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Health Dollars & Sense

One Answer Fits All? Far From It


"Medicine is not an exact science--it's an educated guess," says my friend "Dr. Eddie," who has been in family practice for 35 years. He knows that too often patients worship the person in the white coat, without realizing that he or she can be fallible, even with an MD after his name and diplomas from big-time schools hanging on the wall.

"There are no clear-cut answers on most subjects," Dr. Eddie wants patients to understand. "A doctor trained in San Francisco and a doctor trained in Boston may treat the same disease in different ways."

That makes it all the more important for physicians and patients to understand each other. The doctor must tell the patients about all the choices available in dealing with an ailment. The patients must understand the limits of medicine and that it's no insult to the doctor to seek a second opinion.

Consider the range of views about prostate cancer. Bob Dole and Gen. Norman Schwarzkopf talk on television about undergoing prostate cancer surgery, known as a radical prostatectomy. Millions of men might think that is the only choice they have.

But the surgery carries significant risks of impotence and urinary incontinence.

"Only the patients themselves can weigh the importance of these side effects against the potential benefits of surgically removing the prostate cancer," according to the 1999 edition of the Dartmouth Atlas of Health Care, which studies the geographic variations of medical treatments for millions of Medicare beneficiaries.

There is no increased survival rate among patients who undergo the prostate operation, compared with those who opt for "watchful waiting," which means doing nothing, said Dr. John Wennberg, the Atlas editor. Prostate cancer grows very slowly, and most older men will die of something else before the cancer gets them.

So the choices range widely: Cut the cancer (surgery), burn the cancer (radiation, either conventional or by implanting radioactive "seeds" in the prostate) or watchfully wait.

For women with breast cancer, the challenge is the same: getting doctors to spell out the benefits and risks of each course of treatment.

Clinical trials show the same life expectancy for women who choose a lumpectomy (surgical removal of a small area of the breast where a cancerous tumor is located) and those who opt for a mastectomy (the removal of one or both breasts). The lumpectomy requires treatments with radiation and chemotherapy, and there is a risk the tumor will return. Mastectomy avoids radiation, but the patient needs breast reconstruction.

The lesson here is that despite all the fervor with which we embrace science and medicine, there is never one answer that fits all patients all the time.

"There is always this problem of disagreement about what the professionals think," Wennberg said.

If medical decision-making were neat and tidy, the Dartmouth Atlas wouldn't show surprising variations no one can fully explain.

Coronary bypass surgery is big in the South, while hip and knee replacements are most popular in the upper Midwest and the Rocky Mountain states. In California, hospital stays are shorter than just about anyplace else. And in Florida, medical spending during a patient's last week of life is unusually high.

Styles of treatment differ even within a state. The rate of back surgery for Medicare beneficiaries is twice as high in Santa Barbara as in Los Angeles. And Redding has double the rate of coronary bypass surgery as that of Orange County.

If the doctors can't always agree on what to do, patients should make sure they ask lots of questions before agreeing to a course of treatment.

"Be pushy and persistent; don't worry about being a pest," Dr. Eddie says. "It's your health and your life. What could be more important?"


I've been getting many e-mails and letters on a hot topic: how to continue medical coverage after you leave a job.

A federal law allows workers with health insurance through their company to continue coverage even after leaving their job. The Consolidated Omnibus Budget Reconciliation Act (COBRA) entitles a worker to retain coverage for 18 months in return for paying the full cost of insurance, worker's share plus employer's share, and a 2% administrative fee. You have the right to keep your coverage after leaving your job under any circumstances, except if you were fired for gross misconduct.

In case of a divorce, the worker's ex-spouse and dependent children can pay the full premium and keep the coverage for as long as 36 months.

Coverage applies to firms with 20 or more workers.

California COBRA extends the coverage to firms with two to 19 workers. Terms are the same, although the administrative fee can range up to 10%. The law is section 1326 of the state health and safety code.

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