Thursday, September 02, 2004

Wait List Woes.....
What if you went to the prom and you had to wait too long for a dance, or some punch, or the line to the bathroom was winding around the gym floor? Is it a lack of suitable partners, not enough refreshments, or broken plumbing? Is it because your prom committee underestimated demand or spent the ticket money foolishly? Or is it because the prom guests are drinking too much punch and taking too much time in the john? Or, to step away from the wilted corsages and ruffled-front tuxedos, is the rationing that goes hand-in-hand with a single-payer system due to a lack of resources or too much utilization by patients or physicians? While the conventional wisdom states that both are to blame, this article places the emphasis on the latter:We can cut waiting lists by cutting into fewer patients:
When the talk turns to waiting lists -- as it does often in political circles these days -- there is an assumption that waits for surgery are caused by inadequate resources.

If we only had more surgeons, more operating rooms and more money, the thinking goes, we could clear up this pesky problem.

If only it were so simple....

A team of researchers from the University of Alberta and the University of Calgary showed that almost half of carotid endarterectomies (an operation to clear blocked arteries in the neck) are of questionable value, and that 10 per cent of these surgeries are entirely inappropriate and probably dangerous to patients.

A second study, conducted by Health Canada, found that the mastectomy rate varies dramatically from one province to the next, which likely means that hundreds, maybe even thousands, of women are having their breasts removed unnecessarily.

The carotid study published in the August 31 edition of the Canadian Medical Association Journal indicates, according to the criteria they used, that overall 52 percent of carotid endarterectomes (CEA) were done appropriately, ten percent were inappropriate, and the remainder were of "uncertain indication". I don't have time today to dissect that paper further, as I am on call. I cannot find a citation of the mastectomy article at this time.

Moving along:
These are but two examples, but there are many more. The vast majority of tonsillectomies were dubious; lower back surgery, once the rage, provided little pain relief in the long term; medically unjustified hysterectomies, gall bladder removals, cesarean sections and cataract operations are legion. More recently, some solid studies have shown that surgery for arthritic knees is of no value, and that "active surveillance" of some cancerous tumours is more effective than surgically removing them.
When Worlds Collide: EBM versus consumer demand. Much like the demand for pricier medications described here there are some patients who will press for surgery. The accusations put forth above seem to tar with a pretty wide brush the medical profession. How do they define a "medically unjustified" cholecystecomy or hysterectomy? I hope the solid tumor under "active surveillance" is prostate cancer and not something else.

I have patients all the time come in with conditions which are not amenable to surgery at all or have not reached the point to where surgery is helpful. Two ways to avoid trouble: don't talk patients into having an operation and don't let them talk you into giving them one. When thing go badly (as they can do) you won't have much of a leg to stand on. I have cancelled patients in the holding area when they began to question their desire for surgery. I have had others see other surgeons when I passed, some did well, others did not. "The customer is always right" does not apply to medicine and may be dangerous when used as justification for surgery, but now I'm just being paternalistic.

One of the criticisms of a single-payer system is the demand for services will rise when the out-of-pocket cost is reduced to zero. The article above seems to place more of the blame on the physician rather than the patient. I am sure both are a little to blame.
Cross-posted at Galen's Log
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