Preventative care: Not all it's cracked up to be
For the second time in as many days I’ve been inspired by a New York Times column. Everywhere you turn it seems, you hear people lamenting that we could reduce health care costs so much if only we were more in tune with preventative care. Everyone pays it lip service, including the two candidates for president who both pride themselves on straight talk. Writes Dr. H. Gilbert Welch, professor of medicine at Dartmouth in today’s paper:
Senator John McCain argues that “the best care is preventative care,” and his health care reform plan claims that “by emphasizing prevention” and other measures “we can reduce health care costs.” Senator Barack Obama’s plan says, “Simply put, in the absence of a radical shift towards prevention and public health, we will not be successful in containing medical costs or improving the health of the American people.”
It may sound like common sense. But it is still a myth.
The term “preventive medicine” no longer means what it used to: keeping people well by promoting healthy habits, like exercising, eating a balanced diet and not smoking. To their credit, both candidates ardently support that approach.
But the medical model for prevention has become less about health promotion and more about early diagnosis. Both candidates appear to have bought into it: Mr. Obama encourages annual checkups and screening, Mr. McCain early testing and screening.
Like most platitudes spouted by politicians, it sounds good. But is it? The idea is, of course, that with all these early checkups, tests and screenings, doctors will discover serious disease in its early stages when treatment is easier and less expensive. Were that all that happened, preventative medicine might be worthwhile. But that’s not all that happens. Unfortunately, today’s doctors use physicals, tests and screenings to pinpoint diseases that aren’t really diseases. And these non-diseases are not inexpensive to treat. Let me give you an example.
I have a friend who recently turned 49. He is to all outwards appearances health as a horse. He hikes, he works out, he plays a lot of golf, always walking and carrying his bag, he isn’t overweight, and he has a good family history. His father died in his late 70s and his mother, age 84, is still living and drives her car everywhere. This guy is your basic active healthy middle-aged male with no obvious problems. Then he goes to the doctor to get a physical exam.
All the tests and screenings come out normal except for one. You probably guessed it. His cholesterol was a little high. At 215 mg/dl it came in over the magic cutoff of 200. And like all ‘good’ doctors, his recommended that he go on a statin drug. So he went on Lipitor. And promptly got muscle aches and felt lousy. He called his doctor about the pain, and his doctor told him to keep on taking the Lipitor. He said the aches should subside with time. So my friend soldiered on and took his medicine. But his pain continued. After several months of this aggravating pain, my friend asked me about it. I was stunned to learn that with his age, condition, and family history, his doctor had started him on a statin. I suggested that he discontinue the drug and load up on some CoQ10, which he did. His muscle pain went away and he was soon back to his old self.
But, he had had the fear of high cholesterol laid upon him. He asked me about it and told me that he was a little worried. I gave him the talk that I have given ad nauseum on the pages of this blog about the lipid hypothesis being only a hypothesis and that cholesterol doesn’t mean squat and that a statin wouldn’t help him improve his overall chances of not dying. He was reassured but not totally convinced. I suggested an EBT scan of his heart for a calcium score, an actual indicator of coronary plaque. We went for it and ended up with a calcium score of zero, which indicates virtually no coronary plaque. The doctor who gave him his physical was treating him for a non-existent disease. An elevated cholesterol isn’t a disease – it’s a lab value.
So, we have a healthy guy who goes in for a little preventative care and comes out with coronary angst and a prescription for a medicine that does him absolutely no good and that even may have been doing him harm. He then underwent yet another screening procedure to allay the fears that had been created by the first round of preventative care. He (or his insurance company: read you and I) paid several hundred dollars for the first go round, another couple of hundred for the three month’s worth of Lipitor, and another $700 for the heart scan. After at least $1500 of someone’s money, the guy isn’t any better off than he was before he went for his physical exam. In fact, he would have been much better off had he never gone to the doctor in the first place.
The above example is preventative care as we know it today. And it doesn’t save money overall; it costs money. A lot of money. Had I not entered the picture, this guy may have been on Lipitor for years at God only knows what cost. Preventative medicine today doesn’t reduce medical spending – it increases it.
As Dr. Welch confirms:
Increasing the amount of testing for an ever-expanding list of problems always identifies many more people as having disease and still more as being “at risk.” Screening for heart disease, problems in major blood vessels and a variety of cancers has led to millions of diagnoses of these diseases in people who would never have become sick.
Likewise, recent expansions in the definitions of diabetes, high cholesterol and osteoporosis defined millions more as suddenly needing therapy. A new definition of “abnormal bone density,” for example, turned 6.8 million American women into osteoporosis patients literally overnight.
These interventions do prevent advanced illness in some patients, but relatively few. Any savings from preventing those cases is dwarfed by the cost of intervening early in millions of additional patients. No wonder pharmaceutical companies and medical centers see preventive medicine as a great way to turn people into patients — and paying customers.
Many of whom pay through the nose for a long, long time.
In a brilliant analogy, Dr. Welch compares early screening for disease to the ‘check engine’ light in your car. When it comes on, it may indicate that a problem exists, but more often than not it comes on due to some trivial cause
like one sensor’s recognizing that another sensor isn’t sensing.
I’ve made many a trip to the mechanic to get my car looked at after the annoying ‘check engine’ light came on, and most of those trips resulted in the mechanic resetting the ‘check engine’ light. Many times the light came on simply because it was programmed to come on when the car reached a certain mileage. Just like we are encouraged to have certain screening procedures when we reach a certain mileage.
If when our own ‘check engine’ light comes on, and we head to our doctor, we would be time and money ahead were we given advice to cut the carbs, get more sleep, and quit stressing. But that’s not what happens. We get our cholesterol checked and thus begins a life-long fight to get it lower, when all it is is a lab result. If you don’t believe me about this, search the comments of this blog using the word ‘statin’ and you’ll see how many people write telling me that their cholesterol was found to be a little high, and their doctor wants them to go on a statin. It’s pitiful. In fact, it’s an outrage.
I’m not saying you should never go to the doctor or never have a screening to see what’s going on. But I do say that you should undertake these procedures only when they provide some value. Colonoscopies are worthwhile because colon cancer, caught early, can be successfully treated. Same with PAP smears and cervical cancer. An EBT scan of the heart for a calcium score is valuable because it measures plaque. If you see a mole that is changing in shape or color, it’s good to get it checked. There are a few other screening tests that are of value, most routine lab tests can only steer your doctor wrong. And put you at odds with him/her.
Take the time to read the full New York Times article. You’ll never look at the idea that preventative care is the panacea for all that ails us the same again. Now, if only the candidates could get the message.