Friday, January 14, 2005

The Ulysses Syndrome

Long-time friend Claus Curdt-Christiansen is Chief Medical Officer of the International Civil Aviation Authority, a U.N. agency located in Montreal. Claus passed along the following without identifying the author, leading me to suspect that he might have written it himself.

Much has been written about the incompetence of modern day doctors, the swelling costs of medical care, malpractice, and the need of patients to be in charge of or at least contribute to the medical decision-making process.

In this context, I wold like to tell you a story which I have called

The Ulysses Syndrome

Ulysses was, as I am sure you know, a hero who left his home, roamed the world of antiquity for twenty years, experiencing much excitement and many adventures, and then returned to his home to find that, in the meantime, he had lost his wife, his house and everything else too.

Now there was a time (in my childhood, I think) when a patient with a sore throat and coughing would go to his family doctor or even have the doctor visit him in his home. The doctor would look at his throat, listen to his lungs, diagnose a viral infection, pat the patient’s shoulder, prescribe hot milk with honey and a scarf, and promise him that he would be all right in few days time and ready to go back to work. And quite right, the patient having full confidence in his doctor, got better and resumed his work next week. All were happy. That was then.

Not so today. The patient may visit the doctor but he knows that there are limits to what the doctor knows and what a clinical examination can reveal. The doctors knows that too and doesn’t want to be sued for malpractice, so after the examination with, or more likely without, patting the patient’s shoulder, he refers the patient to X-ray of the lungs, just to be on the safe side, and because the patient wants it, of course. He also takes blood. After all, medicine is a science and a diagnosis must be based on scientific evidence. Both procedures entail some waiting time and delays before the results are ready. Treatment cannot be delayed, so the doctor prescribes an antibiotic (completely useless and possibly harmful) but necessary to be on the safe side and the patient, of course, wants it. He also wants and gets sick leave until the matter is resolved. Although the lungs are fine, the radiologist will in some 5% of cases find a suspicious looking area that calls for further examinations, and modern laboratory procedures do not allow single tests to be carried out but, in the name of efficiency, examine the blood for some 20 different qualities, including those in which the doctor is interested but many more which in the context are of little or no interest. The so-called ‘normal range’ is usually defined as the results obtained when analyzing the blood of a high number of healthy young medical and nursing students at a major teaching hospital. The top and bottom 2.5% of results are taken away, the remaining 95% of results form the basis for what is considered ‘within normal limits’ in that region of the country. Of course, the last 5% were also taken from healthy young students, at least so they believe themselves, just a little extreme. To be on the safe side we disregard the extremes. This means that out of twenty blood analyses, 5% or one will be outside the ‘normal’ range. So when the results come back, the doctor will be obliged to consider this abnormal finding – and to do something about it. The same goes for the suspicious chest X-ray. So the patient is referred for a tomography of the lungs, which unfortunately doesn’t exclude a possible pathology. So the next step is a CAT-scan, later to be followed by an MRI. The waiting lists for these advanced high-technological examinations can be many months, so the sick leave is continued. Also the blood must be considered, so more blood-letting ensues and more ‘abnormal’ results arrive. The picture is unclear, so the patient, who had little confidence in his family doctor in the first place, insists on a referral to a specialist. The specialist has a long waiting list, so the sick leave is continued. There are, however, limits to what even a high-powered specialist can find out in his down-town clinic, so he suggests in order to crack this difficult case that the patient be admitted to a hospital for further in-depth investigations. This is no emergency, so there is a waiting list. The sick leave is continued. But finally the patient is admitted, fully investigated in accordance with best medical practice, and found to be normal. He now leaves the hospital – as healthy as can be – to find that after this period of extended sick leave, he has lost his job, gotten behind with the mortgage on the house so that it now has to be sold, and the wife, being unable to put up with 24/7 care of a sick spouse, has left him. Returning to a normal healthy productive life after a prolonged period of absence is not easy, so in many cases the patient will need professional help from a psychologist or a psychiatrist to cope with being normal.

Okay, this is just a story. But I think it provides some of the explanation why health costs have been rising in recent years.

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