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Healthy Discourse


When my May 29 Cover Story "Medical Guesswork" went to press, I had some trepidations. The story asserts that there's little evidence to support much of what is now common practice in medicine. It questions the value of high-risk procedures such as coronary bypass surgery for many people. As the story's central figure, Dr. David Eddy, bluntly observes: "The problem is that we don't know what we are doing." When Eddy began to push what he called "evidence-based" medicine in the 1980s, the response was mostly hostile. I was bracing for the same.

Sure enough, there are plenty of critics among the 100-plus letter writers and online commentators who have responded so far. "As a 12-year survivor of Stage IV colorectal cancer, I can attest to the fact that my [doctors] knew what they were doing," writes Dan Verdirame of Far Hills, N.J. "Your article does them a disservice and provides incentive for those looking to avoid uncomfortable, but necessary, medical treatment."

One common charge is that the whole "evidence-based" idea was cooked up by insurance companies. "It sounds like a ploy to lower patient access to the latest technologies," complains one online writer. More substantively, readers said that while evidence is lacking that treatments work, firm proof that the treatments are unnecessary is also lacking. Good point.

Other readers said I'd missed major issues. The threat of lawsuits forces doctors to treat patients aggressively, even when physicians know the treatment is dubious, several wrote. Others wished I had mentioned the importance of diet and lifestyle in keeping people healthy -- and the need for a health-care system that's primed to prevent diseases.

On the other hand, a great many readers applauded BusinessWeek's willingness to "print the truth about our current health-care system," as one online poster put it. The story won praise from doctors, economists, and patients. And readers provided us with some poignant glimpses of what happens when health care falls short of its promises. "Medical science is nowhere near as exact or insightful as many people have been led to believe," laments one online poster who lost his wife to breast cancer. "There are no magic bullets in medicine, and I am glad to see the story start to bring that idea to light. Perhaps now it will get people to think more realistically about treatments that cost a small fortune, have little or no curative effect, leave families drowning in debt, and have survivors wondering whether it was all worth it."

The responses show that this subject is far too large to encompass in one magazine story. Here is a sample of what readers said:"

Having been diagnosed with colon cancer less than three months ago, I have experienced the predicament posed by Dr. David Eddy, i.e., receiving contradictory opinions from physicians. Choosing the right doctor becomes an exercise in guessing and hoping for the best. Fortunately, the oncologist I am working with seems flexible and open to discussing options based on evidence. The glimmer of hope is that medicine is facing several forces that will provoke a change. Dr. Eddy is right on track, and many others will follow in his footsteps. - Carlos A. Valenzuela, Bethlehem, Pa.

In mental illnesses it is very easy to show that medications can lessen psychosis or block depression and anxiety. But they create a multitude of metabolic problems and cognitive compromises. Just think about virtually every treatment guideline and algorithm issued by cost-conscious insurance companies, prestigious universities, and learned societies like the American Psychiatric Assn. In the name of evidence-based medicine, these academicians have flooded the field of psychiatry with shallow diagnostic manuals, irrelevant brain studies, and treatment guidelines. Instead of painstakingly going into the meaning of patients' symptoms, dreams, and intrapsychic conflicts, they teach how to ask a few rote questions, prescribe the algorithm-based medications, and get to the next patient within 15 minutes. - Surendra Kelwala, M.D., Livonia, Mich.

"First, do no harm" has been totally replaced by "just do any old thing and bill to the max." - Ron Tripp, Johnson City, N.Y.

Reevaluation of gold-standard treatments is a good start on the path to more effective and efficient health care. However, your Cover Story overlooked the key reason why we have costly, inefficient health care today: The system is designed for crisis management rather than for fostering optimal health. A top-to-bottom restructuring with changes in incentives is needed for every party, including insurers, health-care providers, employers, and patients. All other changes are like putting duct tape on a leaking pipe. - Candice M. Hughes, Hughes BioPharma Advisers, Darien, Conn.

Your story was right on the money. Until the "Art of Medicine" becomes the "Science of Medicine," we are doomed to suffer the consequences. - Subash Khadpe, Slatington, Pa.

John Carey's article blames the failures of medicine on financial self-interest three times. Adam Smith demonstrated that financial self-interest generates a creative-productive economic system. Drop the trite 16th century ideology of blaming self-interest, or you will rapidly watch your subscription base move to magazines that aren't stuck with outmoded ideology. - Michael Phillips, San Francisco

Regarding the suggestion that income clouds judgment, reimbursement is so poor for procedures that I am incentivized to be in the office rather than the operating room. - Daniel A. Spilman, M.D., Santa Cruz, Calif.

In your cover package, you say: "Surgery can cure early-stage colon cancer." This seems to advocate currently popular routine colonoscopies, which I'm personally biased against. According to my research, colorectal cancer occurs in 24 of every 100,000 people aged 40 to 49 and in 48 of every 100,000 people aged 50 to 54. Assuming that all of those would be discovered and cured by routine colonoscopy is a stretch. Moreover, we will never know how many benign polyps are precancerous unless someone follows untreated polyps in a large group of patients for a long time. In simple terms, if my local gastroenterologist performs three colonoscopies a day, or 1,000 per year, at $600 per exam (a reasonable assumption), he earns $600,000 a year. In 10 years, he will have prevented between 2.4 and 4.8 colon cancers. Mindful of the recognized procedural colon perforation rate of 0.2%, he will have perforated 20 colons, i.e., he will have seriously injured many more people than he will have helped. Many men will die of old age harboring prostate cancer. At least in the old days, they never knew they had it. Medicare has it partly right: They'll only pay for one colonoscopy every 10 years for average-risk individuals. - Jay G. Selle, M.D., Cornelius, N.C.

The true reduction in health-care costs will come from education and prevention. However, education and prevention will only work if getting and staying healthy is rewarded in a manner that will encourage such lifestyle changes. - Michael J. McKeown, M.D., Hillsboro, Ore.

One thing your article failed to mention was doctors' fear of litigation (especially in California) when expensive testing procedures are not provided. If a doctor provides all alternative-procedure information to a patient, and the patient then makes the decision on which treatment he should use, the doctor should not have to fear a lawsuit over the outcome. - Lance Becker, La Mesa, Calif.

Physical therapists know firsthand about physicians' "vested interests" as you stated in your Cover Story. [This is] a subject that has been causing physical therapists great concern for years. Today a physician can receive financial gains by having total or partial ownership of the physical therapy practice to which he or she refers. - Ben F. Massey, Jr., P.T., M.A., President, American Physical Therapy Assn.

Until high-quality evidence is produced, well-reasoned decision-making based on lower-quality evidence (e.g., tradition, experience, anecdotes) will still be needed. High-quality evidence is downright rare in terms of the series of lifelong care decisions often needed for chronic diseases where initial treatment (sometimes the topic of clinical trials) is followed by reevaluation, follow-on treatment (rarely the topic of clinical trials), more reevaluation, etc. - Mike Rethman, D.D.S., Honolulu

Dr. David Eddy's computer model makes perfect sense in an ideal world with ideal patients, but it may not be powered for "real world" medicine. Physicians practice in a very complicated world. They see patients with varying severities of sickness. And there are other characteristics such as economic, cultural, intellectual, and linguistic barriers and other social factors. Numerous studies with conflicting and contradictory conclusions cast doubt in the minds of clinicians as well as patients. There are many flaws in medical research, compared with other sciences. There will always be a divide between the analog life of the physicians and their patients and the digital age we are in. - Joseph K. Chemplavil, M.D., Hampton, Va.

"Medical Guesswork" convincingly portrays the potential of advanced computer-based technology to improve the diagnostic and treatment power of evidence-based medicine. Such technology has been underutilized because of conflicting incentives among physicians, hospitals, and payers. Fortunately, innovative ways of deploying computer-based technology are enabling the rapid, cost-effective, and highly accessible delivery of evidence-based best-practices information. In the course of a five-year clinical trial, a research team from the University of Vermont has been able to demonstrate the power of an advanced computer-based system to deliver health improvement to diabetic patients. - Benjamin Littenberg, M.D.; Charles D. MacLean, M.D.; Michael Gagnon, Vermont Clinical Decision Support, Burlington, Vt.

To view the May 29 Medical Guesswork Cover Story and scores of thoughtful reader comments, go to www.businessweek.com/go/medicalguesswork/

By John Carey


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