Do doctors still know best?

Hadassah doctors left their ivory towers to explain their changing roles in the Internet Age and present their innovations to the general public.

doctor 88 (photo credit: )
doctor 88
(photo credit: )
Although Israelis probably have greater access to doctors than ever, the distance between physician and patient is wider than ever. The complete trust with which patients followed their doctors' orders has been almost totally erased, while the Internet has given individuals information - correct or not - of which their doctors may be unaware. To help narrow the gap and expose the public to the latest developments, the Hadassah Medical Organization (HMO) last week launched the first Israel Medical Convention at Jerusalem's International Convention Center. Open to all who registered, the day-long event attracted nearly 700 people, about a third doctors or nurses and the rest laymen. HMO and the Israel Medical Association (IMA), which organized it with help from the Ha'ir chain of Hebrew weeklies and helped finance it with commercial displays, hope to make it an annual event. "We hope it will become a tradition and a stage for public discussion," said HMO director-general Prof. Shlomo Mor-Yosef, who urged Health Minister Ya'acov Ben-Yizri (who also delivered greetings) to make medical tourism a "national goal" and more than triple income from the treatment here of foreigners to $100 million in 2012. The resulting income, he said, could be used to improve the health of the needy, who have more chronic diseases than those at higher socio-economic levels. Jerusalem Mayor Uri Lupolianski, who said the group that eventually became the IMA first met in Jerusalem in 1913, called for efforts to make the city the "world capital" of medical research and treatment. Prof. Avinoam Reches, a senior neurologist at the Hadassah University Medical Center and chairman of the Israel Neurology Society, stressed the changes in the doctor-patient relationship in recent years. The Hippocratic era, in which the doctor had all the information about his patient's disease, and autonomy in professional considerations, is gone, Reches said. We are living in a "post-Hippocratic era - a time when patients may know as about their disease and potential treatments as the doctor." Reches noted that in 1993 there were 19 million health-related Web sites, compared to 178 million today. "Information helps people decide and criticize, and weakens the doctor's traditional status. It is causing historical changes in their relationship. The public learns the medical terminology and is very involved, but it understands medicine the way the media reflect it, not the way doctors do. This revolution creates expectations that doctors will never be able to meet. Just look at TV, where nearly every resuscitation succeeds." As a result, said the Hadassah neurologist, people's exaggerated expectations lead some to be violent. Fully three-quarters of all emergency rooms have reported at least one violent incident in the past year. Economic considerations often come ahead of a doctor's obligation to his patient because the health fund limits expensive procedures such as CT or MRI, and instructs him (or her) to give cheaper generic drugs. There have even been cases of health funds issuing "gag orders"; doctors are threatened with dismissal if they inform patients about the availability of more advanced technologies. In addition, some insurers have gone into doctors' computers to see whether they have prescribed drugs that cost more, said Reches, whose patients complained that their health fund demands approval from hospital departments to get advanced drugs and sets down restrictions even though they are in the basket of health services. BUT MACCABI Health Services president (and former director-general) Prof. Yehoshua Shemer dismissed some of these claims, insisting that economic considerations must have a role. "I don't think the doctor is a double agent. There is unity in working for patients and for a health fund," said Shemer, who blamed the Treasury for eroding the value of the state's basket of services and demanded that it help the 20 percent of the population who can't afford supplementary health insurance - which includes additional drugs and treatments. The "romantic period" in which doctors were able to give all available treatment to each patient is past, added Gabi Bin-Nun, the Health Ministry's deputy director-general in charge of economics. In 1960, he said, health expenditures in the US constituted 5.2% of the annual Gross Domestic Product. Today, it is 15%, and about half that in Israel. "You can't give everything to everybody, or nobody will get. You have to set priorities." IMA chairman Dr. Yoram Blachar, a former member of the public advisory committee on expanding the basket of health services, bemoaned the fact that the Treasury wants every health fund to offer its own basket rather than having a universal one for all patients, and that a new committee has not yet been appointed. He insisted that the basket expand automatically by 2% a year. Even in the Israel Defense Forces, where soldiers get generous healthcare benefits and are not able to be health fund members, there is pressure to cut costs. IDF Chief Medical Officer Tat-Aluf Yehezkel Levi explained that soldiers deserve benefits because they are in danger, are excluded from National Health Insurance by law, serve unusual hours and work under risky conditions. "We are like a fifth health fund whose basket can't be any smaller than the four civilian health funds. Soldiers are entitled to a variety of dental care, contraception and fertility treatments [for women], and even medical care abroad if it's not available on a high level here. Such benefits are part of the defense budget, but when there are Treasury cuts, health care can be affected. "There have been calls in the Treasury, but on the battlefield no one can do it better than us," Levi declared, although "with routine care, it will be difficult, with all needs taken into consideration." AN ISRAELI innovation that combines Zaka rescue and evacuation motorcycles and videocameras to improve care for road accident victims was described by Prof. Avi Rivkind, chief of surgery and trauma care at Hadassah University Medical Center. Half of the more than 500 road accident victims each year die on the scene, he said. As there is a "golden hour" for treatment, during which bleeding must be stanched and other vital care given, said Rivkind, if the hospital can see the condition and position of the vehicle and of the wounded in advance, by real-time video to the duty doctor's cellular phone at home or on a screen at work, the trauma room can prepare equipment and staff in advance. The technology, developed by the SerVision company and Hadassah, can be adopted around the world, he said. Another budding technology, which was British in its primitive form, is infrared technology that allows doctors to diagnose brain hemorrhages non-invasively at the site of accidents and mass catastrophes, and in the emergency room in seconds. "The device involves the absorption of light," said Rivkind. "If there is internal bleeding, a red circle appears on a screen." The integration at Hadassah of computerized tomography (CT) and positron-emission tomography (PET) to diagnose cancer and see the effects of targeted drugs on tumors was discussed by Prof. Eyal Mishani of the nuclear medicine department. The combination of the two technologies, he said, illustrating his lecture with many slides, can make certain kinds of tumors much more visible, and can even show the effects of neurotransmitters on sleep, mood and appetite. Prof. Meir Liebergall, Hadassah's head of orthopedic surgery, predicted that his field will routinely integrate 3-D imaging and computer guidance to help surgeons perform implants and repairs. He and his team have performed 850 such operations in the past six years, many of them hip replacements but increasingly for knee replacements and vertebral repairs. An even newer technology in the very early stages of development in Texas, said Liebergall, is a portable ultrasound device for treatment on the battlefield. It could be used by any soldier to detect internal bleeding and cauterize torn blood vessels on the spot. The unique genetic profiles of cancer patients and of the tumors they have has led to customized treatment of a growing number of them, said Prof. Tamar Peretz, chief of Hadassah's Sharett Institute of Oncology. Bits of a patient's tumor are processed in the lab and then injected back into the patient so that his or her immune system can fight it, she said. Knowledge of the patient's genetic profile can predict the tumor's behavior. As an illustration of genetic influences on tumors, Peretz gave the case study of a 24-year-old woman who developed breast cancer on both sides and underwent surgery, radiation and chemotherapy. But not long after, new metastases spread to other parts of her body, and she died. Later it was found that the woman had a gene that made her highly susceptible to cancer caused by radiation itself; if this had been known, other aggressive treatments would have been used. But genetic analysis for cancer treatment requires money, equipment and skills that many hospitals lack. A panel discussion of health reporting, led by Hadassah Prof. Mayer Brezis, who earned a master's in public health for his study of Israel's medical journalists, discussed the roles of health journalists, whether they were qualified for their jobs and whether publishers are interested in enlightening readers. Among the potential roles were to provide information; expose shortcomings and protect the weak and needy; health promotion and education; lobbying for changes in health policy; and to entertain and relax the public. Brezis advocated quick and voluntary disclosure of errors by medical institutions - without punishment - so doctors and nurses will be encouraged to learn from their mistakes. Finally, Prof. Ya'acov Neparstek, chief of the internal medicine branch, described the paradigm shift in medicine - from knowing "everything" and giving treatment by personal experience, intuition and book learning, to the current situation, in which medical students have to digest 20 times as much information as they did a few decades ago. Doctors today must consult databases and seek treatments based on clinical studies, and the growing number of lawsuits induces many to send patients for unnecessary tests. Because doctors can't cure everything and everyone, patients increasingly seek "unproven" complementary medicine such as homeopathy, Neparstek said, and "natural cures" that supposedly cause no harm. Health is not the complete absence of disease, he concluded. In many cases, "we don't cure disease, but we alleviate it, minimize pain, extend life and improve the quality of life. Health is physical, social and emotional well being." This is a concept that both doctors and patients should keep in mind.