by Dr David KL Quek
Increasingly we are bombarded by more and more stories about health care rationing and what is prudent or parsimonious healthcare practices. The latest salvo came in the wake of a post criticising former President GW Bush's angioplasty and stenting, as unnecessary http://www.washingtonpost.com/opinions/president-bushs-unnecessary-heart-surgery/2013/08/09/c91c439c-0041-11e3-9a3e-916de805f65d_story.html
Another article continues the trend against so-called unnecessary screening tests for health (http://www.huffingtonpost.com/leana-wen-md/medical-tests_b_3735156.html).
How do we draw the line between being blissfully ignorant vs. being worried well and having health check-ups?
Is our human body only to be treated like some automobile/motor car only when it runs into trouble or breaks down? Or shouldn't we carry out maintenance checks so that we can perform that much more efficiently and perhaps more safely, even enhance our chances of living better, with less hassles of disease/disability/incapacity, or living longer!?
I think society is increasingly straitjacketing itself into economic silos, where the individual's benefits or rights have increasingly been giving way to societal and community constraints, rights and well-being, primarily driven by escalating costs issues...
Because on a larger scale for the community such health 'screening' practices even out toward neutral or no benefit or that appears on cluster analysis to show no significant difference for the greatest majority of the people; or so our growing armies of health economists have deemed... So such practices need to tow the line, we need to be more prudent and therefore cut out all the fat, i.e. all that's unnecessary and wasteful!
Even if it means sacrificing some "inconvenience" such as perhaps suffering an arguably low risk of an unannounced heart attack or stroke, or a silent cancer, just because there have been no symptoms or signs...
So it appears that we have been urged to be sensible and brave, to wait until complications or disability occur, or is it really? What about the famously silent hypertension, diabetes, the high blood cholesterol levels, and yes even the many lurking coronary narrowings and cancers? Do we do nothing until announced by an untoward event?
According to the US Preventive Task Force (driven in large part at trying to rein in healthcare costs, and dredging evidence-based cost-effectiveness research and data, much like UK's Cochrane Institute, NICE), more and more so-called health screenings are now rendered pointless and discouraged because these have not been shown to offer significant benefits on multivariate analysis and reviews. That many of these tests have resulted in further testing and sometimes even more complications from the more intrusive and invasive diagnostics or even therapies... means that these are not to be preferred as health pathways... So what are we to do?
Of course, truth be told, a good history taking and simple comprehensive physical exam could obviate further testing in perhaps 80% of the time... The best diagnosticians among us doctors would of course be superb in picking up the near-miss diagnosis of any major potentially catastrophic illness! But can the majority of us, mere mortals, bread and mortar physicians, be as good or expert? Can we be certain we have not missed some or any silent illness or unheralded risk factors? Have every one of our patients been totally open with us the doctors, and have they disclosed all that matters, accurately? Can we as doctors be allowed to risk being fallible in our medical checks without some of these newer tests and technologies?
But we know intuitively and also practically that primary prevention measures and some screening can and does pick up hidden covert dangers (although we should never dare boast of our 100% certainty!). We are aware that some of these silent health hazards can endanger lives, risk complications and could possibly result in some health catastrophes and even death!
Otherwise why indeed do we still offer health check ups that appear to have stood the test of time and tradition? Of course these may not be very cost-effective, even 'expensive' on a larger scale; but barring that, no one can dispute that early detection might or could actually save some lives whose symptom-free disease would otherwise have been missed.
Perhaps, President Bush should just go on and live a busy energetic life, oblivious of his narrowed heart artery... the heart is certainly 'usually' resilient, but it's also notorious with that minuscule chance of being twitchy and deadly, an off-chance risk really... ;)) Perhaps, he should just have allowed his acceptable chance of possibly dropping dead suddenly during his long-haul cycling exercises or running, then what?
Perhaps, Steve Jobs shouldn't have had a scan to pick up his pancreatic cancer, perhaps his liver transplant was a dodgy wasteful therapeutic choice... then he could have passed on after just a few months (usual prognosis for most pancreatic cancer, <5-15% survival beyond 6 months) ... certainly much more cheaply, instead of that 2 - 3 years or so of extended meaningful life that he chose to have and could afford to have...
Perhaps Angelina Jolie shouldn't have had her bilateral mastectomy and reconstruction, because the BRCA testing is still so expensive (USD4k) and this celebrity option might spark too many wannabee worried-well women from asking for such testing! Perhaps she should have just taken this lying down, like her now demised middle-aged mum and aunt...
Perhaps in cost-strapped health systems, we should allow a few people to die suddenly; suffer some heart attacks and increase more heart failures; have more advanced incurable cancers because these have only marginally improved with not very effective but terribly expensive 'therapies'!
Perhaps, in the near future, society should dictate who should live and for how long, who should be treated and who not, and who should be allowed to die... an Orwellian "1984" beckons!