Saturday, December 20, 2008


This was a good read and if the author wanted the reader to be outraged she succeeded. Unfortunately, she might have been so successful to the point that while her examples and stories are valid I am sometimes skeptical about the size of the effect. One story that sticks in my head is the Oprah Winfrey effect on health care expenditures on full body CAT scans. While it is probably true that her endorsement sent demand for full body CAT scans soaring, I find it implausible that insurance would cover such a scan without adequate reasons. If they do (and I suppose it is just as plausible that they would cover the cost) then it is an indictment of the health care system and perhaps Oprah.

1. Why consumer driven health care does not work (pg. 64-65) talks about when how a physician (Donald Berwick) was not able to take control of his wife's care. "The neurologist told us in the morning, 'By no means should you be getting anticholinergic agents'; and a medication with profound anticholinergic activity was given that afternoon. The attending neurologist during another admission told us by phone that a crucial and potentially toxic drug should be started immediately. He said, 'Time is of the essence.' That was on Thursday morning at 10:00 am. The first dose was given 60 hours later .... Nothing could I do, nothing I did, nothing I could think of made it any difference. ... '

2. Even doctors persist to perform aggressive cardiac treatment despite evidence from large randomized trials showing that they are not effective. (pg. 105). There is also the result of 'oculostenotic reflex': 'You see a stenosis and you automatically think 'We need to do a stent.' Seeing is very powerful.' (pg. 106)

3. Inability to get patients to participate in clinical trials of high dose chemotherapy with transplant (pg. 130). Because some experimental procedures come before clinical trials, it is hard to convince those who have tried it and seen it succeed to want to put it to a test: "By the time Peters had organized his trial, neither doctors nor their patients wanted to participate. Transplanters were already convinced that they could cure at least some patients with a transplant, a conviction driven in part by Peters's own enthusiasm and his 1993 paper. Why would they ask half their patients to accept anything less than a possible cure?"

4. Different doctors see look at the same problem with different lenses: ... rheumatologists, ..., tended to give back pain patients blood tests, to look for rare immunological disorders.... Neurologists performed tests of how well nerves conducted impulses ... Surgeons ordered MRIs an CT scans .... (pg. 136) Dawes had made more than two hundred visits to emergency departments over the years and had referred herself to a string of specialists whenever one symptom or another grew intolerable. Each visit to a specialist led to a different set of tests - and different diagnosis. ... a gastroenterologist did an upper GI series, .. a neurologist gave her a head CT sca ... She was dignosed at various times with gastroenteritis, dehydration, depression, and "functional disorder," a term physicians use when they can find no organic or physical explanation ... As a physician's assistant, Lenzer was trained to think like a generalist.... Lenzer performed the most basic of tests: She took Dawes's pulse and blood pressure. Dawes heart rate went up when she went from sitting to standing, while her blood pressure dropped. Next, Lenzer drew blood and sent it to the lab. The results came back showing Dawes had low levels of salt in her blood and high levels of potassium. Lenzer immediately suspected Addison's disease. (pg. 69) The second story was also used to illustrate the lack of generalists and too many specialists.

5. Some possibly speculative reporting on her part: According to another estimate, out of six hundred thousand children a year under the age of fifteen who receive a head or abdominal CT scan, five hundered could ultimately die in adulthood from cancer due to the radiation they received as youngsters. (pg. 169) This worries me since K1 has had 3 head CT scans even before she was 6! Unfortunately, the author doesn't really expand on this - for instance: What is the typical exposure to a head CT scan? The actual report only talks about full body CT scans.

6. The paradox of technological progress in medical care (pg. 171): ... unlike technology in almost any other industry, new medical devices don't lower costs. ... Yet the view that al new medical technology is worth the price is at odds with the evidence - and no more so than in the field of imaging. ... A study performed fro the Medicare Payment Advisory Commission ... found that patients suffering from heart attacks, hip fractures, and colon cancer did not benefit from more imaging tests. Moreover, the fact that physicians can see better through imaging technology may not mean much: i.e. not all tumors are cancerous.

7. On preventive medicine (pg 200-201): ... the logic of the PSA test seems unassailable. It can detect prostate tumors on average eleven years before a digital rectal exam. ... If early diagnosis of prostate cancer really worked, then the mortality rate, or prostate cancer deaths per one hundred thousand in the population should go down, ... There has been a slight drop in the dath rate from porstate cancer in recent years, but many cancer epidemiolgists and doctors argue that there is little evidence that the PSA test is responsible.

She also covers how doctors tend to overcharge and over prescribe tests and how it interplays with fear of lawsuits although she believes that lawsuits themselves are not the whole problem. Her model of good health care is something like Kaiser Permanente. Doctors are salaried and hence have little incentive to order unnecessary tests or procedures to boost their incomes and they take the "whole patient" model more seriously than doctors in private practice. Like many books that cite studies after studies I feel that she is not presenting the entire picture - only studies that support her thesis are supported. As a general rule, one study that claims one thing will result in another study claiming another.

No comments: