Mortality. And the Most Expensive Medical Care in the World.

The town of McAllen, sitting at the south end of Texas, leads the US sweepstakes for high-cost medical care. Writing in the New Yorker, Dr Atul Gawande explains why. Chest pain in a forty year old trauma victim usually merits a careful exam and maybe an EKG. In McAllen an insured patient will get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization. Gawande quotes one of "the few vocal critics of what's happened in McAllen. ‘We took a wrong turn when doctors stopped being doctors and became businessmen.'" The excess treatment brings money into doctors' and hospitals' pockets and results in an annual cost to Medicare of $15,000 per enrollee. It does not, however, buy longer lifespans or better outcomes.

Why do people, such as those in McAllen, accede to excess medical care?

The Illusion of Immortality

Certainly, the information mismatch between the well-educated physician and the information-challenged patient plays a role in excess medical care. How can someone argue with the high-status physician, who says that such and such test or procedure can improve or save the patient's life? Yet our own illusions that we can live forever or avoid the suffering inherent in living encourage us to believe that another procedure or an expensive drug will save us. Our illusion of immortality leaves us vulnerable to people selling hi-tech cures. Both as individuals and as a society, we waste our money so we are not as able to buy what we really need when we really need it.

The Will to Live Forever

Years ago in medical school I watched an elderly man with tetanus fight for life. His body was wracked with spasms; his jaws clenched so tight he couldn't speak. His doctors held out little hope. They tweaked the respirator and adjusted his fluids while the battle raged in his nervous system. Every day I walked into the ward expecting to hear he had died in the night, but still he held on. There was no "power of positive thinking" going on; rather every cell and tissue and organ in his body held on to life from minute to minute. The animal in him, in all of us, showed itself to me. That animal is married to life. It hangs on with every breath. At the end of the week, the man finally succumbed.

Psychiatrists say that most of us don't really come to terms with death; instead we push the idea away. We are creatures of life. So naturally we hope that we doctors can accomplish the impossible. Our fierce attachment to life may explain the reverence for high tech machines and unpronounceable medical specializations. Medicine can do a lot, but only within limits. Medical science is the science of the possible.

What is actually possible depends upon two things:

1. what the human system is and is not capable of and
2. what medicine can and cannot do.

A yawning gulf lies between what physicians understand and what laypeople wish to believe about those two factors. Let me tell you what we physicians know.

What the Human System Can Do

Live a Long Time without Modern Medical Care (if you are lucky)

One idle day, I went through a book called "The Timelines of History," checking out life spans of the ancients. The first individual for whom the birth year and death year was listed is a Greek historian named Hecataeus (547- 486 BCE) who lived 61 years. I recorded everyone down to Seneca the Younger, born in 4 BCE, lived 69 years. (His father lived to 93, falling short of the record set by the Athenian orator Isocrates who lived 98 years) I counted everyone for whom the book listed a lifespan, even Alexander the Great (died of illness age 33) and Marcus Brutus (who murdered Julius Caesar, then committed suicide at age 43). When I added up the lifespans of all 58 people in the list, the average came out to 66 years. Pretty respectable lifespans!

Of course, this calculation of lifespan does not include people who died in childhood or young adulthood as so many did back then. We can safely bet that people less well fed, housed, and cared-for died far sooner than the 66 years lived by the leaders and aristocrats. Still, get us past the dangers of infancy and childhood illnesses and the human system, if not brought low by contagious illness or poverty, is going to last, on average, for the better part of three-score and ten. Even without antibiotics and intensive care units.

Heal and Regenerate

I have seen so many people brought low by serious illness and come back, their spirits and energy intact, that it no longer surprises me. I remember a yacht delivery captain with relentless low back pain. An MRI showed a lumbar disk pressing on a nerve, and the orthopedist told him that surgery was the only hope. The patient couldn't afford the surgery so he pushed himself back to work, and two years later had saved up the money. By then he didn't need it. His back pain had spontaneously resolved over those two years. As they say, "The doctor's job is to entertain the patient while nature does the healing." Nature is a truly powerful force. The life you enjoy is robust and strong.

What Medicine Can Do

Most of the benefits of our medical system are taken for granted. You can see what our medicine can do by contrasting our lives with those of the people in sub-Saharan Africa.

• Bearing an average of seven births per woman, about one in fifteen women die in childbirth.
• Each surviving woman loses one or more of her children before the child is five years old. One in seven children dies by age 5.

Here in the US, the relatively invisible specialties of obstetrics, pediatrics, and public health protect us from the above, and more: HIV, malaria, pneumonia, diarrheal diseases, perinatal illnesses, and measles. (See page 72 (page 102 of pdf document) of the DCPP's Global Burden of Disease and Risk Factors) Simple measures such as immunization prevent epidemic illness in both children and adults, while provision of safe food and clean water forestall a host of water- and food-born illnesses such as cholera.

These efforts are tried-and-true, and cost a modest amount of money. For that money, we get two more decades of life and a much more comfortable existence than the average person in sub-Saharan Africa enjoys.

Perhaps what is note-worthy in Africa is not that most people do not make it to 65, but that so many survive the social disruptions, the hunger and the privation and make it into their forties.

What Medicine Cannot Do

Make Us Live Forever

What the human system cannot do is to break the inexorable law that our lives will come to an end. Time harvests all of us. We human beings have some influence on how long we have left to live. What we eat, the environment we life in, the medical care available — these factors might bring the date closer or push it away. But not forever. For every ten people born on your birthday, nine will live to age 56 years, eight to age 65, half to age 80, and only two of you to age 90. (One of whom will probably have dementia)

Healthcare Buyer Beware

The very expensive care in McAllen, Texas, produces mediocre results or worse. In his research, Gawande found that that "the four states with the highest levels of spending — Louisiana, Texas, California, and Florida — were near the bottom of the national rankings on the quality of patient care." By contrast, the Mayo Clinic provides top-tier care while ranking in the lowest 15 percent of medical center expenditures. As a family physician, I find the worship of high tech medicine frustrating. High tech costs a fortune and accounts for only a small percentage of the good that medicine does. When you receive flyers for high tech scans or see TV ads for hospitals with the latest costly equipment, remember this. The basic things — nutrition, exercise (!), sanitary streets, safe water, control of contagious illness — these provide us with so much benefit compared to the counterfeit miracles we see in the advertisements.

The cost of unnecessary high tech medicine is great. If you use up your money in co-pays for fancy scans and procedures, you may be strapped by the time you need some extra funds for a medical intervention that might actually do you some good. Unnecessary treatment also has an aggravation factor — all those unnecessary trips to the hospital and those side-effects you didn't expect, the drug interactions and other iatrogenic catastrophes.

Nifty Thrifty!

So, "Medicine for People" signs off with our customary salute… "Caveat emptor." Don't let people separate you from your currency with scare tactics. When you are aware of what can and can not be bought, you become a cannier shopper.

Medicine for People! Scoops the New York Times

Two days after our June 4th newsletter about public health, Nicholas Kristof of the New York Times acknowledged that they have been remiss in coverage of that subject. We covered that subject in depth in our June 2009 newsletter.

Vitamin D Testing at Reduced Price

Reviewing our lab costs and fees, we've changed a few. There are minor changes in our most common tests, except for vitamin D, now $97 instead of $129.

While our fees for half-hour and one-hour physician visits are unchanged, our fifteen minute rate is now $89.

Cooking Classes

Want to know how to prepare healthful, fresh foods your family will love? You can start a cooking class with Janet Goldenbogen, one of our health educators, on Friday July 10. This six-week "hands-on" program will replace your standard meat & potatoes or commercial prepackaged foods with delicious, high-nutrition, family-pleasing choices. Classes run from 6:00 to 8:30 pm. The $35 fee includes the food you'll prepare.

Janet's next Conscious Eating/Conscious Living series begins Tuesday August 11 10:30am-12:30pm.

Please call Janet Goldenbogen at 379-8134 or email her at janett@cablespeed.com for her current schedule including this and other classes.