4 questions | Applied Sciences homework help

1. The procedure should be utilized by those most likely to benefit from it.

The prevailing medical opinion is that screening tests should be evidence-based and targeted to the individual patient’s risk factors. Scientific organizations may differ somewhat on the recommended frequency of certain periodic examinations, but all authorities agree that they are valuable, especially when combined with evaluation and counseling on nutrition, exercise, injury prevention, and other important aspects of a healthy lifestyle. The U.S. Preventive Services Task Force, which is discussed later in this chapter, has issued the most comprehensive guidelines. History and Physical Examination A thorough health evaluation consists of four phases: (1) a medical history, (2) a physical examination, (3) clinical or laboratory tests, and (4) a report to the patient. It is likely to take 30 to 90 minutes and cost from $100 to more than $200 for the doctor’s time plus additional amounts for diagnostic tests. Internal medicine special- ists tend to charge more than family practitioners. The history should cover more than 100 detailed questions about past medical problems, current symp- toms, social and family history, and health habits. It is obtained most efficiently with a questionnaire completed by the patient (or parent) or administered by a member of the physician’s staff. Before the physician sees the patient, an assistant also measures height, weight, tem- perature, pulse rate, respiratory rate, blood pressure, and, sometimes, visual acuity. The physician then reviews the questionnaire and asks further questions.

A “complete” physical examination may include the following:

general appearanCe: Nutritional status and physical deformi- ties are noted. eyeS: Appearance, movement, pupillary reflexes, and visual fields are checked. An ophthalmoscope is used to examine the insides of the eyes. A tonometer may be used to measure internal eye pressure. earS: An otoscope is used to inspect eardrums and external canals. Hearing is tested with an audiometer. nOSe: The inside is inspected for polyps or deviated septum. Oral CaviTy anD pharynx: Dental caries, tumors, and other indications of disease are noted. neCk: Palpation is used to detect enlargement of lymph nodes or the thyroid gland. Veins are inspected for distention. A stethoscope may be used to listen for arterial murmurs. lungS: A stethoscope is used to hear breath sounds. hearT: Pulse rate and rhythm are noted. Heart is palpated for abnormal rhythms. A stethoscope is used to check heart sounds. breaSTS: Inspection and palpation are done to detect tumors. OTher lymph nODeS: Armpits and groin are palpated. baCk: Percussion with the fist may be used to detect kidney ten- derness. The spine is examined for abnormal curvature. abDOmen: Deep palpation is used to detect tumors or enlarged organs such as the liver and spleen. A stethoscope is used to hear bowel sounds and arterial murmurs. Skin: All parts of the body are examined for evidence of infec- tion, inflammation, cancer, or other skin problems. Sex OrganS, male: Inspection, palpation, and a check for hernias are performed. Sex OrganS, female: External genitalia are inspected. Cervix is visualized with a vaginal speculum. Uterus and ovaries are palpated with two gloved fingers inserted into the vagina and the other hand pressing on the abdomen. reCTum anD anuS: Rectum and prostate (males only) are palpated with gloved finger. Anal area is inspected. Sig- moidoscopic examination may be performed. legS: Varicose veins and swelling of the legs are noted. feeT: Pedal pulses are palpated. bOneS anD jOinTS: Swelling or deformities are noted. neurOlOgiC exam: Reflexes, strength, sensation, coordination, and mental status may be assessed. Laboratory Tests and Procedures A complete blood count is commonly ordered as part of a routine physical evaluation. Whether other tests are or- dered varies according to the age of the patient, the style of the physician, the patient’s history, and the physical findings. The commonly performed tests include: urinalySiS: The urine is tested for the presence of sugar, protein, cells, crystals, and other sediment. The presence of sugar might indicate diabetes. White blood cells might indicate infection. Red blood cells might indicate tumor or Part Two Health-Care Approaches76 inflammation within the urinary system. Protein or other sediment may indicate kidney disease. COmpleTe blOOD COunT: Hemoglobin is measured and red blood cells are examined to determine the presence of ane- mia. White blood cells are counted and examined to help diagnose various infections or leukemia. The platelet count is related to the ability of the blood to clot. blOOD Sugar (gluCOSe) or hemOglObin a1C: Abnormal eleva- tions are a sign of diabetes (see Chapter 14). blOOD lipiD prOfile: Measurement of total cholesterol, low- density lipoproteins (LDL), high-density lipoproteins (HDL), and triglycerides can help determine the risk of cardiovascular disease (see Chapter 15). blOOD ChemiSTry SCreenS: Various tests are available to measure kidney function, liver function, certain enzyme activities, and many abnormal metabolic states. Computer- ized equipment can perform many tests at one time, often at less cost to the patient than a few tests done singly. One common test panel, a chemistry profile, typically has 24 components. ulTraSenSiTive TSh: This blood test reflects the function of the thyroid gland. (TSH stands for thyroid-stimulating hormone.) OCCulT blOOD: Feces may be examined for blood that is not ap- parent. Because bleeding can be intermittent, specimens are usually collected for 3 consecutive days. Positive results do not always indicate cancer; they may be caused by bleeding gums, use of aspirin or other nonsteroidal antiinflammatory drugs, a nonmalignant polyp, diverticulitis, hemorrhoids, or other conditions. papaniCOlaOu (pap) TeST: This is primarily a screening test for uterine cervical cancer, but it may also indicate the presence of infection and the status of certain hormones. To do the test, cells obtained by scraping the woman’s cervix during a pelvic exam are placed on a glass slide and checked for abnormalities in the laboratory. STD SCreening: Individuals who are sexually active and at high risk may be screened for HIV, chlamydia, or other sexually transmitted diseases. eleCTrOCarDiOgram (eCg): This enables abnormal rhythms and certain other heart problems to be diagnosed by analyzing electrical patterns of the heart. Stress tests (ECGs performed during exercise) are discussed in Chapter 15. Although screening tests provide considerable infor- mation at relatively low cost, they are not hazard-free. Minimal departures from “normal” can occur in healthy individuals, and “false positive” reports can result from errors in the testing or reporting procedures. These, in turn, may require further testing to assess whether they are truly significant. The Harvard Medical School Health Letter27 has observed: The needless worry generated by an abnormal result, as well as the more expensive and sometimes risky diagnostic tests that are apt to follow, raises legitimate doubt about ordering too many tests on healthy people. Nobody has yet devised a solution to the problem of having too much information. Many tests are ordered because the doctor is afraid of missing something and being sued. Sometimes tests are ordered because the doctor fears that, without them, the patient will feel that not enough is being done. Financial considerations may play a role; it has been shown that doctors who own testing facilities are more likely to order tests than doctors who do not. Frequency of Examinations Individual consumers must decide whether to invest in complete evaluations and how often to do so. Infants and young children should be checked annually. For symptom-free young adults, once every 5 years is reasonable. Complete examinations might be practical every 3 to 5 years after age 40, every 2 to 3 years after age 50, and annually after age 60. On the other hand, those who consult their physician several times a year for problems can achieve the equivalent of periodic complete examinations if their physician examines a few extra parts of the body during each visit. This system can be both effective and economical. At specific ages, certain medical procedures have special significance because they may prevent problems or detect potentially serious problems that are treatable in their early stages. The U.S. Preventive Services Task Force (USPSTF) was created in 1984 to determine what types of periodic physical examinations, tests, immu- nizations, counseling, and other measures are science- based and cost-effective. Its work reflects the views of public health officials and hundreds of other experts about services intended to improve health outcomes. Updates to its recommendations are published on its Web site (www.uspreventiveservicestaskforce.org). Its latest (2010) comprehensive report28 contains more than 65 separate recommendations. Its overall advice includes:

• Effective interventions that address personal health prac- tices are likely to substantially reduce the incidence and severity of disease and disability. Preventive advice need not be confined to visits devoted entirely to prevention but can be dispensed during almost any visit.
• The clinician and the patient should share decision-making. Rather than having a uniform policy for all patients, doc- tors should educate their patients and consider individual preferences in deciding which interventions to recommend.
• Clinicians should be more selective in ordering tests and providing preventive services. Although certain tests can be highly effective in reducing mortality and morbidity, many others in common use have neither been proven nor disproven. The latter category includes screening tests

Chapter Five Science-Based Health Care 77 for detecting diabetes, anemia, thyroid malfunction, and glaucoma in individuals who have no symptoms and are not considered to be at high risk. The USPSTF’s specific recommendations vary considerably by age, risk factors, and health status. This chapter covers its guidelines for cancer screening, and other parts of the book discuss preventive strategies for cardiovascular disease and a few other conditions. Consumers who wish to delve into other USPSTF rec- ommendations can access them online. Some physicians treat problems as they arise and spend little time educating their patients about pre- vention. McCall21 has noted that if preventive advice and care are not incorporated into a doctor’s everyday dealings with patients, such care may never take place because many people only see a doctor when they are ill. Cancer Screening Tests Because breast cancer is common, it is important for women to have periodic screening tests. The guidelines for the USPSTF are more conservative than those issued by the American Cancer Society (ACS) Mammography uses x-rays to examine the female breast. Recent improvements have resulted in much lower radiation doses and better detection ability. The ACS recommends that women age 40 or older undergo mammography every year. The USPSTF recommends it every 2 years from age 50 to 74. However, women whose sister or mother developed breast cancer before menopause should begin sooner, particularly if genetic testing results show changes in breast cancer susceptibil- ity genes (BRCA1 and/or BRCA2). Mammography involves brief discomfort when the breasts are compressed between plastic plates to permit maximum examination with minimum exposure to the radiation. This discomfort can be minimized by schedul- ing the test for the week after a menstrual period, when the breasts are their smallest and least tender. Breast self examination (BSE) has not been found to have an important role in detecting potentially life- threatening breast cancers early enough to make a dif- ference. However, doing BSE is one way for women to know how their breasts normally feel and to notice any changes.29 Testicular cancer, although much less common than breast cancer, is the most common cancer in males between the ages of 15 and 34. It is easy to detect and has a high cure rate, even though half the cases are not discovered until the cancer has spread beyond the testicles. The USPSTF30 has concluded that given the low prevalence of testicular cancer, limited accuracy of screening tests, and lack of evidence that early detection leads to higher cure rates, the harms of screening exceed any potential benefits. The ACS31 recommends that all women begin cer- vical cancer screening about 3 years after they begin having vaginal intercourse, but no later than age 21. Screening should be done every year with the regular Pap test or every 2 years using the newer liquid-based Pap test. Beginning at age 30, most women who have had 3 normal Pap test results in a row may get screened (a) every 2 to 3 years with either the conventional or liquid-based Pap test or (b) every 3 years with one of these plus the human papilloma virus (HPV) test. After age 70, testing is unnecessary for women who are not at high risk and have \had 3 consecutive normal tests and no abnormal tests during the previous 10 years. Prostate cancer, the second most common cause of death from cancer among men, claims about 40,000 lives per year. Asymptomatic prostate cancer is very common as men get older (ranging from about 22% at age 50 to about 54% over age 80), and aggressive treatment has a high complication rate. Only a small percentage of these latent cancers progress to a point where they become a problem, however, and it is not known whether early detection and treatment actually save lives. A prostate-specific antigen (PSA) test and a digital rectal examination (DRE) can detect some cases of prostate cancer. However, additional diagnostic tests are expensive and uncomfortable, and treatment can cause erectile dysfunction, urinary incontinence, and other adverse effects. The USPSTF32 has concluded that PSA screening results in small or no reduction in death from prostate cancer and is associated with harms related to subsequent evaluation and treatments, some of which may be unnec- essary. All authorities recommend that if PSA testing is still considered, patients should be fully informed of the potential benefits and harm that can result from testing and subsequent treatment. Men should also be informed of the gaps in the evidence and helped in considering their personal preferences before deciding whether to be tested. Because most colorectal cancers arise in benign polyps, optimal screening programs seek to detect the polyps before they become cancerous. For people of av- erage risk, the ACS and USPSTF recommend—starting at age 50—colonoscopy every 10 years or flexible sig- moidoscopy, a double-contrast barium enema, or virtual colonoscopy every 5 years. More frequent examinations are recommended for people who have a family history of colorectal cancer or have had a polyp or other condi- tion that places them at higher risk. Part Two Health-Care Approaches78 A sigmoidoscope is a slender, flexible, hollow, lighted tube about the thickness of a finger. It is inserted through the rectum up into the colon. This allows the doctor to look at the inside of the rectum and part of the colon for cancer or polyps. The sigmoidoscope may be connected to a video camera and video display monitor so the doctor can look closely at the inside of the colon. The test is sometimes uncomfortable but should not be painful. Because the instrument is only 60 centimeters (around 2 feet) long, the doctor can see about half of the colon. To prepare for the procedure, the patient admin- isters an enema to clean out the lower bowel. A colonoscope is similar to a sigmoidoscope but long enough to reach the full length of the colon, and the examination is done with intravenous sedation. To prepare for colonoscopy, the patient drinks a laxative solution that cleans out the entire large intestine. The barium enema examination is an x-ray proce- dure in which air and barium are inserted into the rectum to outline abnormal growths. Virtual colonoscopy (also called capsule endoscopy and video colonoscopy) is described later in this chapter. For individuals who are unable or unwilling to undergo one of the above procedures, the ACS recom- mends annual fecal testing for signs of bleeding within the intestine.33 Specimen-collection materials can be obtained from the office of a physician whose staff will perform the test when the specimens are returned. The recently developed fecal immunochemical test (FIT) appears to be superior to the guaiac test that has been used for many years.34 A digital rectal examination can detect abnormali- ties in the prostate and rectum, but it does not reach high enough into the colon to qualify as a stand-alone screening test for colorectal cancer. Immunizations Immunizations should be part of routine health care obtained through one’s personal physician (or, in some instances, through a local health department). Long-lasting protection is available against measles; mumps; German measles (rubella); poliomyelitis; tetanus (lockjaw); whooping cough (pertussis); diph- theria; chickenpox (varicella); hepatitis A and B; and Haemophilus influenzae type b (HIB), a bacterium that can cause meningitis with death or neurologic damage to young children. Immunization against all of these is recommended by the American Academy of Pediatrics, the American Academy of Family Physicians, and the Advisory Committee on Immunization Practices of the U.S. Centers for Disease Control and Prevention.35 Smallpox is now considered eradicated worldwide, so that vaccination is no longer given. Immunization against human papilloma virus (HPV) is discussed in Chapter 19. All states now require proof of immunization or other evidence of immunity against some of these dis- eases for admission to school. However, the requirements vary from state to state, and exemptions may be granted for medical, moral, or religious reasons. Keeping an im- munization diary will help to ensure that one’s protection is up-to-date. In recent years, various individuals and groups that promote unscientific practices have claimed that vac- cinations are unsafe. Chapter 14 debunks these claims. Immunization is also important for teenagers and adults. Those unprotected against any of the diseases just discussed (except HIB) should consult their physicians. A tetanus-diphtheria booster (called Td) should be ad- ministered every 10 years. Pertussis should be included in the booster (Tdap) administered to teenagers or to adults who did not have Tdap during their adolescence. Tdap is particularly important for people who will have close contact with newborn infants. Flu shots (which give only seasonal protection) and immunization against pneumococcal pneumonia are recommended for high-risk patients, elderly individuals, and certain institutional populations. The World Health Organization’s Global Polio Eradication Initiative has reduced the reported incidence of poliomyelitis from 350,000 cases in 1988 to about 2000 per year today, but immunization remains important in the United States to prevent a future outbreak. Figure 5-1. CT scan shows a cross-section of the head with extraordinary anatomic detail. (Photo courtesy of GE Medical Systems) Chapter Five Science-Based Health Care 79 Medical Imaging X-ray films can yield valuable diagnostic information. Cumulative exposure to ionizing radiation is potentially dangerous,36 however, so the possible benefits should be weighed against the risk involved in its use. In most cases the physician is in the best position to do this, but the following points may help patients avoid unneces- sary radiation:

• If the physician suggests x-ray films, the patient should understand why they are needed and whether the findings will influence the treatment recommendations.
• A lead-lined shield should be used to protect the reproduc- tive organs.
• When changing physicians, the patient should request that recent x-ray reports be sent to the new physician. It can also help to keep a list of one’s x-ray examinations, to avoid duplication and to help enable comparisons between current and previous films.
• The developing fetus is especially sensitive to radiation. X-ray films of the abdominal and pelvic regions of pregnant women should be postponed if possible, especially during the first 3 months of pregnancy. Some physicians prefer to avoid pelvic films during the last half of any menstrual cycle in case the woman is pregnant.

Advances in diagnostic scanning have enabled physicians to obtain a great deal of precise, detailed information about internal body structures. Computerized axial tomography uses an x-ray source that is focused on specific planes of the body and rotated to obtain pictures from multiple angles. The data are fed into a computer and processed to create a cross-sectional depiction of density that resembles a photograph. The procedure is commonly referred to as a CT scan or CAT scan. CT scans expose patients to much more radiation than plain x-ray films. However, when used selectively, they are invaluable and have replaced many invasive diagnostic procedures that were dangerous and often less reliable. Figure 5-1 shows a CT scan of the head. Conventional x-ray procedures and CT scans use a machine to generate and project x-rays through the body to produce a visual image. In radionuclide imaging, this set-up is reversed: radioactive chemicals are introduced into the body and taken up by various body structures. These structures then emit gamma rays that produce an image on a special camera outside the body. Radionu- clide imaging can detect tumors, infections, circulatory blockage, and other types of problems. The parts of the body commonly scanned are the bones, brain, heart, thy- roid gland, gallbladder, liver, kidneys, and lungs. Within hours or days, the radioactive substances lose most of their radioactivity or are excreted from the body. Single photon emission computerized tomography (SPECT) is a specialized form of nuclear scanning that produces images similar to those of a CT scanner. Positron emission tomography (PET) combines the use of radioactive substances and computers to produce vivid color-coded pictures. PET scans are useful for evaluating the spread of cancers and for studying several other types of disease. They involve no ionizing radiation but are very expensive. Magnetic resonance imaging (MRI)—sometimes called nuclear magnetic resonance (NMR)—uses ra- diofrequency waves, a very strong magnetic field, and a computer to produce cross-sectional images. In some cases the picture can differentiate between adjacent soft tissues that might look the same on an x-ray film. To produce the MRI picture, the patient is exposed to a large magnetic coil. When the magnetic field is turned on, it causes hydrogen nuclei (protons) within the body to line up in one direction. Then selected radiofrequency waves flip these particles in another direction. When the waves are turned off, the particles realign, releasing an electromagnetic signal that the computer translates into an image. The technique involves no ionizing radiation, but it cannot be used with patients who have a pace- maker, metallic artificial joint, or other metallic implant. Figure 5-2. Patient about to undergo MRI scanning. (Photo courtesy of GE Medical Systems) Part Two Health-Care Approaches80 MRI devices can be open or closed. In the closed type, the patient lies inside a tunnel about 2 feet in di- ameter and 6 to 8 feet long. In the open type, the large magnet that generates the image is suspended a few feet above the patient and, except for its supports, the unit is open all around. Open MRI procedures are more com- fortable for some people but take longer to do and may be more expensive. Figure 5-2 shows a patient about to enter the tunnel of a closed MRI. Ultrasonography is done with a device that transmits sound waves through body tissues, records the echoes as the sounds encounter structures within the body, and transforms the recordings into a photographic image. No ionizing radiation is involved. The variety and useful- ness of diagnostic ultrasound procedures have increased rapidly. A few practitioners, mainly chiropractors, claim that spinal ultrasound enables them to follow the prog- ress of their treatment by detecting muscle inflammation or spasm. No published scientific study supports this contention. Chapter 20 discusses ultrasound use during pregnancy. Magnetic source imaging (also called biomagnetic imaging) uses a device that converts magnetic fields into electrical signals that are amplified and displayed on a computer screen for interpretation. It is used mainly for pinpointing abnormal brain function in epileptics and for diagnosing other disorders of the brain. The FDA has expressed concern about clinics that are offering full-body CT scans to look for warning signs of cancer, heart disease, and other abnormalities. Agency officials have warned that (a) many people will get false- positive results, leading them to seek additional tests or surgical procedures that may be risky and (b) the x-ray dosage from a CT procedure can be much greater than that of conventional x-ray procedures. CT scans can be extremely valuable when used appropriately, but there is not sufficient evidence to justify total body screening for patients without symptoms or a family history sug- gesting disease.37 For similar reasons, consumers should also be wary of other imaging tests marketed to the public without physician referral. Capsule endoscopy, which the FDA approved in 2001, is performed with a disposable capsule that con- tains a miniature color video camera, a light, a battery, and a transmitter. Images captured by the camera are transmitted to sensors attached to the patient’s torso and recorded digitally on a recording device that is worn around the patient’s waist. The test enables viewing of about 20 feet of the small intestine that cannot be effec- tively viewed with other tests. It provides a noninvasive diagnostic option for patients with Crohn’s disease, celiac disease, intestinal tumors, and unexplained bleed- ing that cannot be pinpointed by other means.38 Surgical care Surgery is defined as any operative or manual procedure for the diagnosis or treatment of a disease, injury, or deformity. Contemporary surgery in the United States is probably the best in the world. Improvements in pre- operative preparation, anesthesia, surgical techniques, high-tech equipment, and postoperative supervision have greatly reduced the discomfort and dangers that were a part of most operations in the past. But surgery should never be taken lightly. Any operation carries some risk, both from the surgical procedure and from the anesthetic. To be justified, surgery must be appropriate and the benefits must significantly exceed the hazards. This section provides general information about surgery and several types of operations. Coronary by- pass surgery (Chapter 15), cosmetic surgery (Chapter 18), therapeutic abortions (Chapter 19), and refractive surgery (Chapter 20) are discussed elsewhere. Preparation for Surgery Surgical procedures can be categorized as emergency (as soon as an operating room is available), urgent (should be done within a few days), or elective (can wait from several days to several months). Contemplation of surgery should involve discussion of the patient’s health problem, the general nature of the operation, its risks and possible benefits, whether equivalent nonsurgical treatment is available, the type of anesthesia to be used, how much postoperative discomfort to expect, how and when normal activities can be resumed, and any allergies or other relevant health problems. It is also advisable to voice any special fears or concerns related to the surgery. Before surgery takes place, the patient (or a close relative if the patient is unable to do so) will be asked to sign a statement verifying that this information has been pro- vided. This “informed consent” discussion also provides an opportunity to assess the surgeon’s personality. The best safeguard in selecting a competent surgeon is probably referral by a primary care physician familiar with the surgeon’s work. If this is not available, or if further investigation is desired, the following questions suggested by Bradley39 may be useful:

• Are you board-certified in your surgical specialty? • Are you a Fellow of the American College of Surgeons? This credential, designated by the initials FACS, requires board certification, 2 years of community practice, and a peer-review process in which local surgeons judge the

Chapter Five Science-Based Health Care 81 candidate’s ethics and personality and make first-hand observations of competence in the operating room.

• How many times have you performed the operation pro- posed for me?
• How do your results compare with those of other surgeons?
• What complications have you encountered, how often do they occur, and how do you manage them?
• Is the hospital equipped and staffed to handle a serious complication? Are consultations readily available?

Ambulatory Surgery Hundreds of different operations can be done in an outpatient setting. When appropriate, same-day surgery in a hospital outpatient facility, freestanding clinic, or doctor’s office can save time and money, prevent family disruptions, and reduce the psychologic stress of having an operation. To be suitable for outpatient surgery, one must be in good general health and have adequate help available for postoperative care at home. Ambulatory surgical facilities are discussed in Chapter 22. Unnecessary Surgery During the early 1970s it was noticed that the number of operations performed was rising faster than the growth in population. Critics have charged that 10% to 20% of the operations performed annually in the United States are unnecessary. Criticism has been directed primarily against elective (not urgent) surgery, with hysterectomy; tonsillectomy; D&C; cesarean section; and back, knee, and prostate operations among the leading suspects. Studies by John E. Wennberg, M.D.,40 professor of epidemiology at Dartmouth Medical School, have shown that surgical rates are closely related to the density of surgeons and the number of beds in many communities. Dr. Wennberg has also noted that hospital admission rates for nonsurgical conditions can vary just as widely and that questionable local trends tend to decrease when studies are done. He believes that considerable research is needed to determine what practice patterns may be optimal. He also believes that it is preferable to use the term “unwanted variation,” which is defined as “care that is not consistent with the patient’s preference or related to the patient’s underlying illness.”41 One strategy to reduce the volume of unnecessary surgery has been to encourage or require patients covered by insurance programs to consult a second surgeon when elective surgery is recommended. Under these plans the second surgeon is not permitted to do the operation and thus has no possible financial incentive for agreeing that surgery is needed. Eugene McCarthy, M.D., professor of public health at Cornell University Medical Center, has studied the effects of second-opinion programs on the rates of surgery and concluded that many operations were done unnecessarily. Others counter that disagreement by a consultant does not guarantee that an operation is unnecessary. Some insurance plans offer second-opinion coverage to their subscribers. Other strategies to reduce surplus surgery involve the development and publication of criteria that can be used to measure the appropriateness of surgery. The criteria can then be used for preoperative screening (a preventive measure) or for postoperative review, either of which can be performed by hospital committees or outside agencies. As managed-care and precertification programs have increased, the use of second-opinion programs has dropped sharply. Physician responsibility. Each hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations is required to maintain several active com- mittees of physicians to assess the quality of care at the hospital. A utilization review committee determines the appropriateness of hospital admissions and lengths of hospital stay, a tissue committee reviews operative work, and audit committees look for defective or un- necessary care. A physician whose work is judged to be substandard can have privileges curtailed or terminated. Nonaccredited hospitals may lack such committees. Patient responsibility. Although the ultimate re- sponsibility for preventing unnecessary surgery lies with medical experts, consumers can take a number of steps to protect themselves. If you need to consult a surgeon, preference should be given to one who is board-certified and on the staff of an accredited hospital. If surgery is recommended, a reasonable explanation of what it entails and why it is recommended should be sought. Ask whether a medical alternative is available and consider getting a second opinion from another surgeon. Alper20 suggests that if one’s primary physician has been selected with care, the physician’s opinion may be as valuable as or even more valuable than that of a second surgeon: Capable personal physicians who are familiar with the surgeon’s work will not let their patients be stampeded into an unnecessary operation. They will ask the surgeon to justify the procedure to themselves as well as to the patient. Gallbladder Surgery Most patients who have gallstones never develop symp- toms. For this reason, experts generally recommend against surgical treatment before symptoms appear, except for patients with an unusual x-ray finding that indicates a high risk of developing gallbladder cancer.41 Part Two Health-Care Approaches82 Authorities have also warned against routinely per- forming the operation on patients with symptoms that “might” be related to gallstones, but the relationship is not clear-cut. Knee Surgery Arthroscopic washing and debris removal from the knees of patients with osteoarthritis are among the most com- monly employed orthopedic procedures. However, their effectiveness has never been proven in prospective trials, and a precise mechanism by which these procedures might help has not been established. The procedures involve making small incisions in the knee, inserting a thin instrument that allows the surgeons to see the joint, and then flushing debris from the knee or shaving rough areas of cartilage from the joint and then flushing it. In 2002, the New England Journal of Medicine43 published the results of a double-blind, randomized, placebo-controlled trial that compared washing, debris removal, and a sham procedure among male veterans with advanced disease. About 50 patients were in each group. Over a 2-year period, some patients felt better but there was no overall difference in outcome among the three groups. This suggested that the perceived benefits of arthroscopic washing and debris removal might be due to a placebo effect or the natural course of the condition. However, more research is needed to assess the outcome for other patient populations, and the results should not be used to judge other types of arthroscopic knee surgery. Male Circumcision Circumcision has been practiced for religious reasons since ancient times and for health reasons for more than a century. In the United States most newborn males are still circumcised, although in recent years the rate appears to be falling. Circumcision may decrease the incidence of cancer of the penis, a rare condition that occurs almost exclusively in uncircumcised men. Poor hygiene and certain sexually transmitted diseases also correlate with the incidence of cancer of the penis. Circumcision can also help decrease the incidence of urinary tract infec- tions in young boys. The exact incidence of postoperative complications of circumcision (local infection and bleed- ing) is unknown but appears to be from 0.2% to 0.6%. The American Academy of Pediatrics44 has concluded: Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumci- sion. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. . . . It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for cir- cumcision is made, procedural analgesia should be provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy. QualitY oF Medical care Most physicians are well trained and practice in an ethi- cal manner. However, there are valid concerns about the quality, maldistribution, and cost of health services. The problem areas include incompetence, impersonal care, sexual misconduct, malpractice, questionable creden- tials, and iatrogenic illness. Overutilization and other financial abuses are discussed in Chapter 23. Incompetence Incompetence can be the result of drug addiction, alco- holism, mental illness, senility, or failure to keep abreast of new medical developments. The AMA has developed a model “impaired physician” law that has been adopted in some form by most states. The physician is first asked to seek help voluntarily. Next, hospital staffs are en- couraged to find ways to care for their errant colleague. Failing that, county medical societies must step in. If a physician is not attached to a hospital or medical society, the state licensing board must act. State medical societies in every state operate programs to rehabilitate impaired physicians. For example, in Georgia a committee of recovered alcoholic or drug-addicted physicians reaches out to problem physicians to offer a treatment plan. To keep abreast of medical developments, physi- cians talk with colleagues, read medical journals, attend meetings, and participate in other types of educational programs. Some authorities believe that continuing education should be formal and mandatory. Many states require a minimum number of hours per year for license renewal. Promiscuous use of injections may be a sign of incompetence. Some injections should not be given, and others should be used sparingly. For example, anti- biotics can usually be given by mouth, male hormones are unlikely to cure impotence, vitamin shots are not an appropriate therapy for fatigue, and cortisone injections into joints can cause long-term harm if given too often. The number of unfit and unethical physicians is unknown. During the past few years, the percentage of physicians using unsubstantiated diagnostic and therapeutic methods has risen significantly in response Chapter Five Science-Based Health Care 83 to misleading promotion of “alternative” and “comple- mentary” methods (see Chapter 8). Impersonal Care Patients have a right to receive much more from physi- cians than mere attention to scientific therapy. Intelligent consumers want compassion and concern. They also want the right to participate in the treatment by knowing what is wrong and how it should be handled. It appears, however, that some physicians are more concerned with the number of patients they see than the quality of their interaction with patients. Such physi-

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