Too Much Unnecessary Care

By now I think folks on the business management level of health care are at least aware that we Americans spend a lot of money on health care and seem to get very little in return. The author of a provocative piece in Forbes thinks “unnecessary health care” is our worst problem. This statement hit me broadside.  This does seem pretty true for the example she chose, even though it is decidedly outside of my field.

As far as I can figure, this sort of planned emergency delivery she talks about brings nothing to obstetric science or to the quality of human life whatsoever. Around the net, I see estimates of how much of what we do is actually science.  It usually comes out as about 50 or 60%; maybe a little over half. This is happening as part of what seems to be a massive drive towards EBM, known as “Evidence Based Medicine.”

Psychiatry has been the easiest possible target for “do we need to treat or not” for a long time.  Many psychiatrists have made absolutely wonderful careers by being totally anti-psychiatry. People like R.D. Laing.  He is associated with ideas like “the antipsychiatry movement” or “the new left,” although I think this Scotsman was more of an existential philosopher than anything else. He questioned the use of antipsychotic drugs, and believed schizophrenia was “a theory not a fact.”  He seemed to be in favor of recreational drug use, as it clearly increased the amplitude of that experienced by a human being. I first heard of him when I first saw a patient who believed he was the “one and only living God,” and sheepishly fed him antipsychotics.

My preceptor pulled me aside afterwards and asked me, “what if he is God? it could be.”  At the very least it is his reality.  Who is to say ours is right and his is wrong.” I just sat there.  Silently at first, but as you can tell, this is never an extended state of affairs for me.  “This is our job to figure out?” was the only answer I could come up with. That is when my preceptor told me a little about R.D.Laing. Then he winked and added, “But we’re in Kansas, so we shouldn’t talk too loudly about this. The argument for treatment of such a person as one who thinks he is God is more social than medical. I mean, I suppose we would consider him “normal” if he worked a job and paid his taxes and did not bother telling anyone but a few close friends that he was “God.”

The notion of medical treatment being determined by social norms is not limited to psychiatry is nicely indicated by an operation such as “the sling,” an operation common for older women with stress urinary incontinence; construction of a muscular “sling,” that is supposed to help such woman regain voluntary control of her bladder and urethra. It is a bit more complex than advertised. There are touching if nauseating personal stories on the net, such as some about the “mesh” used to build the sling causing necrotizing fasciitis, and necessitating lots of repair … and lots of bags.

This can be devastating for a “little operation” and a patient who trusts the surgeon.  I am glad I can give an objective, technical report, instead of measuring tears cried….The idea of “unnecessary care” may be at its most dramatic in surgery.  I remember as a young neurosurgeon sitting at a cocktail party with a slightly older-than-I young neurosurgeon and his wife, figuring out how many craniotomies he ought to do a month now they had two little kids and a large monthly house payment. In psychiatry, it is fairly clear to anyone who actually wonders about psychiatric diagnosis, that is is socially, and not medically determined.  We actually know an amazing amount about the neurochemistry and neurotransmitters that are behind what presents to an external human observer. Yet all diagnostic descriptions are descriptions of visible behavior, and not of neurochemistry. That means governments and insurance companies can practice medicine.

I have seen not one, but several patients whose level of “high anxiety” easily fit the criteria for an episode of “mania” of “manic-depressive” fame.  The insomnia, the hyperactivity, the fruitless multitasking, the loud and exaggerated dominating self-expression. In these cases, the onset of the illness coincided with a significant work stress.  Something that had to do, in each case, with them doing more or replacing other people. It took every one of these people both serious medication (or serious natural alternative substance treatment) as well as a considerable length of disability (I usually give about 3 months for an initial manic episode) to look pretty much normal again. This brings up a small eternity of questions.

1.  Is this “real” mania and not just a job-related stress reaction? The only way to know is to follow them into the future for the rest of their lives and know if anything like this is going to happen again.

2.  Is this an illness at all?  We have chosen to classify it as one. It is possible this could happen to absolutely anybody who had too many tasks and too much pressure.  We do not know, and it would be unethical to do experiments to find out. It is possible that because we have classified this as an illness and I can only treat them by giving them some disability, their social treatments; their insurance premiums and/or ability to get benefits, will be seriously different.

3. Whether or not the illness is real, do these kind of disease states represent a lowering of function of the entire human race as tasks are assigned  more to computers and more tasks of the few remaining humans become overwhelming to them??

The jury is still out.