Should High Blood Pressure be Treated?

In last week's post, I promised an explanation why many screening and medical treatments offer so little benefit to individual patients.   If you invest the time to digest last week's post and the post before you now, then you will be equipped with new understanding that will enable you to make much better medical decisions.  In accordance with this blog's mission, this is truly a 'peek behind the curtain'.  I grant you that these 2 posts are a little wonky, but try to stay focused.  

Here is the main reason that ordinary people – and even some medical personnel – become confused on this issue.  Studies that assess screening tests and medical treatments are often performed on very large groups of patients.  The reason for this is that smaller studies, for reasons I cannot fully explain here, are simply not felt to be sufficiently reliable.   This is why the Food and Drug Administration would never grant approval of a new medicine based on favorable results from small studies.   If a benefit or a failure is shown in a high quality study with hundreds or thousands of participants, the results will be highly credible.   It was large studies, for example that demonstrated that blood pressure control prevented serious complications. 

Here is the key point.  When a medical benefit is established in a large study, this benefit applies to a large population of people.   When this medical test or treatment is later applied to an individual patient in a doctor’s office, the benefit that this person receives may be miniscule.   This reality is not appreciated by nearly all patients I have treated in nearly 3 decades.  If a patient reads about a study that concludes that losing excess weight will cut the risk of stroke by 30%, the patient is likely to make 2 false assumptions:

He overestimates his risk of stroke.

He overestimates the true risk reduction of losing 10 lbs.

If his risk of stroke is already very low, then reducing it by 30% offers almost benefit.  Follow the next example.

Will Lowering My BP Save My Life?

Assume a study of 5000 patients with high blood pressure demonstrates that lowering blood pressure 10%, can halve the risk of developing a heart attack.  This sounds like a game changer, but not to an individual patient, such as any person reading this.  The benefit is derived from studying a large population.   Assume that without treatment that 100 patients of the 5000, or 2%, would suffer a heart attack in 10 years.  With blood pressure treatment, only 50 patients would suffer this outcome, a 50% decrease in the adverse event.   Wouldn’t it be true that an individual patient would also have a 50% risk of developing a heart attack?  Yes, but let’s play this out.

A patient comes to the doctor with modest high blood pressure and no other cardiac risks. The patient has read about the landmark study that concludes that treatment would halve his heart attack rate.  Let’s assume, that this person’s risk of developing a heart attack in 10 years is 3%.  That means that this individual already has a 97% chance of staying well without any treatment.  Treating this patient would lower his risk of a heart attack from 3% to 1.5%, representing the 50% benefit we have been discussing.  So, with treatment, he now has a 98.5% probability of avoiding a heart attack.  Would someone enthusiastically take lifelong blood pressure medicine for an additional 1.5% protection when he already was 97% in the clear?   Would most of us welcome this return on investment?  I am not even considering the costs of many of these treatments and the potential side effects.   

When large studies’ benefits are applied to individuals, the benefits calculate out very differently. However, treating hundreds of thousands, or millions of people with elevated blood pressure would save many of them simply because we are dealing with large numbers of people.  A percentage point or two of a million people is a respectable number.  That’s why it makes sense to treat many diseases from a public policy standpoint.  The point is that each individual only enjoys a very modest benefit. 

I hope that readers have found this post – and the blog overall – to offer a very high return on investment.   Your comments are always welcome. 

Does Mammography Save Lives?

I find that the public often exaggerates the benefits of many preventive health measures.  I don’t blame the public for this.  There are several forces conspiring to deceive the average patient into accepting exaggerated claims of various medical tests and strategies.   Of course, the Medical Industrial Complex is a gluttonous beast that must be fed massive quantities of medical testing and treatment if it is to survive.

Most of the public thinks that medical interventions, including mammography, lowering cholesterol levels, blood pressure reduction and even colonoscopy are downright lifesaving.

Recognize that I am in favor of all of these measures, but that the actual benefit to the individual is much smaller than most folks believe.  In the case of mammography, there is uncertainty as to whether it saves lives at all, a view readers can easily find with a rudimentary internet search.  Mammography experts all agree that any benefit of this screening test to the individual patient is very modest.  This is not my opinion; it is a fact.  And yet, most women, including the women in my life, believe that this test offers them solid protection.

Mammography - True Lifesaver?

If I am correct that the individual enjoys only very modest benefit from these routine medical interventions, then how did they gain a permanent foothold in the medical landscape?

Why would physicians zealously recommend tests that were of such limited value?

Why would insurance companies and the government pay for such testing?

Why would patients submit to tests or lifelong medications that offered a very limited benefit?

Why are so many of us unaware of this issue?

As I do not want this post to be double my usual word count, I will provide you next week with a detailed response on this issue.  I strongly urge you to check back here next Sunday for an opportunity to inform and empower yourselves.   I’m not against screening tests or established medical treatments.  I’m for the truth. 

Labor Day 2019

All work is honorable.

Honor everyone's work.

Work with honor.  

The Whistleblower wishes all of you a meaningful Labor Day.

Do Patients Like Weekend and After Hours Medical Care?

I have previously expressed how physicianss feel about treating patients that they do not know in a prior post, which readers are invited to review.  This post is the other side of the story.   

Nowadays, patients are used to seeing physicians who are not their doctors.  Often, patients may be seeing a nurse practitioner, a highly trained professional for their medical care, instead of a physician.  A generation ago, patients nearly always saw their own physician, including if a patient was hospitalized. Imagine that, your own primary care doctor sees you in the hospital, an event that occurred when dinosaurs roamed freely.

The medical universe has changed.  Hospitalists care for most hospitalized patients, which in my view, has vastly improved the quality of hospital medical care.  It is commonplace for patients who need to be seen right away in the office, to see a doctor who is available, who may not be the physician of record.  Pregnant women today often see many obstetricians in the group since it is unlikely that the patient’s designated obstetrician will be on-call on D-day.  One of Cleveland’s corporate medical giants boasts that they offer ‘same day appointments’, which is true if a patient is willing to see a medical professional several zip codes away, not the patient's actual doctor.

In the olden days, one doctor did it all.

Understandably, if you call your physician after hours or on the weekend, you will most likely connect with one of your doctor’s partners.  This is why it is not advisable to call the emergency on-call physician 9 pm for a conversation about your chronic arthritis.

Patients are now used to seeing strangers prescribing their medications and ordering their diagnostic tests.  Hospitalized patients may be treated by several physicians they do not know. They have adjusted as best they can, but there are obstacles and drawbacks to this medical care paradigm.

• It is unsettling for patients to be confronting several medical professionals for their care.  Similarly, if you are reading 4 or 5 books at once, are you really able to keep the separate stories straight in your mind?
• There is unavoidable loss of continuity when there are multiple physicians at the table.  Hospitalists do a great job.  But, do we really think that all of the nuanced knowledge and objective data can be seamlessly transmitted to your primary care physician whom you will see after you are discharged?
• What if different primary care physicians who are seeing the same patient have different opinions?  Who does the patient believe?
• Even in the computerized era, it’s astonishing how often new physicians do not have easy access other physician’s medical records.  Does the weekend physician consultant who is seeing you in the hospital know that another doctor already ordered an ultrasound of the gallbladder a few months ago across town?
• When there are too many physicians involved in a single patient’s care, medical testing and costs tend to increase, which does not increase medical quality.  In my experience, a new doctor is more inclined to order a medical tes, than to advise watchful waiting, a strategy that the doctor who knows the patient well would more likely rely on.  For example, if I see a patient I know for years with the same stomach pain, I may react differently than another gastroenterologist seeing him for the first time. 

Oftentimes, patients and physicians meet as strangers.  This reality creates many challenges.  Both sides need to be understanding.

Should Doctors Offer a Money Back Guarantee?

It may seem odd that a gastroenterologist patronizes fast food establishments several times each week.  I’m in one right now as I write this.  I eschew the food items –though French fries will forever tempt me – and opt for a large sized beverage.  In truth, I am not primarily there for a thirst quenching experience, but more to ‘rent a table’ so I can bury myself in some reading.  Indeed, many thousands of New York Times issues have been devoured at these tables.  I saw a sign posted on the wall here that I had not seen before.

Sorry, No Refunds

Refunds?  How often can this happen in a place like this?  We all know that food items in these institutions are remarkably consistent, which is one of benefits that customers enjoy.  Your Big Mac or Whopper will taste the same in Pittsburgh as it does in Peoria.  I questioned the server on this new development and she explained that increasingly customers were demanding refunds for contrived reasons in an effort to bilk the restaurant.  At some point, the restaurant decided to put an end to this practice. 

Refund Free Zone!

I wonder how my patients would react to being greeted by such a sign in my office?  Of course, physicians do not offer refunds or a money back guarantee for our services, as other industries boast.  Nearly every infomercial includes the tag, “and if you don’t agree that these _____  are the best you’ve ever used, simply return it for a full refund – no questions asked!”  Not so in the medical profession.   We are paid regardless of the outcome or your satisfaction.  It is true that physician reimbursement policy is evolving away from fee-for-service (FFS) toward a value-based system.  In other words, physicians won’t be paid separately for every medical service we provide you, but for the overall ‘value’ we provide, which is a somewhat amorphous concept.  FFS clearly incentivizes the medical profession to overtreat patients because we are paid more for doing more, even if such care may not be truly necessary.   It remains to be seen if the value-based payment approach will protect patients and be fair to physicians. I have my doubts.

Many professionals are paid regardless of how their clients fare.  It you lose your case in court, your lawyer will still be paid.  If a judge is overruled on appeal, his wages aren’t reduced.  If your investment underperforms, your financial planner doesn’t return his fee to you.  Tradesmen, on the other hand, make a commitment to satisfy us as a condition for getting paid.  If we hire a plumber to unclog a sink, for example, he understands that if he doesn’t deliver, then we won’t either. 

What if all of us were paid on results rather than on time expended?  Would this lead to higher quality goods and services?  Could it really apply to the medical profession?  If a patient comes to see me with abdominal pain, which often defies explanation even after a thorough medical evaluation, is it fair that I wouldn’t be paid if the patient’s pain persists?

None of this applies to Whistleblower readers.  These posts are free so don't ask me for refund.  

Joining a Clinical Trial Helps Others

From time to time, I am asked by someone about participating in a medical research study.  These situations are usually when an individual, or someone close to them, has unmet medical needs.  Understandably, a patient with a condition who is not improving on standard treatment, would be amenable to participating in a clinical trial to receive experimental treatment.

I find that most folks misunderstand and exaggerate the benefits they may receive as a medical study participant.  Sometimes, I feel their ‘misunderstanding’ is fueled by study investigators who may overtly or unconsciously sanitize their presentation to patients and their families.  There is no malice here.  Investigators have biases and likely believe that their experimental treatment actually works.  Their optimism is likely evident in their communications.

Here’s what an investigator might say to a patient.

I thought you would be interested in a new clinical trial testing a new medicine for your disease.  Preliminary data show promising results. 

If you were a patient, wouldn’t you infer that the drug might help you?

Patients, I have found, are of the mistaken belief that they may directly benefit from the drug being tested.  Of course, this makes sense to them.  Their rheumatoid arthritis drug isn’t working.  They are informed of a clinical trial of a new treatment for patients who do not respond to conventional treatment.  Obviously, they enter this trial with the hope that their condition will improve.  Unfortunately, this is the wrong way to approach a medical study.

Louis Pasteur - Legendary Medical Researcher

Clinical trials are not designed to benefit the participants.  They are performed to generate new knowledge that may help future patients.  This is the key point that so many study participants are not fully aware of, and they should be.  The investigators do not know important data about safety, efficacy and dosing.  These are among the fundamental data that the study – and future studies – will determine.  If medical investigators knew that the drug actually worked, then there would be no need for a clinical trial.  There’s a reason behind the term experimental treatment.

If you want to enter a clinical trial, know that you are doing so to help others who will come after you.  This is a selfless and praiseworthy event.   Indeed, we have all benefited from the sacrifice and altruism of prior patients who agreed to create new knowledge to help us.   If we enter a study we may not personally receive a return on investment for our efforts, but we are paying it forward to others.

Transparency in Health Care Costs - New White House Proposal

Opaque:  adjective, not able to be seen through; not transparent

Medical pricing is beyond opaque.  It’s a riddle wrapped in a mystery inside an enigma.  Many readers will recognize that this clever phrase is not my own.

Throughout my career, I have been unable to provide an accurate answer to the perennial inquiry, how much does a colonoscopy cost?  Patients, of course, find this to be baffling.  This ignorance is certainly not restricted to my specialty of gastroenterology.  Does it make sense, for example, that the same medication may have wildly different pricing at different pharmacies or in different cities?   In contrast, we would expect to find a similar price for a gallon of milk among supermarkets. 

My strong suspicion is that seemingly irrational, inflated and complex medical pricing is all by design to serve those on the billing end – hospitals, pharmaceutical companies and pharmacy benefit managers.  Before you accuse me leaving physicians off of this list of Greed & Shame, may I remind you that we physicians do not set our own prices; they are all dictated by the payors.  When we send you a crazy bill, it is all according to your insurance company requirements and policies - not us.  Same for the copays patients fork over when they come to see us.  While we are the target of griping and sniping, these cash extractions are mandated by your insurance companies.

The medical arena is unique.  It does not allow consumers to utilize price comparison as they do when purchasing appliances, vacations, private schools,  apartment rentals or an apple.  It is unlikely that one would sign an apartment lease without being told what the monthly rent charge would be.   But, we will proceed to a CAT scan examination without knowing the cost or if a nearby competitor can provide the same service for less.

Fairly Easy to Determine the Cost Before the First Bite

Recently the White House launched an initiative to require physicians and hospitals and insurance companies to inform patients of the costs of medical care in advance.   Of course, this concept should be welcomed and applauded.  Push back against it was locked and loaded before the new policy was announced.   Who’s against price transparency?  Hospitals and insurance companies and drug companies are united in their opposition.  They claim, among other things, that they would be forced to surrender proprietary information,  that medical prices would actually increase and that the public would not be well served.   I am not an economist, but I surmise that exposing the buried secrets of medical pricing will empower the rest of us in making better choices.  Real and open competition will bring prices down, as is true in all other spheres of commerce.

Some economists are warning that this issue is extremely complex and that the outcomes may be paradoxical.  I'm willing to take a chance.

My goal before I retire years from now is to be able to tell a patient how much their colonoscopy will cost.  

Transparent: adjective, allowing light to pass through so that objects behind can be distinctly seen.