Thursday, May 10, 2012

Do No Harm in the Third Age of Medicine

The Doctor- Luke Fildes 1891

We are in the third age of medicine.

The first age ended in the 1930's with the development of antibiotics. Before then, the best doctors took Hippocrates's dictum to heart with the understanding that the profession really did not have much to offer the sick. Their principle tools were 1) First, do no harm--making sure their limited efforts, however well-meaning, weren't part of the problem. 2) Prognostication--explaining the course of disease and so enabling effective planning, estate management for the rich, choosing who will pick up the chores for the poor. 3) Relief--doctors could amputate and dress a shattered leg, as well as provide opiates to relieve pain. Though not cures, they were quite helpful. 4) Comfort--As a profession dedicated to the sick, often they were the only ones whose job description included tenderness and care.

The second age of medicine began with the advent of antibiotics in World War II. Suddenly, doctors actually had treatments to offer, a few cures that beat back some true scourges of mankind. Beyond vanquishing the streptococcus, antibiotics swept aside the sordid record of patent medicines to prove the concept that chemicals could be empirically be marshaled against any threat to health. In this second age of medicine, doctors were able to offer more and more treatments that actually worked against disease. Their jobs of prognostication, relief, and comfort were downsized. Instead, doctors's proper course was to stop doing house calls and set up clinics to efficiently distribute these treatments.

It's not clear when the third age began, but I will date it to 1997 when the FDA essentially green-lighted direct to consumer advertising of pharmaceuticals. Since then, drug companies have set the standard that is defining the age, and the standard is this: Broaden the market for your intervention by convincing people that they have a disease in need of your therapy. This is done explicitly by Big Pharma as they medicalize the slings and arrows of fortune, outrageous or otherwise, by creating diseases through multibillion dollar advertising and lobbying campaigns. It may also be done implicitly by well-meaning providers who conveniently conflate treatments and revenue streams. In this third age were face the paradox of witnessing the genius of modern medicine from our living rooms, illustrated with the best computer animation and doctors smiling serenely in their crisp white coats, while being told that our nation's health is second rate and threatening to bankrupt the leader of the free world. With the cost of unnecessary care estimated at $700 billion, this third age could be called the age of overtreatment.

What is the physicians' proper course of action in this third age?

Oddly enough, it is a lot like that of the first age: First, do no harm. The great challenge to physicians is to shield their patients from unnecessary treatments. They must stay up to date on which treatments don't help patients (PSA testing doesn't reduce prostate cancer deaths, coronary stenting doesn't prevent heart attacks better than medicines), and they must make sure their patients don't receive them. Doing so involves avoiding the tests (PSA) as much as the interventions (an elevated PSA in the chart can lead a different physician to perform the harmful biopsy and surgery).

Perhaps more startling in this age of overtreatment is the presence of undertreatment. In a heart disease center of excellence, patients are in fact more likely to get a stent and less likely to get aspirin, even though aspirin actually has the strongest track record of preventing heart attacks. Unfortunately, unlike drug-eluting stents, we've been using willow bark (from which aspirin derives) for quite some time, and no one makes money off a glossy commercial highlighting its effectiveness.

In the third age of medicine, doctors must recapitulate the first age: 1) First, do no harm by making sure we aren't a $700 billion part of the problem by shielding patients from private interests, and make sure they get the care, and ONLY that care, that they truly need. 2) Prognosticate so that patients can make informed choices, abjuring the rabbit hole of tests and treatments that may only be helping someone else's bottom line. 3) Never substitute tests and procedures for the provision of relief and comfort, which are timeless interventions that never age.

For more on this issue, see


susan said...

Thank you for a simple, clear explanation of the role that overtreatment plays in running up our nation's health care tab - hurting our state and federal budgets, not to mention our household finances.

As you've said, it's time for all of us to look in the mirror and see what role we play and how we can transform our understanding if we are to transform health care.

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