This made me think of a section in the Archives of Internal Medicine called “Less Is More” (2010;170:584), intending to document where “less health care results in better health and offer commentary on the specific implications” of such instances. The first example in the journal was the “First Physical” (Arch Intern Med. 2010;170:583), about which you may have read in the “Green Journal” or in the media. This critiqued President Obama’s inappropriate electron beam CT for coronary calcium, the attendant unnecessary radiation exposure, his failure to stop smoking, and the inappropriate colon cancer screening prior to age 50 years and by the not-recommended virtual colonoscopy. It was argued that this makes the wrong statement about healthcare and sets a poor example at a time when healthcare policy and leadership is sorely challenged. I heartily agree. Indeed, during this past year, our Department of Medicine morbidity and mortality conferences have addressed this theme and included a regular segment called “Sign(s) of the Apocalypse,” with cases illustrating similar problems in medicine.
For example, we discussed a 21-year-old whose extraordinary inpatient evaluation for a cold and a lipoma cost $9,606; an 83-year-old whose hospitalization and evaluation for possible fracture or infection, costing $9,493, should have been easily recognized as pyrophosphate arthropathy; a man with previously documented acute gout spending 11 unnecessary days in the hospital, at $14,756; a man with longstanding gout, resultant weakness, and normal reflexes treated with plasmapheresis and intravenous immunoglobulin for presumptive Guillain–Barré syndrome, costing $51,275; and a woman with familial Mediterranean fever admitted and evaluated, again and unnecessarily, for $3,655. These instances reflected inappropriate admissions and unneeded, expensive, and excessive care.
In our conference, we also presented patients (e.g., patients with parvovirus infection, pseudo-myxedema) evaluated appropriately and economically as outpatients. These documented the value of thoughtful, reflective, clinical evaluations by knowledgeable physicians—encountered, we think, too infrequently today. We should practice and teach medicine that is safe, effective, patient centered, timely, efficient, equitable, high quality, and cost effective. I wrote some years ago that the best diagnostic test remains a thoughtful and thorough evaluation by a knowledgeable end experienced clinician; science does not substitute for art, nor does sophisticated (or expensive) technology substitute for clinical acumen. Rheumatologists know this.
THE JOINT IS JUMPING. HOW DOES RA SPREAD?
This elegant series of experiments attempted to address the question of how rheumatoid arthritis (RA) spreads from a few to many joints (Nat Med. 2009;15:1414-1420). I must confess that I’ve usually encountered and perceived RA as a polyarthritis and presumed it was multicentric. I have certainly seen mono- or oligo-articular disease evolve to polyarthritis. I accept that the problem is relevant, and certainly of interest, while not necessarily the sole explanation for the propogation of RA. I congratulate the authors on their thinking, approach, experimental design, and controls. They implanted human tissues into immunodeficient (severe combined immunodeficiency disease) mice to show that RA synovial fibroblasts migrated to naive cartilage. These observations suggested that transmigration of these cells, at least in part, participates actively in the disease process. This is another obvious target for intervention. Expect to hear more about this.
ONCE MORE, WITH FEELING
Have you ever complained that recently minted physicians aren’t as well trained as in “the old days”? Don’t have the same skills? Have it easier? And haven’t you heard it said, or read, that empathy has declined? Well, it isn’t true. This fascinating exercise meticulously re-analyzed original data from all those studies allegedly finding loss of empathy by physicians at various stages of training (Acad Med. 2010;85:588-593). The authors noted a negative change in empathy of 0.2, on average, from 5.0–9.0-point rating scales from data with poor returns that was largely self reported. Their conclusion was that a decline in empathy has been greatly exaggerated.
