American news outlets this week have been abuzz with news of the much debated, celebrated, and maligned health care reform legislation. What has caught my attention, however, is not the legislation itself, but all the hand-wringing over the costs of broader insurance cover and their effect on government spending, and the inadequacy of the current American primary care workforce to meet the needs of the nation.

None of this is really new news, but this public conversation brings to the national attention three issues we in primary care have wrestled with for a long time:

• Health care is just plain expensive, and American health care particularly so. Worse, many of those most in need of care, are those who have had to rely on personal savings, debt, or charity - or have simply gone without.

• We need more family doctors. This has long been recognized in primary care circles, as fewer and fewer students have entered primary care.

• We can't "fix" healthcare with more money, technology, or practitioners alone - we need a broad values-based consensus on what health and illness are all about before we can make progress on really knowing how to improve American health care.

I'd like to say that I have some wise and wonderful ideas for tackling these challenges - I don't. But, I do know that there are other nations, both rich and poor, around the world who do a better job of caring for their populace than does the USA. While the size and diversity of the US pose challenges not faced by many smaller countries, I am hopeful that the recently increased attention to what reform will actually mean may encourage Americans to see what others have done, and will draw the broader population into discussion of the challenges we in primary care have been facing for a long time.

Recently I’ve been making more of an effort to “personalize” my documentation to include names, rather than just descriptors, in my documentation. Rather than “The patient’s wife says he’s not falling so much…”, I think “Donna says he’s not falling so much” is far less clinically impersonal. Not a big thing, maybe, but it reminds me that these are PEOPLE and not just SUBJECTS. I’m finding, too, that I tend to both read and write my progress notes less like dry clinical data, and more like the stories that they are – stories of my patients’ lives, joys, sufferings, and challenges.

But why do I even need this reminder? I went into medicine to care for people, not numbers or lab rats, so why am I now needing a reminder of who they are? I think it is due in part to the medical short-hand of referring to diagnoses or room numbers, not names. How many times have we heard, or said ourselves, “the gall-bladder in room 16 is feeling better” or “the pneumonia in 202 is still short of breath.” Or perhaps just using the number, “Room 205 is ready to go home today.”

(Frankly, if “Room 205 goes home”, it will leave a big hole in the hospital hallway!)

The craziness of it is that the habit of referring to people by room numbers has at least partly to do with protecting their names! As we’ve become more sensitive to privacy concerns (and appropriately so!), using room numbers or bed numbers has become a convenient short-hand for identifying patients to our professional colleagues, without breaching their privacy to those in earshot who do not have a “need to know.”

So – we’ve tried to protect privacy, and in so doing removed a key reminder of our patients’ humanity!

What’s in a name? Many things – but most importantly a reminder of who each of us is as an individual. And while that needs to be protected to honor privacy, it also needs to be REMEMBERED as we document our thoughts and plan our care for our patients. Medicine is not just about clinical data, it’s about people – and perhaps the right use of names can help us remember that.

It seems our society lives in dread of cancer, one word that is the purgatory of the modern western world. How often does a patient reply, when you tell them the positive results of an investigation, “Thank heavens it isn’t cancer” even though the actual diagnosis may be more life threatening than many neoplasia. The almost biblical belief system behind the word cancer comes with a corollary that poses a major problem to effective rational health care, namely the “must get it out” association. That medical school surgical dictum “When in doubt, cut it out” may have been superseded by more politically correct phrases, but the thought remains ensconced in our own and our patients’ minds when faced with a diagnosis of a solid neoplasia.

But why is this so? Why do we believe that a diagnosis based on visualisation of some cells down a microscope has a 100% positive predictive value, especially when the patient has absolutely no symptoms or clinical signs to support the diagnosis? Have you ever tried to explain the gap between a histological and a clinical diagnosis to a patient?
Not easy, yet we know from the prostate screening studies that a histological diagnosis of prostatic carcinoma is poorly predictive of subsequent death from that cancer. Try the melanoma studies demonstrating a significant interoperator variability in histology results. What about the phenomenon of diagnostic drift, especially the recent study showing that, in current day reviewing of skin biopsy slides diagnosed as normal in the 1990s, a significant number were found to be low grade superficial spreading melanoma. Little wonder we are removing more melanomas than ever before.

What we really need is a change of thinking, more focused on a “cancer” diagnosis based on metastatic disease potential (ignoring the problems caused by primary tumour enlargement, but remember that this includes plenty of non malignant growths). This requires a different diagnostic method and is the likely way things will move in cancer diagnosis. Consider if we had a test for prostate cancer that had a better predictive ability for the development of metastatic or local spread disease. Same for breast cancers, especially the very problematical DCIS.

Sentinel node biopsy seems to have potential, at least in terms of identifying if metastasis has already occurred, but greater potential is likely to lie in biochemical indicators of metastatic activity and potential, such as have already been found in inflammatory breast cancer. It’s unlikely imaging as we know it will be a suitable answer, but perhaps, in conjunction with metastatic markers, we may be able in the future to reassure patients that their cancer is better lived with, rather than without.

Our challenge will be to shift this cancer belief system and the associated concepts of appropriate therapy.