Great Expectations

I only have a rudimentary knowledge of the great pieces of literature, however, as I was thinking, as I often do, about some of the issues in healthcare, and how we are going to solve them, the concept of expectations comes to mind. There is really no way to describe the expectations of the healthcare system today other than, “great expectations” (with all due respect Mr. Dickens). Unrealistic expectations are a source of huge disappointment, frustration, aggravation and cost. Lest anyone feel that this is a one sided equation, I can tell you, unmatchable expectations are a source of angst and aggravation for those that are expected to fulfill them too. If our expectations of healthcare system matched what the healthcare system could provide, we would all be better off; physically, mentally and financially.

I try not to just point out problems’, lists of problems would be easy, especially in healthcare. Solutions are the real challenge, and where the real gratification comes.

So, here are some of the “great expectations” and their accompanying realities, along with some possible solutions.

Expectation: All symptoms can be specifically diagnosed and treated (eliminated).
I don’t know any specific numbers, but this is often not the case. The more vague the symptom; like tired, don’t feel right, or fatigue, the less chance of a specific diagnosis. Lots of unnecessary tests often get done, searching for the proverbial “needle in the haystack”, that may not even actually be there. Ask your doctor if they really think they are going to find something, and if they think you REALLY need the test being ordered. This is especially true when RE-testing starts.

A few specific scenarios:
– The easy fix.
Many people would rather take a pill than change their lifestyle. For example, studies show that without long term lifestyle changes, even people who have had bariatric surgery (“gastric bypass” ) will often regain weight. Reality is, medical intervention can only do so much. 85% of health impact is from lifestyle, pills and medicine etc can really only impact about 15%. I know it is hard to understand what these numbers really mean. The take home message is that it is really all (OK, mostly) about lifestyle, and every little bit counts.

– The quick fix.
People want a pill to make them better immediately. There is a lot of “quick fix” seeking (and selling). I think it’s our culture. Antibiotics are the first things that come to my mind. Example: antibiotics for the common cold. They don’t work. Antibiotics only work on bacteria, most illness is viral. Besides, (most of) us have an immune system. The immune system, and “tincture of time” will take care of most infections, (and diarrhea, vomiting, aches and pains, and other illnesses), both viral and bacterial, with no help needed from antibiotics. Even when taking antibiotics, they rarely actually shorten the duration of illness. This has been well studied in strep throat. In addition, all pills have possible side effects. Antibiotics specifically, can cause upset stomach, diarrhea, yeast infections to name a few, they cost money, (to someone, even “free” medications cost someone), and they cause antibiotic resistance, an individual and societal problem. In my career, I have seen first hand the devastating affect of antibiotic resistance, pretty much everyday, it is that common. Bugs that didn’t even exist when I started are now a common occurrence. Solution: Antibiotics, don’t take them unless absolutely necessary. To help you determine if the are REALLY necessary, make the preemptive strike. Tell your provider that you would PREFER NOT getting antibiotics unless they feel they are absolutely indicated (and mean it. Don’t say it and then be disappointed that you didn’t get any).

Expectation: I can do whatever, and the medical establishment will fix it.
Medical care has come a long way, even since I first started 30+ years ago, before HIV/AIDS had even been specifically identified…However, if you wreck your organs, especially your brain, we can’t always fix them. Wear your seat belts & helmets, don’t shoot up drugs, don’t smoke, drink in moderation, and NOT when driving, don’t saw off the branch you are standing on, etc. As an ED doc, I cannot support motorcycles…AND, I believe you can still have fun despite all of these recommendations! But just remember, thinking that everything can be fixed is not a realistic expectation. Don’t take unrealistic risks. Lots of people show up after taking such risks, having something happen, and still expecting a fix. It breaks my heart….and many others…

Expectation: No risk.
Life is risky. Many people are shocked to hear that ALL medications have potential side effects. It’s true. Same with most studies and procedures too.
Not to sound too paranoid, but, even something as simple as your average vitamin has risks…you can overdose on the fat-soluble vitamins, they can make your urine yellow (basically your vitamins going in the toilet), you can overdose on iron. Bismuth subsalicylate (Pepto-Bismol, others) can turn your stools black. I have seen lots of cases of black stools due to the pink stuff in the Emergency Department. Read the labels. CT scans are a fair amount of radiation, and radiation is cumulative. They can be the equivalent of up to 3-7 years of background radiation or more. If your provider and you feel that there is a reasonable chance that it shows something meaningful, its worth it, but, if is just a “knee jerk”, it may not be. Ask, and talk about it. Acetaminophen is the number one cause of acute liver failure in the US (and the UK). The list goes on. Back to proverbs: “No such thing as a free lunch”.
Solution: Understand risk, only take/use/get things that you really need. Have insight into what you really do need, make sure the benefit outweighs the risk. Try a non-medication solution first. Get educated and participate in shared decision-making. Work WITH your doctor. Remember, MORE is not necessarily better.

Expectation: But on TV…
We all know that is not the case, but it is probably worse than you thought!
A lot of people think CPR is usually effective and always “worth a try”. This is not the case. In what seems like it was probably a sort of fun study to do, published in the New England Journal way back in 1996, and repeated in 2009, the “real life” outcomes of CPR were compared to those seen on TV. Though there have been some improvements (in CPR outcomes, not TV!) over the years, more people survived and did well on TV than in real life. In addition, only seven out or the 60 had other illness, and young people needed CPR on TV more than the elderly, both of which are opposite of real life. So, TV leads folks to, well, great expectations, better than what reality can deliver. So again, work with your physician to have the right things done at the right time; remember, just like everyone poops, everyone dies; the goal is really to do it as well as possible, so do your healthcare planning!

More “great expectations” coming! Do you have a story to share? Please send it along for consideration.