"Sick" care is what doctors are for

The idea that sick care is what ails US healthcare is another example of soft thinking

There is this idea that one of the main problems with US healthcare is that our system is set up to profit from sick care.

This comment from my friend Dr. David Albert captures the idea:

Martha, as you well know, we have a sick care system not a well care system that doesn't make $ from wellness but from caring for the sick. Not sure it will change (Trillions of dollars at stake).

If only we could invest as much in making people well, we would save money, goes the thinking. Like Ben Franklin said: “an ounce of prevention is worth a pound of cure.”

Prevention experts repeat this slogan with great passion. I used to believe it.

But I now see this as soft thinking.

Here are four reasons why I changed my mind.

First is the false notion that prevention saves healthcare dollars. Humans do not live forever. We all succumb to disease.

Say an intervention prevents a 50-year-old from having a heart attack. What happens when he or she turns 60, or 70, or 80 years-old? Does the health system not spend dollars on this older person who will surely incur some disease? Prevention only saves money if it causes people to live longer and then suddenly die in their sleep.

Of course I believe it is a societal good to prevent early disease. But doing so will not reduce cost. There are many ways to reduce costs, but, in 2023, delaying the onset of disease is not one of them.

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Moral Hazards of Prevention

In his book, Medical Nemesis, the bombastic philosopher-priest Ivan Illich wrote of three ways in which the medical system created harm. They are as relevant today as they were a half century ago.

Clinical iatrogenesis

This is a direct harm of intervention.

A person comes in for a yearly physical exam and is found to have an asymptomatic irregular heartbeat. In the course of investigating this benign condition, the patient suffers a stroke from a coronary angiogram. Had this person never seen a doctor, or had no prevention efforts, she would have avoided a stroke.

While this example is extreme, it illustrates the dangers of trying to help people who feel well. The benefit/harm ratio tilts toward harm.

Consider a counter example of ‘sick care’: a patient presents to the emergency room in shock because of an occluded coronary artery and heart attack. A doctor takes that person to the lab, opens the artery, stops the heart attack, and the next day, the patient is sitting up eating breakfast with a band-aid on her wrist.

It’s not risk free to open arteries; coronary interventions can have complications (harm), but, in the vast majority of cases, the skill of the doctor saves or enhances a human life. During ‘sick care’ the odds strongly favor benefit being greater than harm.

Before I move on to a different type of harm, I want to make clear that I am not arguing that we ignore terribly high blood pressure because it is asymptomatic. Or that we not use anticoagulant drugs in patients with AF.

This argument turns on probability: the odds of benefit exceeding harm is greater when we intervene on patients who are asking for our help.

Social Iatrogenesis

Another way the medical establishment can cause harm is the creation of disease.

When I started medicine, we diagnosed people with heart failure when they came to the clinic or hospital because of fluid retention and difficulty breathing.

Our heart failure treatment guidelines now have a category called stage A heart failure.

Being at risk of heart failure! Is it not true that being alive and older is a risk for heart failure? It’s the same with pre-diabetes and pre-hypertension, and a host of other pre-conditions. Don’t get me started on “digital health.”

A particularly problematic disease-creator are scans to detect calcium in the coronary arteries. There exist zero trials demonstrating benefit from doing these scans. Proponents argue they help people decide on whether or not to take a statin drug. But in reality, and I think proponents must know this, these scans lead to investigations, such as stress tests, which then lead patients to have stents or even bypass surgery. (Yet studies show that fixing asymptomatic blockages is no better than treatment with medicines.)

I’ve seen many a healthy older person turned into a worried patient because they had a coronary artery calcium scan. This counts as harm. Calcification of arteries is part of the aging process. Andrew Foy and I have made the case against using these scans—for any purpose.

Cultural Iatrogenesis

Another more pernicious way that prevention can cause harm is a culture of death denial. In the past, before medical innovation, people managed their pain, suffering and deaths.

While we have made great progress in medicine; and clearly, this is a better time to live than the 1800s, the avoidance of death has not changed. We all will die.

The pervasive nature of a prevention mindset can cause a lot of harm at end of life. Some forms of “palliative chemotherapy” come to mind. Drugs that do not meaningfully extend survival may lead to physical suffering and financial ruin.

Why does this happen?

Because of a cultural belief—amongst doctors and patients alike—that medicine is so good, that if we try hard enough, we can prevent death.

Instead of the provision of comfort, people expect that death can always be prolonged. Illich argued that we in medicine were responsible for this false thinking, and thus, it was us who caused harm.

While technology has made decisions near end of life more complicated, death-denial remains a source of potential harm.

Summary

This newsletter likes to hold competing views at the same time.

You can believe that medicine is a wonderful and meaningful job, and that we have made great progress. But you can also believe that it is best suited for treating those who ask for our help.

The primary prevention of disease is best left to society, and of course, luck. Not doctors.