Tuesday, April 20, 2010
In the land of "too much ain't enough," the idea that less medicine could be better medicine is a hard sell. This was impossible to discuss during the fracas over health care reform, when any talk of fewer tests and less surgery was portrayed as rationing or the government coming between you and the doctor.
But more medicine can make you sicker. Sometimes it is worse than the disease it purports to cure.
Take the CT scan. Computerized tomography scans can find injuries and tumors, but they do expose patients to large amounts of radiation, which increase the risk of cancer. Even a properly administered brain scan, used to detect a stroke or aneurysm, delivers radiation equal to several hundred chest X-rays. Head scans are used routinely on victims of vehicle accidents.
Two studies published in the Archives of Internal Medicine linked CT scans to increased cases of cancer. One predicted that a single heart scan at age 40 would result in cancer in one in 270 women and one in 600 men. The younger the patient, the greater the risk.
CT scans can be enormously helpful in finding certain things. But they should not be casually ordered for screening purposes or to look at something the doctor already knows about.
Mammograms involve far lower doses of radiation, but even they slightly increase cancer risk. And they lead to many false positives, which then require biopsies with cutting and anesthesia.
That made the hysteria greeting the U.S. Preventive Services Task Force recommendation that women at low risk of cancer receive fewer mammograms rather off the wall. One may object to the counsel that women under 50 don't need any mammograms (and I would), but the task force was right in noting that over-testing can harm patients.
Mistakes by doctors, nurses and other medical personnel cause up to 98,000 deaths a year, according to the Food and Drug Administration. Hospital infections kill 100,000.
Yet doctors performed 60 million surgical procedures in 2006, one for every five Americans. No other country comes close to that, wrote Atul Gawande in a landmark New Yorker piece on health care spending.
Dealing with prostate cancer has become a battlefield. A man screened for prostate cancer has a 2.4 percent risk of dying from the disease, according to a European study. A man who doesn't get screened has a 3 percent risk. Another study finds that 70 percent of diagnosed prostate cancers could have been left untreated with no harm to the patient. For older men, something else is likely to kill them first.
Nonetheless, many thousands of American men every year subject themselves to painful radiation, sickening hormone treatments and prostate removal -- often leading to impotence and incontinence. New thinking is in order.
Chantix is a drug to help adults quit smoking. The ads warn that the drug may cause "suicidal thoughts or actions, anxiety, panic, aggression, anger, mania, abnormal sensations, hallucinations, paranoia or confusion." Common side effects include "nausea (30 percent), sleep problems, constipation, gas and-or vomiting."
How nice to pop a pill for what ails you. But shouldn't giving up smoking the old-fashioned way be tried first? Modern pharmacology can bring miracles, but it is not necessary a free lunch.
Some of this excess testing and treatment is defensive medicine, for sure. Doctors are trying to protect themselves against malpractice suits. Tort reform was sorely lacking in the health care legislation. Its day must come.
But our system for delivering health care in which each service gets billed separately is also to blame. More testing means more money for the doctors who own expensive diagnostic equipment. The fight to curb this spending is just beginning.
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