Trying to Put Genie Back in the Bottle

Trying to Put Genie Back in the Bottle

We have seen the emergence of “evidence-based medicine” in the last 10 years.  This has been an effort to further legitimize and give scientific basis to common medical therapies.  A medical version of “show me the money.”  I have always thought this was rather inane, since it presumed that all medicine for the last 2000 years has been unscientific and irrational.  Although the reality is medicine is not nearly as scientific as asserted.  Only 10-20% of medical practice is based on sound scientific principles.   This rankles most physicians who believe that conventional medicine is scientifically-based.  The highest form of medicine is the practiced art using scientific principles and technology.

A series of US Task Force recommendations are being rolled out by the Department of Health and Human Services.  These are well-intentioned and rational.  Examining the literature and epidemiology of medical practices in an effort to determine what is safe, sane, practical and effective.   The trap is “effective” as you will see.

The current uproar regarding the task force recommendations on breast cancer screening highlights just how difficult these decisions can be.  This is not easy.  The problem is guidelines and recommendations have a tendency to insinuate themselves into the fabric of bureaucratic mandates.   And you can bet that the rapacious insurance carriers will see the “wisdom” of eventually adopting the task force recommendations as a ruse to further reducing reimbursable testing.

For prostate screening the 2008 US Preventive Task Force recommends:

  • In men younger than age 75 years, the USPSTF found inadequate evidence to determine whether treatment for prostate cancer detected by screening improves health outcomes compared with treatment after clinical detection.
  • In men age 75 years or older, the USPSTF found adequate evidence that the incremental benefits of treatment for prostate cancer detected by screening are small to none.   …
  • The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated would never have developed symptoms related to cancer during their lifetime.
  • There is also adequate evidence that the screening process produces at least small harms, including pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results.

For breast cancer screening the most recent 2009 US Task Force recommends:

  • The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.   …
  • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years …
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older …
  • The USPSTF recommends against teaching breast self-examination (BSE) …
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older…
  • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer…

A Gordian Knot.  My entire AntiAging practice is rooted in active preventive care and proactive lifestyles.  We find ourselves in a gray area.   This is precisely the problem.  Medicine today is so heavily pathology-based.  It is what I call “drive-through medicine.”  Wait until the problem manifests itself and then simply “fix me up.”    All this breast and prostate screening has been an attempt to avert late stage disease.

This is not a mutually exclusive solution, although this is how it will be framed.  There is, and will be, a demand for an early screening of prostate and breast and ovarian cancers.  But I agree with many of the task force recommendations that too many early and “benign” cancers are overly aggressively treated.  Cancer engenders fear.   It is a series of “what ifs.”  What if we do this?  What if we didn’t do that?  So to “cover the bases” virtually all cancers are over-treated.  And, yes, the medical-industrial-hospital complex benefits from overtreatment.

Too often we demand absolutist and simple solutions.

for every problem there is a solution which is simple, clean and wrong.
— HL Mencken

The answer is a wise use of discretionary approaches.   Can this be done?   It must be done.  We must be allowed to individualize and personalize the approach.

Once the genie is out of the bottle – having been so thoroughly conditioned to prevention and early intervention – they will not be able to reverse the tide so easily.   That is, unless you are an HMO member or your insurance carrier simply adopts the recommendations.  In which case they become mandates.  Solution: pay for the services that are not reimbursed.   These are not expensive tests.

But there is a more insidious trap.  The ascendance of the quants.  Less physician discretion, more systemic control.   This is the slippery slope.   This is where this entire “health care reform” is headed.   Make the system more efficient.   The Task force recommendations are well intentioned and constructive.  But the smartest guys in the room with their quants brought you Enron and Wall Street derivatives leading the world to the brink of disaster.   Be forewarned.

One thought on “Trying to Put Genie Back in the Bottle

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