Tuesday, January 17, 2006

Bio-Medical Technology- Label Should Read- “Only Miraculous if Used Properly”

“Symptom” four in my six-point diagnosis of why our US Health Care system is collapsing as put forth on my Jan 3 blog that refers to the
of our Health Care crisis is America’s love affair with technology. Let me begin with an important-very important-disclaimer. I am not nor ever will be an anti-technology Neo-Luddite. Modern bio-medical technology is truly nothing short of miraculous in that suffering is relieved and lives are saved every single day. But as Cervantes, my partner on this blog, has pointed out any technology is simply “tools” and tools alone need humans to be used properly and tools alas are value neutral. Who could possible argue with the benefits of the discovery of penicillin, the smallpox vaccine, the discovery of insulin and the first x-ray and EKG machine just to name a few among hundreds of breakthrough technologies over the past 200 years let’s say. In more recent times one can cite kidney dialysis, in- utero fetal surgery, in vitro fertilization and anti-viral drugs for AIDS patients. Pretty impressive on its merits by anyone’s standards.

Well- here’s the rub. It’s good ole “US of A” excess and greed that causes technology to “bite back” if you will. (Edward Tenner’s phrase in Why Things Bite Back : Technology and the Revenge of Unintended Consequences (Vintage) (1996). Well folks, what do you expect from an adolescent culture that only @ 230 years old? I guess I first learned of the “revenge of technology” (another Tenner Phrase) first from Mary Shelly’s Frankenstein (movie c1931) and Stanley Kubrick’s rogue computer HAL who made a power grab on its human keepers in his movie 2001:A Space Odyssey (c1968) But my real education came in bio-technology from going to medical school in the late 1960’s in Philadelphia. Something didn’t quite compute in my brain as I witnessed the ravages of ghetto life on patients in 95% plus black north Philadelphia only to go home for my evening meal to watch the body count figures from Vietnam coming through the TV. Yet neither of these dominant cultural factors were mentioned by my distinguished and, I’m sure well meaning, Professors of Medicine and Surgery as they spewed forth on the latest technological advances in their give specialties. Hmmmm? I thought “something ain’t right here?” Then a medical student friend of similar cognitive dissonance several years later introduced to Ivan Illich’s groundbreaking work called Limits to Medicine: Medical Nemesis, the Expropriation of Health (1977). Tenner’s book on the revenge of technology which had two chapters on medical technology lead me too Diana Dutton’s book Worse than the Disease : Pitfalls of Medical Progress (1992). These books, in addition to partially validating my sanity in the insane world of US medical education the late 1960s, provided evidence that excess unbridled technology in medicine could and indeed does in fact cause harm. In 1999 I came across a paper in JAMA by Drs Elliot Fisher and H Gilbert Welch from Vermont (Dartmouth and VA Medical Center in White River Junction, VT). In that paper (Avoiding the Unintended consequences of Growth in Medical Care-(JAMA Vol. 282-No 5 Feb 3,1999) these authors put forth the radical proposition that in medicine more might actually be worse? Sounding somewhat similar to part of an oath I took on the first day of medical school written by a guy named Hippocrates that “first I was to do no harm” (actually in oath-“abstain from whatever is harmful or mischievous”) I was intrigued. These two authors put forth the compelling hypothesis that the law of diminishing returns might indeed apply to medical technology and at some point on the medical supply curve additional technology might in fact leads to harm! Ouch! That’s anti-American to believe that technology might not be the only answer to our woes and that the frontiers of bio-medical science might actually reach an l end point.

But we are a can do US culture with infinite limits I thought? Well fast forward the 21st century to the race for new pharmaceuticals that work better and safer than old ones and the hyperbolic promises of the Biotech Industry which, in my humble opinion, provide more very expensive hype than hope. Could it be that “can do” Americans might actually suffer from an excess of hubris? Furthermore, we all know that bio-medical technology ain’t exactly cheap with expenditures attributed to technology accounting for perhaps as much as one-half to two-thirds of cost increases above general inflation of our 1.9 trillion dollar Health Care (whoops Diseases Care) price tag.

Let me provide just one example where biomedical-technology has gone awry. Have you ever had an MRI or Medical Resonance Imaging test for perhaps a pain in your back? (You know that’s the one where you are slid into a hole in a huge clanking noisy metal magnet that surrounds your body) Well if you are an American adult citizen above the age of 40 years of age you are among the thousands perhaps millions who have had an MRI test at 3 to 6 hundred dollars a pop (conventional vs. rapid MRI). That’s a whopping MRI bill we ALL pay for. At a projected $100 billion annually, diagnostic imaging is one of the fastest growing cost areas in American health care. Outpatient imaging procedures increased 44% between 1999 and 2001and spending is expected to continue to grow at an annual rate of 20% or higher.(To get the best numbers for 2004 you have to fork over $7,750 dollars for a well researched marketing report) Maybe you have had several MRIs?. Now mind you MRI technology is good- but it is actually “too good”. In scientific terms this test is too sensitive producing what we call “false positives”. Fully 90% plus of MRIs in patients above the age of 40 have “positive findings” on MRIs and many patients get treated for these findings. Wouldn’t it be cheaper to ask the patient what year they were born and prescribe the same treatments? Or even better to allow for spontaneous healing to occur? My point being this diagnostic technology is diagnosing “getting older” But the diagnosis of “getting older” doesn’t pay much by insurance carriers or other third party reimbursers. So we medicalize the aging process. Many MRI positive patients, especially older back patients go on to have failed surgeries leaving them often more disabled and in more pain than had they been smart enough to not bother to get their MRI in the first place. This is just one instructive example of the how excesses of technology can backfire from health outcomes, human suffering, and economic perspectives. We all bear the dollar and human costs of these diagnostic and therapeutic misadventures. (The truly abusive application of excessive technology applied to the dying deserves a stand alone essay)

In my Holistic Model of Health Care noted in my recent blog on Reductionism I state and deeply believe that a high technology based health care system while not inherently bad is also, to put it simply, incomplete. Integrating the input of competent and values based colleagues from the behavioral and social sciences as well as ethicists, theologians and economists will ensure that our miraculous technology is leveraged to achieve the greatest good for the most US citizens. And that is what I call “Technology Plus” medicine”. This is the medicine we needed yesterday and beginning tomorrow before rigor mortis sets in on our truly moribund disease care system, which by then will surely be too little to late.


Anonymous C. Corax said...

You're talking (almost) about me here. Woke up one mid-November morning with a pain in my leg. Felt like tight muscles so I figured it would stretch out. Come March, I decided I'd better see my doctor. It was a good day, so when he lifted my leg to get an idea of range, it didn't hurt. Sent me to a physical therapist/chiropractor (covered for 90 days, then out of pocket after that). Maybe slightly better, but not significant. She said I needed an orthotic, and a neighbor/friend of hers just happened to make them (I paid out of pocket). Several people swore by acupuncture. I signed up (I paid out of pocket). It had absolutely NO effect. Snake oil. PT recommended Pilates. Signed up. Yup, out of pocket. To help me deal with the pain, which began to increase again, I was on pain killers. Since my doc is a friend, he did everything he could to save me money, so I was on samples he'd gotten for several months so it wouldn't cost me: Vioxx. I do not like using medicine stronger than aspirin, but I needed the wallop that the toxic stuff packed. Pain kept getting worse, couldn't take the bus to work it took me so long to get dressed, spent more and more time lying down at work, cried from pain on the way home. My doc insisted I get an MRI. Ruptured disc, calcification, and a chorus of "don't get surgery!" from the PT and the Pilates teacher. I was guilt-tripped for thinking about surgery. I was told "some people don't tolerate pain as well as most" (the message being I'm a wimp, I suppose). PT didn't want me to see the surgeon I saw ("he always recommends surgery"), but someone else less inclined to recommend surgery. My doc was furious and called her. Next time I saw her, she said, "Oh, I guess you need surgery."

I had a microdiscectomy. Overnight stay. $5000 total, covered by insurance. Best thing I ever did, and I wish I had listened to my doctor instead of putting it off for several months.

I probably spent $1000 to $1500 out of pocket on useless alternatives, endured months of pain, had to take pain medication in order to function well enough to try the alternatives, and had to endure insuations about my character from the purveyors of the alternative medicine for even considering surgery.

I'm lucky that I could afford (by running up credit card debt) to try the alternatives. But they did no good whatsoever and the guilt tripping has left a very bad taste in my mouth about people who say alternative medicine is the "best" way to go.

7:03 AM  
Blogger Blake said...

c corx- thanks for sharing. I won't, as MD, e-comment on specific cases in this blog sufficed to say glad your outcome was good. I am not anti- MRI or anti-surgery. But both are definetly done to excess.Patient and Provider selection are key. Be Well :)

PS-Acupuncture happens to be one of the few alternative therapies that is very well studied. It is definitely not "snakeoil" just because it did not work for you. :)

8:26 AM  
Blogger Blake said...

Dr. Nortin Hadler contacted me and reminded me that he covers this general topic in some depth in his incredible book "Last Well Person: How to Stay Well Despite the Health-care System" He also reminded me of an excellent Editorial he wrote for JAMA on "MRI for Regional Back Pain-Need for Less Imaging, Better Understanding"
JAMA -Vol. 289, No. 21 June 4,2003 Thanks Nortin! You are reminding us that some of the mainstream organized medicine journals are finally coming around? :)

12:20 PM  
Anonymous C. Corax said...

Sorry. I didn't mean acupuncture was/is snake oil. I've heard enough about successes from people I trust to believe that it does work. The woman I saw, however, had quite the sales pitch...

Honestly, if I could have functioned long enough--and had enough money--to find a non-surgical way to get better, I would have done so. Under the circumstances, however, I thought that surgery would be more benign than continuing to ingest pain meds in order to be able to put on my shoes in the morning. When news came out about Vioxx, I knew my hunch had been correct.

6:47 PM  
Blogger Blake said...

yea- good choice- under those circumstances- :)

12:35 PM  

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