Monday, July 19, 2010

Bad Medicine

I just finished reading Worried Sick, a book about delivery of medical services in the United States.  The author's basic premise is that the following conditions must be true before a medical test is worth doing:

1.  The test is accurate.
2.  The result has meaningful predictive value.
3.  There is something meaningful to be done if the test is positive.

The amazing thing is that so many extremely common medical treatments, particularly expensive and dangerous treatments, have tests that simply fail these very simple rules.  I fully expected that all kinds of alternative medicine like homeopathy, naturopathy, aromatherapy, acupuncture and others would completely fail to measure up but I didn't anticipate how incredibly weak the reasons for more mainstream treatments like angioplasty, stents, prostate exams and mammography would be.  It seems to be largely true that doctors want to treat patients who come to them with problems even when the problems are insoluble and that the desire to do *something* overrules the desire to do the right thing.

The best two examples in my opinion are prostate cancer and angioplasties done for heart concerns.  Even if you can easily figure out if someone has prostate cancer you are faced with the problem that removing the prostate has an unimpressive rate of preventing death by prostate cancer and it causes huge numbers of problems including impotence and urinary leakage in many of those who undergo surgery.  The other problem is that prostate cancer usuall  takes a long time to kill people so many older patients who undergo treatment have no reason to think they will live long enough for prostate cancer to kill them.  Even trying to prevent heart attack by angioplasty is noted to cause cognitive problems (due to breaking up plaques that then cause mini strokes) and is wretched to useless at saving lives since so many people die during the operation itself.

I have real first hand experience with excessive medical testing from my work.  In a job I had last year I was working for a private clinic that got CEOs, VPs and the super rich to come in for massive batteries of tests each year.  They were tested far more often than makes any sense even if you assume that the treatments would be helpful... and in many cases it seems that isn't true.  I figured at the time that if rich people want to blow money being pandered to and tested excessively it wasn't any problem of mine since otherwise they would be buying status symbols with that cash but the fact that this was supported by doctors and was only unavailable to the public due to funding constraints is a sad state of affairs.

Just because a doctor can cut you open and make an effort to fix things inside you is no guarantee that doing so is a good idea.  Testing itself costs the patient in time, stress and life disruption and invasive surgery is much worse.  Although we might wish that modern medicine could solve all our health problems that is not the way things are.  We would all be much better off if our doctors could tell us that there is nothing they can do but wait and see and if we were willing to accept that as the best science has to offer.

1 comment:

  1. interesting to see my daily dilemma so clearly laid out. it's a dilemma I try to explain to patients on, I don't think this is an exageration, a daily basis. Is it WORTH doing this test. What will I do differently if it is negative or positive? Will having the results of it perhaps make the situation WORSE? What are the risks of the test itself?
    It's tough for me, and I know tough for my patients. I often offer them a choice. Here's the risks here the benefits of both sides ... what do you think? You'd be surprised how often I get "you're the doctor, you tell me". That is a very burdensome position to be in as the doctor (not that I'm complaining about it ... but certainly a position I take very seriously). I don't think everyone wants to be as involved/knowledgeable or have the understanding of their diseases that perhaps you would like to have. It would make my life easier if they would ...
    Also ... would like to know where you got your information about angioplasties as I agree with most of what you said but don't think of cognitive decline post angioplasty as one of the most common side effects.
    Thanks for the thought provoking blog! Looking forward to seeing you when you're here!