January 23, 2013

Shaywich’s Healthcare Trends for 2013, #1: Preventive Health vs. Excessive Medicalization

In a post on his popular healthcare blog, Dr. David Shaywitz recently predicted three “tensions” we’d see in 2013:
  1. Preventive health vs excessive medicalization 
  2. Relentless standardization of medicine, and 
  3. Industrialization of drug discovery 
They’re interesting trends, which I’d like to consider one at a time. Today, the first: preventive health vs excessive medicalization.

In this first “tension,” Shaywich means that our current efforts to prevent disease – greatly enhanced in recent years through science and technology – so often carry risks which may not be worth taking. Patients now undergo many more screening exams (like mammography) than ever to “get a jump” on possible future health problems. Based on their doctors’ recommendations, they willingly alter their own body chemistry in the hope of reducing risk factors not yet apparent. They take aspirin to reduce risk of heart attack or stroke; they take powerful medications to lower blood pressure and cholesterol to decrease heart attack risk.

While these exams and preventive strategies have a legion of supporters among doctors and patients, there is no question that they also carry risks… risks we don’t yet fully understand.

Radiation and pharmacology are powerful things; millions would say they have benefited, and are living longer, happier lives because of these interventions. But there is something else to remember: the human body has ingeniously evolved through millions of years, developing exquisitely complex molecular strategies along the way to combat infection and disease as a means of preserving the organism. When we introduce powerful external agents, like drugs, we disrupt that purposeful natural process. Yes, those disruptions we create can prolong life; think penicillin. They can also bring unexpected negative consequences. Many obvious examples spring to mind: the cancers caused – not prevented -- by radiation; the horrors of thalidamide… not to mention medical errors, misdiagnoses, and adverse, sometimes lethal, drug interactions.

Enter "Iatrogenics"
Shaywich writes:
In his new book Antifragile, Nassim Taleb focuses extensively on iatrogenics, arguing “we should not take risks with near-healthy people” though he adds “we should take a lot, a lot more, with those deemed in danger.” 
“Iatrogenics” is a new word for me. Wikipedia defines it this way:
inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists. Iatrogenesis is not restricted to conventional medicine; it can also result from complementary and alternative medicine treatments.
It may very well become a word we all see more regularly.

So, how should we deal with risk? I think the answer is pretty simple, really: we should learn as much as we can about them, and then make informed decisions in concert with our doctors.

Concern for Costs, Not Risks, May Show the Way
As the battle continues in Congress over taxes and spending, we will inevitably need to find a way to dramatically reduce the cost of healthcare. It’s an issue I’ve addressed repeatedly on this blog, and negotiating a solution is more urgent than ever. In the final analysis, the system will, I think, make the decision for us: “Sorry, but you (we) cannot afford this test / procedure / operation / treatment .”

How can we learn when to let our bodies take care of themselves? How can we better accept the simple inevitability of death? How can we come to understand that briefly extending the lives of sick and dying loved ones through extraordinary, dead-end, budget-busting efforts isn’t really the best choice, for them OR us?

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