“C-section delivery rate: Up by 2% in 2007 to nearly 32% of all births. That’s another record high for C-section deliveries, and 2007 was the 11th straight year that the C-section rate rose.”¹

A third of all deliveries done in the United States are done by C-section. With an infant mortality rate of 6.3 deaths per 1000 live births, trailing behind places like the Czech Republic (3.83 deaths per 1000)¹ and Singapore (2.30 deaths per 1000)², what benefit are mothers and newborns in the United States receiving from these procedures? Longer hospital stays (3 days for cesarean vs 2 days for vaginal birth)³ and longer recovery periods (4 to 6 weeks for cesarean vs 1 to 2 weeks for vaginal birth)³ are the most readily measurable outcomes. Also, mothers are 10 times more likely to die from complications of delivery if they undergo C-section instead of vaginal birth.⁴

Balancing the risks and benefits of C-sections, the World Health Organization recommends a rate of 15 C-sections per 100 births (15%).⁵ What is causing this increased trend toward the use of C-sections? Are doctors not properly educating their patients about the risks? Could the increased rate of C-section a symptom of a new addiction to painless procedures and “on-demand” conveniences? Either way, C-sections remain a valuable tool, and doctors and patients alike need to consider both the benefits and the risks before committing to the procedure.

1. WebMD – U.S. Births Hit Record High
2. CIA World Factbook
3. WebMD – Cesarean Section Risks and Complications
4. Medscape – Complications of Cesarean Deliveries
5. World Health Organization. Appropriate technology for birth. Lancet 1985; 2: 436-7.

This TIME article really puts a human face to a social issue. In a system where payers and providers battle over who pays the bill, what are doctors to do when they get the short end of the stick? Cost shifting from payers to providers harms patients, many of whom desperately need care. Doctors get stuck in a horrible position; they have to decide either to protect their livelihood or to treat the patient for free:

There was at least one thing we didn’t have to worry about, Haile assured me. Pat’s kidney doctor, Peter Smolens, would keep treating him even if he couldn’t pay. Smolens, a thin, soft-spoken man, later told me that about 10% of his patients have inadequate insurance or none at all. He has agonized with some as they struggled with hard choices, like whether to have a hospital biopsy or pay their mortgage. As a physician, he said, “you just see them. You know you’re not going to get paid.”

Why does the American health care system force doctors to question caring for their patients? Health care only works when a patient centered approach is taken. “What is best for the patient,” should be the main question on the mind of every system participant. The financial incentives of the system, however, have an opposing influence: “What is best for our (insurance companies, hospital administration, drug/device producers, etc) wallet,” seems to be the driving force behind so many patient care decisions. Sadly, overall costs to society continue to increase while quality of care continues to decline.

For further elaboration, read the original TIME article:
TIME — The Health-Care Crisis Hits Home

I always imagined that doctors chose devices and prescriptions based on their benefits to a patient’s health. After all, “I will prescribe regimens for the good of my patients according to my ability and my judgment,” is in the Hippocratic Oath. However, drug companies muddle this process by tempting doctors with vacations, free lunches, and huge salaries for their work as “consultants”. If a doctor is that deep in bed with a manufacturer, how are they to maintain an unbiased opinion on all of the drugs and devices available?

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e-magic

This presents an obvious conflict of interest, but how can we excise these conflicts from the current system? I recently asked a cardiologist what he thought about a Medtronic representative. The doctor told me, “It’s just business. This is just a business, and everyone is trying to get their piece of the pie.” However, he claimed that the drug and device reps had no affect on his ability to make unbiased decisions. “I don’t pick the devices we use, anyway,” he joked.

He might pick the devices one day, though, and that’s precisely what the drug and device companies are banking on. With all the money these companies spend on direct marketing, they obviously are seeing some sort of return on their investment to justify all of their spending.

Here another take on the issue from the New York Times article, “Crackdown On Doctors Who Take Kickbacks“:

A common problem in illegal drug and device marketing cases is doctors’ willingness to delude themselves into thinking that cash, lucrative trips and other kickbacks do not affect them, said Mr. Morris, the chief counsel.

“Somehow physicians think they’re different from the rest of us,” Mr. Morris said. “But money works on them just like everybody else.”

“I have been shocked at what appears to be willful blindness by folks in the physician community to the criminal conduct that corrupts the patient-physician relationship,” he said

But where do we draw the line? Should gifts in excess of $50,000 be prohibited? How about anything more than a $50 lunch meeting? Either way, any relationship with the drug and device companies presents the possibility for a conflict of interest. From medical student to resident to full fledged physician, doctors are bombarded by the wooing of drug and device companies. The habit of accepting their offerings almost seems too ingrained into the medical culture to simply draw a line in the sand, but medical practitioners need take a few steps back and reconnect with more patient centered approaches.

March 5, 2009: Another take on the issue: Why are some Harvard Medicine professors making more money from drug and device companies than from their regular payroll?

New York Times — Harvard Medical School in Ethics Quandary

Why prescribe pain killers when a drug-free solution has better outcomes? Acceptance and commitment therapy (ACT) could offer a long term solution with increased patient benefits. To summarize the study, children who underwent ACT had better outcomes for pain management than those prescribed amiriptyline (a sedative used to treat chronic pain) and traditional therapy.

While prescribing medicine may be straight forward and traditional, for idiopathic symptoms, it may not always be the most beneficial or effective treatment for the patient. The question, “What is best for this patient,” should always come to mind before deciding on a treatment plan.

For further elaboration, read the original TIME article:

TIME — Talk Therapy for Kids’ Pain: Better than Pills?

A recent article in Reuters, “Overexposed: Imaging tests boost U.S. radiation dose“, pointed out that Americans are being exposed to increasingly high levels of radiation as a result of diagnostic testing. The author seemed to mostly point fingers at physicians for overusing scans.

Seriously? I wonder how much influence for these diagnostic tests is coming from the patient side. Also, what role does the trend of decreased reimbursements to doctors play? This has to be a much more complicated process than just “profiteering” by doctors.

The entire health care system (patients, providers, insurance companies, device/drug manufacturers) is plagued by cost shifting. Each player tries to recapture profit by pushing cost onto somebody else. Could the trend towards increased diagnostic testing, which is highly profitable, be another way for providers to shift costs back onto insurance companies? What about the influence of the litigative culture doctors work in?

Regardless, this trend of increased diagnostic testing and imaging (without health benefits) is troublesome. Overall health care costs continually increase while patient health outcomes remain stagnant. Doctors are trapped in a system that reinforces cost shifting as a mechanism for maintaining income. The incentives need to change – the system needs rewarded providers for giving VALUE (better outcomes for lower cost).