Tuesday, November 24, 2009

Well, much has been said about the impending health care reform. Unfortunately, little has been heard or has been published from the medical community itself. It is a shame.

After following the pros and cons arguments there are a few things that I belive are fundamental to the issue. No matter what the politicians say, health care cost are NOT going to fall. All could be attempted is to decrease the rate of expense growth.
There is a simple fact that is inescapable. Our population is getting older and with age comes increase in utilization of medical resources. So, as a jibaro used to say: "They(the pols) are thinking of pregnant birds" This is a literal translation of a puertorrican adage.

Let the actuarians calculate the staggering costs of caring for an increasing aging population and decide how much we are willing and able to commit in a fiscally responsible manner. Then allocate the resources to get more bang for your buck.

The recent published guidelines on mammography also illustrate a point.

In order to catch as many breast cancers as possible you have to cast a wide net. I remember from my training days working at the coronary care unit, we were having a discussion on the accuracy and the diagnostic acumen of the ED docs in cases of suspected cardiac ischemia. We concluded that a doctor who admits mostly patients with a later confirmed cardiac ischemia is likely to be missing some and sending home patients who needed observation. So, it is better to admit patients that end up not having ischemia so that you won't miss the real ones.
In an age of limited resources, is this acceptable? Or should we streamline the system to make it more efficient and less costly at the expense of missing diagnoses? And when a 42 y/o female mother of three, with no risk factors, vegetarian, non drinker, non smoker, physically fit, gets breast cancer that could have been diagnosed earlier with a mammogram not performed because of guidelines, who do we blame?
All this decisions carry a cost either monetary or in human life.

And still there will be breast ca missed and MIs sent home. There is a limit to everything.

Is it not this the meaning of "Shit Happens"?

It will kind of neat for my math whiz kid to design a formula that defines the limits on diagnosis.
All will be needed are the variables used in making a decision, say to admit or not admit to the CCU, find out the limits of the variables and then determine what is an "acceptable" rate of misdiagnosis. I wonder if you could use calculus formulas for this. Double, triple derivatives?Then again there is uncertainty........ Could you adjust for that?

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