Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
17 August 2005

PROBLEMS WITHOUT SOLUTIONS

            This week an article appeared in the Journal of the American Medical Association analyzing something called “Clinical Practice Guidelines”.  This is a well-meaning set of rules designed for doctors and other healthcare providers to follow when caring for a patient with a given disease state.  As an example, if a person is found to have hypertension, it is first recommended that the healthcare provider suggest lifestyle changes whereby the person eats less salt, exercises more, loses weight, drinks less alcohol and cuts down on the stress in their life.  After having cared for several thousand people with high blood pressure, I can’t think of even one who managed to get their blood pressure in an appropriate normal range through these suggestions.  The real answer is that they come back with the blood pressure still high.  It is then suggested by “Clinical Practice Guidelines” that a medication called hydrochlorothiazide be started to lower the blood pressure. Evidence based medicine coming from trials in thousands of people have shown that this particular medication is the cheapest and most effective for lowering blood pressure.  Unfortunately, this medication has several side effects. Its most important problem is that many people with high blood pressure require two or more medications.  If the person is diabetic in addition, on the average, they require 3 ½ medications to get their blood pressure down to an appropriate range.  Thus, the “Clinical Practice Guidelines” prescribed by our various advisory boards work well in the simple situation but break down in the real world where medical considerations are rarely simple.

            To give some idea of the complexity of this problem, the average of the United States population is increasing continuously.  As our population ages, there is more opportunity for degenerative disease that requires treatment to provide comfort for the people who have the illness.  By the very nature of our medical endeavors, we try to preserve life and also the quality of life.  By preserving life to an older and older age, we are given more and more opportunity for degenerative disease that requires intervention.

            As a specific example, in 1999, one half of all Medicare beneficiaries had at least 3 chronic medical degenerative conditions and 20% had five or more.  The healthcare costs for half of our aging population with 3 or more diseases took up 89% of all of Medicare’s expenditures.  This half of the population used more medication, thereby, increasing the risk of adverse drug events in addition to the medical complications the disease already brought upon them.

            I am writing this article in response to a lady who recently came to the clinic with a magazine article advocating certain medications be used for certain diseases.  Specifically, she had diabetes and did not want to be taking insulin.  She had been tried on various oral medications over an extended period of time. The diabetes simply had not been controlled.  I then indicated that in order to control her diabetes, she would require insulin and several of her medications were stopped.  The magazine article that she brought in advocated the use of a drug called metformin and another drug ,TZD.  Both of these drugs had previously been tried with her and stopped because they were ineffective and had their own side effects.  She was not concerned that these medications were stopped.  She cited the magazine article as a reason why they should be restarted and her insulin should be stopped.

            I pointed out that she had kidney failure in addition to her diabetes.  The use of metformin in diabetics with kidney failure is patently dangerous and can cause fatal side effects.  She also had heart failure with a strong tendency to retain fluid and have ankle swelling.  The TZD drug is a potent stimulant to fluid retention making her heart failure worse.  I pointed out to her that in the right situation both of these drugs can be helpful, but that in her particular situation, these drugs were counterproductive, inordinately expensive and potentially dangerous.

            This example illustrates the complexities and difficulties that healthcare providers experience every day in trying to care for our aging population.  As mentioned above, half of our population has relatively little disease.  The other half has at least three or more major medical problems.  The most common medical problems in the United States today include:  1.  Coronary artery disease.  2.  Cancer.  3.  Hypertension.   4.  Diabetes.  5.  Osteoporosis.  6.  Chronic lung disease.  The sad truth about these six diseases is that each could be changed by appropriate lifestyle modifications.  Weight control, adequate exercise, stop smoking, and adequate calcium intake could decrease the incidence of these diseases by much more than half.  Trying to change the lifestyle of the United States population thus far has not been at all successful.

            Instead, patients come for medical attention for the above problems.  In order to effectively treat the six diseases as described above, an average of 15 different medications might be prescribed.  This also is not a solution for most people.  People balk at taking medications and are justifiably concerned about side effects.  But with the structure of healthcare in the United States today, one chooses between having the disease or having the treatment.

            The point of this column is probably best summarized on three points:

1.      Prevention and lifestyle modification is still the very best solution for dealing with all types of degenerative diseases.  Thus far, our society has not generated a method of instituting a lifestyle that effectively impacts the degenerative diseases in our society.

2.  When disease states occur, they tend to occur in clusters.  We have yet to come up with one pill that cures multiple diseases.  Thus, our society is using increasing numbers of medications at increasing expense.  Side effects continue to be an issue and cost is sometimes prohibitive.  This is a problem without solutions.

3.  In the interest of informing the public, our media such  as television, magazines, and newspaper continue to point out the flaws in our healthcare system.  Whatever their intent, the media continues to create a distrust of the healthcare professions.  This is a problem without solutions.

4.  The idea that simple “Clinical Practice Guidelines” can be imposed upon healthcare providers is a naïve and counterproductive idea.  The United States of American is based upon individual rights and individuality.  The idea that the same medication schedule and treatments will work for everyone is intrinsically false.  Each of us is an individual.  We each require individual attention and the concept that “Clinical Practice Guidelines” can be imposed upon the healthcare profession to apply to all patients is a problem without a solution.

            This column maybe looked upon as unduly pessimistic.  The great American way is to believe that there is a solution for every problem.  I think that the message that I would like to send is that individual care for the individual patient is what the healthcare profession tries for.  The healthcare providers at your local clinics practice for the individual patient.  But the care that we give that individual patient is not simple and it cannot be set into a simple set of rules that can be applied to everyone.