Not so long ago, patients went to doctors only when something was bothering them. But then came the rise of preventive medicine the idea that it was the job of the physician to search for diseases and treat them before they caused symptoms.
Recent studies have pushed this view further, suggesting it is necessary to decrease blood pressure and cholesterol to levels ‘well below those previously considered normal.
But must I, as a doctor, always be proactive with my patients? How did medicine go from providing physical relief to a search mission for potential harms? And is it ever acceptable for my patients to tell me that we should just leave well enough alone?
The impetus for seeking out early disease came from public health. When health officials dealing with tuberculosis in the early 1900’s began to trace the contacts of sick people, they were able to find many early cases of the disease. On average, these patients with early diagnoses did better.
The American Society for the Control of Cancer, later the American Cancer Society, developed its list of “danger signals” in the 1920’s. The message was clear: unexplained lumps in the breast or elsewhere, or seemingly innocent bleeding, needed to be quickly evaluated by doctors. Early cancers, it was argued, were more curable.
After World War II, the Framingham Heart Study solidified the “risk factor” model of disease. People with high cholesterol, diabetes and a smoking habit, the study found, were more likely to have heart attacks and stroke.
Thanks to Framingham, eliminating cardiac risk factors has become a basic component of medical practice. In part as a result of these efforts, mortality from heart disease has declined significantly.
In recent years, our ability to discover information at early stages has rapidly increased. Some healthy people now undergo full-body C.T. scans, assuming they will discover early, treatable diseases.
The world of genetics offers even gjeater possibilities. It is now possible to find genetic mutations that make people more likely to develop certain cancers. But there is no guarantee that discovering a mutated gene will prevent them from getting or dying from cancer.
So how far should we push in our search for potentially harmful disorders? One potential answer lies in evidence-based medicine, which relies on sophisticated studies to determine what’s effective. Although “evidence-based” sounds definitive, available data on a given procedure or treatment may still be disputed.
The recent studies are a perfect example. A paper in The Journal of the American Medical Association found that treating patients, whose blood pressure readings were in the range previously considered normal, lowered their risk of cardiac problems, like heart attacks or stroke, by 15 to 31 percent.
Other studies have recently suggested that the target readings for L.D.L. cholesterol, the type associated with disease risk, should be 80 to 100 units, rather than under 130, as previously recommended. A study published in The New England Journal of Medicine found that cardiac patients receiving aggressive cholesterol treatment had death rates 28 percent lower than those receiving standard therapy.
What should patients do? It depends on whom you ask. Dr. Jonathan Sackner-Bernstein, a cardiologist at North Shore University Hospital on Long Island and the author of Before It Happens to You argues that these are exactly the sort of statistics that should encourage people to be proactive.
Dr. Sackner-Bernstein, who has donie researeh and given talks for drug companies [editor’s emphasis], goes so far as to advise patients how to persuade reluctant doctors, suggesting that they tell the physician, “Since our goal right now is the optimal benefit-to-risk ratio for me, and not society, I wanted to talk to you about getting my cholesterol profile to optimal levels.”
Dr. Sackner-Bernstein makes a similar argument for aggressive treatment of high blood pressure. His book, he tells readers, has a simple goal: to save their lives.
Yet for every Dr. Sackner-Bernstein there is a Dr. H. Gilbert-Welch, an internist and epidemiologist at Dartmouth Medical School and the author of Should I Be Test Tested? Studies show, Dr. Welch argues, that mammography; testing for prostate specific antigen (P.S.A.); and other cancer screening tools often lead to ambiguous diagnoses and unnecessary treatment.
Dr. Welch challenges what he calls the “culture of medicine,” questioning the “widespread presumption that it never hurts to look.” Patients, he believes, should be skeptics, asking their doctors: “Why are you ordering the test?” “Has there been a randomized trial of screening for this?” “What will we do if my test is positive?”
What then should I tell my patients? I increasingly find myself discussing with them the kind of people they are: are they “seeking,” who want to know every possible piece of information and try the latest treatments or are they “waiters,” who want more data before acting?
When the statistics are ambiguous, both options may be good ones.
Reprinted from New York Times