Monday, June 20, 2005

So there it is, Doc, spelled out plain

The Ottawa Citizen's Kelly Egan and the sour grapes, see-no-evil approach to fixing health care: There was once a day, not so long ago, when we had no MRIs but still had healthy people. There was once a day, not so long ago, when the number of healthy people walking around was heavily offset by the number of deaths from infection, inoperable diseases, and other unfortunate aspects of the pre-modern medical establishment. There was once a day when hospitals had no specialized neonatal ICU wards, but plenty of newborn babies; so what if premature birth was nearly a guaranteed death sentence before that new-fangled high-falutin' technological advance? It doesn't mean anything, right? Today, in every major Canadian city, we have the most advanced diagnostic tools in the history of medicine, but a population that's constantly being told public health care lives in imminent crisis. Perhaps that's because the myth of Excellent, Free Health Care has been so eagerly embraced by the media and political establishment as the only means of proving Canada's worth, and the slightest crack in the fa├žade threatens to expose such cant for what it is? The MRI is now a weapon to expose our inadequacy: I hope you're suspicious, too. I'm suspicious of those who would crankily bluster on about how having the best in diagnostic technology shouldn't be a goal of a medical establishment in the wealthy and civilized first world, but do continue. Not long ago, I sat at the knee of a brainiac named Dr. Antoine Hakim, who is a trained engineer and a leading physician, the scientific director of the Canadian Stroke Network. Think of health care as a volume of oil that needs to fit through a fixed pipe, he urged. In a public system, where money is a constraint, there is more oil than can fit through the hole. Two immediate options arise: Cut down on the volume of oil (disease prevention) and make the pipe more slippery (improved efficiency in treatment). Incorrect. There's a third: Stop pretending that only one pipe can be allowed to exist. Let others be built as they're needed, funded by those who need them, rather than stubbornly holding on to the illusion that allowing anyone to pay for their own care somehow diminishes the already subpar quality of that provided by the public system. Aim the same beam, for a moment, at the shortage of magnetic resonance imagers, which have waiting lists of six to eight months for things like joint scans. The lack of a scan, in turn, delays eventual treatment, prolongs pain, and puts the populace in a grumpy mood. However, it is to ask: Are MRIs being over-prescribed in this country? [...] [I] came across this: The MRI Lie: A Matter of Economics, by Dr. Ronald Grelsamer, an orthopedic surgeon and the chief of hip and knee reconstruction at Maimonides Medical Center in Brooklyn, New York. Much is made in this country about how we don't have nearly as many imaging machines as the United States, where a single large city will have as many MRIs as all of Ontario. To which he advises, citing an Illinois market-research company: about a third of all advanced imaging tests "are either inappropriate or don't contribute to a physician's diagnosis or ultimate health outcomes." He himself goes even further. "While MRI testing is an extraordinary diagnostic tool in certain areas, its accuracy for knee pain and arthritis is arguably one of the greatest myths of our time. In my experience, the odds of coming across a false-positive MRI range from 10 to 100 per cent, depending on the knowledge and integrity of the radiologist." A competent physician, he says, will be able to diagnose an arthritic knee with an ordinary X-ray, costing about one-tenth the price of an MRI. "The good doctor rarely, rarely, rarely needs an MRI," he said, when reached on the weekend. "I'm talking about knees, now." Maybe true, maybe not. Clearly more studies are needed. But in the meantime, does it really make sense to pissily declare that we shouldn't bother with MRIs, because they might not be necessary in all cases? Grelsamer, also - as he's quick to point out, and as Egan more or less ignores - is only an expert on hip and knee joints. Do we know for certain that his assurances of being able to properly diagnose arthritis from X-rays can be extrapolated to every and any other condition anywhere in the body? Radiology costs are growing so quickly in the U.S. that they now outpace the cost of prescription drugs, he writes. Good Lord, is there anything we aren't scanning? Again, no mention is made of the marginal utility of either. Can future costs on prescription drugs be avoided by early and frequent use of MRIs to detect and quickly treat conditions, before they require medication for long-term symptom management? [...] Secondly, we aren't getting the most from our existing pipe. A new study done for Ontario's Wait Time Strategy agency found some hospitals are operating MRI scanners at only 40-per-cent capacity. The report, published in Saturday's Citizen, found that 69 per cent of the province's 44 scanners were running 16 hours a day, considered a minimum for peak efficiency. If they all went to 24-hour-a-day operation, wait lists in three Ontario regions would be reduced to four weeks, a medically acceptable period for elective procedures. Okay, I'll bite. How much would it cost to hire a sufficient number of MRI technicians to operate the existing infrastructure round-the-clock? Are there enough in the province, or the country? Would their union accept such a scheme without demanding extortionate raises? Would constant operation considerably shorten the life of those machines, forcing earlier replacement than planned? Would any of this be feasible within the existing budget, and more efficient than buying more machines (or allowing private clinics to do so)? Egan is sloppy about the actual facts, as usual, preferring to go for one-sided outrage-provoking talking points. The scary part about medical technology is its unstoppable will to advance. What device will replace the MRI in 20 years? Will the $3-million scanner be replaced by a $30-million whatzit? How many of those will we need? Will the $30-million whatzit save ten times as many lives as a $3-million scanner? Could it help even more, treating conditions for which there are now few or no treatment options? Might the use of such a device save millions more in drug costs? Could it improve the general quality of health care, and thus quality of life? If there's any place in public policy that sneering luddites should stay away from, it's health care - at least, as long as health care remains largely a matter of public policy. Forgotten in all this rush to put an MRI on every street corner is the relationship between better technology and better health. Maybe we should scan a little deeper on that issue. I suggest that next time Kelly Egan requires medical treatment, he ought to subject himself to the tender mercies of, say, the state Cuban health care system. Maybe then, he'd better understand what a difference technology - like, say, regular washing, disinfection, insecticides, a modern electrical grid - can mean to matters of life of death, rather than being contrarian for its own sake. To quibble about the number of MRIs owned by the province is to miss the point entirely: compared to much of the world, even Canada has excellent health care, and it's not because of any governmental commitment to "social justice" - it's because of modern technology. Maybe technophobes like Egan would like to return to the days of surgeons in tailcoats (is the relationship between sterile scrubs and avoiding infection really that strong?) and laudanum prescribed for everything from PMS to TB (what can't a healthy dose of opiates help alleviate, after all?), but I don't. (Thomas Eakins, "The Gross Clinic," 1875) I'll grant that simple numbers of MRIs aren't the be-all and end-all of measuring a medical establishment. But all the same, those numbers are a handy way of benchmarking a commitment to modernity and attempting the best treatment possible - rather than a commitment to ideology, and attempting the most egalitarian treatment possible, given constraints of the public purse.


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