Guest Blog: Morbidity

Dr. Ed Pullen is a family physician who practices at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog, DrPullen.com.

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When I was a first-year medical student, the term morbidity was brand new to me, and I have to say it seemed pretty simple to understand. Mortality is death or the rate of death from a given condition, and morbidity is all of the other negative aspects of a medical condition. Another definition is the rate of a specific disease in a given community. Still, as I have practiced medicine for 30 years now, I have come to have much more respect for this simple term, and all of its subtle and not so subtle aspects.

Almost every decision I make in the office every day is related to trying to minimize both mortality and morbidity, and at the same time almost every choice I make has the potential to cause morbidity and sometimes mortality. Nearly everything we do in life is really to improve our odds. We cross the street when the signal says Walk, knowing that the chances of being hit by an auto are much lower than if we cross when the signal says Don’t Walk. We brush our teeth twice a day to reduce our chances of having a cavity, but have no guarantee that we won’t need a filling at the dentist. We treat patients with acute appendicitis knowing that they are less likely to die of sepsis (mortality) or to have a long miserable hospitalization with intra-abdominal abscesses (morbidity) than if we choose not to subject them to surgery. Still, they could die of an anesthetic complication, but the overall odds favor appendectomy.

Frequently, though, the decisions are much less straightforward and more nuanced than the appendectomy example. The issues with PSA testing are really more about morbidity than mortality. Men seem to fear prostate cancer more than most other health concerns. PSA testing can clearly find and diagnose many asymptomatic prostate cancers. Unfortunately, it is becoming apparent that if there is any reduction in mortality from these early diagnoses, some would argue from this overdiagnosis, then it is very tiny. If you accept that there is not much reduction in mortality from PSA screening, then the issue boils down to morbidity. Is there more morbidity related to treatment of these cancers that were diagnosed long before they would ever become symptomatic, or is there more morbidity from the cancers after they become symptomatic that is avoided by pre-symptomatic diagnosis and treatment? The consensus of many experts is that there is more morbidity from the diagnosis and treatment, and that, therefore, we should not be doing PSA screening. We are likely causing more urinary incontinence, impotence, radiation therapy complications, and emotional angst of being a cancer patient by these pre-symptomatic diagnoses than we are avoiding morbidity from advanced prostate cancer.

Often the decisions faced by physicians and their patients are less dramatic but no less challenging. Look at acute sinusitis. There is a lot of evidence suggesting that acute sinusitis of less than 10 days' duration usually resolves without antibiotic therapy in about the same number of days and with about the same severity of symptoms as with antibiotic therapy. The morbidity related to an episode of acute sinusitis that has not been present long is therefore about the same with or without antibiotic therapy. Antibiotic therapy itself can lead to significant morbidity, both the individual treated and to the larger community. Antibiotic complications like C. difficile related pseudomembranous colitis is becoming more common and antibiotic resistant. So physicians face the challenge of convincing patients who have been treated for their sinusitis with antibiotics for years and usually get well within days of treatment (as they would usually without treatment) that they are better treated with saline nasal rinses, analgesics and tincture-of-time.

These are just a few of the issues we face daily in considering the morbidity of one choice vs. another. Really most of what we do deals with morbidity, not mortality. Maybe the MMWR has it right in calling their weekly newsletter the Morbidity and Mortality Weekly Report, and not the Mortality and Morbidity Weekly Report. Most important things first, right?

The difference between health care costs and investments

Now that the NFL lockout has ended, even sports fans can follow without distraction the ongoing spectacle of federal gridlock leading the government ever closer to defaulting on its more than $14 trillion in loans. With the abundance of fiery, uncompromising rhetoric and arcane terminology such as grand bargains, caps and balances, you may be forgiven for feeling, as I do, we are watching a rerun of the health reform non-debate in late 2009 and early 2010. Indeed, decisions over the next several days have almost as much potential to affect the quality of health care in the U.S., as funds for graduate medical education (and training of family doctors) are on the chopping block in proposals from both parties. While I hope that the advocacy efforts of primary care organizations and their supporters are enough to #SaveGME, the outcome is far from certain.

It's as good a time as any to discuss the difference between health care costs and investments. According to the Centers for Medicare and Medicaid Services (CMS), the U.S. spent $2.5 trillion on health care in 2009, or more than $8000 per person. But this figure doesn't distinguish spending that resulted in health gains from spending that did nothing to improve health. To be fair, no one's really sure how many health care dollars are wasted, beyond administrative costs, but considering how many Americans are overtreated, it could easily run into the hundreds of billions. Whether in the form of payments for bogus preventive health screenings or unproven coronary CT scans, those wasted dollars are the "costs" of health care, money that pays salaries and makes profits for groups providing the services, but doesn't help anyone live longer or better.

In contrast, I think of health care "investments" as spending that actually reduces morbidity and mortality. For example, family medicine professor Steven Woolf has previously made the strong case that although few clinical preventive services save money, the vast majority of screening and counseling interventions recommended by the U.S. Preventive Services Task Force offer excellent value for every dollar spent. Similarly, programs that produce primary care physicians (threatened by current deficit-reduction plans) are good investments because study after study has found that areas with stronger primary care workforces have better health outcomes.

Public health spending, which the nonprofit Trust for America's Health reported has been falling since 2008, is another neglected budget item where modest investments result in large health gains. A recently published study in Health Affairs found that between 1993 and 2005, each 10 percent increase in local public health spending led to reductions in mortality between 1 and 7 percent. The authors put these figures in context:

Achieving this same mortality reduction by increasing the number of primary care physicians would require an additional twenty-seven physicians in the average metropolitan community, based on a recent analysis of physician supply. Increasing the physician supply by this amount would probably require new spending considerably in excess of the amount needed to achieve the mortality reduction through public health spending.

Unfortunately, essential investments in primary care and public health are likely to become casualties of budget cuts - if not directly through federal funding of graduate medical education, indirectly through the further tightening of already strapped state budgets. Meanwhile, thanks in large part to misguided advocacy groups, patients will continue to get their ineffective PSA tests, Provenge for prostate cancer, and Avastin for breast cancer. And policymakers will keep scratching their heads and wondering why U.S. health care costs so much and yields so little in the way of improvements in health.

Reasons to visit U.S. News & World Report's "Top Doctors"

If you've been reading this blog for long, you are probably aware of my skepticism about health care rankings in general, whether these rankings are of hospitals, medical schools, or doctors. Staying true to form, I would advise you to take with a grain of salt U.S. News & World Report's just-released Top Doctors, which purports to identify the top primary care and specialist physicians across the U.S., based on a peer nomination process.

Still, it's well worth visiting the Top Doctors page to read some excellent patient-oriented pieces on "How to Find the Right Doctor," "How to Maximize a Doctor Visit," and "9 Signs You Should Fire Your Doctor," which include advice from me as well as prominent health experts such as Dr. Carolyn Clancy, my former boss at the Agency for Healthcare Research and Quality. Finally, you can also check out my latest Healthcare Headaches blog post on "Decoding Doctor-Speak: Translations of Common Medical Terms."