Saturday, July 13, 2013

Prevention or Crisis Intervention

Preventive Medicine. We hear this phrase all the time. It is supposed to be the panacea, the end all and ultimate solution to the nation’s health care ills. And why not? If everyone would just follow doctor’s orders and get their blood pressure checked, have their mammogram and colonoscopy performed, check their PSA, Cholesterol, EKG, bone densitometry and everything else that is recommended by various medical types, then everyone would be healthy and no one would ever get sick or die. Oh, I forgot to add stop tobacco use, wear one’s seat belt while driving, drink a glass of red wine daily, (but not to excess), exercise ten or thirty or forty five minutes three times or five times or six times per week; avoid trans fat, processed foods,  cholesterol, (or is cholesterol OK now?), eat one egg a day, don’t eat eggs at all, avoid red meat, eat only grass fed beef, have regular sex, regular bowel movements, regular vacations, and avoid generalized irregularity and you will live to the ripe old age of infinity, unless you fail to look both ways and get hit by a bus or take a walk in the rain and get struck by lightning.
The point hits one in the face. Is true preventive medicine achievable or is it akin to the holy grail? Just when should screening mammograms be done? Age thirty, forty, fifty? What are the true risks and benefits. Does the discovery of a ductal carcinoma in situ in an eighty nine year old with woman with congestive heart failure and COPD really warrant aggressive treatment or any treatment?
 What about “suspicious” calcifications in a seventy year old patient. How many complications are suffered going after radiologic abnormalities which are of questionable significance? How many perforated colons or bleeding polypectomy sites following colonoscopy are acceptable as doctors search for that one elusive cancer?
 Should preventive medicine be abandoned*? Although preventive medicine gets all the press, in reality the vast majority of healthcare practiced today is what I call crisis intervention.
A woman notices a lump in her breast and goes to her doctor. Or, an elderly man passes bright red blood in his urine or stool and goes to his doctor. Or a child has a temperature of 103 and is vomiting at 2:00 am and his worried mother, who has to go to work in a few hours, brings her to the ER.
Such common conditions occur commonly and are the main reason doctors and nurses exist. Would health care be better if resources were concentrated on improving such crisis intervention? Is it proper that the worried mother has to wait for three hours to be told her daughter has a virus?
Our emergency rooms are much maligned these days. Politicians, insurance administrators and other bureaucrats wail about the high cost of ER care. But, is this truly justified? If a patient of mine, two days post gallbladder surgery, calls me at midnight saying they have been vomiting and have a temperature of 103 I will instruct them to go to the ER. Most ER’s are equipped to do a thorough evaluation fairly rapidly. Thus I can learn in a few hours if my patient is suffering from a serious complication or a minor post op event.
But, what about the woman who shows up in the ER at 3:00 complaining of “back pain for five years?” Surely, that is no emergency. True, it is not, except to that particular patient who can’t sleep because she can’t get comfortable because her back pain has flared. It’s happened before and will happen again. So, give her a pain shot so she can sleep. But, also be sure that she has someone to follow up with. And, if she calls her doctor at 3:00 am complaining of severe back pain it is very likely she will be instructed to go the ER. Where is all this questioning leading? Medicine devotes a great many words to this perfect ideal called “preventive medicine.” Reimbursement is tied to it, journalists write about it and politicians talk about it. But in the trenches of health care delivery it is crisis intervention which drives the system. And, until we humans can be constructed like cars and refrigerators, it will be almost impossible for any other system to be implemented.
I am not calling for elimination of all preventive medicine. There is no question that PAP smears have saved thousands of lives and vaccinations have virtually wiped out some potentially devastating infectious diseases. But, the idea that preventive medicine, if universally implemented, will eliminate most diseases is, in this day and age, fantasy.

*There is an excellent summary of current preventive medicine recommendations, reviewed by a true panel of experts at the following website: