Apr. 29, 2009 - Issue #706: Nevermore
Costs and benefits
I’ve just spent a few days doing some critical thinking about my
approach to matters of health. Have I become contrary just for the sake of
it? Superficial in my logic, careless with my sources of information? And
then, a most pleasant surprise in Dr. David H. Newman’s
Hippocrates’ Shadow, thanks to my library-loving husband.
Dr. Newman, an emergency room physician who runs a clinical research program and teaches at Columbia University, is both hopeful and refreshingly honest about the state of affairs in modern medicine, and he confirmed my frequent assertions that we are, in practice, always a few steps, and sometimes many years, behind what the science has informed us with.
In sharing the secrets of what he calls the House of Medicine, he brings us face to face with the fact that while we have life-saving interventions for many kinds of emergencies, many of our long-accepted diagnostic tests, treatment protocols and preventative screenings desperately need reevaluation. On his list are mammograms.
Citing the $4 billion spent annually on mammography, a high risk of false-positive mammograms, one in five biopsies done as a result of a false-positive test and the billions of dollars spent each year on unnecessary biopsies of healthy breasts, he broaches the cost/risk/benefit equation. Given the costs and risks, there’s surely major benefit?
Not so, he says, citing a review of the literature by the highly reputable Cochran Collaboration that found, overall, routine screening mammograms to offer zero benefit—women survived at the same rate whether they’d had them or not.
How have the facts about mammograms been obscured? “We have long ignored an essential fact about professional medical societies like the AMA: they are advocacy groups,” Newman argues. “And yet it is difficult to point fingers. What else is a radiologist to do when a woman is referred for a routine mammogram? And what else is a surgeon to do when a mammogram indicates a potentially cancerous area in a woman’s breast?”
Also on Dr. Newman’s list and of particular interest to me is our
love affair with antibiotics. Likening our approach to a game of Russian
Roulette, he cites a startling rate of life-threatening allergic reactions to
the common antibiotic amoxicillin—an estimated one out of every 410
times it is administered. Then, estimating that 90 per cent of antibiotic
prescriptions for sore throats in the US are unnecessary, he calculates an
associated 24 000 life-threatening allergic reactions each year from
antibiotics he says were unnecessary in the first place.
An easy-to-read chart laying out, by treatment, the number of people we need to treat for one person to benefit is illuminating. According to his calculations, we need to treat 2000 women with hormone replacement therapy (HRT) to prevent a single fracture or cancer diagnosis—the other 1999 receive no benefit, and one person out of every 667 treated will actually suffer a heart attack or breast cancer as a result of the treatment.
Why the pervasive use of largely ineffective therapies? No medical student has time to scrutinize everything taught, and in most cases physicians don’t know the evidence that contradicts their practice. But “in other cases physicians are well aware of the evidence but obstinately refuse to reexamine their practice and themselves.”
Time pressures, the desire to avoid negligence, advertising-induced patient demand—doctors, patients and industry, in other words—have all played a role in the current state of affairs.
The only role we can do anything about is, of course, our own. We—the patient, the consumer—want miracles. But it is still, according to Newman, the responsibility of doctors to heed Hippocrates’ caution and avoid pretense of infallibility. “That doctors often don’t have the answers they and their patients seek is a medical secret, the symptom of a quiet and pervasive deception.”
Newman’s hope is that physicians will read his book; I hope everyone will. His honest look at the profession he clearly loves is hopeful, sobering and essential. V
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