While attending the Insight Information Healthcare Technology conference in Toronto recently, I was presented with an interesting conundrum: Just because we can do something, does that mean we necessarily should do it? Let me explain.
In Canada, provincial and federal governments are going through fits trying to shorten delays (wait times) for different medical treatments, such as MRI or CT diagnoses of certain diseases. One solution, says the public, is to simply increase the number or throughput of these capital-intensive instruments. This logic may be totally misplaced, though, if radiologist Dr. Ronn Goldberg of North York General Hospital is any judge.
According to Goldberg, a far better solution to reducing wait times would be more stringent use of clinical guidelines to reduce the ordering of MRI and CT exams to only those situations where the imaging method would have the biggest clinical impact. Rather than automatically check off the MRI or CT box on the radiology form, physicians should make more of an effort to consider other less expensive, more widely available and equally efficacious diagnostic modalities.
Following on the CT vein, although the method offers dramatic improvements in the ability to detect medical problems, radiologist Dr. David Koff of Toronto's Sunnybrook Health Sciences Centre warns that these advantages come with a price tag: equally dramatic increases in radiation exposure. He recounted a 1999 study that showed CT exams representing only 10% of all radiological procedures, but accounting for 67% of the total medical radiation dose. Would other, safer imaging modalities offer equivalent efficacy?
And then Dr. Peter Bach and colleagues at Memorial Sloan-Kettering Cancer Center reported in a recent JAMA that when it comes to lung cancer, CT may do a wonderful job at detecting early tumors, but that benefit doesn't necessarily translate into lower mortality rates. Said Bach: "With lung cancer the number one cause of cancer deaths in the United States, the medical profession continues to seek an effective and safe approach to prevent deaths from this disease. According to our study, CT screening may not be it."
The same can be said for drugs. While the focus in recent months has been on the safety profiles of new drugs and relative risk to patients, perhaps we also need to look at relative benefit. In an industry filled with also-rans and me-toos, are people really benefiting from an expanding spectrum of pharmaceutical panaceas? For this discussion, I lump generics into this category as well.
Does the patient really benefit enough from the incremental improvements of next-generation drugs over first-generation drugs to really warrant all the trouble and expense that went into developing the new drug? Might they not see the same benefit from another practice—e.g., diet and exercise for cholesterol drugs—that doesn't cost the industry billions of dollars?
From the industry's perspective, are drug companies really seeing long-term benefits from these same incremental improvements when in many respects all they do is further fragment an already hyperfragmented marketplace? Might their monies not be more effectively spent on research and development in areas that are either under- or unserved by the current formularies?
A former business professor of mine said that in finding new markets, one had to find the "pain" in existing markets. Nowhere is that more literally true than in healthcare and the pharmaceutical industry.
Sure, the risks are higher; but then so are the potential rewards. And that, my friends, is the name of the game.
OUR READERS RESPOND
You've certainly raised an important issue but medicine and patient care are not just about CT/MRI etc. I'm reasonably sure that, if Dr Goldberg's son (real or hypothetical) were to come to the ER with some unknown symptoms he (Dr G) would most likely order a CT/MRI etc...indeed, the whole "nine yards". Would it be more effective for his son? Not really, but he would feel very guilty were he to forgo it and something would have been missed!
Think about your patients as you would about YOUR kids, and the conclusions change quite a bit. I always think of my patients as I would of my real kids - I feel that it helps me do the right thing more often than I would have otherwise. More importantly - I feel it earns me the right to expect decent treatment for myself and my kids should the occasion arise where we're the patients.
Henry H Kalir, MD, PhD, Clinical Assistant Professor
New Jersey Medical School