Renowned American surgical pioneer William Halsted is probably best known for the cancer operation that bears his name: the Halsted radical mastectomy. First performed in 1882 and the treatment of choice for localized breast cancer until the 1970s, this extremely disfiguring surgery removed the entire affected breast, underlying pectoral (chest wall) muscles, and all of the adjacent lymph nodes. Dr. Halsted and his supporters felt that this operation was superior to removing only the affected breast (or only the affected part of the breast, known as lumpectomy) based on a theory of how breast cancer spread that was ultimately shown to be flawed. When evidence began to emerge in the 1940s that breast cancer recurrence rates following radical mastectomy were no better than those following more conservative surgical techniques, proponents of Halsted's aggressive surgery nonetheless fiercely resisted calls for change for nearly thirty years.
I share this notable episode of medical history to explain the working title of my book-in-progress, Conservative Medicine. In politics, the "conservative" label is usually attached to someone who resists change; in modern medicine, however, conservative physicians are frequently those who are calling for change. For example, the Choosing Wisely campaign sponsored by the American Board of Internal Medicine Foundation discourages physicians from providing, and patients from receiving, common "aggressive" medical tests and treatments that have no clinical benefits and often cause harm. (As general internist and medical educator John Schumann recently observed on his blog, even former U.S. Presidents are not immune to the tendency for physicians to do more than is medically necessary.)
Conservative Medicine will consist of three interweaving and complementary stories. The first is the story of the science of screening tests and other preventive interventions: a tale encompassing a few notable successes but many false hopes and unfulfilled promises. The second story is that of my patients and others whose health was affected by preventive medicine: a few who possibly benefited as well as others who were probably harmed. The third story is my own: the narrative of my gradual evolution as an increasingly skeptical clinician and scientist, including four tumultuous years as a staffer and researcher for the U.S. Preventive Services Task Force, the federally-supported panel that now decides which preventive services health insurers must provide for free.
Only recently have I realized that my personal story will - and must - end up being at the center of my book. Although I have posted many times on Common Sense Family Doctor (and published a longer literary piece) about the adverse effects I experienced from questioning the effectiveness of the prostate-specific antigen (PSA) test for prostate cancer, I wasn't sure who would want to sit through book chapters about the travails of a mid-level government health bureaucrat. On the other hand, working in a federal agency at the center of various political storms provided me with insights that were critical to developing my philosophy as a conservative family physician. The challenge will be using my narrative as a way to advance the larger story of how the good intentions of preventive medicine run amok in our present-day health system. I welcome your suggestions.
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This is the second in a series of brainstorming posts about a book that I plan to write titled Conservative Medicine.