Over-Treatment

Our culture of over-treatment is the subject of one of the main arguments I make on this blog. To discuss it properly we need to define our terms.

Over-treatment, according to the Free Dictionary is "the treatment of clinically insignificant disease, that is, minor or indolent illnesses that do not require aggressive or invasive therapy." Reilly and Evans, writing in the Annals of Internal Medicine, refer to the phenomenon as "unnecessary care", and define it as "diagnostic or treatment service that provides no demonstrable benefit to a patient." They argued that 30% of all medical care in the United States (in 2009) might have met their definition.

I tend to employ a broader definition that encompasses what I have already referred to as The Culture of Over-Treatment: Over-testing, over-medication, over-referral (to specialists), and over-hospitalization. The common feature of these four "overs" is that they satisfy Reilly and Evans' condition of failing to provide demonstrable benefit to a patient. The "culture" of over-treatment refers to the institutions, practices, and mind-sets that propagate unnecessary care.

And I take the argument further. I claim not only does over-treatment fail to provide benefit, but that over-treatment does harm. Always. Sometimes the harms are small - the recipient of over-treatment isn't physically harmed but treatment cost money that didn't need to be spent. Or the treatment did nothing but cause anxiety. This is difficult to measure but cannot be discounted - in future posts I hope to deal more fully with the "anxiety factor." And finally there is physical harm.  It's bad enough when people are harmed in the course of treatment that threaten life or limb: when injuries happen in the course of over-treatment, it is doubly catastrophic.

Measurement of harm in medicine is a relatively new phenomenon. Harms studies are different from mere complication rates after surgery or rates of readmission after hospitalization. Today, more attention is paid to adverse outcomes from tests and treatments previously thought to be innocuous, such as routine blood tests, or antivirals for the treatment of Influenza.

But the harms that interest me the most are more difficult to define and quantify, but are no less devastating, and these are harms related to the ways we think about ourselves: our lives, our health and wellness, and particularly the way we experience our children.

There are several excellent books on the subject, especially "Overtreated" by Shannon Brownlee, about which I have a personal story that will have to wait for a future post.

I hope the tide is turning away from the culture of over-treatment but I see no solid evidence of this happening.  Talking about it is the best way I know how to buck the trend.  Read on.

Rush

When I was growing up, the expression "emergency room", was always appended to the expression "rushed to", as in "he was rushed to the emergency room".

Of course you got rushed to the emergency room: There was some kind of emergency going on! Either you were having a seizure, or you fell off a ladder and broke several bones, or you were having crushing chest pain radiating down your left arm... And virtually always you were rushed to that emergency room in an ambulance.

Emergency rooms back in the day didn't look like they do today. There was very little regular staff, certainly no dedicated emergency room doctors.  An excellent picture of the 1960's emergency room is drawn by the film Parkland , which tells the story of the doctors of Dallas' Parkland Hospital on November 22, 1963, the day JFK was assassinated.  Every physician called to the emergency room that day (and by the looks of it, by the end, every physician in the house was in that room) had been elsewhere in the hospital prior to the President's arrival.   None were dressed in scrubs or operating room gear. Each was wearing white shirt, tie, and black pants. And each was fairly drenched in the President's blood by the end of the code (which is wrenching to watch).

A lot has changed in 52 years. The expressions "emergency room" and "rushed to" have been separated. Ambulances often bring people there, but more often than not people are driven there by family, or drive themselves (presumably not in mid-seizure).

The expression "emergency room" itself has evolved to "Emergency Department", to reflect the fact that these formerly empty, intermittently used spaces are now fully functional, fully staffed parts of a hospital.

Sometimes the word "emergency" is dropped entirely when one talks about a medical misadventure. The word "hospital" is substituted. "I went to the hospital". "We took her to the hospital".  Well of course, the individual went to the hospital, but not exactly.  They went to the emergency room of the hospital. This may be because of tacit acknowledgment that there was no true emergency, but I cannot be sure.

Why does all this matter?

As I hope to describe in future posts, the transformation of the emergency room into the Emergency Department is central to the story I am trying to tell in this blog. It is a multi-layered and nuanced story and by no means do I intend to distill the many issues down to One Big Thing.

For now, I will observe only that the disappearance of the expression "rushed to" is a symptom of our culture of over-treatment, about which I will have much to say later. There are two foci in the universe of over-treatment: one is the private doctor's office, and the other is the Emergency Department.  How the universe of over-treatment came into being is a long story with many parts.

Stay tuned.

The Myth of the Unhealthy Child

My mother once told me that when she and my father were starting our family in the mid 1950's, she never imagined that she would give birth to anything but perfectly healthy children. As it turns out, she was right: between 1956 and 1964 she gave birth to four healthy babies. My mother's expectations were not all that unusual: Sixty years ago, most parents expected that their children were probably going to be born healthy and grow up to lead healthy lives.

Most parents believed this despite the fact that the infant mortality rate was 26 per 1000 live births, over four times what it is today. Polio was still a threat, and public swimming pools were regularly closed during the summers of the 1950's for fear of polio.

As if polio weren't scary enough, twice as many children were dying of Measles as from Polio in 1956. We were years away from an effective Measles vaccine.

And in an age where car seats were never heard of, and seatbelt laws did not exist, four times as many children died in accidents in 1956 compared today.

And yet, our parents believed we would probably be born healthy and grow up safe and sound. They believed that children were essentially healthy human beings. That is to say, it is an element of their essence that children are healthy.  Sure, things would happen: they'd catch the flu, they'd fall down and break a bone, but the children were essentially healthy and they'd recover.

Fast forward to 2016.

The mindset that was common among my mother's peers has been turned on its head. Instead of believing that their children are essentially healthy, it is common today for parents to believe that their children are essentially un-healthy. A version of this mindset is that their children are potentially unhealthy, one sniffle away from certain doom.

The facts suggest the complete opposite.  Babies born in 2016 in the United States belong to a cohort of human beings who are the healthiest that have ever lived on planet Earth. That is not just pie-in-the-sky optimism: that is demonstrable fact. And yet parents are more worried than ever that their children are sick or will become sick.

It is the aim of this blog to explore this phenomenon of the "Essentially Unhealthy Child": to test the truth of the hypothesis; to examine the possible reasons we've come to the pass; and to explode the myths that have come to surround the institution of parenthood. 

There are several consequences of The Myth of the Unhealthy Child that I believe are at best counter-productive to the enterprise of raising healthy, happy children. At worst, the consequences threaten our very self-concept of our health and well-being as adults.

I hope you'll join me on this journey - I look forward to hearing your contributions.