Temple University School of Podiatric Medicine Journal Review Club
Article Title: Efficacy of Cadexomer Iodine in the Treatment of Chronic Ulcers: A Randomized, Multicenter, Controlled Trial
Authors: Radhakkrishnan R, Kethavath SN,...
By Michel H.E. Hermans, MD
Undertreatment of medical issues is not necessarily bad: palliative care usually only treats symptoms but not the underlying cause of the symptoms which, if the patient wants this, is very appropriate. Remember, Hippocrates said something about suffering and while a disease may be not curable, suffering quite often may be treated with proper medication or other interventions (though, unfortunately, this is not always the case). We should not be worried to give somebody with terminal illness and in serious pain the proper type and amount of medication, even if there is a chance the patient would get addicted.
Overtreatment of patients probably happens more often than undertreatment. I remember the case of my grandmother who was suffering from very serious dementia as well as from diabetes mellitus. The nursing home where she resided refused to give her her favorite sweets, one of the few joys in her life. My father, a surgeon in the Netherlands, was livid, rightly so, although of course at that time, when I was 6 years old, I did not understand why he had a vivid discussion with the nursing home doctor.
The mother of a clever nurse-friend of mine was feeling generally miserable without medicine being able to pinpoint why. She suffered from a series of typically-old-age diseases such as osteoarthrosis, COPD, etc., for which she was medicated. My friend took a look at all the medications and found a series of interactions. Reducing the 12 pills per day to just four medications took care of the existing diseases and restored her mother's general feeling of well-being. Another friend of mine had many symptoms of pulmonary hypertension. Scrutiny of his medication showed that many of the symptoms were related to nearly toxic levels of a number of medications, including beta blockers.
When I was hospitalized some years ago, my blood pH was a little on the low side: my doctor wanted to do an arterial puncture to test the blood gasses, an intervention that is painful and not without risks. I refused the test and am back to normal (as far as possible, not for me to judge?).
We all know that, here in the U.S., the larger part of health care costs is spent during the last few years of somebody's life. It is also well established that too many medical diagnostic procedures with, perhaps, inconsequential findings, contribute to these costs. This is not necessarily overtreatment, but rather "overdiagnosis."
New guidelines on cholesterol and triglyceride levels as well as blood pressure now could imply that "virtually everybody," independent of age, has to be on statins and anti-hypertension medication to avoid cardiac problems and stroke. Side-effects of statins are relatively rare but include hepatotoxicity. Side effects of too low blood pressure, though, are not rare, particularly with regard to orthostatic hypotension and dizziness, which in turn may lead to falls and fractures. A hip fracture at advanced age leads to a high level of morbidity, which equates to poor quality of life, and mortality.
Health care is about the restoration of quality of life, not healing or treating per se. There is a fine balance between the patient's quality of life and the level of (over- or under-) treatment and a risk-benefit analysis (not only medical benefits but benefit to the patient's quality of life) on everything we do should always be part of the equation.
About the Author
Michel H.E. Hermans, MD, is an expert in wound care and related topics, trained in general surgery, trauma care and burn care in the Netherlands. He has more than 25 years of senior management experience in the wound care industry. He has conducted a large number of clinical trials relating to devices and drugs aimed at wound care and related indications and diseases. Dr. Hermans speaks internationally and has authored many published works relating to wound management.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.