Ivan Oransky: Are we over-medicalized?

53,602 views ・ 2012-06-19

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Those of you who have seen the film "Moneyball,"
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or have read the book by Michael Lewis,
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will be familiar with the story of Billy Beane.
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Billy was supposed to be a tremendous ballplayer; all the scouts told him so.
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They told his parents that
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they predicted that he was going to be a star.
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But what actually happened when he signed the contract -- and by the way, he didn't
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want to sign that contract, he wanted to go to college --
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which is what my mother, who actually does love me,
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said that I should do too, and I did --
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well, he didn't do very well. He struggled mightily.
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He got traded a couple of times, he ended up in the Minors for most of his career,
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and he actually ended up in management. He ended up as a General Manager of the
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Oakland A's.
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Now for many of you in this room, ending up in management, which is also what I've done,
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is seen as a success.
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I can assure you that for a kid trying to make it in the Bigs,
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going into management ain't no success story. It's a failure.
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And what I want to talk to you about today, and share with you, is that our
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healthcare system, our medical system, is just as bad at predicting
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what happens to people in it -- patients, others --
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as those scouts were at predicting what would happen to Billy Beane.
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And yet, every day
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thousands of people in this country
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are diagnosed with preconditions.
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We hear about pre-hypertension, we hear about pre-dementia,
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we hear about pre-anxiety, and I'm pretty sure that I diagnosed myself with
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that in the green room.
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We also refer to subclinical conditions.
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There's subclinical atherosclerosis, subclinical hardening of the arteries,
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obviously linked to heart attacks, potentially.
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One of my favorites is called subclinical acne.
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If you look up subclinical acne, you may find a website, which I did,
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which says that this is the easiest type of acne to treat.
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You don't have the pustules or the redness and inflammation.
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Maybe that's because you don't actually have acne.
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I have a name for all of these conditions, it's another precondition:
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I call them preposterous.
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In baseball, the game follows the pre-game.
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Season follows the pre-season.
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But with a lot of these conditions, that actually isn't the case, or at least it isn't the
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case all the time. It's as if there's a rain delay, every single time in many cases.
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We have pre-cancerous lesions,
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which often don't turn into cancer.
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And yet,
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if you take, for example, subclinical osteoporosis, a bone thinning disease,
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the precondition,
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otherwise known as osteopenia,
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you would have to treat 270 women for three years
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in order to prevent one broken bone.
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That's an awful lot of women
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when you multiply by the number of women who were diagnosed
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with this osteopenia.
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And so is it any wonder,
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given all of the costs and the side effects
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of the drugs that we're using to treat these preconditions, that every year
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we're spending more than two trillion dollars on healthcare and yet
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100,000 people a year -- and that's a conservative estimate -- are dying
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not because of the conditions they have,
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but because of the treatments that we're giving them and the complications of those treatments?
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We've medicalized everything
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in this country.
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Women in the audience, I have some
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pretty bad news that you already know,
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and that's that every aspect of your life
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has been medicalized.
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Strike one is when you hit puberty.
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You now have something that happens to you once a month that has been medicalized.
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It's a condition;
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it has to be treated. Strike two
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is if you get pregnant.
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That's been medicalized as well.
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You have to have a high-tech experience
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of pregnancy, otherwise something might go wrong.
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Strike three is menopause.
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We all know what happened when millions of women were given hormone replacement therapy
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for menopausal symptoms
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for decades until all of a sudden we realized, because a study came out, a big one,
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NIH-funded.
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It said,
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actually, a lot of that hormone replacement therapy may be doing more harm than good
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for many of those women.
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Just in case,
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I don't want to leave the men out --
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I am one, after all --
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I have really bad news for all of you in this room,
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and for everyone
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listening and watching elsewhere:
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You all have
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a universally fatal condition.
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So, just take a moment.
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It's called pre-death.
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Every single one of you has it, because you have the risk factor for it,
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which is being alive.
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But I have some good news for you, because
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I'm a journalist, I like to end things in a happy way or a forward-thinking way.
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And that good news is that if you can survive to the end of my talk, which
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we'll see if that happens for everyone,
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you will be a pre-vivor.
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I made up pre-death.
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If I used someone else's pre-death, I apologize,
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I think I made it up.
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I didn't make up pre-vivor.
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Pre-vivor is what a particular cancer advocacy group would like everyone who
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just has a risk factor,
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but hasn't actually had that cancer,
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to call themselves.
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You are a pre-vivor.
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We've had HBO here this morning. I'm wondering if Mark Burnett is anywhere in the
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audience, I'd like to suggest
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a reality TV show called "Pre-vivor."
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If you develop a disease, you're off the island.
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But the problem is, we have a system
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that is completely --
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basically promoted this.
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We've selected, at every point in this system,
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to do what we do, and to give everyone a precondition and then eventually
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a condition, in some cases.
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Start with the doctor-patient relationship. Doctors, most of them,
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are in a fee-for-service system. They are basically incentivized to do more --
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procedures, tests,
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prescribe medications.
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Patients come to them,
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they want to do something. We're Americans, we can't just stand
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there, we have to do something. And so they want a drug.
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They want a treatment. They want to be told, this is what you have and this is how
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you treat it. If the doctor doesn't give you that,
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you go somewhere else.
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That's not very good for doctors' business.
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Or even worse,
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if you are diagnosed with something eventually, and the doctor didn't order that test,
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you get sued.
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We have pharmaceutical companies that are constantly trying to expand
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the indications, expand the number of people who are eligible for a given treatment,
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because that obviously helps their bottom line. We have advocacy groups,
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like the one that's come up with pre-vivor,
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who want to make more and more people feel they are at risk, or might have a condition,
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so that they can raise more funds
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and raise visibility, et cetera.
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But this isn't actually,
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despite what journalists typically do, this isn't actually about blaming
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particular players.
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We are all responsible.
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I'm responsible.
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I actually root for the Yankees, I mean talk about
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rooting for the worst possible
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offender when it comes to doing everything you can do.
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Thank you.
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But everyone is responsible.
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I went to medical school,
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and I didn't have a course called How to Think Skeptically,
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or How Not to Order Tests.
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We have this system
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where that's what you do.
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And it actually took being a journalist
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to understand all these incentives. You know, economists like to say,
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there are no bad people,
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there are just bad incentives.
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And that's actually true.
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Because what we've created is a sort of Field of Dreams, when it comes to medical technology.
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So when you put another MRI in every corner, you put a robot
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in every hospital saying that everyone has to have robotic surgery.
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Well, we've created a system where if you build it, they will come.
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But you can actually perversely
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tell people to come, convince them
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that they have to come.
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It was when I became a journalist that I really realized how I was part of this problem,
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and how we all are part of this problem.
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I was medicalizing every risk factor, I was writing stories, commissioning stories,
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every day, that were trying to,
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not necessarily make people worried, although that was what often happened.
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But, you know, there are ways out.
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I saw my own internist last week,
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and he said to me,
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"You know," and he told me something that
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everyone in this audience could have told me for free,
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but I paid him for the privilege, which is that
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I need to lose some weight.
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Well, he's right. I've had honest-to-goodness high blood pressure
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for a dozen years now, same
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age my father got it,
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and it's a real disease. It's not pre-hypertension, it's actual
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hypertension, high blood pressure.
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Well, he's right,
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but he didn't say to me,
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well, you have pre-obesity or
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you have pre-diabetes, or anything like that. He didn't say,
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better start taking this Statin, you need to lower your cholesterol.
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No, he said, "Go out and lose some weight. Come back and see me in a bit,
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or just give me a call and let me know how you're doing."
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So that's, to me,
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a way forward.
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Billy Beane, by the way, learned the same thing.
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He learned,
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from watching this kid who he eventually hired, who was really successful for him,
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that it wasn't swinging for the fences, it wasn't swinging at every pitch
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like the sluggers do, which is what all the expensive teams like the Yankees like to --
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they like to pick up those guys.
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This kid told him, you know, you gotta watch the guys, and you gotta go out and find
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the guys who like to walk,
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because getting on base by a walk
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is just as good, and in our healthcare system
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we need to figure out,
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is that really a good pitch
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or should we let it go by and not swing at everything?
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Thanks.
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