August 26, 2015

Another Call for "Less Medicine, More Health"

That's the title of an excellent book by Dr. H. Gilbert Welch.

An internist at the White River Junction Veterans Administration Medical Center in Vermont, and a researcher at the Dartmouth Institute, Welch presents an informal, witty, and wise argument that less "care" may result in better health and less harm to the patient.

He systematically debunks seven widely held assumptions about the value of more tests and treatments. His book is "more narrative, with fewer numbers, and perhaps most importantly, no scary tabular and graphical data and no superscript references."

The Seven Assumptions
Welsh devotes a chapter to each assumption, and he ends each chapter with a "prescription" of simple, actionable strategies to avoid too much medical care.

1)  All risks can be lowered. The disturbing truth is that risks can't always be lowered, and trying creates new risks. All health risks are not equal. Some are real; others may not even exist. Some are really important; others are overstated. I was happy to see this quote: "Lowering blood pressure is not always a good thing" (see "Efforts to reduce small risks -- like minimally elevated blood pressure and blood sugar -- can produce big problems."

2)  It's always better to fix the problem. The disturbing truth here is that trying to eliminate a problem can be more dangerous than managing it. Welsh gives this example: former President Bush went in for a routine physical in 2013 and was given a cardiac stress test. It showed some abnormality -- as it would in many 67-year-olds. Bush then received a catheterization which identified a partial obstruction ("as I expect it might in me," Welsh wrote). As a result, Bush was given a balloon angioplasty. The American Heart Association suggests that people without symptoms should not be given stress tests.

3)  Sooner is always better. The disturbing truth: early diagnosis can needlessly turn people into patients. Much of Welch's narrative in this chapter involves screening for breast and prostate cancer. I had a radical prostatectomy in 1995 and -- as a result -- have spent 20 years dealing with incontinence and erectile dysfunction. Some cancer cells remained after my operation, but they have been growing very slowly. Welsh suggests that if you want to get a feel for the problem here, imagine that you are "a middle-aged [pick one: woman/man] who was encouraged to participate in cancer screening." That screening led to the detection of the small cancer for which you received surgery. "Because of complications from my therapy, I do not feel as well now as I did before this whole thing started. Imagine how angry I became to learn I went through all this for nothing -- my cancer was not going anywhere anyway." I don't need to imagine this scenario; it's real for me. Welsh says he doesn't get screened for prostate cancer.

4)  It never hurts to get more information. The disturbing truth here is that "data overload can scare patients and distract your doctor from what's important." Welsh notes that it's easy to collect data, but hard to produce useful knowledge from that information. He thinks the single most important biometric measurement in human health is blood pressure. Figuring out how to monitor something like blood pressure is a lot easier than figuring out what the data mean. Again, Welch's example resonates: I remember when one of my doctors -- after seeing a single high blood pressure reading -- diagnosed hypertension and urged me to resume taking blood pressure meds. That doc was wrong (see Welsh also has a good discussion of the current controversy about the usefulness of annual physicals. If the checkup means taking lots of tests and having a structured interview in an exhaustive search to see if there's something wrong with you, Welsh would agree with the critics who question the value of annual physicals. But he favors a yearly visit when it's more of a check-in than a check-up. The session might yield positive results if the doctor simply talks with you about what's going on in your life, how you're feeling, and what is bothering you. (Lots of luck finding a doctor who is willing to sit down and chat with you for 30 minutes or more, which is what this would require.)

5)  Action is always better than inaction. The trouble here is that action is not reliably the "right" choice. In this chapter, Welsh considers surgery -- the area of medicine where action is the most dramatic. He thinks the case for surgical inaction is particularly strong for low back pain. He concludes: "Back surgery is not a panacea; it's an invasive operation." The human body has a remarkable ability to heal. We might question any surgical strategy that disrupts -- or destroys -- the body's own powerful drive toward wellness.

6)  Newer is always better. The disturbing truth here is that new interventions are typically not well tested and often end up being judged ineffective or even harmful. "I don't want a new drug," Welsh says. "I want an old drug. Not one that is outdated, mind you, but one that has been road tested -- one that has been around for awhile." (In a recent post  on the new drug rytary, I noted reports that the effectiveness of new drugs has plummeted since the 1970s. ) As for new procedures, Welsh says, "I don't want a new procedure. I want one that is known to work and one my doctor knows how to do."

7)  It's all about avoiding death. I particularly like the disturbing truth here: A fixation on preventing death diminishes life. Welsh talks about his own experience witnessing his father's death. He wants patients and their families to understand the tension that exists between medical care designed to prolong life and medical care designed to provide comfort. "It is hard for us to make people comfortable while we're doing things to them."

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