Below an excerpt from an essay by Dr. Nortin Hadlerprofessor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America," "The Last Well Person," and “Stabbed in the Back.”
I am always delighted when Hadler contributes to HealthBeat. He is willing to tell the truth about medical evidence and comparative effectiveness research– even when candor may not be popular. You don’t have to agree with him, but without question, you should read his work. Hadler is not a pundit offering one man’s opinion: his writing is studded with footnotes and links to rigorous medical research.
This post is excerpted from a piece which originally appeared on ABC.com, Health Care Reform: The Difference Between Rationing and Rational.“There Hadler explains why, if a doctor recommends angioplasty, you should ask some questions. At the end of the post, you will find my “Note” on what I find the most intriguing aspect of Hadler’s essay: how to win the healthcare lottery without buying a ticket.
In the United States, well over a million people undergo invasive coronary procedures each year for various manifestations of coronary artery disease including Coronary Artery Bypass Grafts, Angioplasties and surgeries involving Stents.
These are technological advances designed to overcome blocked arteries. They all have technical limitations in that the unblocking or bypassing tends to reverse itself. So there is much invested in the attempt to more permanently overcome the blockage.
There are four stents licensed for this purpose and many in the "pipeline"—and there are many surgical approaches to bypassing. There are also thousands of trials comparing one technique with another to determine the relative fate of the unblocking.
However, I don't care about the fate of the unblocking. I care about the fate of the patient. Is the patient better off for all this technology?
That central question gets lost in the race for technological achievement. There have been strong reasons for doubt for years. Doubt is now dispelled thanks to four recent randomized controlled trials comparing such interventions with medical care without the interventions.
Three of the trials were American—OAT, COURAGE and BARI 2D—and one—RITA-2—was European (these are all acronyms based on the type of heart disease studied). Each recruited thousands of patients and followed them for years. Each recruited a somewhat distinctive population in terms of the manifestations of their coronary artery disease (active angina, after a heart attack, angina and diabetes, etc.), but all recruited patients for whom interventional cardiology was thought to be a reasonable option.
No one, I'll say it again, NO ONE was advantaged by submitting to the intervention. They did not live longer, or have less chest pain, or suffer fewer heart attacks than they would have without the procedure.
When Clinical Science and Clinical Judgment are Dissonant
Not long ago, I attended "Grand Rounds" at a prominent medical school where the professor and director of the Cardiac Catheterization Laboratory was holding forth on the mechanisms by which newer stents can stay open longer. I asked him how he explains the stent option to a patient with chest pain in view of the results of OAT, COURAGE, BARI 2D and RITA-2. He, of course, was aware of all these trials. Even though the trials recruited patients with four very typical patterns of disease, he suggested many patients do not quite fit these categories. He was willing to rely on his clinical judgment to infer that a particular patient would be advantaged because he is endowed with a special level of expertise.
I asked him if he told the patient that his judgment was superseding a compelling science and that his judgment had not been subjected to testing. He ducked the question. As far as I'm concerned, when the precedent is not even encouraging, such an inference demands scientific validation before it is put into clinical practice.
The Lottery Mentality
For me, this is irrational behavior on the part of the patient and worse on the part of the navigator [the physician]. It survives in America because of what I call the "lottery" mentality: "Doc, if you can get me through this and it only works one time in a thousand, I want to be that one. Go for it!" True, someone wins the lottery, even if it's exceedingly improbable. But the science we're considering is not a lottery. The argument that pertains is that the patient is as likely to do as well without the procedure as with it. It would be as if you could win the lottery without buying a ticket.
Furthermore, would the American lottery mentality drive clinical decision making if the patient had to buy the "ticket" instead of all of us sharing its cost? And if we knew the science, would we be willing to share the cost? If not, is that rationing, or rational?
"No discernible benefit," we can free up about half of the finite resource and easily provide rational care and caring for all.
Then we can tackle the thorny issues of interventions that work sometimes or just a little, and of interventions yet to be discovered. If we hold the care of the patient as the entire reason for the enterprise, even the thorniest of issues are surmountable.
Note from mm: I particularly like Hadler’s “lottery” argument.” He suggests that the patient who doesn’t buy a ticket for a lottery which offers him a one in 1,000 chance of winning might actually walk off with the prize.
When I first read the post, it took me a minute or two to understand what Hadler was saying. While Hadler is undeniably right, his argument is counter-intuitive. On the face of it, the patient who says, “Doc, if . . . this works one time in a thousand, I want to be that one. Go for it!" sounds sensible, especially if his insurer covers the treatment. If the patient doesn’t have to pay for it, why not take the shot?
Because every medical treatment and test carries some risks. Imagine a 60-year-old male who decides not to undergo a PSA test for prostate cancer. He lives for another 25 years and never experiences any symptoms of this slow-growing cancer—even though, if he had been tested and a biopsied when he was 60, he would have been diagnosed with early stage prostate cancer. Twenty years later he dies of something else, without every knowing that he has cancer. Like the majority of American men of his age, he dies “with” prostate cancer, but not “of” it.
He has won the lottery while not buying a ticket: He didn’t “buy” the PSA test, and as a result, he never experienced the anxiety of knowing that he had cancer, and he never suffered the side effects associated with treatment for early-stage prostate cancer (which can include incontinence and impotence).
Of course, his undetected prostate cancer might have spread silently and killed him. But the National Cancer Institute (NCI) tells us that “the benefits of screening and local therapy (surgery or radiation therapy) for early-stage prostate cancer remain unclear.”
We don’t have evidence that screening and early detection saves any lives. In fact, initial results from a long-term trial supported by the NCI show that “annual PSA testing for 6 years . . . did not reduce the number of prostate cancer deaths through a median follow-up period of 11.5 years.”
Or, as Hadler puts it, this is a case where “the patient is as likely to do as well without the treatment.” Thus, it makes little sense to buy the ticket, and expose yourself to the risks of unproven tests and procedures.