Ignorance is Difficult to Treat

Filed under: by: Hey Doc Wait

These two articles point out that the American public and the medical establishment do not see eye to eye at ALL on health care. Kent Bottles' article refers to this Kaiser Family Foundation article comparing polls of "experts" and "the public" regarding health care costs.

I realize it's a tough sell to ask someone NOT to undergo screening for cancer. The very word "cancer" strikes such fear into our hearts that people rush out to get tested. It is a tough sell to say to people that they may be in a low risk group, and that even if they test positive the cancer may not kill them, etc. A gentleman patient I treated a while back had asked for (and received) a total radical prostatectomy for localized, lower-grade prostate cancer, thus leaving him with erectile dysfunction and urinary incontinence for the rest of his life. His risk of dying of this cancer was low, but his fear was such that he traded his ability to hold his bladder for the rest of his life.

Another patient I treated as an outpatient came to me after a lengthy hospitalization. This person has moderately severe dementia (able to know their name and sometimes where they are, unable to dress themselves, bathe themselves, or otherwise care for themselves). This person came to my clinic after receiving a screening test for colon cancer--screening because this patient was asymptomatic--that was positive. Patient had a small cancer removed by the colonoscope but was referred to the oncologist "just in case". Onc recommended simply observing by scope, but somehow the patient was already referred to surgery. Surgery inexplicably (to me) performed a colectomy on this patient, who now has a colostomy and spent a long time (months) in rehabilitation. This patient's life expectancy was already likely less than 3 years, given the advanced dementia. This patient was also asymptomatic from a small cancerous polyp, which would not likely have started causing any problems for several years. Now, the patient is cancer-free, but also has a colostomy bag that requires extra care. We did not improve this patient's quality of life or extend their life by this procedure; in fact, you could argue that we decreased the qualify of life by adding the colostomy and depriving the patient of time spent outside the hospital. The patient did not likely ever understand the diagnosis, and was unlikely the one pushing for radical treatment... *sigh*

I don't mean to say that patients with dementia, or any other condition, or simply elderly patients, should be discriminated against. If this patient had been symptomatic, fine, do what you need to do. Life-saving treatment should be offered unless there is a valid DNR order or it is refused. But screening should be used judiciously for those who may actually benefit from it--the otherwise healthy and asymptomatic who are likely to survive for some length of time into the future AND who are likely to have increased survival odds should a small cancer or disease be found early. The diseases where this is the case are few and far between. There is a reason we don't routinely screen 20 year old women for breast cancer--the odds are extremely small (though non-zero) that any one of these women will have cancer; we are not doing the population as a whole any favors by overscreening this group. For that matter, health care dollars are limited. If we spend all of our money screening every single citizen for every single disease we can think of, we will have no money left for treatment or prevention (perhaps an over-dramatization, but you get my point). Screening should get the biggest bang for the buck.

Let's put this article on the front page of the NYT: "Overscreening Causes Hairy Palms, Anxiety, Insomnia, Heart Disease, and Hemorrhoids". Perhaps the public, and we as citizens of this country with such a large amount of debt, should be taught to be more afraid of over-using screening tests, and less afraid of the bad cells hiding in our bodies whether we find them with screening or not.