Friday, July 19, 2013

Conservative Medicine: the big idea (and title) of my book

A few days ago I was reminiscing about my family medicine residency, where at one of my outpatient training sites I provided care to Amish patients in rural southern Lancaster County, Pennsylvania. The Amish didn't believe in checkups and rarely visited doctors, so we knew that when they did come in, there was usually a serious problem. Abdominal pain was more likely to be from perforated appendicitis than indigestion; leg pain was more likely to be from a life-threatening traumatic injury than a sprained ankle; and so on. There was nothing routine about providing health care for this population, and I found the experience refreshing.

On the other hand, my residency training also made me a big believer in preventive medicine, which is why I subsequently spent several years working with the U.S. Preventive Services Task Force, searching the literature for evidence to distinguish effective screening tests (such as screening for osteoporosis in older women) from ineffective and potentially harmful ones (such as screening for prostate cancer in older men). Unfortunately, as in other areas of health care, preventive medicine has been corrupted by big business, fear of lawsuits, and the widely held (and generally wrong) notion that more care is better care. As a result, unscrupulous companies such as Life Line Screening take advantage of vulnerable elders by selling packages of unnecessary tests at health fairs and churches; obstetricians continue to perform annual pelvic examinations even though these exams have no value in nonpregnant women without symptoms; and gastroenterologists tell patients with normal screening colonoscopies to return for repeat screenings much sooner than the appropriate interval of 10 years.

Looking back on my nearly 4 years of blogging, an overarching theme has been finding the "sweet spot" between too little care ("Amish medicine") and excessive medical interventions ("Life Line medicine"). This sweet spot is the starting point for a book that I'm planning to write with the working title of Conservative Medicine. It would have been easy to borrow the title of this blog and just call it "Common Sense Family Doctor," but the reality is that a lot of truths about preventive care and screening aren't common sense, and family doctors are not the only health professionals with expertise on these subjects.

The big idea of Conservative Medicine is that much of what passes for preventive health care in this country (and will be paid for by the implementation of the Affordable Care Act, aka Obamacare) is useless, unhelpful, and likely to make patients less, not more, healthy. There is no such thing as a harmless test; seemingly "routine" tests may do more harm than good; and even the well-established preventive health physical has little evidence of benefit.

My next several posts will flesh out Conservative Medicine by addressing the 5 questions that I'm told every prospective author needs to answer in a serious nonfiction book proposal:

1. What's the book about?
2. What's new about the book?
3. Why are you the best person to write it?
4. Why is now the right time for it?
5. Who needs to read it?

This book proposal is a work in progress, and this set of posts will in some ways be a departure from the usual fare of Common Sense Family Doctor. For one thing, I hope to receive many constructive comments about how to best shape my book and distinguish it from similar books (for example, Shannon Brownlee's Overtreated, H. Gilbert Welch's Overdiagnosed, and Otis Brawley's How We Do Harm). I want my book to be about a lot more than prostate cancer politics, but welcome suggestions about how to incorporate my compelling personal narrative into the larger story of a health system that has largely lost sight of what health really means. To my longtime and occasional readers, thanks in advance for your words of wisdom.

1 comment:

  1. You need to focus on what people can do to empower their own healthcare experiences. Part of the problem that you touch on is that many people implicitly follow what they are told to do by "experts" and end up getting those tests you mention. The issue is that the system is set up with assumption that individuals are too stupid to make their own decisions. Patient empowerment (such as ability to find out pricing) is solution I recommend.

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