Sam Uretsky

Health Care Games

Three of a kind: military intelligence, jumbo shrimp, medical science. Like it or not, health care comes under the heading of “healing arts,” a collection of bits of formal knowledge mixed with intuition and dumb luck. We have lots of medical journals that publish studies that certainly look scientific, but then, for a lot of us, the bridge of the Starship Enterprise looked fairly convincing too. Studies aren’t absolute, they just help tell what the odds are on something good happening, or something bad. We tend to focus on the good outcome, which is why people still buy Lotto tickets, or vote. Incurable optimism may be an essential trait for species survival.

To a large extent, we’ve been indoctrinated in unreality. Advertising is a powerful force. Automobile ads show us cars gliding along empty roads, when the reality is we’ll spend most of our time stuck in rush hour traffic. No fast food franchise has ever produced a hamburger that looked remotely like the one in their advertisement.

Television ads for prescription drugs promise not only relief from debilitating disease, but a granddaughter who will be accepted to Harvard Medical School and the Wharton Business School, both on a full scholarships. It’s only at the very end that a disembodied voice rattles off the litany of things that can go wrong, ranging from upset stomach and skin rash to encounters with flesh eating zombies. We tend to ignore that stuff.

To go one step beyond that, we believe that more is better. This gives us 500-horsepower supercars and 5,000-calorie supersized meals. We have a major political party so convinced that lower tax rates increase tax receipts that the only way to wipe out the deficit is to stop collecting taxes from anyone with an income over $1 million a year. Truth is, it doesn’t work in economics, and it doesn’t work in medicine. Studies give inaccurate conclusions and lead to treatments that can do more harm than good, tests give inaccurate results that lead to more tests that can have adverse problems, and treatments all come with that disembodied voice warning of diarrhea, sleep disturbances, gastric ulcers and anaphylactic shock. Good medical practice calls for balancing the risks and benefits, and the sad fact is that the choices which are good for most people aren’t always the best choice for any single individual.

The recent recommendations for reducing the frequency of cancer screening tests are based on economics, in part, but they’re also based on legitimate health considerations. Positive screening tests aren’t definitive — they’re just alerts that it may be useful to perform additional tests, and the additional tests invariably come with risks. Consider that the baby aspirin used to reduce the risk of heart attack may cause serious ulcers, that something as common as an intramuscular injection can accidentally hit a nerve, causing long term pain.

Cutting back on the frequency of tests represents a balance — the risk benefit ratio. Some cancers will go undetected, and consequently untreated, but fewer people will have needless surgery with risk of infection, bleeding and nerve damage. Even when a cancer is detected, there can be legitimate questions about rushing to treatment, since in some cases, the cancer is growing so slowly that it may not pose any real risk in this lifetime, while the treatments are more likely to cause problems than the cancer itself. These are legitimate questions, grounds for more studies, and thoughtful evaluations.

The recent recommendations for cutting back on some screening tests, PAP smears, mammograms, prostate exams, were intended, not to cut costs, but to cut risks. There’s no evidence that the recommendations were politically motivated, let alone planned to be released at the same time. In spite of that, politicians, who often make the best conspiracy theorists, are quick to see the new recommendations as a plot to ration medical care.

It’s of passing interest that the Republicans, who have seized on the recommendations for reduced cancer screening as evidence of government interference in health care, are the same people who voted overwhelmingly in favor of the Stupak (D-Mich., with 63 other Democrats and 176 Republicans) amendment to the House health care reform bill, that would block any health insurance plan bought with any federal money from paying for abortions. The people that opposed having health-care decisions made by bureaucrats finds it perfectly proper to have these decisions made by political hacks.

Medical judgements are just that, and often have as much science as a decision to lead trumps, or bet on filling an inside straight. But the new recommendations are based on the best informed opinions working with the best information currently available. The GOP response is a play to our belief that all will go well, and more is better. There is no cynic like an politician swearing idealism.

Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.

From The Progressive Populist, December 15, 2009

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