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:
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