명의(名醫)는 환자의 건강에 해롭다? Are Good Doctors Bad for Your Health?

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    나는 종종 다급한 친구나 형(동생)의 친구로부터 SOS 전화를 받는다. "어머니가 집에서 심장발작을 일으켜, 앰뷸런스를 타고 XXX 주의 YYY 병원으로 가는 중이야. 최고의 심장전문의를 좀 추천해 줄래?" 

가족이나 가까운 친지에게 심장 문제가 발생했을 때, 온갖 인맥을 동원해서 최고의 심장전문의를 찾게 되는 건 인지상정이다. 하지만 불행하게도 그건 잘못된 행동이다. 놀랍게도, 올바른 행동은 정반대다. 유명한 의사나 고참 의사들이 자리를 비웠을 때가 환자에게는 더 유리할 수 있기 때문이다. 

최근 《JAMA Internal Medicine》에 실린 논문은 더욱 충격적이다

(http://archinte.jamanetwork.com/article.aspx?articleid=2038979&resultClick=3). 내용인 즉, "지난 10년간 미국 최고의 대학병원에 입원한 환자 수만 명을 대상으로 조사한 결과, 치명적인 급성 심장발작으로 입원한 환자들은 고참 의사가 자리를 비웠을 때 더 경과가 좋았다"는 것이다. 그리하여 저자들은 다음과 같은 결론을 내렸다. "대학병원에 입원한 고위험 심부전 및 심장정지 환자들의 30일 사망률은 전문의들이 미국 심장학회 모임에 참석하기 위해 자리를 비웠을 때 가장 낮았다." 그런데 연구진이 계산해낸 차이는 결코 만만치 않았다. 일부 환자들의 사망률은 최고의 의사들이 병원에 없을 때 약 1/3 감소한 것으로 나타났다. 

미국에서 제일 가는 심장전문의가 당신을 돌보는데, 생존율이 상승하지 않는다니! 직관에 배치되는 쇼킹한 결과가 아닐 수 없다. 연구진은 흥미로운 방법으로 결론의 타당성을 확인했다. 암이나 정형외과 전문의가 학회에 참석했을 때는 심장질환으로 인한 사망률에 변동이 없었으며, 심장전문의가 학회에 참석했을 때는 비심장질환(예: 고관절 골절)으로 인한 사망률에 변동이 없었다. 

전체적으로 볼 때, 대학병원에서 치료받은 심장질환 환자들은 동네병원에서 치료받은 심장질환 환자들보다 경과가 좋았다. 그러므로 심장질환 환자들은 가능하면 대학병원을 선택하는 것이 유리하다고 볼 수 있다. 그렇다면, 대학병원에서 고참 심장전문의들이 자리를 지키고 있을 때 환자의 사망률이 올라가는 이유는 뭘까? 

두 가지 가능성을 생각해볼 수 있다. 첫째, 고참 심장전문의들은 엄청난 학구파여서 이론에만 능한 반면, 신참의사나 수련의들은 최근에 훈련을 받은 관계로 임상에 능하다는 것이다. 둘째, 고참 의사들은 다양한 시술을 시도한다는 것이다. 예컨대 심장정지 환자의 경우, 고참의사들은 신참의사들보다 스텐트를 삽입하거나 관상동맥을 여는 수술을 더 자주하는 경향이 있다. 한마디로 말해서, 과유불급(過猶不及)이라는 것이다. 

과유불급의 폐해를 지적한 연구결과는 또 있다. 이스라엘의 연구진은 여러 가지 질병을 앓고 있는 노인들에게 투약을 중단하고 어떤 일이 벌어지는지를 지켜봤다(이런 노인들은 평균적으로 7가지 이상의 약을 먹는 게 예사다). 90% 이상의 노인들에게 약 5개의 약물복용을 중단하게 한 결과, 그로 인해 사망하거나 심각한 부작용을 겪은 환자들은 거의 없었다. 거의 모든 환자들은 되레 건강이 호전되고 약제비가 절약되었으며, 경과가 악화되어 약물투여를 재개한 사람은 겨우 2%에 불과했다. 

의사든 환자든 다다익선(多多益善)을 선호하는 경향이 있다. 그러나 모든 검사와 치료에는 오류와 부작용이 수반되기 마련이며, 하나의 치료로 인해 또 다른 치료가 불가피해져 결과적으로 일을 그르치는 경우도 있다. 그 대표적 사례로는, 인후염이나 귀 감염과 같은 간단한 질환에 항생제를 남용하는 것을 들 수 있다. 의사들은 과유불급의 지혜를 잊고, 약물투여, 혈액검사, 영상촬영, 수술을 강행하는 경우가 왕왕 있다. 

다다익선에서 과유불급으로 이어지는 악순환의 고리를 끊는 방법은 무엇일까? 첫째, 모든 치료를 행하기에 앞서서, 성공률이나 합병증 등에 관한 자료 일체를 환자에게 제공하는 것이다. 둘째, 약물을 과도하게 복용하는 노인들의 경우, 최소한 1년에 한 번씩 일부 약물의 복용을 중단시켜 보는 것이다. 

환자와 가족들에게 당부하고 싶은 게 있다. 의사가 어떤 치료나 검사(예: 엑스레이, 유전자검사, 수술)를 제안할 경우, 다음과 같은 질문을 던져보기 바란다. 첫째, 검사를 하면 뭐가 달라지나? 치료의 접근방법이 달라지나? 둘째, 치료를 하면 수명이 얼마나 연장되고, 심장발작 위험이 얼마나 감소하나? 셋째, 심각한 부작용은 없나? 넷째, 의과대학 부속병원인가?(《JAMA Internal Medicine》의 논문에 의하면, 의과대학 부속병원에서의 사망률이 더 낮다고 한다. 

이런 질문을 하면 의사가 불쾌한 반응을 보일 수 있다. 자신의 전문적 결정을 설명하거나 판단받는 게 기분좋은 일은 아니기 때문이다. 그러나 여러 조사결과에 의하면, 치료의 득실에 대한 정보를 체계적으로 제공받은 환자들은 과잉치료를 삼가고 의학적 결정에 만족하는 경향이 있다고 한다. 그러므로 당신의 어머니가 응급실로 향하고 있다면, 그 병원에서 가장 유명한 의사를 찾을 게 아니라, 위의 네 가지 질문을 해보기 바란다. 

※ 필자: 에제키엘 이매뉴얼(펜실베이니아 대학교) 

출처 KISTI 미리안 『글로벌동향브리핑』

PRETTY regularly, I receive an urgent call from a distraught friend or friend of a brother. “Zeke, Mom was at home and her heart stopped. The E.M.T.s are rushing her to XYZ hospital in Miami. Can you help me find the best cardiologist there for her?”

“Get me the best cardiologist” is our natural response to any heart problem. Unfortunately, it is probably wrong. Surprisingly, the right question is almost its exact opposite: At which hospital are all the famous, senior cardiologists away?

One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals. As the article concludes, high-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away.

Truly shocking and counterintuitive: Not having the country’s famous senior heart doctors caring for you might increase your chance of surviving a cardiac arrest.

The researchers did interesting checks to be sure the results were valid. They noted that there was no difference in mortality from heart conditions when physicians were attending the cancer or orthopedic meetings, presumably because the oncologists and orthopedic surgeons, not cardiologists, attended those meetings and don’t care for patients with heart problems. And when the cardiologists were at their national meetings, there were no changes in mortality from nonheart conditions such as hip fractures.

Overall for all heart conditions examined, patients cared for at the teaching hospitals did significantly better than those cared for in community hospitals. So choosing a teaching hospital, when possible, makes a difference.

It is not clear why having senior cardiologists around actually seems to increase mortality for patients with life-threatening heart problems. One possible explanation is that while senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically. Another potential explanation suggested by the data is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest, for example, were significantly more likely to get interventions, like stents, to open up their coronary blood vessels.

This is not the only recent finding that suggests that more care can produce worse health outcomes. A study from Israel of elderly patients with multiple health problems but still living in the community tried discontinuing medicines to see if patients got better. Not unusual for these types of elderly patients, on average, they were taking more than seven medications.

In a systematic, data-driven fashion, the researchers discontinued almost five drugs per patient for more than 90 percent of the patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improvements in health, not to mention the saving of drug money.

We — both physicians and patients — usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less — even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery.

There are potential policy solutions. One would require that doctors provide patients with data about a procedure, including its rate of success, complications and the like, before every major intervention. A solution for overmedication, especially in older people, would be to require that doctors attempt to discontinue medications at least once a year.

This is not the only recent finding that suggests that more care can produce worse health outcomes. A study from Israel of elderly patients with multiple health problems but still living in the community tried discontinuing medicines to see if patients got better. Not unusual for these types of elderly patients, on average, they were taking more than seven medications.

In a systematic, data-driven fashion, the researchers discontinued almost five drugs per patient for more than 90 percent of the patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improvements in health, not to mention the saving of drug money.

We — both physicians and patients — usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less — even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery.

There are potential policy solutions. One would require that doctors provide patients with data about a procedure, including its rate of success, complications and the like, before every major intervention. A solution for overmedication, especially in older people, would be to require that doctors attempt to discontinue medications at least once a year.

One thing patients can do is ask four simple questions when doctors are proposing an intervention, whether an X-ray, genetic test or surgery. First, what difference will it make? Will the test results change our approach to treatment? Second, how much improvement in terms of prolongation of life, reduction in risk of a heart attack or other problem is the treatment actually going to make? Third, how likely and severe are the side effects? And fourth, is the hospital a teaching hospital? The JAMA Internal Medicine study found that mortality was higher overall at nonteaching hospitals.

It is surprising how uncomfortable some physicians get when you ask these questions. No one likes to be second-guessed or have to justify their decisions. But studies show that when patients are systematically given information about benefits and risks they tend to consent to fewer interventions and feel more informed about their decisions.

So when your mother is being rushed to the hospital, it might be best not to seek the most famous senior doctor, but to ask those four questions.

One thing patients can do is ask four simple questions when doctors are proposing an intervention, whether an X-ray, genetic test or surgery. First, what difference will it make? Will the test results change our approach to treatment? Second, how much improvement in terms of prolongation of life, reduction in risk of a heart attack or other problem is the treatment actually going to make? Third, how likely and severe are the side effects? And fourth, is the hospital a teaching hospital? The JAMA Internal Medicine study found that mortality was higher overall at nonteaching hospitals.

It is surprising how uncomfortable some physicians get when you ask these questions. No one likes to be second-guessed or have to justify their decisions. But studies show that when patients are systematically given information about benefits and risks they tend to consent to fewer interventions and feel more informed about their decisions.

So when your mother is being rushed to the hospital, it might be best not to seek the most famous senior doctor, but to ask those four questions.

http://www.nytimes.com/2015/11/22/opinion/sunday/are-good-doctors-bad-for-your-health.html

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