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View Diary: Healthcare Reform and the Economy (160 comments)

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  •  We mostly agree... (0+ / 0-)

    except who should decide...you think it should be some central planner like in Canada...I think it should be the doctor along with the patient...

    But we mostly agree on that it should be the most effective treatment with the least amount of side effects and risk...I just believe that should be regardless of cost..you think cost should come into the picture..

    The other thing I vehemently disagree with is looking at procedures only based on outcomes...it should also be based on the overall comfort and benefit to the patient...

    So if there are 2 procedures one being bypass that has a 4 month recovery and one being angioplasti which has a 2 week recovery and they are equally effective...then the less invasive procedure should be used...

    Obama - Change I still believe in

    by dvogel001 on Sun Jul 26, 2009 at 02:32:29 PM PDT

    [ Parent ]

    •  but in the latter case (0+ / 0-)

      there are clear guidelines about who should be referred for cardiac surgery. There are far less clear guidelines about who should get stents, and there are no guidelines about who should get multiple drug eluting stents, and the outcomes data does not show a benefit of multiple DES over BMS. And many patients will have a similar outcome with medical therapy alone.

      What I am saying is not that there should be a central decision maker, but we need guidelines, evidence based guidelines, that allow us to make proper decisions for the individual patient. I would not have wanted my active 75 year old mom to not have had surgery based on some arbitrary decision maker, anymore than you would. The problem with evidence based medicine, as I've always said and have always taught the residents, is that studies are done on populations in aggregate, but that the patient in the bed is an individual. You can't determine their particular outcome, just discuss the risks.

      But we don't have enough data out there to even begin to counsel patients appropriately. That's what we need.

      I don't disagree with you, mostly, on what you say about the issues of comfort. When the spouse blew a disk and had neurologic problems related, I knew that if there was a good response to the physical therapy, it would save several weeks of being off work and laid up in recovery - and would still have required PT at the back end. So we saved the costs of surgery, not only monetarily but also in terms of time and pain of surgery. However, had there not been some improvement, let me tell you I would have been on the phone to my friend the neurosurgeon pronto.

      But too many people think the first thing is to cut, and the idea of watchful waiting is not acceptable. A few years back, my mom, again, had problems with her knee. She'd had problems with her knee for a long time, but it got worse over a several week period. My parents called their regular doc who suggested she see a particular orthopedist, who was supposed to be the best in the area. But it was going to take several weeks to get in to see him, and my dad found that to be unacceptable, so he got her in with another doc, who also had a good reputation. Unfortunately my mom had a bad outcome. Would it have been better had she been to the original doc? Maybe. But this wasn't an acute, life threatening problem and waiting a couple of weeks might have led to a better outcome, of course, it might not have either.

      I tend to be a therapeutic minimalist, and I like to deal with specialists who are very conservative and don't do things unless they are indicated. And I have attracted patients who have a similar mindset. People who want treatment now, right now, don't tend to stick around in my practice, but there are plenty of people in Baltimore who will accomodate them. Too many, probably.

      Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

      by stitchmd on Sun Jul 26, 2009 at 03:24:11 PM PDT

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      •  Believe me... (0+ / 0-)

        as someone who has been through 3 major neurosurgeries...surgery sucks...so by all means it should be a last resort...and that is why when my condition started...the last person I spoke to was a surgeon...

        Obama - Change I still believe in

        by dvogel001 on Sun Jul 26, 2009 at 05:14:48 PM PDT

        [ Parent ]

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