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Health care by the numbers

Once again I feel the need to reiterate that my comments about health care are personal opinions only, and do not reflect anyone’s positions but my own.

Part of the reason I am so opposed to the private delivery of health care is that the market tends to work on a principle of caveat emptor - let the buyer beware. The problem with this generally-sound skeptical principle when it is applied to health care is that people are not “buyers” of health care, nor can they said to be “consumers” in the same way as someone walking into a hardware store or restaurant. A hefty proportion of our interactions with the health care system are in times of crisis, meaning that it is unreasonable to expect us to do the kind of cold, rational calculus that one might expect of someone choosing a realtor or a bottle of fine scotch.

Congruent with this issue of need-based service consumption is the incredibly high bar of education required to understand how the health care system works. Most people are capable of understanding a basic supply chain, and can usually navigate the hoops needed to ensure they don’t get screwed on a car loan or a warranty on their stereo (although not always, which is why we have consumer advocacy and protection groups). The kind of education needed to understand health care is, to put it mildly, extensive. Regardless of which country you live in, health care systems are often fragmented and convoluted. Even those who work within the system have difficulties navigating it – how could a lay person possibly expect to do better? This question becomes more acutely important when you consider the fact that those laypeople are in crisis while trying to do it.

It is for this reason that we are best served when treatment decisions are made based on the evidence, as interpreted by people who are educated enough to understand it. While it seems unfair that your medical care might be guided by someone you’ve never met, it is far preferable than being pressured into decisions you don’t understand – particularly at a time when you are particularly vulnerable to either manipulation by outside agendas that may not have your best interest in mind, or when you are psychologically less able to make rational, informed choices. While patients must have the right to make the ultimate choice about their care, we are best served as individuals and as a system when the choices available to us are based on the best evidence rather than our own ‘best guesses’.

Well, maybe not if you ask this guy:

In Tuesday’s column about the new guidelines for breast screening, I related how my wife discovered her own breast cancer using self-examination and mammograms: the very tools the federal review panel that formulated the new guidelines had dismissed as being ineffective. My email inbox filled with testimonials from women who went through the same experience, and who expressed nothing but scorn for the new guidelines – guidelines, I believe, which will not be adopted in B.C.

(snip)

While the panel maintains that the efficacy of self-examination and mammograms is statistically negligible – regular biannual mammograms might save a single woman out of 2,100 – the chance of being that single woman carries incalculable emotional weight. My wife’s case was “very, very rare,” according to Tonelli? Easy for him to say. I say: She is my wife, not a statistical anomaly. Not many women want to take the chance of being that statistic. If, in the estimation of the review panel, women put an irrational and unfounded faith in self-examinations and mammograms, it wasn’t because they were calmly calculating their odds.

In this emotionally-charged opinion piece (gallingly titled Individual Lives are More Important Than Statistics - I wonder if the author knows that statistics are made up of individual lives), the author decries the very idea of making policy decisions based on evidence, but instead demands magic bullets and foolproof screening systems. He feels justified in eschewing the idea of evidence-based medicine because he knows people who are exceptions to the rule, therefore the rule must be flawed.

This piece is in reaction to newly-released guideline recommendations for breast cancer screening that suggest, based on the best available evidence, that breast self examination is not useful in detecting cancer, and that annual mammograms may not be useful in low-risk women. There is, as with any medical screening technique, a rate of ‘false positives’ – results that look like disease but actually aren’t. Those, when coupled with the increased risk of cancer that accompanies mammography (due to radiation exposure), mean that there is a point at which screening is not effective at reducing cancer at an aggregate level. Yes, there will always be some exceptional cases – my own mother’s breast cancer occurred before she reached the age of 40, but there is at present no foolproof way of discerning where those cases will come from. The best we can do is make clinical guidelines based on the evidence we have, and do our best for the exceptions.

While these guidelines were not made on economic grounds, I feel it prudent to point out that the reduction in unnecessary screening frees up machine time, physician time, and financial resources, that can be re-allocated to better serve patients with confirmed cancer. Those women are individuals with needs as well. Insisting on delivering inefficient care based on emotive reasoning and anecdotal evidence is certainly not helping them at all. Nor will it help the women who develop cancer or have an unnecessary surgery because of misguided insistence on administering health care based on feelings rather than numbers.

I am relatively sure the main thrust of the opinion piece was supposed to be that the guidelines need to be communicated expertly to women, particularly those who would not be eligible for screening under the new scheme. There is a conflict between the statement ‘screening prevents cancer’ and ‘you don’t need screening’ that requires the same kind of education needed to understand the system to tease apart. If you’re not an expert, it’s important that someone who is an expert takes the time to help you understand why the new recommendations are in place. However, taking those experts to task because you don’t like reality is definitely unhelpful.

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Comments

  1. thaismcrc says

    Thank you for this! This is one topic which I find especially annoying. My mother is an epidemiologist, so she could explain to me the reason behind these recommendations. All too often, though, there are (admittedly well-intentioned but entirely misinformed) people telling women to self-examine and get yearly mammograms in the guise of “raising breast cancer awareness”. This is a very good post to point them to.

  2. Tisha Irwin says

    If we can use anecdotes as susbstitutes for evidence, here’s one: a few years ago my mother had a mammogram which showed something. After going through two very painful (and expensive) needle loc biopsies (because they missed the first time) all they came up with was scar tissue, possibly from the mastitis she had while breastfeeding me 37 years ago.

    Therefore the risks outweigh the benefits and mammograms should be abandoned.

    I’m glad to see that someone else is as dismayed as I am about the notion of patients being consumers as if they’re just buying a pair of jeans. I’ve worked in health care since I was 16 and that totally rubs me the wrong way.

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