Is the advice of a skilled medical
professional who knows you, cares about you, and sees you regularly,
worth anything? According to one of the NYT's anointed medical
columnists, Ezekiel Emanuel, the answer is no.
http://www.nytimes.com/2015/01/09/opinion/skip-your-annual-physical.html?ref=todayspaper.
It will be hard for me to obscure my
disdain for Zeke Emanuel. His arrogance is apparently familial. He
doesn't seem to question his blinkered viewpoint of an academic
administrator, an academic specialist as an oncologist, and his
reflections on his role in shaping Obamacare seem always to be
defensive – what we did was unalloyed good, and the best that could
be had. He must be a politician of the “admit no mistakes”
school. Although everyone does
admit that he is smart, I have to say.
Zeke
argues in this article that the yearly physical is an invalid
procedure, something to be avoided. He says that “research shows”
that little significant disease is discovered – “the annual
physicals did not reduce mortality overall or for specific causes of
death from cancer or heart disease.” He casts doubt on the value
of early detection of disease. He implies that too many tests and
studies are ordered by the doctors at a yearly physical. He says
that these visits drive up health care costs. He compares the visit
to an automobile service, but with fewer positive results. He
denigrates the value of the doctor-patient relationship.
What a
turkey he is.
First,
let's look at research. If you want to prove something is worthless,
the best tactic is to posit an end result that is either impossible,
impossible to measure, or just not the reason that the thing is done
in the first place. And if you are to practice sophism, make sure
you simply assume that the goal of the procedure is what you want,
not what the practitioners want it to be.
So,
Zeke – remember, he is an oncologist who treats severe disease –
assumes that the primary goal of the annual physical is to detect
cancer (or, possibly, heart disease or something else) early. Then
he says there is no evidence that the annual PE does this, and that
screening asymptomatic populations is not a good procedure. Yes,
Zeke, it's not good for cancer detection – except for mammograms
and Pap smears, and I would say PSA in the hands of good doctors.
Not that early detection doesn't happen – it does, it does, and it
can save lives. Maybe not “cost effective,” but that's another
argument. But Zeke – that's not the purpose of the periodic PE.
The
purposes of the periodic PE are several. Health promotion and
prevention are important objectives – maddeningly derided by Zeke
as something he can do himself. Surveys show that the leading
motivation for smoking cessation is recommendation by a doctor. Yes,
we know “we should.” But when a doctor talks, we listen.
Likewise for weight loss, exercise, and healthy eating. Zeke might
say “I don't need no stinkin' primary care doctor,” but most of
us really do.
Moreover,
where exactly are we supposed to find out if our cholesterol and/or
our blood pressure are too high? Careful questioning and screening
can reveal depression, a condition with high prevalence, and
eminently treatable. Alcohol addiction can be detected and discussed and treatment begun. Even as a general pediatrician I routinely
inquire about the state of the parents' marriage, knowing that this
is the most consequential condition for child health, and that once
again, intervention can make a difference.
Measuring
the results of health promotion and prevention is terribly difficult.
In cancer it's pretty easy to distinguish useful from worthless
therapies. But healthier lives are hard to identify in themselves,
and the effects of prevention can be felt so far in the future that
research can fail to find it. No one has done in depth studies of
the results of close relationships with a primary care doctor, and I
don't know how it could actually be done. For Zeke to place the onus
of proof of effectiveness of primary care on those who practice it,
according to his own rules of science, is outrageous. Prove that a
caring parent is necessary for a child, why don't you, and banish
them all to orphanages if you don't find that it is cost-effective.
His “science” is suited to him, and he wants to use it on
everything, which just coincidentally puts him in the driver's seat.
Actually, probably the worst sin of
Zeke's jeremiad against PE's is his denigration of the doctor-patient
relationship. Particularly in our world today, what is the value of
being cared for? What is the value of having a serious professional
who knows you well and who cares, who is on your side, paying
attention to you, and helping you with your health in sickness and in
health? The cyber-billionaires contend that 80% of what a doctor
does will be supplanted by computers – you think? You think that
what a doctor does is to reason all day? This is personal,
gentlemen. We have a need to be cared for, and this is not
irrational. There are choices to be made, there are feelings to be
accounted for, and one size does not fit all, at all.
Finally, how specious is the cost of
care argument! One of the first things I learned in the Public
Health Service was, if someone says they can't do something “because
of the budget,” it means they don't want to it. The budget is
generally an excuse. In health care, we know that high costs reside
in specialist care and hospitals – and remember, “costs” are
related to “price,” which is highest by far in the US compared to
Europe, probably especially in cancer care for all I know – not in
primary care. Cut costs in primary care and you have accomplished
very little except degrading quality, Zeke. Look to your own
institutions if you want to cut costs. Gore your own calf, why don't
you.
Let's once again revisit where Zeke
sits – he is an influential voice in establishment medicine. All
too many establishment policy makers truly believe his
self-interested point of view. Prevention and health promotion are
not sexy and not remunerative, and not what the academic centers
interest themselves in. Training for prevention and health promotion
in internal medicine and even family medicine are usually deficient.
Even in these potentially primary care producing training programs,
more and more subspecialists continue to be churned out, with fewer
and fewer primary care docs. As a result, fewer and fewer practicing
primary care docs have less and less time, training, and attention to
spend on periodic PE's.
The biggest structural problem in the
health care system of the United States is too much specialty and not
enough primary care. Zeke Emanuel would do well to support primary
care docs in their tasks rather than to attack their rationale.
Budd Shenkin
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