Distinctive features of American culture include a strong commitment to business models of economic activity, a high correlation between income and prestige, competitive drive, and a rejection of fatalism. The medical profession, like the legal profession, has embraced a business as distinct from a professional model of service. In a business model, success is measured by profit. Physicians embrace opportunities for increasing their incomes by increasing the demand for their services.
The only folks I know who eschew the profit motive are mendicants. I know because I spent time in a Franciscan seminary where poverty, chastity and obedience were demanded. Never had a problem with the first two but it always was that obedience thing. Back to Posner. He seems to imply that physicians should do what they do for some charitable reason. Ever see what Harvard charges per year recently! How about insurance rate recently. Rent, staff, and the list goes on Judge. So why denigrate the physician when it come to profit as a measure, we are in a capitalist country. As a physician you can't even get away with a parking ticket, except in NYC, where I really do not think many make house calls anymore.
Now as to the book he references, Overdiagnosed: Making People Sick in the Pursuit of Health, it is in my opinion a simplistic presentation with many good and ever so many weak points.
Let me make a few:
1. Prostate Cancer: I really love it when physicians recount their clinical experience without adequate understanding of the literature and I suspect this may be the case here. As we have argued and written the Prostate Cancer problem is one of a complex nature. I have seen patients with HGPIN regress to fully benign when statistically that almost never happens and usually 25% of the time the next biopsy is PCa. Why does this happen, well frankly we do not know, yet. The pathways are now better understood and their full identification and dynamics must be understood and then we hopefully will understand. The path forward is understood. Yet that fact seem lacking in both Posner and in the authors of his reference book.
2. Melanoma: Let's face it, this kills and kills quickly. If one has the slightest predisposition to the disease then it is mandatory for semi-annual dermotological examinations with dermoscopy at least and removal of any suspicious lesion with biopsy by a highly competent dermatopathologist. Otherwise you just will die a horrible death for want of a $75 procedure and $150 biopsy. Pay it out of your own pocket if necessary and do not listen to the Judge.
3. Colon Cancer: Colonoscopies work, especially if you have a first degree relative who had the disease. Get the polyp, one every 3-5 years, and it costs $1500-$2000 and that is less than five years of oil changes in one car!
4. Breast Cancer: Yes mammograms work! Need one say more.
As to the other measurements, the best advice is to stop smoking and lose weight. Those two things alone will reduce hundreds of billions from our health care. Let me give a simple example. A physician can have a significant influence on some patients, say those who are obese and have Type 2 Diabetes due to their obesity. First the physician can recognize this and second if the physician will deal with the problem rather than the symptom, use their relationship with the patient to get the patient to reduce their BMI and thus rid themselves of the Type 2 Diabetes. The worst thing often is to treat the symptoms by using drugs and allowing the patient to migrate from metformin to insulin to kidney failure!
An set of examples where the philosophy proposed in the above mentioned book appears to be practiced, namely England and its medical establishment, results in the highest mortality rates from cancer in the developed world. A recent article in the UK Mail states:
A quarter of cancer sufferers are being sent away by GPs with their early warning signs dismissed as minor ailments, a study reveals today...Tens of thousands of patients are initially told that their symptoms are ‘nothing to worry about’ or advised to take painkillers or antibiotics for months....They have to make repeated trips to their doctor before being given a correct diagnosis, the report concludes.
My point is that we are in the midst of a drastic change in health care. Genetics using pathways and marker genes will play a dramatic role in diagnosis and staging. Being able to integrate those will be the essential factors. Then using genetic tools to treat the diseases will follow. Telling people not to go until you are passing blood rectally for six months or until that mole is 3" wide with an irregular border and bleeding will only send us back several hundred years. One need look say to Harrison's 5th in 1966 and see where we have come from! The Judge perhaps should also deal with facts in which he has some detailed demonstrated expertise, and perhaps this is not one of those areas, perhaps, I really do not know.
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