The Secret of Health

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It’s been observed that, eventually, animals come to resemble their owners — or maybe it’s the other way around. Certainly, in many cases it’s true.

And, similarly, people, I’ve noticed, often resemble their doctors. As a resident, I was impressed that a physician who was easy-going and jovial often had patients with the same characteristics, while the jittery, brusque, demanding doctor often had flighty, neurotic and demanding patients. Opposites attract? Nonsense. That only applies to magnetic poles.

And now I find it happening to me: I’m old (funny, yesterday I was young) and my patients are old also! So we talk about general health quite a bit, even though my specialty is ophthalmology. One sure way to get an old-timer to open up is to bring up the subject of health. I’ve found that I can delight most of my patients with a recommendation for good health that instinctively appeals to them: avoid doctors as much as possible. My tongue is only partially in my cheek.

It may seem strange advice, coming from a physician, but that is what gives it whatever force it may possess. I’m not so foolish as to suggest that a person who finds himself in pain simply put up with it, or who suffers some alarming symptom — shortness of breath, paralysis, double-vision, etc., should laugh it off. But how many people visit a doctor with such alarming symptoms? (And such symptoms as the patient may describe could be the result of treatment for previous symptoms!)

There are forces at work in society that tend to make our population over-medicated, over-operated, and over-treated in general. Not surprisingly, these forces are the result of efforts to make medical care better and more affordable. Good intentions can backfire! It started, I suspect, with health insurance. As more and more people had their medical bills paid, at least in part, by third parties, the demand for medical care was bound to increase. The medical profession certainly did not discourage people from frequently visiting doctors, and the idea of the "checkup" took root, although I am not convinced that frequent checkups equate with better health or longer life. The term "wonder drug" appeared, leading people to believe that there was a pill for every disease, or even every symptom, and nothing was incurable. Fantastic new surgeries, almost unheard of in my medical school days, became popular, such as cardiac bypass. Expensive, yes, but with insurance, so what? The evidence that bypass surgery prolongs life is minimal, if at all, but the operation remains extremely popular. You can blame Medicare.

Medicare likes to refer to itself as insurance, but it’s insurance with a difference! An insurance policy will pay for all or part of some medical procedure, period. Medicare does that, but, in addition, prohibits the doctor from charging more than Medicare has determined to be the "right" fee for the operation. In the case of cataract surgery, for instance, ophthalmologists were "permitted" to charge 1500 some years ago, then 1200, then smaller and smaller amounts, with the current "allowable" fee being in the 700 range. The announced goal is 600. What does this signify for the doctor? Well, if he wishes to maintain the standard of living he had when the fee was 1500, he must do two and a half times as many surgeries, or find some other way to boost his income. For ophthalmologists, this could mean doing LASIK, which is un-regulated by Medicare, particularly because most of those having the operation are too young to be Medicare patients. I assume that all surgeons have encountered similar restrictions on their earnings, and turned to various other means to bolster their incomes. Does this lead to unnecessary surgery, and over-treatment in general? I don’t know, but it wouldn’t surprise me. Are the practitioners of any other occupation told that they will only be allowed to charge 40% of their prior fee for doing the same work? And, if so, would they not respond by seeking to find alternative sources of income?

Of course, the malpractice situation doesn’t help. As doctors (and hospitals) became perceived as more mercenary, the willingness of the patient to sue for a less than desirable result increased. As insurance premiums skyrocketed, the physician, if his income was largely derived from Medicare patients, was in a bind, because he couldn’t raise his fees. Again, the impetus to perform more operations, and recommend more office visits and procedures.

But all of this would be fine if it resulted in better health. Does it? My feeling is that physicians are far better at diagnosis than treatment. Present yourself to a physician for a "checkup," and, if you are elderly, you can almost be sure that some ailment will be diagnosed, or at least suspected to such an extent as to warrant various diagnostic procedures. It would be a mistake to simply attribute this to greed on the part of the physician. The patient, after all, inaugurated the process. He demanded a checkup, to rule out serious disease, and treat what disease was found. Why else have a checkup, anyway? That leaves the doctor in something of a quandary. If he does a rather superficial exam, based upon the patient’s history of generally good health, he saves the patient time and money: good. But if he, as a result, misses an unsuspected serious illness: bad!! Enter the lawyers! So the tendency is, inevitably, to do exhaustive testing at the slightest indication — especially as someone else is paying for it! The term "vicious circle" comes to mind.

What if a very incipient cancer is found in, say, breast or prostate? Surgery? Radiation? Chemo? All three? I have friends and family members whose treatment for cancer, if not as lethal as the disease, left them debilitated and discouraged. It would be hard to know whether they benefited from their medical treatment, or were made worse by it.

Hence my semi-serious advice to my patients: stay away from the doctor! If you are feeling well, and ask a doctor to examine you to make sure there’s nothing wrong, it’s quite possible that, if he looks hard and long enough, he’ll find something to treat. Will the treatment be worse than the disease? I simply don’t know, and I don’t know of any way to find out with certainty. There are statistics, to be sure, and the medical profession’s reliance upon them is understandable. The patient is not a statistic, however. To subject him to arduous therapy because several studies have shown that it reduces mortality by twenty percent may not be in his best interests. At least, he should be given some voice in the matter. It’s his body, and his health, after all.

It’s hard to imagine a time when medical care was not a top priority with a majority of the people. Yet that was the case throughout most of history. Somehow, people survived, and there was no "health care crisis," or "malpractice crisis." The quickest way to ill health, or at least perceived ill health, is to think about it a lot. Do that, and you will become sick, or think you are. Quick — run to the doctor!

Dr. Hein [send him mail] is a semi-retired ophthalmologist in St. Louis, and the author of All Work & No Pay.

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