Defining "Success"

 

This week's New Yorker features another Atul Gawande article that I'd love to photocopy & send to all my friends, young & old.  Overkill, about America's current epidemic of unnecessary tests & procedures, spotlights something I bring up constantly to John, who tends to have utter faith in physicians & other medical specialists - be very leery about how they define "success" when it comes to recommended medical testing & procedures.

Atul talks about a friend of his, a man with an elderly father who suffered from a variety of medical complaints.  They could be a bother, but none reduced the older man's quality of life.  Until...

My friend Bruce told me what happened when his eighty-two-year-old father developed fainting episodes. His doctors did a carotid ultrasound and a cardiac catheterization. The tests showed severe atherosclerotic blockages in three coronary arteries and both carotid arteries. The news didn’t come as a shock. He had smoked two packs of cigarettes a day since the age of seventeen, and in his retirement years was paying the price, with chronic lung disease, an aortic-aneurysm repair at sixty-five, a pacemaker at seventy-four, and kidney failure at seventy-nine, requiring dialysis three days a week. The doctors recommended doing a three-vessel cardiac-bypass operation as soon as possible, followed, a week or two later, by surgery to open up one of his carotid arteries. The father deferred the decision-making to the son, who researched hospitals and found a team with a great reputation and lots of experience. The team told him that the combined procedures posed clear risks to his father—for instance, his chance of a stroke would be around fifteen per cent—but that the procedures had become very routine, and the doctors were confident that they were far more likely to be successful than not.

It didn’t occur to Bruce until later to question what the doctors meant by “successful.” The blockages weren’t causing his father’s fainting episodes or any other impairments to his life. The operation would not make him feel better. Instead, “success” to the doctors meant reducing his future risk of a stroke. How long would it take for the future benefit to outweigh the immediate risk of surgery? The doctors didn’t say, but carotid surgery in a patient like Bruce’s father reduces stroke risk by about one percentage point per year. Therefore, it would take fifteen years before the benefit of the operation would exceed the fifteen-per-cent risk of the operation. And he had a life expectancy far shorter than that—very likely just two or three years. The potential benefits of the procedures were dwarfed by their risks.

Bruce’s father had a stroke during the cardiac surgery. “For me, I’m kicking myself,” Bruce now says. “Because I remember who he was before he went into the operating room, and I’m thinking, Why did I green-light an eighty-something-year-old, very diseased man to have a major operation like this? I’m looking in his eyes and they’re like stones. There’s no life in his eyes. There’s no recognition. He’s like the living dead.”

A week later, Bruce’s father recovered his ability to talk, although much of what he said didn’t make sense. But he had at least survived. “We’re going to put this one in the win column,” Bruce recalls the surgeon saying.
 
“I said, ‘Are you fucking kidding me?’ ”

His dad had to move into a nursing home. “He was only half there mentally,” Bruce said. Nine months later, his father died. That is what low-value health care can be like.

 

You're probably tired of hearing about the complete blood transfusion one of the staff doctors - NOT my mother's physician - wanted Mom to undergo.  Praise be for the nurse who called to let me know something was afoot that I might want to check out.  She risked her career to spare my mother a procedure that even the doctor admitted - when asked - might make her feel just a tad better.  To him, thinking of his charts, better was better.  Not so to Mom, who hated blood transfusions with a fierce passion.

People like my John are suckers for low-value health care, care that is unlikely to do much if any substantial good & can end up doing considerable harm.  Mom was already seriously weakened, would be gone in a couple weeks.  Imagine how a complete blood transfusion could have affected her, emotionally as well as physically!

Another story Atul shares spotlights why doctors & other medical professionals can be so persuasive - 

Even reputable professionals with the best intentions tend toward overkill, he said. To illustrate the point, he, too, had a medical story to tell. Eight months earlier, he’d torn a meniscus in his knee doing lunges. “Doing lunges is probably something a sixty-five-year-old should not be doing to begin with,” he admitted. He was referred to an orthopedic surgeon to discuss whether to do physical therapy or surgery. “Very good guy. Very unassuming. I had no reason not to trust the guy. But I also know he’s a surgeon. So he’s going to present surgery to me.”

Sure enough, the surgeon recommended arthroscopic knee surgery. “This is going to fix it,” Ray recalled him saying. “In by nine, out by noon.”

Ray went for a second opinion, to a physical therapist, who, of course, favored physical therapy, just as the surgeon favored surgery. Ray chose physical therapy.

“How’d it turn out?” I asked.

“Amazingly well,” he said. “I feel pretty darn good right now.”

“What did the surgeon say when you told him you weren’t going to do the surgery?”

“He said, ‘No problem, go to P.T., and when that doesn’t work we can schedule the surgery,’ ” Ray recalled. “Who knows? Maybe I will end up having to go back. He wasn’t trying to pull the wool over my eyes. But he believed.”

But he believed.  Mom's covering physician wasn't trying to bamboozle her into unnecessary care.  He believed that it would provide some benefits, which it might have.  Just not sufficient to justify the discomfort & risk.  But if I was a patient, a family member concerned a parent was getting the best care possible?  His belief might have trumped any hesitation.  Too many patients & their loved ones don't realize that best available & most appropriate are often two very different things.

It was my good fortune to work for two of the nation's top health care benefit providers - US Healthcare & Prudential HealthCare.  At USHC, I started in Member Services & ended as the primary Physician Liaison, as well as serving as the first level of the Medical Excellence Review procedure (approving or denying requests for out-of-network care).  At PHC, my work in Public Relations included writing both member & participating provider newsletters, getting our region's Washington Watch effort up & running, steeping myself in health care issues in order to proactively address them.  

Best training in the world to become what Atul tags as a virtuous patient - and a canny advocate.  Doctors will always be light years ahead of me in their knowledge, but I can be a real pain in the butt when it comes to asking questions!  I have known top flight surgeons look for the nearest exit on spotting me with my notebook & pencil. 

Smiling, remembering Mom's cardiologist.  When a simple stay for a couple days turned into a major health crisis, the specialist insisted he'd prescribed correctly, that Mom's body was wrong reacting as it had.  One day, he came into her room - well after visiting hours were over - and was taken aback to see me perched on Mom's bed.  His audible sneer is forever etched in my mind - "There SHE is, with that damned book, ready to write."  Those few words were a wake-up call for Mom, who'd always assumed that doctors focused on what was best for a patient, shared her definition of success.  To her, what I was doing was geared to making a success of her care.  To him, it was a direct threat.  She never looked at doctors with such unquestioning eyes again.

Now, how to get that same message through to John?