Soltalk March 2018 | Page 44

Doctor’s notes
Dr Rik Heymans is a general practitioner in Nerja and writes on developments in the world of medicine
outcomes of surgeries, interventions, and medical care overall.
The desire for public reporting arises from this attempt to
inform a public eager for information. The Institute of
Medicine’s seminal report in 1999 suggesting that 98,000
patients die owing to preventable medical errors every year
added a sense of urgency and necessity to the urge of grading
and attaching percentages, etc to providers.
### Difficulty in swallowing, first for solid foods, and later
even for liquids, are warning signs of a problem in the
oesophagus. Once these symptoms present themselves they
must be investigated. The most appropriate test to do is a
gastroscopy, which allows the doctors to have a direct view of
the cause of the symptom, and to take a biopsy if needed.
Some of the more frequent causes of this symptom are chronic
oesophageal inflammation due to reflux, ulcers of the
oesophagus, and cancer of the oesophagus. In cancer the
leading factors are alcohol and smoking. People who consume
more than 30 gr. of alcohol daily have statistically about five
times the risk of getting this type of cancer of those who do
not drink.
Public reporting actually began more than 30 years ago - in
1984 - when the U.S. Health Care Financing Administration
(HCFA), now known as the Centers for Medicare & Medicaid
Services (CMS), began to publicly report the hospital mortality
rates of Medicare patients. The agency identified 269 hospitals
that were outside of what was deemed acceptable with regard
to death rates. Although the analysis attempted to control for a
variety of risk factors, it was heavily criticized and eventually
the HCFA stopped publishing the data.
### Further to this topic, cancer is always one of the most
feared diagnoses in clinical practice, and studies from the
American Cancer Society focus on potentially modifiable risk
factors to prevent cancer: more than 40% of cancers are
attributable to these known risk factors. Despite trends toward
reduced cigarette consumption in the United States, cigarette
smoking remains too ‘popular’, and is still number one among
these factors. Taxation has had the greatest impact on reducing
the consumption of tobacco (like the gun lobby there must be
a tobacco lobby at work somewhere…), and a higher price
logically affects mostly the lower income groups, and the
young. Smoking is and stays Public Health Enemy number 1.
The second most common and modifiable risk factor is excess
body weight, playing a role in about 8% of all cancers. In third
place came alcohol, responsible for about 7% in women, and 5%
in men. Dietary factors came after these factors, especially low-
calcium diets, low-fibre and diets low in fruits proved harmful,
as well as diets high in red meat and processed meats. Recent
studies found that the ultra-processed foods (as found in pot
noodles, shelf-stable ready meals, cakes and confectionery
which contain long lists of additives, preservatives, flavourings
and colourings) are part of the problem - and in the U.K.
account for about half of the food consumed by families!
Physical inactivity accounts for about 3% of all cancers overall.
UV radiation, and exposure to infections (especially Hepatitis B
and C, and Human Papilloma Virus) completed the list of most
relevant risk factors.
Similarly, outcomes of cardiac surgery are publicly reported
for all institutions and surgeons nationally, and this means that
surgeons become unwilling to operate on high risk patients
with an uncertain outcome, because it will affect their “rating”.
And since the statisticians are not taking these risk factors into
account, doctors shy away from doing what may well be a
lifesaving intervention. Compare this to a (possibly winning)
penalty kick in the dying minutes of a rugby test, the penalty at
40 metres, wind and rain - with the kicker not risking it
because his success percentage will go down…
The only thing more noteworthy is the drop in bypass
procedures done in the U.S. between 2000 and 2015—which
reflects an almost 60% drop from 20,029 procedures to 7,962
procedures. An optimistic conclusion to draw from the data is
that there are fewer unnecessary procedures being performed
and those that are being done are of higher quality in a safer
environment. The more troubling explanation is that surgeons
are operating less, and “improved” mortality relates to
avoiding high-risk patients, not necessarily saving more lives.
Let us hope it doesn’t come to this here in Europe, where,
when faced with bad odds, doctors, in consultation with family
and patients, will try to do what is needed, regardless of
statistics, ratings and future job prospects.
### As our society becomes more and more informed and
information-hungry, institutions have also started looking at
the medical field and started comparing hospitals’ and doctors’
© Dr RIK HEYMANS
c/ Angustias 24, Nerja. Tel: [phone]
42