Transcription
I'm Dr. Gil Welch. Let's imagine a world with less medicine and more health, and examine some widely held assumptions about the value of medical care. Seven assumptions, seven minutes, so I better get going.
Assumption one: All risks can be lowered. Sounds right, doesn't it? Medical care can reduce some risks, and the effort is most likely to be successful when the risk is high. Imagine someone at really high risk with a 50% chance of something bad happening in the next 5 years. Treatment may dramatically reduce that risk, even cut it in half, as is the case for people with very, very high blood pressure.
But most of us are not at really high risk. Our chance of something bad happening in the next 5 years is at most a few percent. It's hard to lower a small risk, and all of our interventions pose some harm: medication side effects, surgical complications, even death. As studies have shown, when we lower blood pressure and blood sugar too aggressively.
The assumption is all risks can be lowered, but the disturbing truth is risks can't always be lowered, and trying creates risks of its own.
Assumption two: It's always better to fix the problem. But that's not always true. Often, it's better to manage the problem of heart disease with a healthy diet, regular physical activity, and a few good medications than it is to try to fix the problem of heart disease by inserting wires, blowing up balloons, and installing stents.
But it's not just about heart disease. Managing many medical problems is often safer than trying to fix them. This is particularly true when the so-called problem is not bothering you. The reality is that it is hard for us to make people who feel well feel better. It's less hard to make them feel worse.
So the assumption is it's always better to fix the problem, but the disturbing truth is trying to eliminate a problem can be more dangerous than managing one.
Assumption three: Sooner is always better. We've all been taught that early detection is the best way to deal with a feared disease like cancer. But our understanding of cancer is changing. We now know it is an extraordinarily diverse set of diseases. Consider what's been called the barnyard pen of cancers: the birds, the rabbits, and the turtles. The goal is not to let any of the animals escape the pen to become deadly.
The birds are the most aggressive cancers, the ones that have already spread by the time they can be detected. Early detection doesn't help the birds; they're already gone. The rabbits are hopping around, and you might catch them if you build enough fences. They are the cancers that may be helped by early detection. Then there are the turtles, the cancers that aren't going anywhere anyway. Screening finds lots of turtles. The problem is you never want to be treated for a cancer that's not destined to ever bother you.
So while early diagnosis may make sense in selected settings, its widespread adoption has been a recipe for making people sick. The disturbing truth is early diagnosis can needlessly turn people into patients.
Assumption four: It never hurts to get more information. The value of information seems to be the central tenant of the 21st century, but it's a tenant that conflates data with useful knowledge. And there's a lot of data out there. There are thousands of bits of metabolic data, millions of pixels of imaging data, data over 3 billion data points in your genome. And some folks would love to send those data to you on your smartphone or smartwatch. "Your lung is now filling with fluid. Oh my gosh, your lung is now filling with fluid. Wow!"
The assumption is it never hurts to get more information, but we need to distinguish between data and useful knowledge. Because the disturbing truth is data overload can scare patients and distract your doctor from what's important.
Assumption five: Action is better than inaction. Isn't it obvious? The most dramatic action in medical care is surgery. All surgery involves trauma. That's why we say you need to recover from surgery. And trauma to the protective layer of the skin can lead to infections. But it's not just surgery that leads to infections. Inserting tubes into the body provides a path for bacteria to enter. And administering antibiotics can ironically kill good bacteria while providing a new ecological niche for the bad. The Centers for Disease Control now considers a broad category of infections healthcare-associated infections. And it's not just about infection. Our interventions can cause strokes, heart attacks, and blood clots.
The assumption is action is always better than inaction, but the reality is our actions can impair the body's ability to heal. So the disturbing truth is action is not reliably the right choice. Sometimes doing nothing is exactly the right thing to do.
Assumption six: Newer is always better. But if you know the story of Vioxx, or autologous bone marrow transplantation for metastatic breast cancer, or metal-on-metal hip replacements, you already know newer is not always better. Do you really want to beta test software or buy a new car in its first model year? Remember the single by Huey Lewis and the News: "I want a new drug. I don't want a new drug. I want an old drug." And a procedure that's known to work, and a medical device with a track record.
Because the disturbing truth is new interventions are typically not well tested and often wind up being judged ineffective, even harmful.
Assumption seven: It's all about avoiding death, really? Ask yourself this: If life is really all about avoiding death, why do we climb mountains? Why do we swim in the ocean? And for those of you driving on rural interstates, why aren't you driving 55? Because other things matter. It's not all about avoiding death. Because, you know, the disturbing truth: a fixation on avoiding death diminishes life.
Medical care can do a lot of good in selected settings. I'm a conventionally trained physician. I see the value of medical care, particularly in the care of those who are acutely ill or injured, what you might call acute care medicine. But in many other settings, we have exaggerated the benefits of medical care and understated its harm.
You want to know more? Read the book, "Less Medicine, More Health: Seven Assumptions That Drive Too Much Medical Care." And if all this feels like just another medical advertisement, let me be clear: all the royalties go to local charities. I have no financial interest. But if you're interested, I hope you read it.