A take on why US patients are sicker

It’s because real diagnosis and treatment takes time, something that is not valued here, where volume takes precedence:

What the report has not considered are some of the most obvious differences:
* We die the soonest and are the sickest of First World countries.
* We spend far more per capital on health care than our peer nations.
* But, aha, much of that expenditure is prescription drug related.
* It is quick, easy and profitable for a doctor to treat symptoms with drugs rather than diagnose and treat underlying conditions, which may lead to sickness and death.
Let’s put it out there. American doctors are drug pushers. This makes perfect sense. They are under considerable pressure to maintain their own high incomes and the profits of their hospitals and practices. They do this by seeing more patients. They see more patients by spending less time with each. They spend less time with each by using drugs instead of diagnosis, treating a symptom and hoping that this drug or the next will fix something. This also has a good chance of keeping the patients returning for more drugs and for fine-tuning of the levels.

Comments

Barry
A few years ago, I was treated for depression. I went to a counselor and a psychiatrist. The counselor was very helpful, but what shocked me was the psychiatrist. Her whole job was prescribing the appropriate anti-depressant. What I always thought of as the job of a psychiatrist was done by the counselor. I’d be really bummed if I had become a psychiatrist, only to find that I was seeing people for 30 minutes, and then writing a prescription.
Anonymous
30 minutes? That would be for an initial visit, not followup.
A colleague–an experienced and thoughtful psychiatrist–said that the real objective of a psychiatric residency has to be to produce a clinician able to assess and dispose of a patient on followup in fifteen minutes. Anything less, and that practitioner will not be able to survive in practice. He was also not shy about the role of clinical psychologists: he felt that psychiatrists needed the psychologists and the psychologists needed the psychiatrists, and that griping by one profession about the other was a wasteful failure to recognize that truth.
WilliamManginoMD
Long a critic of the American medical system; I fail to see the ‘take-home’ message in “A take on why US patients are sicker.”
With all due respect, what are you trying to tell us? Are you saying Israeli medicine is better? Then what happened to Sharon?
British and Israeli doctors are no smarter or more well intentioned than ours. There are plenty of bad doctors and ‘pillpushers’ in every country.
What do you think, that Sherlock Holmes helps British doctors divine your disease process.
And as far as psychiatric care is concerned – all that therapy and Freudian stuff is great – now try taking it into your daily activities without Effexor – give me a break !!
Tell you what – go have a divination session with your favorite cardiologist for paroxysmal a – fib. Skip the beta-blocker and aspirin; see how long you last until your first episode of PSVT.
Americans are not overmedicated – and doctors are not pill pushers – you are way off base.
Anonymous
How much of the drug expenditure relates to drugs that demonstrate a small but “statistically significant” effect and quickly become standard of care and on everyone’s guideline list? You show me a study demonstrating more than a 10% absolute risk reduction for statins, ACE’s and ARB’s, etc. We’re spending a lot of money to achieve rather modest risk reductions, and most people will eventually succumb to their diseases. Yes, I would rather practice medicine than remain a numbers chaser, but under P4P it’s only going to get worse. The American public must decide what they want from their medical providers.
WilliamManginoMD
Are Americans overmedicated or undermedicated?
The reason I took issue with the original article in this forum is as follows –
1- Beta blockers – we are undermedicated.
2- hypertension – we are undermedicated.
3- ACE inhibitors – dosage ranges are insufficient [ where this medication would otherwise prove to be efficacious when indicated ].
4- opioids for pain – we are undermedicated.
If there is a problem with doctor prescribing it apparently lies in the fact that doctors may not be aggressive and courageous enough to titrate medication to effect; for fear of overhyped side effects.
In general, doctors don’t give enough medicine to do the job.
There is no one solution to this problem – but solutions, in general, probably will not include the hypothesis that “Doctors are pill pushers.”
As an anesthesiologist one of the biggest problems I faced, on a daily basis, was that most patients on antihypertensives came to the OR with poorly controled high blood pressure.It was epidemic. Most of these patients were under the care of an internist or GP.
Debate exists about whether or not we need to treat “prehypertensives” and if such treatment has real long-term value.
Debate exists about many medications we use.
So until outcome studies are complete-and there is consensus, why bother to blame american physicians for being “Pill pushers,” when, in fact – they may not be quite pushing enough.
You decide – I am merely commenting that this is not the solution to our woes.
Anonymous
“As an anesthesiologist one of the biggest problems I faced, on a daily basis, was that most patients on antihypertensives came to the OR with poorly controled high blood pressure.It was epidemic. Most of these patients were under the care of an internist or GP.”
Dear Sir:
Looking at one isolated number (unless it’s 200/100) in a clearly stressful circumstance (the OR) is NOT how you diagnose poorly controlled HTN. How about you stick to what you know.
WilliamManginoMd
Dear anon 11:13,
Sorry you were so insulted by the truth. You sound like one of those doctors who thinks anesthesiologists are bag squeezers without awareness of anything other than dripping open drop ether on a mask.
I did cardiac anesthesia, exclusively for a year. I interacted with invasive and intensive care cardiologists during that time on a daily basis.
No one had ever accused me of not knowing what I was doing.
Why don’t you pin a name on your accusation. If you want to have an open forum on this subject-ask Kevin to arrange it-then I’ll show you what I know- and what you don’t.
William Mangino MD
Anonymous
“I did cardiac anesthesia, exclusively for a year. I interacted with invasive and intensive care cardiologists during that time on a daily basis.”
Well goodie for you, I have interacted with cardiologists for many years let alone managing HTN on my own. But since you “know” more than me why don’t you “play internist” for these people. Oh, I get it. Like every other arrogent subspecialist you moan and bitch but when it comes to DOING something you say…go see your PCP. I have all the respect for anesthesia when they are in THEIR scope of practice. You right now are not.
PS: Try reading the latest JNC guidelines. You will sound less like a pompous fool.
Anonymous
Anon 359,
You need to address the issue rather than use ad hominem attacks.
I concurr with Dr. Mangino that hypertension in the population is generally poorly controlled, more so in the elderly. The following link, although from 2004, shows that and is still applicable in 2006:
http://www.northwestern.edu/univ-relations/media_relations/releases/2004/06/hypertension.html
I’m not an anesthesiologist, just an ER doc who wants to remain anonymous.
Anonymous
“The American public must decide what they want from their medical providers.”
As a member of the American public:
Enough time for good communication concerning the problem at hand. That will obviously vary from circumstance to circumstance.
What I don’t like is going to see a specialist and spending 5 minutes with a physician’s assistant, five with a resident, and then 5 with the attending…being asked nearly the same questions by all three…and ultimately spending the least amount of “quality” time with the attending because most of it goes to staring at his back while he fills out paperwork.
Also have found that while my PCP generally gives me about 15 minutes per annual physical, when I review my record later I find that he has provided my answers to questions that he never asked.
That said, my PCP has prescribed only two medications, Lipitor and Synthroid. While I can’t really “feel” the benefits of the first, my cholesterol numbers did improve very significantly. And I would say the thyroid medication has been a true blessing.
And despite not having a lot of interaction with the surgeon, he did resolve the problem for which I was referred to him.
So…while I would ideally like more personal care, it would be inaccurate for me to say that the diagnoses and treatment I have received were negatively impacted by any perceived lack of attention. My impression is that American doctors do pretty well under some pretty crazy conditions.
WilliamManginoMd
ALLRIGHT- so we got off to a bad start. I’m sure you are an excellent physician. You started with the insult – not me. And your subtle reference is that you work hard and subspecialists’ don’t.
Can we stop now. I’m sure your experience is vast-that you are very knowledgeable and I respect you-but the fact remains, a lot of patients don’t do well in the OR due to poor control-and more than you and I care to see in that sitution.
We [ anesthesiologists ] don’t make snap judements based on a single pressure reading-and contrary to what you may think, most patients don’t have wide pressure swings under stress of being in the holding area , before periop sedation,and under asnesthesia, unless their HTN isn’t well controlled. It wasn’t intended as an insult.
You know that poorly treated HTN is often accompanied by contracted blood volumes – which do not lend themselves well to undergoing the rigors of surgery.
Tha ASA has strict guidelines about anesthetizing uncontrolled or poorly controlled HTN. Much of what is known comes from shared literature, from your field and mine. While you may be on target and very good at what you do-I stand by my experience that many patients are poorly controlled, and that this is a reflection of less than aggressive care.
Doesn’t mean you aren’t a good guy-and a good doctor.
At least you are out here debating – which in my estimation means -you care. That’s good enough for me. I wish you the best.
I’m out of this discussion for now.
Bill Mangino
Anonymous
you know the poster ahead of this one makes perfect sense. Since most of the physicians offices have gone to the in room computer’s I’m also tired at looking at my Drs. backside while he spends our entire visit looking and typing into a computer screen. It has taken the place of hands on, face to face examinations. Why?
I also got tired of being an experiemnt object for some physicians. I have HBP and have been on medication since I was 18 years old. I think it must be some genetic HBP. My mother also had it all of her life. We are not overweight or out of condition people. My Mom was a little mite of a woman at 4ft 11in and about 100 lbs.
Invaribly some Dr. will come along that thinks we can try to get me off of medication. It goes like this. “You know your BP seems really good, lets disc. this medication. Your not overweight, and otherwise your in good health.” So, not wanting to argue with my Drs. I have played this game. 3 times this has happened and 3 times within a week of disc. my meds, I have been in the ER having terrible nose bleeds. Not a little run of the mill nose bleed but hugh ones that ER Doc’s can’t even get stopped. Every time I have had to have my nose packed for 48 hours. That 72 inches of gauze being shoved up there with a pair of tweezers isn’t so bad going in,(they try to numb it) but 2 days later coming back out it is hell. Also I have had the packing start to go down my throat causing a big mess. My BP will quickly go to the 210/120 mark when they disc. my meds. Even when I say to a Dr. “We have tried this before”, the answer I get is “Well, lets try it again.” …Makes no sense.Afterwards it takes longer and stronger meds to get it back under control.
Why don’t you listen EVER to your patients?
Anonymous
“You need to address the issue rather than use ad hominem attacks.”
The issue is you shouldn’t look a just one isolated number (unless significantly elevated) under a stressful cirmcumstance (surgery) and say oh well his BP is poorly controlled…..typical idiot PCP. Heck don’t believe me talk to your friendly cardiologist (though a good Internist, which Dr. M apparently doesn’t believe exists will tell you the same thing). The latest NHLBI JNC 7 guidelines are on the web for those interested.
PS: Dr. Mangino your self-importance and expanded opinion of yourself is clear. I have no interest in debating someone so full of himself.
Anonymous
It is one thing to note elevated BP…any anesthesiologist or pcp can do that…it is another thing to get a patient to take meds. How many times has the average pcp heard “I’ll try diet a few more months and then come back”, “I want to go the natural route…”, “I’ll lose 40 pounds and then I won’t need medication…”. Anesthesioogists have no idea what it is like to prescribe chronic meds and assess compliance…they are mere technicians…
Anonymous
Where is the evidence that foreign docs push less drugs or do a better job of treating/diagnosing than american docs?
I find that hard to believe.
So what theh origianl post really meant to say was that ALL DOCTORS AROUND THE WORLD ARE PILL PUSHERS, not just american docs.
WilliamManginoMd
Anon 5:09 and 5:45 -
Most internists and PCP’s are good doctors. I do not believe that there aren’t any good internists. I agree that getting patients to comply is difficult. I applaud your efforts, hard work and dedication/expertise. Anesthesiologists are not “Mere technicians.” While I am not offended by that statement-I would suggest to you that it is way off base ,factually.
Sorry if you drew those impressions from my trying to point out what I thought were issues for dispassionate discussion.
I do not have an expanded opinion of myself.
I attempted to rectify these bad feelings you have in my prior communication.
I hope this is clear.
Best wishes
Anonymous
Agreed
My apologies to Dr. Mangino.
WilliamManginoMd
I think everybody who commented today offered some really great insight into the difficulties inherent in taking care of patients and being a patient.
My hat is off to every doctor who has struggled to do the right thing.
If I get sick-I’d be proud to have you all take care of me.
You are in my prayers
Anonymous
Text of statements in the Rep. Patrick Kennedy crash help to highlight the possible perils of prescription medication.
“Last Tuesday, the Attending Physician of the United States Congress treated me for Gastroenteritis. The Attending Physician prescribed Phenergan, an anti-nausea medication, which in addition to treating Gastroenteritis, I now know can cause drowsiness and sedation.
Following the last series of votes on Wednesday evening, I returned to my home on Capitol Hill and took the prescribed amount of Phenergan and Ambien, which was also prescribed by the Attending Physician some time ago and I occasionally take to fall asleep. Some time around 2:45 am, I drove the few blocks to the Capitol Complex believing I needed to vote. Apparently, I was disoriented from the medication. At that time, I was involved in a one-car incident in which my car hit the security barrier at the corner of 1st and C St., SE. At no time before the incident did I consume any alcohol.”
Unfortunately, I believe there are some physicians who place the public in peril by excessively prescribing drugs which may impair their automobile driving patients.
Papers have been published on the impairment caused by opioids
http://www.ndaa-apri.org/pdf/ntlc_opioids.pdf
and impairment caused by benzodiazepines
http://www.aafp.org/afp/20000401/2121.html
It seems the legal system may deem physicians to be accountable for their prescriptions as seen in the following case:
http://www.usalaw.com/a-aa-doctors-sued-drugs-auto-crash.html
Anonymous
Well, if he was on medication that hindered his driving why didn’t he hire a driver. None of the Kennedy’s seem to be able to drive…sober, drunk or whatever.
This group of men live on the edge, don’t you know that?
Anonymous
Anon 10:33 from your article:
“The doctors had prescribed a patient-controlled Demerol pump for pain”
The patient was sent home on a PCA with demerol. Perhaps Dr. Mangino can add his two cents butI have never sent home someone with a PCA. Additionally, why demerol? It has a seizure risk (though I have never seen it) and people seem to love demerol (that is TOO much). Why not a long actor of some sort. Fentanyl patch? MS-contin? Methadone? Seems to me there is a lot more to this story than your typical shark-blurb of how you have been wronged call us blah blah blah…..
Anonymous
Anon 10:33
a.) Even if his prescribing doctor didn’t explcitly warn him about the effects (drowsiness) of taking a sleeping pill (trying to keep a straight face here…) all those little stickers on the precription bottle did. All Ambien prescriptions dispensed in the U.S. have a warning sticker against “driving or operating heavy machinery”. He knew better.
b.) Yesterday, Patrick Kennedy admitted to a substance abuse/addiction problem and is currently in drug rehab.
Anonymous
While it seems that Patrick Kennedy is looking for someone to blame, in some cases doctors do make mistakes in writing instructions on how to take medication.
For example, my HRT consists of estradiol/micronized progesterone (Prometrium). When I got the prescription bottle for Prometrium, the instructions said “take one pill every morning”. If you read the long insert for Prometrium, it says “can cause drowsiness or dizziness, don’t drive or operate heavy machinery after taking it”; it also contains recommendation to take it in the evening to avoid the problems. Most women do take it in the evenings. I don’t know who or why wrote the instructions to take it in the morning – there is no reason at all to do it.
Now it could very well be that it was the pharmasist who made this mistake and not the doctor. But imagine for a moment that someone gets into in accident after following these instructions. Whom is this person likely to blame? Note, that Prometrium is not a sleep aid or a pain killer, so most people are not familiar with this side effect. I’d imagine that my habit of reading package inserts and looking up information about drugs I am taking on the web is an exception rather than the rule.
As far as overprescription goes, look at the use of statins for primary prevention in women. Show me some evidence that it reduces mortality. Also, a lot of times the women who get this prescriptions have high HDL and perfect ratio – medrants had a surway once, find it and read up personal stories. Lots of healthy women with HDL in the 80s and excellent ratio. Not that I believe it is any better in England.
agave_azulito
In Mexico City, many drugstores hire a doctor for their clinic at the same location. These doctors typically have a list of about twenty common complaints that they treat, and I suspect that the quality of treatment of these specific ailments is at least as good as those generally provided by USA doctors.
The cost of a consultation is typically between $0.90 and $2.00 US money (10-20 Mexican pesos).
I will tell you nothing about the cost of generic drugs in Mexico vs the USA to treat these common ailments–I hate to see grown people cry.
Anonymous
In Mexico City, many drugstores hire a doctor for their clinic at the same location. These doctors typically have a list of about twenty common complaints that they treat, and I suspect that the quality of treatment of these specific ailments is at least as good as those generally provided by USA doctors.
The cost of a consultation is typically between $0.90 and $2.00 US money (10-20 Mexican pesos).
I will tell you nothing about the cost of generic drugs in Mexico vs the USA to treat these common ailments–I hate to see grown people cry.
agave_azulito
n Mexico City, many drugstores hire a doctor for their clinic at the same location. These doctors typically have a list of about twenty common complaints that they treat, and I suspect that the quality of treatment of these specific ailments is at least as good as those generally provided by USA doctors.
The cost of a consultation is typically between $0.90 and $2.00 US money (10-20 Mexican pesos).
I will tell you nothing about the cost of generic drugs in Mexico vs the USA to treat these common ailments–I hate to see grown people cry.
agave_azulito
n Mexico City, many drugstores hire a doctor for their clinic at the same location. These doctors typically have a list of about twenty common complaints that they treat, and I suspect that the quality of treatment of these specific ailments is at least as good as those generally provided by USA doctors.
The cost of a consultation is typically between $0.90 and $2.00 US money (10-20 Mexican pesos).
I will tell you nothing about the cost of generic drugs in Mexico vs the USA to treat these common ailments–I hate to see grown people cry.

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