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Editorial JUNE 2010
A James Joyce–Like Journey: Depression, Technology, and Health Care Costs
Ronald T. Burkman, MD
In this issue of The Female Patient, Kahn and Lusskin review the important topic of depression in pregnancy. As they point out, nearly 15% of pregnant women will experience this disorder. They make a strong case for obstetricians to identify these women,
in order to initiate treatment and follow-up, due to the significant consequences of depression when it occurs in pregnancy.
Now for the James Joyce free-association journey. In reading
the article, I was struck by the fact that the diagnosis
of depression is based purely on careful history taking and
allowing patients to express themselves. There are no lab
tests or imaging procedures required. The only “ancillaries”
are various questionnaires, which essentially are focused screening
questions related to the patient’s history.
Much of the rest of medicine is practiced quite differently. All of us, at one time or another, were taught that a careful history and physical examination were essential components in evaluating patients and establishing a diagnosis. Yet when I observe many medical students and residents, it appears that the “H & P” is no longer as
important as it once was. Presentations on rounds tend to quickly morph to what an ultrasound or CT scan showed, with far less attention paid to the patient’s complaints, past history, and physical exam findings. Further, testing is often initiated before a reasonable
differential diagnosis has been established.
This can create several problems. Either the wrong test or too many tests are ordered. Further,
a test such as an ultrasound may identify an incidental finding
that has nothing to do with the
patient’s problem but which may take on a life of its own and lead to further evaluation. In my view, it’s akin to throwing a dart and hoping that you get lucky and hit a bull’s eye. Lest we blame the poor students and residents too much for lack of basic diagnostic skills, we must keep in mind that many medical schools have great difficulty in getting experienced clinicians to take the time to help teach students proper history taking and physical diagnosis.
In fairness, all of us, not just the younger generation, have rapidly embraced technology. Although there is absolutely no question that many of these advances have improved the health and well-being of the patients we treat, still, technology drives practice. That is, if it’s there, and there is some information touting benefits, it tends to get used.
Unfortunately, the introduction of these new advances often is not accompanied by level I evidence to demonstrate benefits over what already exists nor what the costs are likely to be. An example is the growing interest by many ObGyns to learn robotic surgery, when the advantages compared to laparoscopic surgery for most patients are at best unclear. Put another way, is it cost-effective from a
national perspective to have every hospital own a robot?
It is fair to say that one of the reasons for the use of more technology, particularly related to testing, is due to the practice of defensive medicine. Unfortunately, the current health care
reform legislation did not adequately address this problem, even though the “neutral” Congressional Budget Office has suggested that meaningful reform could reduce the budget deficit by about $54 billion over 10 years. Regardless, clinicians will be faced with the need to reduce our appetite for indiscriminate testing and new technology, as part of the need to contain costs. However, such behavior change may be difficult, since our current approach to diagnosis and treatment has been imbedded in our psyche for at least a couple of decades. Further, we have been teaching these same approaches to our students and residents.
Clearly, there is a need for comparative-effectiveness research that allows us to compare different approaches to care and to develop reasonable guidelines. Without such tools, coupled with meaningful liability reform, it is likely that only more draconian measures, eg, payment rate cuts, will produce the changes needed to make health care reform affordable. If that happens, to come full circle with this editorial, ObGyns, not just their patients, will suffer from depression.
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Ronald T. Burkman, MD, Editor-in-Chief |
