“The American health care systems perform impressively, producing what they are designed to deliver: cost inflation, inefficiency, and inequity.” This first line in Alan Maynard’s comment leads us to our bottom line. The United States needs a new design that would address cost inflation, inefficiency, and inequity. The first step would be to establish an equitable, efficient national health insurance program that could begin to tackle the rapidly rising costs of health care. That won’t be easy, but it’s impossible under the status quo.

This may help answer the question: On our WellnessWiki, we addressed the issue of improving care quality with evidence-based practice guidelines , along with 18 other tactics for dealing with our healthcare crisis. I welcome any feedback!

(I am a pathologist, who like many of my peers in the US, is actively involved in cancer diagnosis on a daily basis).

Someone very close to me was just recently diagnosed with bladder cancer, which after my review of all the available data, appears to have been detected somewhere in the mid-stage of the disease’s natural history. ) The clinical implications of late vs. early detection of this disease can be quite significant, and in older adults it frequently turns out to be their life limiting disease, (depending on the presence or absence of other significant diseases).

This individual “felt fine” throughout the early stages of her disease. In fact, she had been quite pleased with the care that her physician (board-certified in internal medicine) had been giving to her, (for other comparatively minor conditions).

There may indeed be a place for patient reports about “feeling better” in the overall scheme of measuring “value” and oucomes, but we must be cautious to define precisely the circumstances where this type of reporting might be used such that it provides reliable and relevant information.

Perhaps younger patients as a group will provide us with more useful information, but older patients still tend to “trust their doctors’ judgment” and they also tend to evaluate their doctor’s performance based on subjective criteria that are related more to the physician’s interpersonal skills, rather than his or her actual clinical expertise.

If the patient that I am telling you about had a relatively inexpensive urinalysis test at any point over the four year period that her internist had been taking care of her, there is a very high probability that small numbers of red blood cells would have been detected in her urine and this would have led to detection of her bladder cancer at an earlier stage.

Every 4th year medical student knows that bladder cancer is in the differential diagnosis of “painless microscopic hematuria”. I also have no doubt that there are practice guidlines that have been issued by various professional organizations concerning the performance of a screening urinalysis as part of a complete annual medical examination.

The reality is that many patients don’t know anything about these guidelines.

Another paniful reality is, that (unlike the situation with the Joint Commission and Hospitals)
there does not appear to be any mechanism in the US to hold clinical practitioners accountable for following professional guidelines or performance standards in the office practice setting, (other than litigation).

Prof Maynard, I like your thinking and agree with much of your criticism of the current healthcare system. However, concerning the above quote from your writings, I have got to wonder if patient reports of feeling better are any more reliable than hearsay in regard to real evidenced-based data about actually being better. Especially in a third party payment arrangement, getting a message every other day is bound to make one feel better, but is that evidence of successful treatment of a real disease condition?

Could you maybe elaborate on how you see successful evidenced-based diagnosis and treatment ever really being measured and incorporated to a meaningful level in a healthcare system??