Tuesday, October 06, 2015

Less Medicine, More Health

Less Medicine, More Health was especially relevant to me because my mother (65 years old) underwent colonoscopy as part of a routine control in which the doctor removed a few polyps and one of them had cancer cells close to the colon wall. Three out of four doctors said that she must have an operation which would remove a quarter of her colon (without saying anything about the risks of the operation). Only one doctor pointed out that may be all the cancer cells were taken out during the polyp removal, the risks and probability of success of the operation (which were horrible numbers). In the end my mother reasoned that the operation was not worth it. This was 6 months ago. Today she is alive and well, tending her garden.

Almost everybody has some sort of abnormality that won't hurt him but becomes a problem due to early diagnosis, i.e. you would be better of if did not perform the checks in the first place. Lesson: Don't do full checkups, only deal with things that you have symptoms of.

It shows the importance of randomization and biases that can be overlooked when performing medical trials, for example a trial based on volunteers can be biased because health conscious individuals are healthier than the average.


...as a society, we have overstated the benefits of medical care and underplayed its harms.

Risks can’t always be lowered— and trying creates risks of its own.

...the topic of health risks is one that helps sell magazines, or teases viewers into watching the evening news, or drives people to websites— and, in turn, helps sell medical care.

My use of the word noise actually combines two attributes: risks that do not exist in the first place and risks that are so small that they are unimportant, even if they do, in fact, exist.

Pay attention to those things that double, triple, or increase your risk tenfold and ignore those stories that talk about “threats to your health” followed by double-digit percentage increases.

Baseline risk: How much an individual stands to benefit from a risk reduction effort is directly related to how high their current (or baseline) risk is. The higher the baseline risk, the higher the expected benefit.

...observational data can be very misleading for preventive interventions— interventions to reduce risk. The reason is that people who seek out preventive interventions (in our jargon, exhibit health-seeking behaviors) are very different from those who don’t. In a word, they are healthier.

Vitamin A, vitamin C, and vitamin E supplementation each appeared to produce big beneficial effects in observational data. But the effect disappeared in randomized trials.

Treating very high blood pressure is one of the most important things doctors do.

...the minute something has to be done to you— an intervention like a drug, test, or procedure— you want to know whether the benefits are real and what harms exist.

...interventions to reduce average risks can create as many problems as they solve.

Trying to eliminate a problem can be more dangerous than managing one.

Ask any hospital administrator what their big revenue generators are. They’ll tell you the radiology department, the outpatient surgery center, the endoscopy suites, and the rooms where cardiologists guide these catheters— the cath lab.

Clinicians tend to underreport, not overreport, complications.

...the institutions that tend to do analyses of complications tend to be high-volume prestigious academic medical centers, which tend to be those with low complication rates.

Early diagnosis can needlessly turn people into patients.

...because the promotion of genuine health— largely dependent upon a healthy diet, exercise, and not smoking— did not fit well in the biomedical culture, preventive care was transformed into a high-tech search for early disease.

...this imbalance— the number who could benefit being so much smaller than the number who could be harmed— makes it very hard for screening to help more than it hurts.

...screening doesn't avoid most cancer deaths.

...autopsies have shown that many of us have small cancers that never bother us during life— particularly cancers of the prostate, breast, and thyroid gland.

If mammography was a treatment, we’d never do it. The effect is too small.

One of my gastroenterology colleagues recently embarked on a randomized trial of colonoscopy screening to determine its effect on colon cancer mortality. Believe it or not, it has never been done... He started in 2010; he won’t be finished till 2025.

...we should dump the “screening saves lives” language. We should publicly acknowledge that we cannot be sure whether early detection lengthens, shortens, or has no effect on how long people live. And we should be clear that if it takes so many people to find out for sure, then the benefit must be, at best, small.

...people need to be scared about dying from the disease; they need to be made to feel more vulnerable.

...it’s the harms that are certain, not the benefits.

Of course survival rates go up if you add in patients with cancers that were never going anywhere anyway. Screening gets credit for curing turtles.

I place considerable value on not having my life become medicalized— until my symptoms demand it.

What should you do if your screening test is a bit abnormal? Take your time. Often the best strategy is simply to repeat it in six months. Time has real diagnostic value.

As we try to amass more information about a patient’s symptoms, we increase the chance of stumbling onto something else.

...more information led to more detection of metastases, more cancer surgery, and a statistically unchanged death rate...

Seeking information about early signs of metastatic cancer doesn’t help cancer patients live longer. But it does scare many and leads a few to live longer with the knowledge that they have incurable disease. They are subjected to additional therapies and their toxicities earlier— at a time when they would be otherwise asymptomatic.

Just because you have data doesn’t mean you have information. Having information doesn’t mean you have useful knowledge. And wisdom— well, that’s a whole new ball game.

...the opportunities for physicians to be overwhelmed with data are continually increasing.

Minimizing back pain is less about taking surgical action and more about general conditioning, warming up, lifting technique, and knowing when to get mechanical (and human) help. Back surgery is not a panacea; it’s an invasive operation.

The fact that healing without intervention is possible can be lost on a highly medicalized society.

Whatever benefits are associated with a surgical intervention, those actions are also associated with obvious harms— the risk of infection, cognitive dysfunction, and physical injury.

...doing something concrete may be a way for physicians to compensate for poor communication skills.

...your strategy should be to pose a simple question: What happens if I do nothing?

New interventions are typically not well tested and often wind up being judged ineffective (even harmful).

In the case of marrow transplantation, what was challenging was not the transplant itself— recall, it is not that different from simply giving blood. What was challenging was learning how to manage all the subsequent complications: infection, bleeding, immune self-attack, etc.

A fixation on preventing death diminishes life.

It' hard not to do everything possible.

...breast cancer deaths in women under forty have been cut almost in half. And this is not about screening— this age group is rarely screened; it’s about better treatment.

...my father’s colon cancer, like most colon cancer, was likely a sporadic cancer— simply put: it was bad luck. Given our colonoscopy findings, the best bet now is that my brothers and I are not at elevated risk but at average risk for colon cancer.

I’m on a blood pressure medicine now. Why? Not because I am sure I want to live longer but because I am sure I would like to try to avoid having a stroke.

The reason to be active is less to avoid a heart attack in the future and more to sleep better, think better, and feel better now.

...aggressive intervention in the dying is not only futile, but inhumane.

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