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Healthcare stateside

On her return from the States, Dr Karine Nohr reflects on the good (and bad) aspects of American-style healthcare.

I have recently returned from the States, where I spent one week each ‘observing' in a cardiology clinic in San Diego and in a primary care clinic in New York City.

Both took an 'integrative medicine' approach, and it was wonderful to see, for example, cardiac rehabilitation, that in addition to physical rehabilitation in a gym, also offered vegetarian cooking classes, music classes, yoga, meditation, relaxation, guided imagery, managing anxiety and so on, as well as other modalities such as acupuncture and spiritual healing.

Aside from this integrative aspect, however, I was shocked to see how much unproductive time and energy in American medical practice, was devoted to financial matters. A substantial part of the consultation might address what a particular patient's insurance might, or conversely might not cover. This was completely irrespective of the patients needs and I did not witness any discussions with patients as to how important it was for them to undergo a particular investigation.

If a patient was well insured, then the degree of over-investigation or unnecessary investigation or unnecessary follow-up could be shocking. This is partly because doctors are reimbursed for procedures (and not for talking with patients). Additionally, American doctors are so litigatious-conscious (even more than our good selves) and so if a patient requests an investigation, that investigation would be done. Furthermore, there are no incentives to reduce investigation costs.

When phoning the hospital, you would get put on hold whilst a sugary-sweet recorded message delivered PR about how wonderful that clinic was. It was ghastly. Whole legions of bureaucrats are employed to promote clinics and to negotiate insurance schedules and payments, with patients and clinics/hospitals.

Ultrasound scans that pick up a corpus luteum lead to repeat ultrasonography. Repeat findings of a corpus luteum lead to MRI. (Yes, you can get another corpus luteum in the following month, surprise surprise!) One young woman in the general practice setting requested blood typing. Why? No reason, she just wanted to know. Perhaps, it was postulated, she wanted to go on the ‘blood-group diet'. She also wanted annual HIV testing (but her HIV tests to date had all been negative and she hadn't had any unprotected intercourse).

Everybody who came to the general practice had their vitamin D levels checked. Epidemiological evidence strongly suggests that low vitamin D levels are associated with higher rates of hypertension, certain cancers, risk of some auto-immune diseases, depression, as well as the more well-known boney problems. What is not clear, at this stage, is whether vitamin D supplementation lowers these risks back to normal.

At a cost of nearly £200/test, and a low vitamin D level in 80% of patients in New York City, with subsequent (inexpensive) vitamin D supplementation, I queried the value of this test. The multidisciplinary team (MDT) brought this up for discussion and asked whether it might be more useful to recommend vitamin D supplementation to all patients, without prior investigation. But there was concern about patient dissatisfaction; if they were to decline vitamin D testing was there a risk that patients might leave the practice? Lack of agreement led to the proposal that only those patients where clinical indications suggested investigation, or those who requested it, should have vitamin D levels checked. Others could simply have vitamin D supplementation.

An asymptomatic middle-aged woman in the cardiology clinic wanted reassurance that she had no ischaemic heart disease. All (extensive) investigations were negative and yet, for no clinical reason, she was offered three month follow-up by the clinical lead cardiologist. What a waste of precious time!

When I commented on the cost of over-investigation to a colleague, he described how a patient presented to him at one hospital requesting MRI, which was performed and found to be negative, only for the patient to state that the same test had been performed 12 hours earlier in another hospital in the same city, but the patient didn't trust the result.

So what with its procedure-lead litigatious-sensitive emphasis and its individualised insurance system, the USA seems to spend a massive amount of money on ‘healthcare', a large proportion of which is not producing any actual beneficial healthcare itself.

Dr Karine Nohr is a GP in Sheffield

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