Wednesday, August 1, 2012

The Paradox of Medicine -- Why More is Not Always Better

I am in the process of writing a new book so it takes a lot to divert my attention.

Dr. Sanjay Gupta's brilliant OpEd in yesterday's New York Times, "More is not always better in medicine," which has been reprinted on  not only have I read and reread but it deserves a commentary. Unlike Andrew Hacker's OpEd, also in the Times, to which I, and many of my colleagues, had strong negative reactions, I applaud Dr. Gupta's brilliant OpEd.

Of course, the OpEd title itself intrigued me,  especially the part --  more is not always better.  Although his OpEd  is focused on medicine,  it reminded me of  the Braess paradox in transportation and the Internet -- when adding capacity can actually make everyone (travelers, or computer messages) worse-off in terms of travel time. In that context, we also speak of the price of anarchy, which seems, to me, also very relevant in the medical context.

His OpEd begins with the doctor's oath:  "First, do no harm," and notes that, whenever a medical professional makes a mistake that affects a patient, this oath is violated.Coincidentally, this past Sunday, in holding a second and belated graduation party for my daughter, a mother of a fellow Deerfield Academy graduate, remarked to me, that, as a child of doctors, she would regularly hear: "Do no harm," and, interestingly, she brought this up in talking about college guidance counselors (I may cover that topic in a future blogpost).

Dr. Gupta's  major thesis is that, in practicing defensive medicine, with many more tests given to patients and medicines prescribed, patients are being injured, since the former  may result in false positive results with infections and other complications possibly occurring and the latter may result in allergic reactions, or inappropriate treatments (and he gives examples from his own experiences).

According to Dr. Gupta:

It is a given that American doctors perform a staggering number of tests and procedures, far more than in other industrialized nations, and far more than we used to. Since 1996, the percentage of doctor visits leading to at least five drugs' being prescribed has nearly tripled, and the number of MRI scans quadrupled.

Each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error. 
Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24% of the tests they ordered were medically unnecessary. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

He cites the horrific, tragic death of 12 year old Rory Staunton, who died in NYC due to an infection that was not properly recognized and  treated.

Dr. Gupta eloquently argues for medical quality assurance through M and M's -- Mortality and Morbidity meetings in which medical professionals regularly discuss what has transpired in their hospital/practice, etc., so that proper procedures can be followed and lessons learned from mistakes made.

My colleague, Dr. Soren Bisgaard, who passed away in December of  2009 of lung cancer, attributed to his childhood spent hanging around the shipyards of his native Greenland, edited a volume, "Solutions to the Health Care Quality Crisis," published in 2009.  

A few years back, Dr. Gupta withdrew his name for consideration for the US Surgeon General position..Perhaps one day he will reconsider -- although he already is doing incredible work not only as a practicing neurosurgeon, CNN commentator and reporter in the field, but also as a  brilliant writer.

It is truly frightening that, when people are most vulnerable,  that is, when they are sick, that those that they trust and depend on  -- the medical experts -- may let them down.