Healthcare Should Not “Be About Prevention”

The last several years has seen dramatic changes implemented to the American healthcare system. In addition to the passage of the Patient Protection and Affordable Care Act, the President’s flagship piece of legislation (known colloquially as “Obamacare),” into law in 2010, we have seen a paradigm shift in how healthcare is delivered to patients in this country. Physicians and hospitals are more committed than ever before in attempting to provide the most efficient care possible; that is, minimizing a patient’s length of stay in a hospital, reducing the amount of patient readmissions, and providing only those treatments or procedures that have been deemed “medically necessary” to the patient’s care.

Quality improvement is another newer concept in American healthcare: it describes the processes by which healthcare providers measure the effectiveness of the procedures and treatments that they administer to patients. Other outcomes measured include the sufficiency of hospital safety procedures and patient satisfaction scores, which are measured using surveys. At their core, quality improvement programs seek to emphasize treatments that have been demonstrated to be efficacious. Safe, efficient, evidence-based care that meets the patient’s needs is the name of the game now and providers must work in unison to ensure these processes and outcomes are maintained if they wish to be reimbursed and to avoid financial penalties levied by government insurers and accrediting organizations.

Medicare, our federal government’s health insurance provider for citizens over age sixty-four, and private insurers have led this charge in this new era of managed care. Medicare, working through private contractors (known as MAC’s), is more stringent and discerning than ever before in determining what it will and will not reimburse based on a host of criteria such as medical necessity, the comprehensiveness of the patient’s medical documentation, the competency of the staff involved in the patient’s care, and the safety procedures utilized. Healthcare providers must meet these benchmarks to receive payment for their services. To make matters more difficult, these goals are in constant flux and practitioners must keep up with the frequent revisions.

In this swirl of efficiency modeling, data analysis, outcomes assessment, government oversight, and seemingly endless documentation, many providers worry that healthcare is forgetting the most important piece of the puzzle: the patient.

Often, patients themselves can attest to feeling overwhelmed, under-informed, and hurried through their treatment. Some will feel confused, others angered or frustrated, and still other patients will maintain that they were violated or harmed in some way by the medical juggernaut.

Many view this emphasis on streamlined managed care and evidence-based treatments as having detrimental effects on the patient and perhaps even crumbling the most sacrosanct component in all of healthcare, the doctor-patient relationship. Physicians themselves have expressed these concerns. Some pundits, many of whom are healthcare practitioners, argue for blowing the whole thing up and starting anew. Medicine as it’s currently practiced, they allege, is failing our patients. A cursory glance at our overcrowded emergency departments, our hopelessly sick patients requiring repeated lengthy hospitalizations, and our expensive treatments that can lead to debilitating complications, serves to reinforce these concerns, so says these commentators. One study even demonstrated that the majority of treatments rendered to patients are wholly ineffective.

One idea that has gathered steam in recent years is the belief that healthcare practitioners (and presumably insurance providers) should focus their efforts primarily on preventing illness rather than simply treating it when it occurs. This romantic notion has been trotted out as a solution by many to the perceived problems that arise resulting from our traditional concept of medicine. In essence, this idea stems from the logic that, by addressing and reversing disease risk factors, such as lifestyle habits, and potential medical conditions early before they can become full-fledged chronic disease, we can reduce the incidence and severity of disease itself, better treat the patients who are sick, and save untold billions of dollars in the process. We could improve our citizens’ health and provide superior care in the hopefully rare event that some of them do fall ill.

Certainly a noble suggestion. One problem, though:

It doesn’t make any sense.

Let’s first examine the disease component of this idea.

The Centers for Disease Control (CDC) track mortality rates of adult U.S citizens and compile this data into a report known as the “Leading Causes of Death.” The most recent report available online is from 2013. Here we can examine the pertinent statistics regarding the primary causes of death in our population. The following chronic conditions, taken from the aforementioned report, kill tens of thousands of Americans every year:

  • Cardiovascular disease
  • Cancer
  • Chronic respiratory diseases
  • Stroke
  • Alzheimer’s
  • Diabetes
  • Kidney failure

All of the above conditions have multifactorial etiology; usually some combination of genetic predisposition, a multitude of lifestyle elements such as smoking history and nutrition, perhaps even DNA mutations and/or congenital defects, and plain bad luck all contribute to their development. How are we supposed to prevent, say, cancer when cancer is considered to be not necessarily a single disease but instead a term to describe literally dozens of cellular malformations that can affect every tissue and organ system in the human body? Oncologists struggle to treat cancer patients as it is, but to task them with preventing it’s occurrence throughout our population? Unfathomable hubris or naivete, one. As one of the leading killers of American adults, cancer is an undeniably complex, insidious, and resilient affliction that has proven extraordinarily difficult to treat and so far impossible to cure despite centuries of dedicated research. We cannot fall into such unrealistically idyllic thinking to posit that cancer incidence could be drastically reduced by “prevention” strategies.

What about lung disease? Surely by greatly reinforcing the benefits of tobacco cessation we can successfully prevent the large majority of these conditions, such as lung cancer and chronic obstructive pulmonary disease (COPD). But other common lung conditions, such as interstitial disease, fibrosis, pulmonary hypertension, sarcoidosis, and bronchiectasis aren’t all directly caused by cigarette smoking per say. Many patients with severe pulmonary disease have never smoked.

How would “prevention” help these patients, some of whom are ill through no fault of their own? Many of these diseases can be associated and potentially may be caused by environmental factors such as pollution and toxins. This would presume that people living in congested urban areas or people who frequently work around toxic substances would be at a higher risk for lung disease than people who do not. This disparity would negatively impact any prevention efforts, as we can’t tell people in Los Angeles, for example, to all move to somewhere less crowded in the hopes of preventing respiratory ailments caused by polluted air.

Some of these conditions are idiopathic, meaning that the patient’s physicians (and maybe even medical literature) don’t know what caused it. We can’t prevent these maladies when we have no idea what brought them on in a particular patient, let alone millions of potential patients.

What about osteoarthritis? A degenerative condition in which the joints of the skeletal system deteriorate with age and overuse, this condition affects tens of millions of Americans, crippling a great many of them. It is the leading cause of chronic disability in this country. Osteoarthritis is the reason orthopedic surgeons perform hip and knee replacements, home health companies distribute countless canes and walkers, and the pharmaceutical industry is booming with painkillers.

Prevention of a degenerative joint disease that could be caused by mechanical stress, ie. overuse, would prove tricky. Current physical activity guidelines, proffered by the Department of Health & Human Services (HHS), recommend up to five hours per week of aerobic exercise for improving health and maintaining an ideal body weight. We could hypothesize that this chronically high volume of repetitive motion could have a deleterious effect on the joints. Research in this area is inconclusive but we can’t completely disregard the idea that exercise, while the source of many health benefits, might be injurious to our joints if done as frequently and for as long as the federal government is recommending.

But how would we prevent osteoarthritis? Caution Americans to exercise, but not too much? Inform them that while climbing stairs gets the heart rate up, it could also cause wear-and-tear in the knee joints and should be done sparingly? How do we tread this line?

Coronary artery disease (CAD) is another chronic condition that presents it’s own set of questions. If the healthcare system sought to eradicate CAD by funding extensive nationwide prevention strategies, we would certainly see some benefit as a society. But not everyone would enjoy the same downtrend of heart disease risk factors. While the typical cardiac patient can probably be described as older, overweight, and having a history of smoking and poor diet, there are a great many patients who are otherwise remarkably healthy, or at least engage in all of the behaviors theoretically associated with good health. There are many instances in which marathon runners arrest out in the field, lifelong vegetarians need bypasses, and health nuts drop dead in their thirties and forties after throwing a clot. While rare, these cases present serious challenges to the preventative healthcare model.

How can we advocate prevention when a small but important fraction of people would still fall ill despite religiously following preventative health advice?

Besides, how do we even know what advice to give? Are we settled on the ideal healthy diet? Is the research conclusive? What do we still question?

There have been and still remain critical questions as to what we should eat if we want to remain healthy. While the message of the Department of Agriculture (USDA), arguably the federal government’s mouthpiece on nutrition, has long been to consume a low-fat diet rich in fruits, vegetables, and grains, randomized trials and meta-analyses have raised doubt as to whether this diet, or perhaps one higher in animal products and lower in carbohydrate, would the best option. Zealots from both sides continue to keep this debate stirred up as the research is still inconclusive. The fact remains that our best data demonstrates that a reduced-carbohydrate diet is at least as effective in the short-term (two to eight years) as a low-fat diet for improving body weight, blood lipids, glycemic control, and markers of inflammation and metabolic dysfunction, all considered vital constituents of an individual’s overall health. While we can’t yet say that the traditional diet advice is wrong, we can’t state with confidence that it’s right, either.

Maybe prescribing medications to prevent diseases such as CAD would be prudent and effective. Elevated blood lipids, also known as high cholesterol, is usually considered to be a risk factor for future heart disease. The word “usually” is apt: while the majority of cardiologists support the notion that assaying lipids and prescribing statin (cholesterol-lowering) drugs to improve them will reduce the likelihood that the patient develops CAD, a great many physicians have long been skeptical of the cholesterol-heart disease connection.

Nevertheless, we can take solace in the fact that prescribing a statin to most of the adult U.S population would presumably curb the occurrence of CAD. Many doctors would comfortably agree with that statement based on the seemingly overwhelming support of the available data. But the research might not be conclusive. It is here I will very highly recommend the book Worried Sick: A Prescription for Health in an Overtreated America by Nortin Hadler, M.D. The book’s third chapter brilliantly describes the methods by which data is twisted and tortured in these statin trials to exaggerate the cholesterol-lowering and life-saving benefit of these drugs in a way that I cannot. Hadler’s work informed much of this article.

What Hadler contends based on the cholesterol data is that if physicians were to treat one hundred well people (ie. people without diagnosed heart disease) with statins to prevent CAD, very few of these people, perhaps only one or two would be spared a heart attack. He describes the results of the seminal West of Scotland study thusly: although purporting to demonstrate the efficacy of statins for preventing CAD, the data shows that prescribing statins to adult males with elevated blood lipids for up to ten years would result in not one person being spared from early death from heart disease. Potentially hundreds of people would need to take statins in order for a handful of people at most to realize any benefit whatsoever.

The Cochrane Collaboration, a not-for-profit organization of volunteer medical researchers, publish extensive meta-analyses of data collected from randomized trials that examine the efficacy of drugs, treatments, and procedures in treating diseases. Their systematic reviews are considered to be the most accurate and reliable medical knowledge that we have available and physicians routinely utilize their database in determining best practices for patient care. Their process is very scientifically stringent and their work is unadulterated by outside financial interests.

In 2011, the Cochrane Collaboration published a review examining the data on statins prescribed as primary prevention for CAD. The results were far less than encouraging. In fact, the authors espouse that some of this data may have been manipulated in order to suggest a benefit greater than in reality.

We’re forgetting the potential harms associated with statin use, such as liver damage and deterioration of the skeletal muscle. Memory problems correlated with statin use is still a matter of debate. Are we improving our health if, by taking a drug to lower our cholesterol by a little bit (at no benefit to our longevity), we’re experiencing potentially stifling pain throughout our body and maybe even some deficits in our cognition? Doubtful.

So “prevention” might not be the best idea from a medical standpoint seeing as how the diets may be ineffective, the drugs may be ineffective and dangerous, and the diseases themselves are still not thoroughly understand enough to offer reliable advice on how to impede their development.

This bring us to the other component of the healthcare prevention model: how would this be implemented?

Remember that in order for this to work, we would have to reach the maximum amount of people, ideally the entire U.S. population, and get them to follow lifestyle recommendations to the best of their ability.

But this would be inconceivably difficult to accomplish.

Think of all of the advertising, the public service announcements, the social media campaigns, the television and radio commercials, the internet memes, and the “expert” interviews which would need to be disseminated regularly to the American people. The messages to eat healthy, exercise (correctly), and stop smoking would have to incessant yet nuanced. Whomever took on this task would constantly have to find new and interesting methods to say basically the same thing over and over. Public interest would have to be maintained. Strategies would have to be multifaceted in order to reach such a wide range of demographic groups; senior citizens would have to be reached through newspaper columns and mainstream news media broadcasts. The younger generations would respond most favorably to grassroots campaigns and viral marketing on the Internet, perhaps using celebrities and athletes as pitchmen for the cause. Children could be taught the value of preventative healthcare as part of grade school curriculum. That is, if they have time for any more subject matter.

And on top of that, people would have to believe what we’re saying is right. Consider that faith in the competence of our government and support for our political leaders are at all-time lows, we probably can’t put this job in the hands of federal health agencies such as HHS or the USDA. So many citizens believe the government is fallible on issues foreign and domestic; they’re certainly not going to view government health recommendations as inerrant.

Finally, the public needs to act on this advice. Getting Americans en masse to put down the junk food and permanently alter their lifestyle habits is a pipe dream. It’s just not going to happen.

But maybe we have an ally in this fight, a willing battalion ready to help in the war against disease:

Physicians.

We can surmise that anything will suppress or even prevent chronic disease would have the support of our doctors. But here again we run into the challenge of trying to reach everyone. If we want to make a quantifiable dent in the prevalence of chronically diseased patients, then we would have to intervene in people well before they reach retirement age in order to increase our chances of addressing risk factors and improving lifestyle habits long enough to show significant benefit. This means getting those 20- and 30-year-olds to visit the doctor, something that this demographic just doesn’t regularly do.

Former Democratic Presidential candidate John Edwards mentioned in 2007 while promoting his universal healthcare plan that all Americans should be mandated to visit a doctor once every year. His idea, which he portrayed as a “continuum of care,” would force people, many presumably against their free will, into an examination room with a physician for a physical and a health history taking. What Edwards did not say, but can be logically implied, is that any condition or disease uncovered during these forced check-ups would have to be treated with or without the patient’s consent. What good is a doctor visit that results in a diabetes diagnosis or the discovery of a breast lump if the patient walks out the door without any treatment or guidance? Edwards assuredly would want these people treated regardless of their consent. All in the name of preserving their health. Does this sound like a reality you want to experience?

One Cochrane Collaboration review published in 2012 demonstrated that regular doctor visits did nothing to reduce morbidity or mortality in patients. The only thing these visits did do was increase the number of diagnoses a patient had. This only holds true if we can remember and effectively process the information the doctor is telling us, something with which many patients struggle.

So, according to our best research, going to the doctor does not improve health (or delay death or disease) but does saddle a person with the stigma of disease. Does this sound like preventative medicine to you?

Step back a second and look at the big picture.

Do we want to be assaulted daily from every angle with preventative health messages and advice? Is it beneficial to always be keenly aware that we may be festering with disease, riddled with plaques, and likely to keel over at any minute?

Should we trade our current system (go to the doctor when you’re sick, live your life when you’re well) for the opposite (go to the doctor when you’re well, live the rest of the time like you’re sick)?

Healthcare should not be about prevention because there’s too much to prevent. It shouldn’t be about prevention because we don’t know how to reliably prevent many of the conditions that afflict us. Healthcare shouldn’t be about prevention because we might turn healthy people into anxious hypochondriacs always shuffling to their next specialist visit or blood lab appointment.

Healthcare should be about treating patients safely, effectively, and as kindly as possible. Let them present to the doctors and hospitals when they fall ill; don’t waste the effort trying to reach them when they don’t need healthcare. You risk jading some to the benefit of medicine while inciting others into a worried frenzy about their next possible diagnosis.

The onus is on us as adults to take care of ourselves. We need to assume the responsibility for making healthy choices in our lives. In order for this to work, in order for us to avoid believing the questionable advice dispensed by government health agencies, celebrity doctors, news media, and our social circle, we must be very selective in whom we trust. A skeptical eye towards any health recommendation is prudent; there’s just too many talking heads with too many conflicts of interest. It’s easy to get overwhelmed by it all.

But we must try. At our fingertips is a wealth of information provided by National Institute of Health’s Library of Medicine. It’s a searchable database known as Pubmed. This invaluable resource allows users to search the medical literature for specific studies, papers, and data analyses of nearly every known human disease. While many of the journal articles require a paid subscription in order to access the full text, there are plenty of free papers wherein one can get a grasp on the research about a particular condition, medication, or syndrome. Pubmed, along with the aforementioned Cochrane Collaboration database, are the two preeminent sources of reliable healthcare information.

Use them when you have questions about the effectiveness of a particular drug or diet or exercise regimen. Education is the most powerful tool we have in our quest for health and we can’t expect a bloated healthcare system or an incompetent (and perhaps misleading) government health agency to do these things for us.

If we want to prevent disease, then that is our responsibility as individuals, not the job of a third party.