Tuesday, November 17, 2009

Confusing Doctors Again


Not much funny about breast cancer, eh? However, the medical community is giving us a big yuk on mammogram schedules.

Like the ending of G.I. Joe cartoons, the moral of the episode invariably included, "And now we know...and knowing is half the battle." In this case, the U.S. Preventive Health Task Force announced new guidelines for routine breast-cancer screenings. Fundamentally, instead of annual mammograms from 40, the new rule would be every other year from 50.

Alas for the medical community, this is only the latest care that exposes its frailty, its reliance on fungible vetting for diagnosis and care. Truth be told, most doctors have as much to do with medical science as pop journalists do. They wave the current perceived wisdom, call, "Aha!," and congratulate themselves.

So in the media including talk shows, they find women to say this is putting their lives at risk. They find doctors who say they are confused. They find researchers who were behind the previous perceived wisdom implying that a massive die-off of U.S. women will follow. A few alarmists also say this is all insurance companies need to deny annual breast-cancer screens to women who want them anyway.

The joke here is that this is common, if less dramatic and less discussed, in the profession. With a herd instinct, nearly all non-specialist doctors have to rely on the best guesses from the most accepted reports and studies. That means they end up continually circling back pretending that each change of diagnostic or treatment protocol is a breakthrough and G.I. Joe style new knowledge.

I became aware of this first when I was in elementary school. My mother ran Red Cross chapter, putting her in charge of and teaching first aid, home nursing and such, with the accompanying textbooks. I remember her alternately laughing and complaining when the national organization revised those manuals every year or even less as the American Medical Association changed its mind.

One trigger was burn treatment. It was cover or leave exposed to air and use gooky medicine or let it form a scab on its own. Back and forth it went with one major reputable study after another.

With the imprecision of care and the reality that most primary care physicians — PCPs or what we used to call general practitioners or family practitioners (GPs or FPs) — are not particularly good diagnosticians. They reply on plugging symptoms into their experience or searching software or a book for the most likely fit. In all likelihood, they end up treating symptoms with drugs and never diagnose anything. That means 1) the body cures itself, 2) symptom relief is coincident with improvement, or 3) yet another patient on a long-term regimen of a drug which may or may not address the cause of the complaint.

We really can't fairly call that medical science. Yet, we do cut docs some slack here. Much of the time they are pretty much the best health gamble around. We know they are not likely to discover or cure underlying causes, particularly of chronic problems. We also know that the system requires them to move a lot of patients through, so that they really don't have time to muse or deeply investigate or even research beyond reading current medical journals. They aren't scientists.

Moreover, they are easily misled by extrapolations from the research on which they rely. An obvious example is the silly reliance on body mass index (BMI) for individuals. While useful as a broad-brush measurement for big groups, it is often invalid per patient. Thin looking folk with little muscular development may have fine BMI but have organs swimming in their fat. Athletes with well developed muscles are often obese or overweight by BMI while being very healthy and having a great body fat level, much more meaningful than BMI.

It is easy to see how PCPs can fall back on the lazy solution of BMI though. Plug in a height and weight and there's a number for comparison. Doctors worthy of their oaths would look at and palpate patients. They would take the same two measurements, but put them into a hand-held body-fat analyzer instead (those are very accurate and inexpensive at $25 to $50). Then nutrition and exercise recommendations would be meaningful. Oops, let's not forget that most PCPs know little about diet or exercise.

So we are stuck with a system that hurries docs along, encouraging them to be reliant on easy ways out for diagnosis and treatment. We end up with increasingly unrealistic guidelines in many areas, while the population gets widely wide and heavy. Those guidelines have not resulted in greater longevity either, we struggle around 17th in the world, despite our disproportionate health-care cost and use of prescription drugs.

Treat Cause or Symptom?


A real solution would be a hard one, finding and treating underlying causes for conditions. As our system is now, that would happen only if considerable research was done asking such questions as is the mid-term and long-term outcome for patients better with treating symptoms pharmaceutically or changing the underlying cause of their problems. In a country where nearly all medical research is funded directly or secondarily by drug companies, you can imagine how likely it will be for such massive studies to occur.

In many areas, the research that our docs rely on seems misused as well. Consider for one, the famous Framingham Heart Study. It is a massive, on-going and very useful project, even though it has the limit of covering only men, only in a age range, and with rebutted results in the British Medical Journal among other places. Yet is is a hook to hang a medical hat on and as such used for various guidelines.

One such is that acceptable blood pressure has dropped from 140 to 130 to 120 to 115 upper number, for example. One effect is from the study that the recommendation is that over 90% of men should be on anti-hypertensive drugs by 60.

You needn't be the worst cynic around to question the relationship between drug companies, doctors and that guideline. Think in contrast if PCPs worked with patients to reduce body fat, up potassium intake, reduce stress and such. would the patient be better off than a remaining lifetime of one or more drugs?

What would G.I. Joe say? Maybe, "Well, we'll never know and not knowing leaves us unprepared for the battle."

Cross-post note: I have other medical rants at Harrumph!, where I'll put this.

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