Conventional Magic

OK.

Some liked it, some didn\’t like it.  At least my recent post that equated alternative medicine with magic wasn\’t ignored.

Now, perhaps it wasn\’t clear to some of my readers, but the purpose of that post was not to critique alternative medicine.  The point was that people like magic foot baths better than doctors who practice evidence-based medicine.  There is little flashy about what I do on a regular basis; I occasionally pull out my magic wand and dramatically help people, but most is little by little, day by day.  That is why some of my patients elect to go the foot bath route rather than follow my advice.

Oh yes, and I did paint all that is alternative in the light of magic foot baths, which isn\’t really accurate.  But again, that wasn\’t my point.

As I responded to those who felt I shorted alternative therapies, I saw that I needed to delve into a point I touched on in the post.  Here\’s what I said: \”The majority of healthcare dollars are spent on technological “miracles,” not the hum-drum treatment and management of disease.  When we in medicine go for the glamor, we sell our soul to the highest bidder and walk away from where we can do the most good.\”  The more I thought about this point, the more I saw its significance.  Here\’s what I mean:

1.  Magic Images

Have a headache?  You need your head imaged.  CT scans are passe\’; MRI scans are OK, but PET scans are where it\’s at.  The images are colorful!

I am sure that few physicians order PET scans for headaches, but I am also sure that few patients would complain if they did.  Doctors have ordered MRI angiograms, and ultra-thin slice CT scans when less expensive procedures would work fine.  Yes, these tests may have certain advantages, but is it always necessary to use the best possible procedure?  Is a test that costs 10 times more worth a 10% gain in quality of information?

The MRI scan of the back is a good example of \”better\”tests gone awry.  It took the heavy hand of insurance companies to stop the routine ordering of this test for simple back pain.  Patients didn\’t object to getting the best technology has to offer, as it seems like they are getting better care.  But in truth, these MRI scans resulted in many people getting back surgery who did not need it.

\”You have a bulging disc,\” the doctor tells the patient who has back pain.

\”Ah,\” says the patient. \”That is certainly the cause of my back pain.\”

\”Yes,\” says the doctor.  \”If I remove that bulging disc, your problem will be solved.\”

And so the neurosurgeon \”fixes\” the bulging disc in the patient\’s back to \”cure\” the back pain.

Here\’s the catch: just as many people without back pain have bulging discs as those who do have back pain.  The disc is an incidental finding on the MRI scan, but its presence with back pain seems to imply causality.  It is simply not true.

Did the patients complain?  They thought the smart doctor found the cure for their problem with the fancy machine.  Do the neurosurgeons complain?  They triple their business overnight, thinking the MRI scans are truly magical.  It took insurance denials of these unnecessary tests to eliminate this practice.  Yet I still have patients with back pain tell me about their \”bulging discs,\” as if these are clinically significant.

The technology makes the magic.

2.  Magic Tests

We need to get rid of cancer!  Cancer is causing all sorts of pain and suffering in our country.  What can we do to get rid of this scary disease?

Let\’s do some magic tests!  Let\’s screen the public with a test that shows the presence of cancer and then treat the cancer early.  Let\’s call July national pancreatic cancer month and screen the entire population for this horrible disease.  We all loved that movie star who just died of it, and so now let\’s prevent others from getting it!

That sounds great, but there is one tiny hitch: there are a pitifully small number of tests that are valid screening tests.  Most screening tests are flawed; they either falsely reassure people, falsely identify cancer, or cost a lot of money.

Yet with all of these tests we have celebrities campaigning on TV for us to urge our parents, kids, and coworkers to get them done.  They save lives. Well, at least we would rather spend a ton of money thinking we may be saving lives than sitting around feeling like we are doing nothing.  But there really are no good inexpensive tests.  Mammograms aren\’t as good as breast MRI scans.  PSA testing will be replaced with a more expensive immunological test.  There will eventually be a line we can\’t cross.

3.  Magic Drugs

I remember when Zantac was the wonder drug for heartburn.  It was amazing.  Then came Prilosec, and nobody was prescribing Zantac.  It just wasn\’t very strong.  But wait; Prilosec goes off of patent and along comes Nexium to save the day.  Prilosec is now a weak drug and Nexium is all patients want, and all doctors want to prescribe.

Drug manufacturers have capitalized on the \”new and improved\” model.  This model works because it taps into the search people have for the \”magic bullet.\”  If these drugs were all the same price, why not get the best?  The problem is, of course, that Nexium is 10 times more expensive than Zantac.  But doctors and patients all want to spend more so they feel that the care given is better.

There is Nothing New Under the Sun

No, conventional medicine is guilty of the same magical thinking that they condemn alternative medicine by.  It seems far better to do the latest expensive thing than to do what has been shown to work: live a healthy lifestyle and take care of treatable diseases.  My job, primary care, is not at all glamorous.  I work with patients over decades.  I build relationships with them and try to help them to change.  But my patients will just as easily leave for the latest fancy scanner as they will the colored foot bath.

I do believe there is a basic difference between conventional western medicine and many of the alternative treatments: dependence on science.  Conventional medicine succeeds only as it depends on science to be its guide.  But if we forfeit the science and order expensive, unproven, yet glamorous tests or treatments, we are no different.  We forfeit our position for the sake of winning converts.

We also spend a bus-load of money.