“Clinical Man”–by Clifton Meador (Why Do So Many Of Us Need Medical Tests to Tell Us That We Are Well?)

Posted on March 21, 2015 by Maggie Mahar

Editor’s Note–

Below, a post by Dr. Clifton Meador, author of more than a dozen insightful, often witty books including Sketches of a Small Town, Circa 1940 and True Medical Detective Stories. (When reviewing Sketches on Amazon, I compared Meador to Mark Twain.)

In the post below, Meador refers to one of his best-known stories, a tale set in the not too distant future titled “The Last Well Person.” The fiction, which was published as an “Occasional Note” in NEJM in 1994, uses satire to comment on the folly of our obsessive drive to test and screen every well person in America–until we find something wrong with each and every one of them. That “Note” ultimately inspired Dr. Nortin Hadler to write a book that would help many begin to understand what is wrong with American healthcare: The Last Well Person: How to Stay Well Despite the Health Care System. (2007)

This is not the first time that Clifton Meador has published on HealthBeat. Some of his most popular posts include:

–“The Mind-Body Connection: Could Psycho Somatic Conditions Account for 30% of Chronic Conditions?

–“Unheard Hearts–a Metaphor”

— “How Medicine Became a Growth Business;”

Today, Meador is a professor of clinical medicine at Vanderbilt. The essay below originally appeared on The Pharos of Alpha Omega Alpha Honor Society, November 2011, and was recently cross-posted on The Health Care Blog (THCB)

M. M

Clinical Man

by Clifton Meador

In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging: homo clinicus.

An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.

Nothing has changed so much in the health-care system over the past 25 years as the public’s perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.

There has been a progression of terms for this new species. First, there was the “early sick” then “the worried well.” That was followed by “the worried sick.” We now have arrived at a definable new species that differs from pre-clinical man.

Pre-clinical man lived largely with medicine out of his consciousness. In fact he lived to avoid medicine. Those of us who are still pre-clinical will recall the earlier saying, “An apple a day keeps the doctor away.” That is almost pure pre-clinical thinking. Pre-clinical man only went to the doctor when he was sick or injured. It was up to pre-clinical man to decide if he was sick or well. It did not take a physician to make that decision. If he felt all right he was well; if he felt sick he was sick. Not so with clinical man. Feelings are no longer a reliable guide to health. Feeling good is not enough. There must be objective data that nothing is wrong. That’s the problem. Something is always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, “A well person is someone who has not been worked up. We can always find something wrong, if we look hard enough.”

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George W. Bush’s Recent Stent Surgery—Two Perspectives

Posted on August 16, 2013 by Maggie Mahar

Last week, when former President George W. Bush underwent stent surgery, the procedure was declared a great success. What is surprising is that not everyone in the mainstream media applauded.

From Bloomberg News “Former President George W. Bush’s decision to allow doctors to use a stent to clear a blocked heart artery, performed absent symptoms, is reviving a national debate on the best way to treat early cardiac concerns.

“The discussions have been ongoing since 2007, when the trial known as Courage first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with chest pain. The results were confirmed two years later in a second large trial.

“The debate has centered on both the cost of stenting, which can run as high as $50,000 at some hospitals, and its side effects, which can include excess bleeding, blood clots and, rarely, death. Opponents say the overuse of procedures like stenting for unproven benefit has helped keep U.S. medical care on pace to surpass $3.1 trillion next year, according to the U.S. Centers for Medicare and Medicaid Services.

“’This is really American medicine at its worst,’” said Steven Nissen, head of cardiology at the Cleveland Clinic in Ohio . . . ‘It’s one of the reasons we spend so much on health care and we don’t get a lot for it. In this circumstance, the stent doesn’t prolong life, it doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better’” . . .

“’Stents are lifesaving when patients are in the midst of a heart attack’ added Chet Rihal, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota . . . ‘They allow immediate and sustained blood flow that help a patient recover. For those who aren’t suffering a heart attack, the benefits are less clear . . . While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks.’ A review of eight studies published last year in JAMA Internal Medicine also found no differences.

“Two large-scale clinical trials completed within the last seven years have shown that drug therapy works just as well as stents in preventing cardiac complications. (The three major U.S. heart associations changed their guidelines in 2011 in an effort to reduce excess treatment. )

[This is important. The major U.S. heart associations have absolutely no vested interest in recommending fewer procedures. When they say “Do Less,” everyone should listen–mm. ]

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A New IOM Report Reveals Why Medicare Costs So Much (Hint–It’s Not Just the Prices)

Posted on August 16, 2013 by Maggie Mahar

George W. Bush is 67. Chances are Medicare paid for the stent operation that I describe in the post above. For years, medical researchers have been telling us that this procedure will provide no lasting benefit for a patient who fits Bush’s medical profile. Nevertheless, in some hospitals, and in some parts of the country, stenting has become as commonplace as tonsillectomies were in the 1950s.

Location matters. Last month, a new report from the Institute of Medicine confirmed what Dartmouth’s researchers have been telling us for more than three decades: health care spending varies across regions. More recently, as Dartmouth’s investigators have drilled down into othe data,, they have shown that even within a region, Medicare spends far more per beneficiary in some hospitals than in others.

In a recent Bloomberg column, former CBO director Peter Orszag notes that “Because this variation doesn’t appear to be reliably correlated with differences in quality, the value [that we are getting for our health care dollars] seems to be much higher in some settings than in others.” He asks the logical question: “What is causing this and what might we do about it?”

Some health care analysts claim that as a nation, we spend far more on health care than any other developed country because we over-pay for everything—from statins to surgery. (A landmark article that appeared in Health Affairs in 2003 put it this way “It’s the Prices Stupid!” )

Others put more emphasis on overtreatment. Up to one-third of Medicare dollars are squandered, physicians like Dartmouth’s Dr. Elliott Fisher, Boston surgeon Atul Gawade and former Medicare director Dr. Don Berwick argue. As Fisher puts it, “hospital stays in the U.S. may not be as long as in some other countries, but more happens to you while you’re there.” (Note: the authors of “It’s the Price’s Stupid” also point out that care in the U.S. is “more intensive.”)

I agree that both theories are true: We have managed to devise a health care system where we both over-pay AND are over-treated. The Institute of Medicine report that came out at the end of July supports this thesis.

The Difference between Medicare and Commercial Insurers

The IOM report reveals that both Medicare and commercial insurers are spending about 40 percent more per patient in some areas and in some hospitals than in others. “This has persisted over decades;” Orszag observes. “Regions that spent the most in 1992 tended to remain big spenders in 2010.”

But, he adds, “There is one important difference between Medicare and commercial insurance, the Institute found, and that is in the causes of spending variation. With commercial insurance, spending is higher in some areas because of markups — that is, the difference between the charge for a service and the cost of providing that service.

“Seventy percent of the variation in commercial spending was attributed to differences in markups, which in turn probably reflect local differences in market power among hospitals and other providers relative to insurance companies and beneficiaries.”

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