condition. Sometimes a test that is suggestive requires more tests. Even though doctors are taught to approach patients in the most costly way, they change during residency and practice.

Experienced physicians spend a lifetime unlearning this Dr. House method to be more relevant and choose the most likely reason for a patient to come to care and the most likely tests to confirm a diagnosis - if such a test exists - and if such a test is able to detect the condition reliable.


The Diagnostic Dilemma of the Mammogram

Mammograms have changed detection of breast cancer, but not necessarily the outcomes. Mammograms were switched to digital for no improvement in quality but higher cost. Mammograms still miss cancers and also still result in patients being sent for biopsy. Biopsy has an error rate too. About 7% of biopsies are positive for presence of cancer but actually there is no cancer as demonstrated by surgical removal. Substantial amounts problems are caused for no gain.

Now there is a more balanced approach to breast cancer - less guided by media, promotions by those who profit, and less guided by advocacy groups or by relatives or friends of those who died of breast cancer. It has only taken 20 years to get to a reasonable balance. Even so, not all benefit because many still have problems with lack of access or avoid screening due to attitudes or behaviors or poor health literacy.

Even so, the major groups that recommend screening cannot always agree on what is best.

A Return to Scientific Decision-Making

The scientific process must proceed through all stages in an iterative process to come to balance. External pressures due to misguided advocacy groups, media, corporations, and journal articles do not help. Drug company advertising may contribute to the problem of costs too high and uses too much as well as distractions from care delivery.


How Many More Trillions for Health Care?

Constant promotion of the Dr. House method of patient care could easily result in acceleration of health care costs past 3.5 trillion to 4 trillion or more. There is little doubt that this would result in even more squeezed from basic services with the worst impact where most people already have the least local workforce and the least access.

More trillions spent on clinical interventions, the most costly with little gain, would not improve outcomes because clinical interventions involve so few and impact so little of life lost. The long shot tests and other interventions for few conditions impact care so little - like 2 trillion of the 3 trillion we already spend. Other nations that choose to invest in children and people have one-third to one-half the cost of the US that has chosen to invest in the most costly impacting the least at huge cost of administration getting worse. 


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Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Copyright 2016



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