- Email: [email protected]
Health problems and priorities and the health professions
PREVENTIVE
MEDICINE
6,560-566
(1977)
EDITORIAL Health
Problems
and Priorities Professions’
and the Health
KERR L. WHITE* Director, Institutefor Health Care Studies, United Hospital FundofNew NeB: York, New York 10022
York,
What exactly is a health problem? What can we learn about our common tasks and about our common responsibilities to the people we serve? What can we really offer in the way of “curing” based on scientific evidence that what we do is more useful and beneficial than it is useless or even harmful, or that it is more useful than doing something else or even than doing nothing at all? What can we offer in the way of “caring” or “counseling” ? Or can we help the patient and the family in just “coping” with the vast majority of problems of living and dying that are, at present, insoluble? “Problems that have solutions,” as John Updike tells us, “are no problems.” People bring their health problems to the medical profession, and they want help in understanding them, and in resolving or managing them. There is no such thing as a “trivial” problem. As a friend of mine says, “There must be something the matter with a person who goes to see a doctor when there is nothing the matter with him.” If what we do and what we say to our patients does not contribute to improvement in the understanding, resolution, or management of the patient’s presenting problem, what are we all about, both as physicians individually and as a profession collectively? Ordering tests, taking X rays, making diagnoses, doing surgery, and prescribing drugs are means, not ends, to managing problems. The patient and the family could not care less if we do not do something that helps in understanding the nature of the patient’s problem. And, if we cannot cure or control the disease, what can we do to avoid unnecessary disability, to alleviate discomfort, or to ameliorate distress? Yet, what does the health care establishment face? We are asking the public to “pony up” about $140 billion annually for the nation’s health care expenditures. This is almost 9% of our Gross National Product; for every man, woman, and child in the country, it amounts to about $600 a year, or almost a month’s earnings for the average worker. These are tremendous sums, and they are increasing rapidly. ’ Adapted from the Commencement Address given at the Medical College of Wisconsin, Milwaukee, May 30, 1976. z Address for reprints: Kerr L. White, M.D., Director, Institute for Health Care Studies, United Hospital Fund of New York, 3 East 54th Street, New York, New York 10022. 560 Copyright All rights
@ 1977 by Academic Press. Inc. of reproduction m any form reserved.
ISSN 0091-7435
EDITORIAL
561
Until last year, however, we have had no nationwide marketing survey of the problems brought to physicians in their offices. How, you may ask, can enterprises like medical education and the health care industry expect to meet the needs of its clientele, its patients, its public, and society without objective measures of the patients’ problems? It simply does not make sense to run an enterprise of this magnitude without a marketing survey. It is at home, at work, or sometimes at play that the patient first experiences discomfort or disturbances in his well-being that initiate the sequence of discussions with relatives, neighbors, pharmacists, perhaps with chiropractors, or even with gypsies or clergymen, that may or may not eventually bring him to a physician’s office. There are about one billion such visits to physicians per year in the United States; almost two-thirds of these are to physicians in office-based practice. Of these 645,000 ambulatory care visits, about 40%, are to general practitioners or family physicians and about 20% are to general internists and pediatricians. And what sorts of problems do these patients bring to these sources of care? About one-third of all visits to general practitioners, family physicians, and internists are made up of 10 common problems; it only takes six common problems to make up 30% of the visits to pediatricians. And what, indeed, are the common problems? They include fever, sore throats, coughs, colds, fatigue, earaches, backaches, armaches, legaches, headaches, chest pain, and probably many other underlying forms of heartache (5). For all types of doctors, for all ambulatory visits for the whole country, 16 problems produce half of all the visits, 40 problems produce 75% of the visits, and 60 produce 82%. All the rest of the people’s problems produce the remaining 18%. Now, some would say that these first 16 problems, or even the first 40 problems, are not the proper business of contemporary American doctors. They suggest that “proper doctors” should only deal with the remaining 18% of the problems. This is not an unreasonable argument, but then many physicians had better plan to get other jobs tending bar or driving cabs, because they are obviously superfluous. It is argued that about half of the problems brought to sources of primary medical care cannot even be given a diagnosis; they are just “problems.” And what do we do? The median time for all ambulatory care visits is 12 minutes; three out of four of the more common drugs we prescribe are not specific for any particular disease. Some would say that most, if not all, of the 20 most commonly prescribed drugs have nothing to do with the practice of first-rate medicine. If we do not prescribe drugs or surgery, we order tests. We can even examine the latest solution to one of the country’s common health problems. Each year, there are about 23 million people in this country who admit to having headaches. This group generates 16 million visits a year to consult physicians about their headaches; it is the fourteenth most common problem overall. Recently, the multinational corporation that brought us the Beatles from England has brought US the EM1 (CAT) brain scanner. This is an extraordinary technological breakthrough. It is a computer-assisted X-ray machine that uses a painless, relatively risk-free technique to produce a three-dimensional picture of the head. It is medical technology at its best. The machine costs about half a million dollars to install, and
562
KERR
L.
WHITE
the usual charge for each test is about $200. Great Britain, where the machines are made, has about ten machines for about 55 million people. How many does the United States have for four times the population of Great Britain? At last count, we had installed or had on order almost 1000 of these machines. These 1000 machines will have a capacity to do about 5 million brain scans a year, or almost one scan for every two people who consult a physician with a headache in the course of a year. Something must be wrong in one or both countries! And why should patients with headaches have brain scans? Because medical students have been taught that people with headaches sometimes have brain tumors, and that it is a very serious medical crime, perhaps even leaving one liable for a malpractice suit, to miss a brain tumor in a patient. But exactly how many people die of brain tumors each year? The last available figures for the United States show that about 6100 persons died of malignant tumors, about which medicine can do very little, and only 200 persons died of benign tumors, which might have been helped as the result of a brain scan. Then somewhat more than half a million people are hospitalized each year with strokes, and many of these patients can have the level of certainty of a probable clinical diagnosis increased by a brain scan, although exactly how many of which types is not entirely clear as yet. In addition, 270,000 persons are hospitalized annually with head injuries, and, here again, a brain scan may be useful. But exactly what do we mean by useful, and how useful is it? There are precious few true evaluations of the benefits of the EM1 scanner in relation to the final outcomes of the patients’ presenting problems. One objective study shows absolutely no reduction in death rates from head injuries after introduction of the EM1 brain scanner (1). It is true that the EM1 scan replaced other unpleasant, risky, and expensive brain studies, but neither these nor the EM1 scanner had any apparent benefit whatsoever on the outcome of the patients’ problems beyond the clinical assessment of competent neurosurgeons. Nor is there evidence that a brain scan makes any contribution to those patients who simply present with a headache and nothing else. So what do we have here? We have half a billion dollars invested in equipment, and more is on its way. Undoubtedly, there will be improvements in the equipment, and many of these are already in the works, and, to add to all this, we now have a full-body scanner. In addition, we have annual expenditures of about $2 billion being spent on the brain scans themselves, and frequently the requirement of an extra day or two’s wait in the hospital queuing up for the scan at another cost of $1 or $2 billion annually. True, there are some savings, and some medical centers have unemployed neurosurgeons on their hands! So, although as medical students the doctors of today may have been taught that it is a serious clinical crime to miss a brain tumor, they were not taught that it is a serious social crime to saddle the community with expenditures of these vast sums without providing better evidence that they truly make a difference, how much of a difference they make, and for whom. There are other examples, such as the lack of evidence that coronary care units or coronary artery bypass surgery really contributes sufficiently to the overall outcomes or the longevity of the entire population of patients with chest pain who consult physicians to warrant their widespread, even indiscriminant, use. What I am attempting is to document ways of thinking about priorities and of encouraging points of view of which both the public and the profession should be aware.
EDITORIAL
563
But what about headaches and chest pains? As any one knows, the vast majority of headaches is associated with hangovers, domestic strife, occupational stress, defects in vision, or emotional upsets. The underlying problems are usually elicited by talking with the patients, listening carefully, and offering simple explanations. The chance of anyone who presents solely with a headache actually having a brain tumor is apparently almost zero; the chance of anyone with a headache and at least one other symptom or sign may be about 1 in 2500. And yet, we are equipped with a technological device that assumes there is a risk of about one in every two patients with a headache having a brain tumor or something seriously wrong with his head. As far as chest pain goes, evidence from England suggests that patients who are not in serious heart failure or do not have an abnormality of their heart rhythm do as well at home as they do at the hospital (3). An additional unpublished study suggests that the further and longer patients with supposed heart attacks associated with chest pains travel in speeding ambulances, the greater their chances of going into heart failure or developing some other complication for which they require additional medical intervention if and when they eventually reach the coronary care unit alive. Apparently, traveling in an ambulance with the noise of the siren, the two-way radio communication, and the eager ministrations of the attendants in the ambulance may be more alarming and distressing to the patient than it is beneficial and comforting. We have a society and a medical profession which seem to take for granted that any new form of technical intervention must obviously represent an improvement, and that, because we can invent it and make it, we should apply it to everyone we care to without regard to relative benefits, costs, hazards, or risks. Now, why go into all this detail? What does it mean to the health professions? It means that collectively we seem to be out of step with the anguished cries for help of our patients and unaware of the angry frustrations of society. Our patients have a set of problems, symptoms, and complaints with which they want help-better help and faster help. Society has a limited set of resources, most of them scarce, for which there are multiple competing demands, and we have a vast technological array of pills, potions, and procedures that are occasionally useful, often painful, sometimes hazardous, and nearly always expensive. Most frequently, these procedures remain totally unevaluated with respect to their impact on the resolution of our patients’ collective presenting problems. The profession faces an increasingly doubting and critical community, an avalanche of malpractice suits, and growing outrage with escalating costs of health care. But what both the patients and the public are telling us is that they are totally frustrated and fed-up with the lack of availability and accessibility of compassionate and scientifically competent general physicians. What they want are personal physicians who care about their individual patients’ presenting problems, and a collective medical profession which cares about the collective benefits of our activities in relation to the expenditures we generate. As a consequence, the profession now lives in an increasingly open and accountable health care system. There are Professional Standards Review Organizations to monitor the nature and quality of the health care we provide; there are Health Systems Agencies at the local and state levels responsible for allocating scarce resources, especially hospital beds and their attendant equipment; there
564
KERR
L.
WHITE
are Health Services Cost Review Commissions setting rates not only for hospitals, but also probably soon for physicians’ fees, and undoubtedly there will be federal and state manpower commissions determining the numbers and kinds of generalists and specialists to be trained. Much of this might have been avoided had the leadership of organized medicine and academic medicine behaved differently in recent decades. But neither is it all bad, and many of these new ventures can be very good, if the profession will provide leadership and participate actively with the public’s representatives in all these matters. If not, it will be done in any event. Physicians in all other countries have found that it works out best when they assume their roles as true professionals and realize that the precise translation of the term “doctor” means teacher-teachers of our individual patients and teachers of our communities. What can be learned? First, we should help both patients and society to understand that good health is quite different from good medical care, and indeed, that the attainment and retention of good health has virtually nothing to do with medical care. Most of the major improvements in health have come about as a result of improved nutrition, better housing, cleaner water supplies, adequate sanitation, and higher standards of education (4). The decline in the tuberculosis rate proceeded relentlessly to its present level without any noticeable impact from the introduction of rest cures, surgery, or chemotherapy, as Rent Dubos showed us many years ago. The environment about us, whether it be polluted by smog, radiation, wastes of various kinds, food additives, chemicals, noise, or even the visual horrors along the streets and highways, is a major determinant of health. Second, there is the influence of lifestyle and personal behavior on health. Cigarette smoking, abuse of alcohol or other drugs, failure to use automobile safety belts, lack of exercise, domestic strife, the presence of unwanted children, excessive caloric intake, destructive human relationships, inequitable housing, social and personal discrimination of any kind, unemployment, premature retirement, and excessive residential mobility, all of these are major factors in infhrencing the health of individuals, families, and communities, and are important determinants of disease. Both patients and the public need to know and understand these facts. Valium and Librium, two of the most widely prescribed drugs in America, cannot do a thing for these problems. Third, there are genetic and biological factors that influence health. We need better genetic and family counseling, before children are conceived. Certainly, we need more and better biomedical research to understand basic biological processes, and certainly, there are noxious agents in our environment that need to be identified and understood. However, it should be recalled that the great plagues of cholera were controlled by altering the polluted water supply 30 years before anything was known about the organism that was the relevant agent. What we need to recognize is that, while you cannot have cholera without the Cholera Vibrio any more than you can have tuberculosis without the tubercle bacillus, you also cannot have either of these diseases without a patient. Not all persons who harbor the Cholera Vibrio, the tubercle bacillus, or the pneumococcus have cholera, tuberculosis, or pneumonia. The organism may be a necessary factor in the development of a disease, but it is rarely a sufficient factor. We may need to know
EDITORIAL
565
as much or even more about the patient who has the disease and the circumstances under which the disease arose, including the interactions between the patient and his environment, as we do about the noxious agents involved and the pathophysiology of the disease itself. Life and death and medicine are extremely complicated, and we are only at the beginning of our understanding. Into this ever-wondrous maze of factors that impinge on our health come medicine and medical care. It is here that we spend the bulk of our national health care budget; but what does it all accomplish? The answer is, more than it used to, thanks to the advances of fundamental biomedical research, but, on balance, still not very much. We have truly efficacious forms of beneficial intervention for only about 10 or 20% of the problems that people bring to physicians. Certainly, substantial benefits accrue to the patient even as a result of his visit to a doctor, but these are more due to the fact that the physician took an interest and was seen to care in various ways than to the specific form of intervention. But do the benefits justify the costs, especially the costs of an exponentially increasing volume of tests, diagnostic procedures, and dubious treatments? Few of our new procedures, apart from drugs, are subjected to truly scientific evaluation of their clinical efficacy and their dangers in comparison with the procedures they are supposed to replace or in comparison with doing nothing. The result is a proliferation of what can only be described as clinical hocus pocus that is in desperate need of being sorted out critically by objective scientific study. We need more science, not less science, in medicine; but we need a balanced array of scientific approaches that include social and behavioral sciences, epidemiology, and demography, as well as the traditional natural sciences in medicine. We need to understand the true meaning and true nature of our patients’ problems; what are they really complaining about or reacting to? Can we help them to understand those problems? And, if we can, do we have a useful, efficacious, relatively inexpensive form of intervention that will help to resolve the patient’s problem? If we do not, then let us be honest; let us comfort the patient and either ourselves conduct or urge others to conduct further research into the problems, so that we have a deeper understanding and a useful form of prevention or treatment. Let us, above all, be honest with ourselves about what we know and what we do not know. To do otherwise is to indulge in what the Greeks call “hubris,” a form of rather insular pride or unwarranted security, or what some who are less classical in their analogies or less charitably inclined have described as “contemporary medical witchcraft.” But it would be misleading to suggest that physicians, especially practicing physicians, can or should accept all of the responsibility for the present state of affairs. The developers of new procedures, the officials and review panels of the National Institutes of Health and other elements of the Department of Health, Education and Welfare, the editors of journals, the manufacturers of drugs, reagents, and equipment, local, state, and federal legislators, hospital administrators, third-party payers, and hospital trustees, as well as the public itself, all shoulder responsibility for this state of affairs. We need to ask ourselves what we mean by health and good health, and what we ourselves can do about it. But there is also a list of questions, paraphrased from Sir Douglas Black, formerly Professor of Medicine at the University of Manchester in England and now Chief Scientist for
566
KERR
L.
WHITE
the Ministry of Health and Social Security in the United Kingdom, that any administrator or politician responsible for resource allocation and health care should address to the proponent of any new procedure or service (2): (1) What are the aims of the procedure or service in question? (2) How many people, and of what kinds, are potentially eligible for help from these procedures or services? (3) What proportion of these people will actually get help? (4) What kinds of people are they, and who fails to get help? (5) What determines who gets this help and who does not? (6) Does the procedure or service do any good or make any discernible difference? How much difference does it make? To whom? (7) What does this procedure or service cost? How do these costs compare with those of potential substitutes? (8) Who pays? (9) What does the public-those served, those eligible but not served, and those who are ineligible-think about the procedure or service? (10) What impact might the procedure make on the demand or effectivness of other procedures or services? These are exciting times for medicine. Great changes are ahead; the medical profession can be part of shaping a future that can help our fellow citizens to improve our national health. However, it is a future that can only be partly shaped by medical intervention alone. Caring and counseling are as important as curing, and the doctor who is a teacher, both of patients and communities, may contribute as much to the amelioration of health problems as the doctor who is a clinician. The profession is still a mixture of science and compassion, and we need much more of both. We need more of the natural sciences and we need more of the social sciences; we need more individual compassion and we need more statistical compassion if we are to help people with their problems. REFERENCES 1. Ambrose, J., Gooding, M. R., and Uttley, D. EM1 Scan in the management of head injurk. Lancet 1, 847-848 (1976). 2. Black, D. What should now be done by government? Symposium No. 15, Constraints on medicine. Proc. Roy. Sot. Med. 47, Part 2, 1036-1308 (1974). 3. Mather, H. G., Pearson, W. G., Read, K. L. Q., Shaw, D. B., Steed, G. R., Thorne, M. G., Jones, S., Guerrier, C. J., Eraut, C. D., McHugh, P. M., Chowdhury, N. R., Jafary, M. H., and Wallace, T. J. Acute myocardial infarction: Home and hospital treatment. &it. Med. J. 3, 334 (1971). 4. McKeown, T. “The Role of Medicine.” Nuffteld Provincial Hospitals Trust, London, 1976. 5. National Center for Health Statistics. “The Nation’s Use of Health Resources,” DHEW Publication NO. (HRA) 77-1240. U.S. Department of Health, Education and Welfare, Washington, D.C., 1977.
MEDICINE
6,560-566
(1977)
EDITORIAL Health
Problems
and Priorities Professions’
and the Health
KERR L. WHITE* Director, Institutefor Health Care Studies, United Hospital FundofNew NeB: York, New York 10022
York,
What exactly is a health problem? What can we learn about our common tasks and about our common responsibilities to the people we serve? What can we really offer in the way of “curing” based on scientific evidence that what we do is more useful and beneficial than it is useless or even harmful, or that it is more useful than doing something else or even than doing nothing at all? What can we offer in the way of “caring” or “counseling” ? Or can we help the patient and the family in just “coping” with the vast majority of problems of living and dying that are, at present, insoluble? “Problems that have solutions,” as John Updike tells us, “are no problems.” People bring their health problems to the medical profession, and they want help in understanding them, and in resolving or managing them. There is no such thing as a “trivial” problem. As a friend of mine says, “There must be something the matter with a person who goes to see a doctor when there is nothing the matter with him.” If what we do and what we say to our patients does not contribute to improvement in the understanding, resolution, or management of the patient’s presenting problem, what are we all about, both as physicians individually and as a profession collectively? Ordering tests, taking X rays, making diagnoses, doing surgery, and prescribing drugs are means, not ends, to managing problems. The patient and the family could not care less if we do not do something that helps in understanding the nature of the patient’s problem. And, if we cannot cure or control the disease, what can we do to avoid unnecessary disability, to alleviate discomfort, or to ameliorate distress? Yet, what does the health care establishment face? We are asking the public to “pony up” about $140 billion annually for the nation’s health care expenditures. This is almost 9% of our Gross National Product; for every man, woman, and child in the country, it amounts to about $600 a year, or almost a month’s earnings for the average worker. These are tremendous sums, and they are increasing rapidly. ’ Adapted from the Commencement Address given at the Medical College of Wisconsin, Milwaukee, May 30, 1976. z Address for reprints: Kerr L. White, M.D., Director, Institute for Health Care Studies, United Hospital Fund of New York, 3 East 54th Street, New York, New York 10022. 560 Copyright All rights
@ 1977 by Academic Press. Inc. of reproduction m any form reserved.
ISSN 0091-7435
EDITORIAL
561
Until last year, however, we have had no nationwide marketing survey of the problems brought to physicians in their offices. How, you may ask, can enterprises like medical education and the health care industry expect to meet the needs of its clientele, its patients, its public, and society without objective measures of the patients’ problems? It simply does not make sense to run an enterprise of this magnitude without a marketing survey. It is at home, at work, or sometimes at play that the patient first experiences discomfort or disturbances in his well-being that initiate the sequence of discussions with relatives, neighbors, pharmacists, perhaps with chiropractors, or even with gypsies or clergymen, that may or may not eventually bring him to a physician’s office. There are about one billion such visits to physicians per year in the United States; almost two-thirds of these are to physicians in office-based practice. Of these 645,000 ambulatory care visits, about 40%, are to general practitioners or family physicians and about 20% are to general internists and pediatricians. And what sorts of problems do these patients bring to these sources of care? About one-third of all visits to general practitioners, family physicians, and internists are made up of 10 common problems; it only takes six common problems to make up 30% of the visits to pediatricians. And what, indeed, are the common problems? They include fever, sore throats, coughs, colds, fatigue, earaches, backaches, armaches, legaches, headaches, chest pain, and probably many other underlying forms of heartache (5). For all types of doctors, for all ambulatory visits for the whole country, 16 problems produce half of all the visits, 40 problems produce 75% of the visits, and 60 produce 82%. All the rest of the people’s problems produce the remaining 18%. Now, some would say that these first 16 problems, or even the first 40 problems, are not the proper business of contemporary American doctors. They suggest that “proper doctors” should only deal with the remaining 18% of the problems. This is not an unreasonable argument, but then many physicians had better plan to get other jobs tending bar or driving cabs, because they are obviously superfluous. It is argued that about half of the problems brought to sources of primary medical care cannot even be given a diagnosis; they are just “problems.” And what do we do? The median time for all ambulatory care visits is 12 minutes; three out of four of the more common drugs we prescribe are not specific for any particular disease. Some would say that most, if not all, of the 20 most commonly prescribed drugs have nothing to do with the practice of first-rate medicine. If we do not prescribe drugs or surgery, we order tests. We can even examine the latest solution to one of the country’s common health problems. Each year, there are about 23 million people in this country who admit to having headaches. This group generates 16 million visits a year to consult physicians about their headaches; it is the fourteenth most common problem overall. Recently, the multinational corporation that brought us the Beatles from England has brought US the EM1 (CAT) brain scanner. This is an extraordinary technological breakthrough. It is a computer-assisted X-ray machine that uses a painless, relatively risk-free technique to produce a three-dimensional picture of the head. It is medical technology at its best. The machine costs about half a million dollars to install, and
562
KERR
L.
WHITE
the usual charge for each test is about $200. Great Britain, where the machines are made, has about ten machines for about 55 million people. How many does the United States have for four times the population of Great Britain? At last count, we had installed or had on order almost 1000 of these machines. These 1000 machines will have a capacity to do about 5 million brain scans a year, or almost one scan for every two people who consult a physician with a headache in the course of a year. Something must be wrong in one or both countries! And why should patients with headaches have brain scans? Because medical students have been taught that people with headaches sometimes have brain tumors, and that it is a very serious medical crime, perhaps even leaving one liable for a malpractice suit, to miss a brain tumor in a patient. But exactly how many people die of brain tumors each year? The last available figures for the United States show that about 6100 persons died of malignant tumors, about which medicine can do very little, and only 200 persons died of benign tumors, which might have been helped as the result of a brain scan. Then somewhat more than half a million people are hospitalized each year with strokes, and many of these patients can have the level of certainty of a probable clinical diagnosis increased by a brain scan, although exactly how many of which types is not entirely clear as yet. In addition, 270,000 persons are hospitalized annually with head injuries, and, here again, a brain scan may be useful. But exactly what do we mean by useful, and how useful is it? There are precious few true evaluations of the benefits of the EM1 scanner in relation to the final outcomes of the patients’ presenting problems. One objective study shows absolutely no reduction in death rates from head injuries after introduction of the EM1 brain scanner (1). It is true that the EM1 scan replaced other unpleasant, risky, and expensive brain studies, but neither these nor the EM1 scanner had any apparent benefit whatsoever on the outcome of the patients’ problems beyond the clinical assessment of competent neurosurgeons. Nor is there evidence that a brain scan makes any contribution to those patients who simply present with a headache and nothing else. So what do we have here? We have half a billion dollars invested in equipment, and more is on its way. Undoubtedly, there will be improvements in the equipment, and many of these are already in the works, and, to add to all this, we now have a full-body scanner. In addition, we have annual expenditures of about $2 billion being spent on the brain scans themselves, and frequently the requirement of an extra day or two’s wait in the hospital queuing up for the scan at another cost of $1 or $2 billion annually. True, there are some savings, and some medical centers have unemployed neurosurgeons on their hands! So, although as medical students the doctors of today may have been taught that it is a serious clinical crime to miss a brain tumor, they were not taught that it is a serious social crime to saddle the community with expenditures of these vast sums without providing better evidence that they truly make a difference, how much of a difference they make, and for whom. There are other examples, such as the lack of evidence that coronary care units or coronary artery bypass surgery really contributes sufficiently to the overall outcomes or the longevity of the entire population of patients with chest pain who consult physicians to warrant their widespread, even indiscriminant, use. What I am attempting is to document ways of thinking about priorities and of encouraging points of view of which both the public and the profession should be aware.
EDITORIAL
563
But what about headaches and chest pains? As any one knows, the vast majority of headaches is associated with hangovers, domestic strife, occupational stress, defects in vision, or emotional upsets. The underlying problems are usually elicited by talking with the patients, listening carefully, and offering simple explanations. The chance of anyone who presents solely with a headache actually having a brain tumor is apparently almost zero; the chance of anyone with a headache and at least one other symptom or sign may be about 1 in 2500. And yet, we are equipped with a technological device that assumes there is a risk of about one in every two patients with a headache having a brain tumor or something seriously wrong with his head. As far as chest pain goes, evidence from England suggests that patients who are not in serious heart failure or do not have an abnormality of their heart rhythm do as well at home as they do at the hospital (3). An additional unpublished study suggests that the further and longer patients with supposed heart attacks associated with chest pains travel in speeding ambulances, the greater their chances of going into heart failure or developing some other complication for which they require additional medical intervention if and when they eventually reach the coronary care unit alive. Apparently, traveling in an ambulance with the noise of the siren, the two-way radio communication, and the eager ministrations of the attendants in the ambulance may be more alarming and distressing to the patient than it is beneficial and comforting. We have a society and a medical profession which seem to take for granted that any new form of technical intervention must obviously represent an improvement, and that, because we can invent it and make it, we should apply it to everyone we care to without regard to relative benefits, costs, hazards, or risks. Now, why go into all this detail? What does it mean to the health professions? It means that collectively we seem to be out of step with the anguished cries for help of our patients and unaware of the angry frustrations of society. Our patients have a set of problems, symptoms, and complaints with which they want help-better help and faster help. Society has a limited set of resources, most of them scarce, for which there are multiple competing demands, and we have a vast technological array of pills, potions, and procedures that are occasionally useful, often painful, sometimes hazardous, and nearly always expensive. Most frequently, these procedures remain totally unevaluated with respect to their impact on the resolution of our patients’ collective presenting problems. The profession faces an increasingly doubting and critical community, an avalanche of malpractice suits, and growing outrage with escalating costs of health care. But what both the patients and the public are telling us is that they are totally frustrated and fed-up with the lack of availability and accessibility of compassionate and scientifically competent general physicians. What they want are personal physicians who care about their individual patients’ presenting problems, and a collective medical profession which cares about the collective benefits of our activities in relation to the expenditures we generate. As a consequence, the profession now lives in an increasingly open and accountable health care system. There are Professional Standards Review Organizations to monitor the nature and quality of the health care we provide; there are Health Systems Agencies at the local and state levels responsible for allocating scarce resources, especially hospital beds and their attendant equipment; there
564
KERR
L.
WHITE
are Health Services Cost Review Commissions setting rates not only for hospitals, but also probably soon for physicians’ fees, and undoubtedly there will be federal and state manpower commissions determining the numbers and kinds of generalists and specialists to be trained. Much of this might have been avoided had the leadership of organized medicine and academic medicine behaved differently in recent decades. But neither is it all bad, and many of these new ventures can be very good, if the profession will provide leadership and participate actively with the public’s representatives in all these matters. If not, it will be done in any event. Physicians in all other countries have found that it works out best when they assume their roles as true professionals and realize that the precise translation of the term “doctor” means teacher-teachers of our individual patients and teachers of our communities. What can be learned? First, we should help both patients and society to understand that good health is quite different from good medical care, and indeed, that the attainment and retention of good health has virtually nothing to do with medical care. Most of the major improvements in health have come about as a result of improved nutrition, better housing, cleaner water supplies, adequate sanitation, and higher standards of education (4). The decline in the tuberculosis rate proceeded relentlessly to its present level without any noticeable impact from the introduction of rest cures, surgery, or chemotherapy, as Rent Dubos showed us many years ago. The environment about us, whether it be polluted by smog, radiation, wastes of various kinds, food additives, chemicals, noise, or even the visual horrors along the streets and highways, is a major determinant of health. Second, there is the influence of lifestyle and personal behavior on health. Cigarette smoking, abuse of alcohol or other drugs, failure to use automobile safety belts, lack of exercise, domestic strife, the presence of unwanted children, excessive caloric intake, destructive human relationships, inequitable housing, social and personal discrimination of any kind, unemployment, premature retirement, and excessive residential mobility, all of these are major factors in infhrencing the health of individuals, families, and communities, and are important determinants of disease. Both patients and the public need to know and understand these facts. Valium and Librium, two of the most widely prescribed drugs in America, cannot do a thing for these problems. Third, there are genetic and biological factors that influence health. We need better genetic and family counseling, before children are conceived. Certainly, we need more and better biomedical research to understand basic biological processes, and certainly, there are noxious agents in our environment that need to be identified and understood. However, it should be recalled that the great plagues of cholera were controlled by altering the polluted water supply 30 years before anything was known about the organism that was the relevant agent. What we need to recognize is that, while you cannot have cholera without the Cholera Vibrio any more than you can have tuberculosis without the tubercle bacillus, you also cannot have either of these diseases without a patient. Not all persons who harbor the Cholera Vibrio, the tubercle bacillus, or the pneumococcus have cholera, tuberculosis, or pneumonia. The organism may be a necessary factor in the development of a disease, but it is rarely a sufficient factor. We may need to know
EDITORIAL
565
as much or even more about the patient who has the disease and the circumstances under which the disease arose, including the interactions between the patient and his environment, as we do about the noxious agents involved and the pathophysiology of the disease itself. Life and death and medicine are extremely complicated, and we are only at the beginning of our understanding. Into this ever-wondrous maze of factors that impinge on our health come medicine and medical care. It is here that we spend the bulk of our national health care budget; but what does it all accomplish? The answer is, more than it used to, thanks to the advances of fundamental biomedical research, but, on balance, still not very much. We have truly efficacious forms of beneficial intervention for only about 10 or 20% of the problems that people bring to physicians. Certainly, substantial benefits accrue to the patient even as a result of his visit to a doctor, but these are more due to the fact that the physician took an interest and was seen to care in various ways than to the specific form of intervention. But do the benefits justify the costs, especially the costs of an exponentially increasing volume of tests, diagnostic procedures, and dubious treatments? Few of our new procedures, apart from drugs, are subjected to truly scientific evaluation of their clinical efficacy and their dangers in comparison with the procedures they are supposed to replace or in comparison with doing nothing. The result is a proliferation of what can only be described as clinical hocus pocus that is in desperate need of being sorted out critically by objective scientific study. We need more science, not less science, in medicine; but we need a balanced array of scientific approaches that include social and behavioral sciences, epidemiology, and demography, as well as the traditional natural sciences in medicine. We need to understand the true meaning and true nature of our patients’ problems; what are they really complaining about or reacting to? Can we help them to understand those problems? And, if we can, do we have a useful, efficacious, relatively inexpensive form of intervention that will help to resolve the patient’s problem? If we do not, then let us be honest; let us comfort the patient and either ourselves conduct or urge others to conduct further research into the problems, so that we have a deeper understanding and a useful form of prevention or treatment. Let us, above all, be honest with ourselves about what we know and what we do not know. To do otherwise is to indulge in what the Greeks call “hubris,” a form of rather insular pride or unwarranted security, or what some who are less classical in their analogies or less charitably inclined have described as “contemporary medical witchcraft.” But it would be misleading to suggest that physicians, especially practicing physicians, can or should accept all of the responsibility for the present state of affairs. The developers of new procedures, the officials and review panels of the National Institutes of Health and other elements of the Department of Health, Education and Welfare, the editors of journals, the manufacturers of drugs, reagents, and equipment, local, state, and federal legislators, hospital administrators, third-party payers, and hospital trustees, as well as the public itself, all shoulder responsibility for this state of affairs. We need to ask ourselves what we mean by health and good health, and what we ourselves can do about it. But there is also a list of questions, paraphrased from Sir Douglas Black, formerly Professor of Medicine at the University of Manchester in England and now Chief Scientist for
566
KERR
L.
WHITE
the Ministry of Health and Social Security in the United Kingdom, that any administrator or politician responsible for resource allocation and health care should address to the proponent of any new procedure or service (2): (1) What are the aims of the procedure or service in question? (2) How many people, and of what kinds, are potentially eligible for help from these procedures or services? (3) What proportion of these people will actually get help? (4) What kinds of people are they, and who fails to get help? (5) What determines who gets this help and who does not? (6) Does the procedure or service do any good or make any discernible difference? How much difference does it make? To whom? (7) What does this procedure or service cost? How do these costs compare with those of potential substitutes? (8) Who pays? (9) What does the public-those served, those eligible but not served, and those who are ineligible-think about the procedure or service? (10) What impact might the procedure make on the demand or effectivness of other procedures or services? These are exciting times for medicine. Great changes are ahead; the medical profession can be part of shaping a future that can help our fellow citizens to improve our national health. However, it is a future that can only be partly shaped by medical intervention alone. Caring and counseling are as important as curing, and the doctor who is a teacher, both of patients and communities, may contribute as much to the amelioration of health problems as the doctor who is a clinician. The profession is still a mixture of science and compassion, and we need much more of both. We need more of the natural sciences and we need more of the social sciences; we need more individual compassion and we need more statistical compassion if we are to help people with their problems. REFERENCES 1. Ambrose, J., Gooding, M. R., and Uttley, D. EM1 Scan in the management of head injurk. Lancet 1, 847-848 (1976). 2. Black, D. What should now be done by government? Symposium No. 15, Constraints on medicine. Proc. Roy. Sot. Med. 47, Part 2, 1036-1308 (1974). 3. Mather, H. G., Pearson, W. G., Read, K. L. Q., Shaw, D. B., Steed, G. R., Thorne, M. G., Jones, S., Guerrier, C. J., Eraut, C. D., McHugh, P. M., Chowdhury, N. R., Jafary, M. H., and Wallace, T. J. Acute myocardial infarction: Home and hospital treatment. &it. Med. J. 3, 334 (1971). 4. McKeown, T. “The Role of Medicine.” Nuffteld Provincial Hospitals Trust, London, 1976. 5. National Center for Health Statistics. “The Nation’s Use of Health Resources,” DHEW Publication NO. (HRA) 77-1240. U.S. Department of Health, Education and Welfare, Washington, D.C., 1977.