With medicine, it seems less can be more

Sometimes when I’m lecturing, I talk a bit about conventional medicine. There are undoubtedly parts of orthodox medicine I am hugely enthusiastic about including, for instance, hip replacements and cataract surgery. The problem is, however, much of medicine is stunningly ineffective. And it’s not without risks either. It’s perhaps a personal view, but my opinion is that conventional medicine is not as effective as its image suggests, and it generally riskier too.

The reason for talking (or writing) such things is that I generally encourage people to se conventional medicine when they need to, but not to rely on it too heavily (better, I think, to wrestle control regarding one’s health into one’s own hands as much as possible). I also like to challenge the idea that the more money and resources we throw at healthcare, the better off consumers of it are.

A few years back I became aware of a curious phenomenon: when doctors go out on strike, death rates have been noted to fall. One potential for this is that conventional medical kill more people than it cures. This may seem utterly counterintuitive, but I believe it’s a phenomenon that should not be dismissed. Bearing in mind the ineffectiveness of much of medicine, and the hazards associated with it, perhaps medicine does actually kill more people than it cures.

If this is true, then we may perhaps need to revisit the notion that the more healthcare we provide to people, the better off those people will be. And this is precisely the theme of a editorial that appears in the latest edition of the Archives of Internal Medicine [1]
This editorial starts by citing evidence which shows that some measures of health are actually worse in areas where people receive more health services [2]. The editorial goes on to itemise just a small sampling of conventional medical care that at best, appears not to work at all well, and at worst, exposes individuals to unnecessary risks.

These include:

• Arthroscopic (key-hole) debridement (cleaning up) of the knee joint

• The use of antidepressants in individuals with mild depression

• Mammography (breast cancer screen via X-ray) in younger women

• CT scanning of kidney stones to ‘follow’ their progress (no benefits, but increases the risk of radiation-induced cancers)

The authors of the editorial make the case that there’s the potential for some cost-cutting, though this may be perceived as ‘rationing’. However, as they quite rightly point out: “Rationing implies that the care being withheld is beneficial and is being withheld simply to save money. But as we have noted above, there are many areas of medicine where not testing, not imaging and not treating actually results in better health outcomes.”

The authors also refer fleetingly to some of the reasons why doctors may provide more care than needed. These include:

• Payment systems that reward procedures compared with talking to patients

• Expectations of patients who may equate testing and treatment with better care

• The ‘glamour’ of technology

• The ease of writing a prescription or test order over explaining to a patient why they are not being treated

What the authors do not mention, though, is the sometimes cynical attempts of the pharmaceutical industry to paint their products as better and safer than they really are, to ‘invent’ illnesses for which they have the ‘magical’ solution, and to promote the use of their drugs for types of patients or even conditions that extend beyond what the evidence supports.

Excitingly, though, the authors announce that the Archives of Internal Medicine will be running a new series under the heading ‘Less is More’, which will highlight situations in which less care is likely to result in better health. My sense is that the Archives of Internal Medicine will be able to tap into a very rich vein, here.

I remember reading a piece some years ago about medical care which made similar points to this latest editorial. I don’t remember the detail. What I do remember, however, was the assertion that some doctors could do with being told: “Don’t just do something – stand there!”

References:

1. Grady D, et al. Less is More: how less health care can result in better health. Archives of Internal Medicine. 2010;170(9):749-750

2. Fisher ES, et al. The implications of regional variations in Medicare spending, part 1: the content, quality, and accessibility of care. Ann Intern Med 2003;138(4):273-287

9 Responses to With medicine, it seems less can be more

  1. Chris Kresser 12 May 2010 at 7:10 pm #

    Great post, Dr. Briffa. Check out a similar post I wrote a while back called The Failure of U.S. Healthcare. (The problems aren’t confined to the U.S., but that’s my primary audience.)

    I discuss a paper published by Dr. Starfield in JAMA a few years back indicating that medical care is the 3rd leading cause of death in the U.S. Because only 5% to 20% of iatrogenic incidents are ever reported, it’s very likely that medical care is actually the #1 cause of death.

  2. Jamie 12 May 2010 at 9:38 pm #

    Brilliant piece.

    I have long pondered the place of doctors in overall healthcare, particularly from the position of an allied health professional (nutritionist) who struggles to gain traction when promoting that patients take responsibility for their own health (in a system that promotes reliance on doctors as their primary healthcare provider). In my mind, the primary healthcare provider for a person is that person themselves.

    It is a shame that most people perceive doctors as the gatekeepers to true health.

  3. Donald G 13 May 2010 at 9:02 am #

    Dr. Briffa,

    Your open-mindedness is refreshing and very valuable.

    From a 1959 issue of The Lancet (I copied it out half a century ago!):

    …advice given by Sir Heneage Ogilvie when asked to suggest a subject for a thesis: “Look around for some subject on which we are all agreed, and start thinking for yourself. You will find you are on virgin ground.”

  4. Jo 13 May 2010 at 1:48 pm #

    I hear what you’re saying but it’s a question of perspective.
    Without taking two little pills every day i would have gone into a coma and died (by way of going bonkers first) in my early thirties, like my grandmother (profound hypothyroidism). So I thank the two little pills (and modern medicine) every day. In my own little way. And from time to time one does meet with the view that this is all very horrid and ‘unnatural’ (agreed, naturally I would be dead – nature sucks!). I know that this isn’t what you meant at all, Dr Briffa. I’m just saying. That viewpoint is out there, believe me!

  5. Nigeepoo 13 May 2010 at 4:54 pm #

    Jo, taking thyroid hormone because your body doesn’t produce enough is good medicine (I also take thyroxine). Taking a drug that tweaks how the body works to compensate for wrong diet/lifestyle is bad medicine.

    John, I was given annual KUB X-rays and Ultrasounds since 2002 to monitor kidney stones until I pointed out that the kidney stone that was removed was 94% uric acid which is invisible on X-rays. I’m now given annual Ultrasounds only.

  6. DavidC 13 May 2010 at 11:18 pm #

    To build on Nigepoo’s remarks, having surgery to compensate for a body imbalance could also be considered bad medicine. The example given in the first paragraph – hip replacement – often falls into this category. I’ve seen poor posture as the underlying cause while the surgery is only addressing the symptom.

  7. Beth 14 May 2010 at 2:16 am #

    I have noticed this, simply as a person interested in my own health. :-)

  8. Chris 14 May 2010 at 2:34 pm #

    John, Nigel et al.
    I was listening to BBC Radio 4 around 2330 on Wednesday last and caught parts of a broadcast that featured talk involving a medically trained person who also has strong affiliations with art and who has transposed lessons from art to aid his contextualization of science. His interest in sculpture and fluid flow had directed interest in and experiment with water sculptures and the design of ‘cavities’ in fluid flow circuits that could induce pulsing or periodicity in the flow rate of the fluid.
    Advancements in scanning and imaging techniques have improved the ability to see inside a living heart and the person concerned is now engaged in a cardio department interpreting heart scan imaging. He openly declared that his interpretation of the heart and heart function has advanced from the classical and orthodox view that the heart should simply be compared to a mechanical pump; he sees features in heart vessel cavities that may be functional in creating the kind of fluid periodicity that he has experimented with. He melds artistry and imagination with medical science to ‘visualize’ contrasting features of healthy and unhealthy hearts.
    Some comments and observations were passed about the possible limitations of a purely empirical approach to science and that not everything can be explained from mathematical analysis.
    According to the schedule this slot was given over to ‘Today in Parliament’ but there would be reason to substitute for the published and intended broadcast. Sadly I cannot find the program information nor trace to a listen again feature or podcast.
    To the best of my recollection the surgeon involved was named Philip Kilburn. He spoke of the difficulty of having such findings published in journals but referred to having an essay published in ‘Nature’.

    Curiously via an unrelated search a couple of weeks ago I chanced upon an expression of a view by Prof. Bruce Charlton, “The cancer of bureaucracy: how it will destroy science, medicine, education; and eventually everything else”, published in the quirky journal ‘Medical Hypotheses’. The piece seems to rail at the stagnation of beneficial decision making in science and at the reluctance of those of orthodox persuasion to entertain debate about non-orthodox ideas, theses and submissions. On 11 May Prof. Charlton blogged that Elsevier had killed Medical Hypotheses.

    The signs that science and medical science is being applied for economic benefit seem stronger than the signs that science, medical science, and healthcare is being directed, managed and applied for the true and anthroplogical benefit of fellow humans. Optimistically there are minority exceptions.

    Hearing the broadcast on R4 I could not help thinking how it might be of interest to at least three other people I know of and each for slightly different reasons. Such a shame I cannot trace its origin.

  9. Vince Edghill 15 May 2010 at 12:20 am #

    Interesting revisit to a nice cynical topic. I’ve long lost my copy of ” Confessions of a Medical Heretic ” setting out, among lot’s of other cock-ups, how the undertakers nearly went broke during a strike by doctors in Tel Aviv many years ago. Then we got back to work and business picked up….Nice little story to tell my patients when they go glassy-eyed at me for advising some lifestyle things instead of reaching for the script pad.

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