Responding to Abigail Zuger’s column in the New York Times. Zuger notes that today doctors spend most time prescribing for pre-illness, which means they try to predict the future.
I am amused by, “For people who feel fine… It is the patient … firmly planted in the here and now, while medical personnel spin wild tales of coming catastrophe…”
“In fact, our future of treating pre-illness will simply catapult us right back to a priestly past, as we offer up misty visions of the future and encourage the masses to see with us and act accordingly.”
Zuger’s image – emotional doctors versus patients demanding evidence – captures my experience perfectly. When I declined a mammogram, citing research in top journals, the doctor responded emotionally, literally throwing up her hands: “It must be better than nothing.”
Urging a bone density scan, she cited relative risk (50%) rather than absolute risk (3%). Outpatient surgical clinics require pre-op tests for despite published research consistently showing no difference in outcomes. Most doctors don’t know the Society for General Internal Medicine’s guidelines limit testing for asymptomatic adults.
Doctors eagerly embrace studies questioning the value of herbal or alternative options, but shrug off equally credible reports showing the low value of mainstream “preventive” medicine. In fact “preventive” really means “risk reduction” and often the reduction is so low as to be meaningless. Thus the line between science and magic become blurred, educated skeptics resist medical advice, and most doctors hate patients who know how to read statistics in the medical journals.
Today’s Wall Street Journal had yet another story by a disillusioned doctor: Why doctors are sick of their profession
Jauhar actually offers a balanced view. He points out that doctors were warned they would kill the goose that laid the golden eggs; many doctors still perform unnecessary surgery. I am healthy and rarely see doctors, yet when I had a small ovarian cyst, a doctor tried to persuade me to undergo a complete hysterectomy! I switched doctors and had an outpatient procedure in just a few hours.
The irony is that managed care often doesn’t prevent unnecessary or wasteful treatment. The term “preventive care” should be replaced with “risk reduction medicine.” Much of a primary care doctor’s work involves screenings of perfectly healthy, asymptomatic people that cannot be justified by research findings.
Doctors are still trained to memorize molecular structures but they need courses in statistics and decision making. Recently the WSJ published a review by a cardiologist who insisted that deaths from heart disease were down by 60%. I looked up the numbers: the reduction was 172/100,000 and that doesn’t account for things like errors in coding causes of death.
And while doctors complain bitterly about lack of respect, many of them persist in making elderly patients (and those close to end of life) suffer with unnecessary treatment. Just read any list of comments in a NYT article. I’ve heard first-hand accounts of 90-year-olds given colonoscopies, paid by Medicare; a doctor writes about aging Alzheimer’s patients getting painful needle tests for diabetes, ordered by a doctor, who can’t be stopped. yet few insurance companies give them what they need – massage, good food and privacy. I’ve heard even more horror stories of doctors who disregard DNR orders and who think they’re doing a service by keeping someone alive for a meaningless, drugged-up existence in a nursing home.
Finally, doctors have limited accountability. It is very, very hard to sue a doctor. Doctors make claims on their websites (and in practice) without disclaimers and disclosures of conflict of interest. Eye doctors actually place ads in their office magazines (“Want great vision? Talk to us about …”) without warning that these procedures do not always turn out well and sometimes make vision worse.
Recently I came across this article, allegedly reporting that being married confers health benefits: http://www.medicalnewstoday.com/articles/274828
Here’s my comment:
Being happily single and disgustingly healthy, I had a few concerns about this article.
Bella DePaulo’s book, Singled Out, provides a rigorous discussion of flaws in research comparing single and married people. For instance, often researchers lump together the “never-married,” divorced and widowed, without controlling for recency of divorce or widowhood. Those who never married actually have an advantage as they age because they are used to being alone.
As for cancer patients living longer, I’d want to know, “Are these people holding on longer, even living in pain, because they’re waiting to see a grandchild get married or graduate from college? Are their spouses and children reluctant to turn off life support, as compared to the more distantly related proxies of single people?”
Rather than emphasize the health benefits of marriage (which aren’t entirely clear), I’d like to see some focus on how the medical community treats married vs single people. Many singles find that getting an “approved” ride home from out-patient surgery has been so stressful, I will avoid having elective procedures that require a ride from a responsible adult. A woman with a tall husband or son at her side will be treated far more courteously than a single woman who shows up alone. There’s nothing wrong with solitary life (see Anthony Storr’s classic book, Solitude), yet the system discriminates against them. I’m pretty social, but if I choose to be a curmudgeonly hermit, why should I be denied access to quality health care? That’s the *real* question.
In an article, “Patient satisfaction: Hospitals are not like car dealerships” (March 22, 2014) David Mokotoff
DAVID MOKOTOFF, MD | PHYSICIAN | MARCH 22, 2014
The article is here.
Mokotoff writes, “Here’s what I would like to ask the patients:
Did the condition for which you entered the hospital improve or go away?
Was the hospital bill clear and accurate and easy to understand?
Did a doctor explain procedures to you fully and in enough detail?
Was the food hot and edible?
Here’s how I commented:
Up to a point you are right. However, I am a super-healthy person who avoids doctors and declines tests. Recently I had cataract surgery as an outpatient in a top hospital. The surgery went well. My surgeon and anesthesiologist were superb once we got to the OR. To them, my case was boring because I’m so healthy.
For me, the whole experience was so stressful I developed physical symptoms. I was horrified by what I experienced: incorrect data entered in my records, repeated queries about irrelevant personal information; failure to note allergies on my chart till we got to the moment of entering the OR; required pre-op tests that are dismissed as useless in research published in leading medical journals (along with a scary high probability of false positives); inflexible requirements for finding a ride home when operations are scheduled at the last minute (hello – friends and even some relatives can’t get off from work); pre-op and post-op instructions presented in a disorganized, incomprehensible fashion (I have a Ph.D. and professional writing experience); stressful noisy waiting rooms with blaring TVs; rude nurses and technicians; and a lot more.
You may think it’s no big deal, but my relationship with the medical profession is more hostile than ever and it was pretty bad before. I was so traumatized that I’m refusing all future tests for cancer, heart disease or other illnesses. There’s no way I could handle the stresses of a major episode. I’m putting an advance directive in place and becoming an advocate for assisted dying, which I think should be made even easier.
After all, spy pilots used to get cyanide pills to avoid getting shot down in POW camps. Modern hospitals aren’t much different. You underestimate the impact of stress on otherwise healthy people.
In his New York Times op-ed piece, “”How Long Have I Got Left,” Paul Kalanithi (Jan 26) eloquently describes his dilemma when faced with an open-ended diagnosis.
His challenge isn’t all that different from the one facing ordinary people over 65. Even healthy people realize their chances of dying increase each year, even when they appear healthy. Apart from the lesser probability of dying from an accident in your youth, everyone faces the question he poses, “I don’t know if I’ve got 6 months, 10 years or much more.”
However, Kalanthi violates the boundaries when he writes. “What patients seek is not scientific knowledge doctors hide, but existential authenticity each must find on her own.” And we won’t find solace in statistics: “the angst of facing mortality has no remedy in probability.”
Typical medical arrogance. The doctor morphs from a scientific expert, providing information to help patients make informed decisions, to high priest of a cult with access to secret mysteries. The oncologist’s know-it-all attitude? Appropriate, says Kalanthi.
The truth is, many scientists who look up articles about their own diseases have realized they are probably outliers. They can ignore recommendations based on the “average” outcomes because they’re not average. They use their knowledge to pursue more hopeful outcomes and sometimes succeed.
Pharmaceutical companies and journalists provide pseudo-statistics so people are induced to accept risky treatments and useless tests, based on “relative percentages” and weak correlational studies. Think of headlines like, “reduces risk by 70%,” which journalists take from a drug company’s press releases.
Why not allow dying patients – in fact, all patients – to have access to real numbers, if that is their choice? For some of us, statistics would truly relieve the angst.