Things donors know: Does medicine make us healthy?

After we checked Why do you need lawyers? It was Efrat's turn to wonder about the medical profession, "How much do we really need doctors?"

It is hard to think of such a question being seriously asked thirty or more years ago. A doctor was until about a generation ago an undisputed source of authority. But something has happened since then to our trust in doctors and the medical establishment. In a comparative international survey, about a third of Israelis answered in the negative to the question "Are the doctors in your country trustworthy", the situation in the USA is worse where only 56% trust the medical establishment. About twenty years ago, the General Health Insurance Fund changed its name to "Health Services" in a move that appears to be a rebranding for marketing purposes. But the very presentation of medicine as a "service" similar to towing or insurance services was a revolution. In Western culture the status of the doctor and the trust in him was unique and cannot be reduced to a "provider of health services" just as a Rabbi in the community is not a "provider of religious services" and a mother is not a "provider of breastfeeding and diapering services". The transformation that medicine has undergone from an authority to a service and the transformation of the patient into a customer allows us to examine your question, Efrat, in a manner similar to any consumer examination: how useful is the service to us.

One option is to compare health indicators such as life expectancy or infant mortality between countries according to the number of doctors. Here it will turn out, as expected, that it is healthier to live in Austria (5 doctors per 1,000 inhabitants) than in Bangladesh (0.6 doctors per 1,000 inhabitants). But such a comparison ignores the difference in the level of income, nutrition, education and infrastructure between the countries. Is the improved health in developed countries the result of the doctors' work or do rich populations tend to be healthier and also to sacrifice more doctors?

To complicate the matter even more, the boundaries of medicine in developed countries tend to expand, a phenomenon known as "overmedicalization". The World Health Organization defines health as "a state of complete physical, mental and social well-being". The intention of this definition was to establish a holistic medicine that focuses on the well-being of the person and not on his illnesses, but the result is that it is difficult to find any problem - from violence to baldness - that does not justify medical intervention according to this definition. This is how character traits such as shyness or absent-mindedness have found themselves medically defined as "social anxiety" or "ADHD" respectively, and doctors are called upon to diagnose and treat problems that were previously not recognized as diseases, for example "pathological grief" or a decrease in sexual desire that won not only a ringing medical nomenclature (Hypoactive sexual desire disorder) ) but requires prescription drugs. It is possible that this conquest of Western medicine from its traditional boundaries of preventing and curing diseases towards the treatment of any cause of discomfort or deviation from norms (have you had a hair transplant yet?) makes it even more difficult to compare health systems in the countries of the developed world with those in less developed countries where there are few doctors more but their scope of activity does not include hair transplantation or botox injection.

Another way to answer Efrat's question is to examine the consequences of stopping the work of doctors in a certain country, that is, to monitor mortality during doctor strikes.

In 2011, the Medical Association announced a doctors' strike. The Minister of Health at the time, Yaakov Litzman, was not particularly moved and said "there is a certain curiosity - it is not nice to say - in the strike fewer people died"

The statistics, surprisingly, are on Litzman's side. Tracking the death rates during various doctor's strikes suggests that people don't die more when doctors don't work.

Statistics on mortality during doctors' strikes around the world show surprising results.

In 1976, doctors in Los Angeles went on strike to protest professional insurance rates. For 5 weeks, 50% of the doctors were absent from their workplaces. A series of statistical tests were applied to assess the impact of this strike on mortality and the way statistics are used is confusing: a sample examination of deaths presented to experts to find out if it was likely that their lives would have been saved had it not been for the strike revealed that the strike caused 31-132 deaths. However, at the same time, the strike saved between 55 and 153 people who were supposed to die from surgical complications.  

Overall the mortality during the strike was quite similar to what could be expected based on the mortality rates for the corresponding month in previous years. The sanctions lasted for seven weeks: the figures for the first week show an increase in mortality (1472 dead compared to a weekly average of 1140 for this week of the year) but it is consistently decreasing and in the last two weeks the mortality rate is significantly lower than the weekly average in Los Angeles (about 950 compared to 1250).

When the strike ended, an expected increase in mortality was recorded for those whose planned surgery was postponed so that over time the effect of the strike faded. Mortality insisted on remaining constant even during a strike by hospital doctors in Spain and during a general strike by health care workers in Croatia.

When evaluating the significance of the data, it should be taken into account that the sanctions were partial and the emergency services were hardly affected, so it is difficult to learn from them what is expected in a general strike.

In 1983, a doctors' strike took place in Israel, it lasted almost 4 months and encompassed most of the system. Apart from the emergency services in the hospitals ("Saturday format"), centers where clinic services were provided for a nominal fee were also available to the patients. Even then no significant changes in mortality were recorded, one study stated that mortality was not affected at all by the strike and according to another study it even decreased slightly.  

  Between March and June 2000, a doctors' strike broke out, during which tens of thousands of planned (elective) surgeries and hospitalizations were postponed, but the oncology departments, the intensive care, the dialysis departments, the delivery and preterm rooms continued to operate as usual.

The Jerusalem Post conducted a survey among Kadisha companies about the number of funerals during the strike. The director of Hevra Kadisha "Jerusalem Community" reported that the number of funerals in May 2000 was 93 compared to 153 in May 1999 and 133 in May 1998. A decrease in the volume of work was also recorded at the Shamgar funeral home and at Hevra Kadisha in Tel Aviv. On the other hand, in Netanya, where the doctors of the local hospital in Nyado did not join the strike, there was no change in mortality.

Strangely, when doctors work as usual and hospital nurses strike, there is a clear and distinct increase in mortality. A comprehensive study in US hospitals revealed a 19% increase in mortality and a 7% increase in the need for re-hospitalization in those who were unlucky enough to be hospitalized during a nurses' strike.

Public health experts offer several explanations for the strange results: doctor strikes are never full, emergency rooms operate as usual, and life-saving treatments are not affected by strikes. Doctor strikes are not long and no real damage is caused by a delay of a week or a month in most pre-planned surgeries. In addition, the extent of the decrease in the scope of actual treatments is smaller than the scope of the strike: some doctors deviate from the union's guidelines and also treat cases that should be postponed, and some treatments simply go through the strike process from the public system to private medicine. An observation of the functioning of a hospital in New Zealand revealed that there are patients whom the strike actually benefits: the waiting time in the emergency room for an examination by a specialist decreased during a strike and the division of work between the doctors operating the emergency services changed so that the chance of a patient being examined by a senior specialist rather than a specialist increased.

So do you even need doctors?

Yes: we need doctors and probably quite a few of them. Infant mortality, for example, drops significantly when there are more doctors in the population. But we need doctors and especially specialist doctors less than we think. When you examine the dependence between spending and health, the number of doctors and the health of the population, it becomes clear that the gray family doctor produces more health than the high-tech and famous doctor in the hospital. A study that examined the dependence between health indicators (weighted for a general score) and the number of specialist doctors in different countries received a decreasing graph, meaning that the health of the population is better in countries where the number of specialists is small. The strange dependence can be explained by the fact that specialist medicine is expensive and comes at the expense of community service. An inverse dependence exists when examining health as a function of the number of GPs. Strictly establishment doctors also raise the possibility that we, the people of the developed world, receive too much medical attention and that perhaps quite a few of the tests, treatments and medicines are simply unnecessary.

And what about the corona virus?

The media highlights the shortage and attrition of the medical staff in the intensive care units and the lack of experts to operate the Acmo machines, but the condition of the neighborhood HMO clinics is more important to the health of most of us. The heroes of the epidemic are not only the bleary-eyed staff in the inpatient wards, but also many family doctors who diligently collected the morbidity data for the clinical tests of the vaccines and are engaged in the Sisyphean and gray work of encouraging people to vaccinate and protect themselves and their relatives. The seller who earned the trust by daily work on sore throats and stomach aches.

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