DRUG BUST Alan Cassels
Aristotle said that man is a political animal. To Descartes, man was a thinking being. Jean-Jacques Rousseau said that man was ultimately a moral being. I am prone to think that what most characterizes humanity is the fact that we create tools – man as toolmaker.
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Empowered Patients Conference |
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Alan Cassels speaks at the Empowered Patient Conference, |
Of course, we are moral, thinking, political animals, but the ingenuity we apply to making tools to serve our needs and make our lives easier and more fulfilled, as well as healthier, is a useful lens through which to examine the state of healthcare today.
Modern healthcare is mostly about the creation of systems that manage the use of tools – pharmaceuticals, vaccines, complementary medicines, surgeries, medical diagnostic equipment and computers – all of which make the delivery of healthcare more efficient and more capable of conquering disease and alleviating suffering. Improvements in the important determinants of health – better hygiene, working conditions and social supports – provide many of us with lives that are less nasty and brutish and longer than our forebears, but healthcare technologies have also helped make us healthier.
The importance of focusing on the use of healthcare technology is intensified by one simple fact: so much of our collective wealth goes toward paying for it. In Canada, public healthcare continues to eat more than 40 percent of provincial revenues, an amount that, similar to an unchecked tumour, only knows how to grow. Our neighbours to the south, currently facing the most monumental healthcare debate in a generation, spend more per capita on healthcare than any nation in the world, trapped by a dysfunctional system that manages to leave 47 million people without healthcare insurance.
It comes down to our use of tools. Are we using healthcare technologies – both high and low tech – optimally and efficiently, with the right tool being used at the right time on the right patient for the right reasons? And if not, why not? We’ll never get to a sustainable, patient-centred health system without a more rational and judicious use of these tools and we certainly can’t keep throwing more and more money down the black hole of healthcare and getting less and less in return.
Yet how often do we hear policymakers talk about the systematic elimination of waste in our health systems? Strangely, not often. When healthcare wonks frame discussions on how to improve healthcare, they tend to focus on the desire for new gadgets, more MRIs, new drugs and evidence of an enduring belief that improving healthcare is really just about getting the next newest thing. For years now, academics and policymakers have been beating the drum about the need for the adoption of electronic patient records, acting almost as if digital records were the deus ex machina that would drop on to the stage and save us from a tragic end.
I agree with some of their reasoning. For instance, I agree that computerized physicians’ offices could make patients visits more efficient and drug prescriptions more readable, while also preventing needless in-office duplication and disruption. Electronic records could help patients acquire important, health-related information, tailored for them with the touch of a button and potential negative drug interactions could be identified and avoided.
As a researcher, I see great promise in electronic records, especially in the use of monitoring and analyzing the impact of decisions made by the healthcare system. How did patients fare on drug X? Did drug X cause more hospitalizations or deaths in patients who took it, compared with patients who took the older drug Y? With electronic systems, we could answer those questions and ensure we are getting the healthcare we are paying for. When new information emerges about the safety of a drug or a diagnostic test, doctors could use their computers to find their patients and advise them of a particular drug or test recall, something which can’t happen now in the paper-based way of doing things.
At the end of the day, electronic patient records are unlikely to save healthcare. It’s going to cost a lot of money to create an army of digital doctors, and, as with the adoption of any new technology, things sometimes go horribly wrong in unintended ways. I’m mindful of the central tenet of Edward Tenner’s book, Why Things Bite Back: Technology and the Revenge of Unintended Consequences, which reminds us that despite how clever we humans are in creating new tools and gadgets, they often crash and burn when used in the real world.
One of the ways electronic health records might backfire is in breaches in privacy and confidentiality that arise from the collection and storage of confidential patient data. Data can be used, but it can also be abused. I don’t think a considerate approach need slow down the adoption of electronic records for the simple fact that many other industries and more advanced health systems have developed the necessary laws and safeguards to protect privacy.
Another use of the computer, related to electronic communications in medicine, is rapidly transforming the nature of medicine: namely, the explosion of web-based information and tools. Who hasn’t first visited Dr. Google with a health care issue nowadays? But that’s only the beginning and a post-Google world is expanding to become the “Brave New World” of “Medicine 2.0” where serious advances in patient empowerment are being made.
“Medicine 1.0” is a static monologue where people use the Internet only to find medical information. In contrast, Medicine 2.0 is about dynamic dialogue, dominated by Internet-based social networking. Proponents of Medicine 2.0 are harnessing the Internet in ways that are truly astounding, employing listserves, chatrooms, blogs, Twitter, Facebook and a ton of other networking tools to bring patients closer to healthcare workers and to each other, for the purposes of research, data collection and storytelling. The world just got that much smaller when people across the globe can share their medical experiences, talk about the effects of drugs or other technologies and exchange information as easily as talking to their next-door neighbour. One such site bringing people together on the topic of diseases and healthcare treatments is www.patientslikeme.com and it makes the future of healthcare appear to be engaged, deeply personal and empowered.
The champions of Medicine 2.0 want to use the Internet to transform the world of the patient and they are perplexed by the slow rate of change. They rail against the paper-based, physician-centric, doctor-knows-best mode of healthcare, which seems impervious to change and mired in somewhat outmoded ways of thinking.
Social networking might be a revolution and it is certainly going to disrupt the traditional doctor-patient relationship. But will it really take hold? Clayton Christensen recommends that, in order to rebuild healthcare, we must effectively disrupt many of the systems currently in place. His book, The Innovator’s Prescription: A Disruptive Solution for Health Care, presents a provocative perspective: that we need to blow up the current system to make way for a newer, better and more sustainable one.
While Christensen speaks from an American perspective, his lessons could apply to Canadians too: we must revolutionize the way hospitals are funded and operated as well as the way physicians work – under a fee-for-service model – which tends towards over-treatment and leads to many overworked, unhappy doctors. Our medical education is begging for reform and the development and deployment of new pharmaceuticals, medical devices, and diagnostics need to be fundamentally rethought because the old business model isn’t working any more.
At the heart of it, any reform to healthcare must fundamentally address the elephant in the room: the waste that infects all parts of healthcare. Shannon Brownlee, in her excellent book Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, reiterates the fact that medical systems around the world deliver an enormous amount of care that does nothing to improve our health or lengthen our lives. She estimates that somewhere between 20 to 30 percent of every healthcare dollar goes towards “useless treatments and hospitalizations” like drugs, tests and surgeries for people who don’t really need them.
It seems to me that much of that waste – the unnecessary and sometimes harmful and dehumanizing healthcare that is thrust upon people – happens both at the front end and the tail end of life, when we are born and when we die. Maybe that’s the place we need to start the healthcare revolution: at birth and at death, the two most common times in our lives where we typically don’t need the routine use of more and more technology. In fact, we need it less. A lot less.
If we are talking about tools, let’s start by creating a healthcare system that sometimes favours the ‘low-tech’ solution – humans instead of machines. Let’s make hospital births the exception, not the rule, by facilitating the delivery of babies at home with properly supported midwives. Let’s allow elderly people whose days are coming to an end feel supported in how they choose to spend their final days: in their own bed surrounded by family or on a hospital gurney, hooked up to machines and tubes and subjected to painful, unnecessary and sometimes inhumane procedures.
Rethinking and redesigning healthcare is a very tall order so let’s start by looking at how we are using our tools, both the high-tech and the low-tech. Let’s start by re-examining the gross intrusion of the healthcare system at birth and at death.
Alan Cassels is a drug policy researcher at the University of Victoria and author of The ABCs of Disease Mongering, an Epidemic in 26 Letters.cassels@uivic.ca
