Monday, November 23, 2015

First, Do No Harm

I don’t know quite what to make of this, but some others might have more informed opinions. We ought to note, if only in passing, that the author of the New York Times column, one Ezekiel Emanuel is both the brother of Chicago mayor Rahm Emanuel and a supporter of Obamacare.

True enough, that’s only two strikes, but still his views have some research behind them.

Emanuel explains that, according to recent research, if you have a heart attack you should want to be taken to a teaching hospital when the senior cardiologists are on vacation. In other words, your chances of survival are far better if you are being treated by a junior cardiologist at a teaching, not a community hospital.

Emanuel summarizes the research:

One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals. As the article concludes, high-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away.

He adds:

Overall for all heart conditions examined, patients cared for at the teaching hospitals did significantly better than those cared for in community hospitals. So choosing a teaching hospital, when possible, makes a difference.

One understands that a teaching hospital will be better equipped and will have attracted the best residents and young attending physicians. And yet, the question of why the absence of senior cardiologists contributes to patient well-being remains in doubt.

Emanuel offers this explanation:

It is not clear why having senior cardiologists around actually seems to increase mortality for patients with life-threatening heart problems. One possible explanation is that while senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically. Another potential explanation suggested by the data is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest, for example, were significantly more likely to get interventions, like stents, to open up their coronary blood vessels.

Senior physicians are more likely to order more treatments. Apparently, these are not always necessary. Surprisingly, senior physicians order them without significant regard for the potential problems they may cause.

Emanuel is arguing against overtreatment. For all I know he will next be promoting more rationing. In any event, his argument seems to have some clinical evidence in its favor:

This is not the only recent finding that suggests that more care can produce worse health outcomes. A study from Israel of elderly patients with multiple health problems but still living in the community tried discontinuing medicines to see if patients got better. Not unusual for these types of elderly patients, on average, they were taking more than seven medications.

In a systematic, data-driven fashion, the researchers discontinued almost five drugs per patient for more than 90 percent of the patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improvements in health, not to mention the saving of drug money.

To understand these results one would need to know the medical history of the patients and the medications that were discontinued. Again, I am not qualified to offer an opinion.

Emanuel’s larger argument can be questioned on other grounds. We might ask whether our culture encourages us to consult with physicians too often and whether it makes us judge the quality of their medical care on the basis of how many medications we are taking.

How many patients doctor shop? How many would refuse to go back to a physician who told them there was nothing wrong and did not prescribe something. If so, patients are no longer really patients; they are consuming medical care, whether they need it or not. It is better than thinking that they are imagining an illness when they do not have one. Note also that at a teaching hospital families of patients are more likely to accept the physician's opinion than they would at a community hospital. 

Emanuel argues a point that others have certainly made:

We — both physicians and patients — usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less — even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery.

In order to have a better take on these statistics we need also to adjust for the demands that patients and their families place on physicians and the way the culture has defined the relationship between physician and patient. 


David Foster said...

I suspect the relative levels of arrogance vs humility and openness to evidence may play a part here

Mat said...

I thought the answer would be that older physicians might not be as focused on patient recovery as younger more naive physicians might be.

Or even from the patients perspective if I was allocated the best most senior doctor that would mean I was going to die right?