Editor's Note: The following is an excerpt from The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care (Basic Books, 2012), by Eric Topol, a professor of innovative medicine and the director of the Scripps Translational Science Institute.
Nearly 7 Billion people on the planet
Over 3 million doctors
Tens of thousands of hospitals
6000 prescription medicines, 4000 procedures and operations
Countless supplements, herbs, alternative treatments
Who gets what, when, where, why and how?
When a 58 year old, active, lean, intelligent financier from Florida came to see me for a second opinion, I should not have been surprised. For Valentine's Day the prior year, his wife's present was a computed tomography (CT) scan for his heart. She heard about it on the radio and also saw heart scan billboards on the highway. There was even a special deal of $100 off for Valentine's.
But her husband didn't have any symptoms of heart disease, didn't take any medications, and played at least two rounds of golf a week. On the other days, he worked out on an elliptical machine for 30 to 40 minutes. Until he got the heart scan.
My patient was told that he had a score of 710—a high calcium score—and his physician had told him that he would need to undergo a coronary angiogram, a roadmap movie of the coronary anatomy, as soon as possible. He did that and was found to have several blockages in two of the three arteries serving his heart. His cardiologists in Florida immediately put in five stents (even though no stress-test or other symptoms had suggested they were necessary), and put him on a regimen of Lipitor, a beta-blocker, aspirin and Plavix.
Now, in my office four months later, this patient is not doing well at all. He is worried that he might have a heart attack if one of the stents becomes clotted. He feels profoundly tired and has muscle aches that are so disturbing he can neither play golf nor do his usual exercise. He complains of marked depression and an inability to have or sustain an erection. A fit individual, who had taken good care of himself and was enjoying his life, was now debilitated and depressed. The cardiology trainee who saw this patient with me asked, "How could this have happened?"
Unfortunately, this individual's story is not so uncommon. Think predator and prey: the physicians and hospital advertise, leading to a high volume of heart scans, billed directly to the patients at some $500 each. Then, should an abnormal score come up, the patient may be quickly referred for first a diagnostic procedure, and then one to implant metal stents in the arteries on the surface of the heart. Naturally the cardiologist who put in multiple stents feels gratified to have saved the patient's life with unsuspected, advanced coronary disease. Overall, however these cases are like riding a train to the last stop, regardless of the most logical destination. All procedures are performed, as likely as not, the outcome is not a saved life but a "cardiac cripple."
I didn't enjoy telling the patient that he should probably not have ever had the stents. I could see the cholesterol buildup in the two arteries on an angiogram he brought with him, but the case was not severe. Of course, it was too late to do anything about the stents, which can't be removed, except to reassure him that he was not in any imminent or real danger, but I could get him off some of his medications, which would help his current symptoms and get him back to golf and exercise.
Mark Twain said, "To a man with a hammer, a lot of things looks like nails that need pounding." Surgeons are notorious for a similar bias: "When it doubt, cut it out." My patient was the victim of the same tendency. As badly as he got pounded, it could have been worse: in 2010 the "Olympic record" of stenting was published. One patient had sixty-seven stents placed throughout his coronary arteries and bypass grafts, in the course of twenty-eight coronary angiograms over a ten-year period.
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23 Comments
Add CommentThe problem is that most doctors are idiots. I don't mean that in the strictly pejorative sense. Like idiots, they can do what might seem to be brilliant tricks that mimic real intelligence. However when it comes to integrating their knowledge into a larger scale synthesis of how to use their tricks to enhance the life of patients, they often fail.
Reply | Report Abuse | Link to thisWhat do you call the person who graduated last in their class at medical school??? Doctor
Reply | Report Abuse | Link to this50% of the doctors "practicing" medicine graduated in the lower half of their class.
Buyer beware when we choose our physicians...
It is totally unnecessary to inform patients with technical details,and lots of advice.They simply get confused,and bother time and again the doctor or the pharmacist.Also it is useless to give printed details with each and every medicine.It is a NATIONAL wastage!
Reply | Report Abuse | Link to thisiakhan: Where do you get that notion? I simply disagree with you - I never get confused when a physician provides me with technical details about a medical condition. When an operation was suggested for one of my knees, I simply wrote down what the procedure was; then I went to the Medical Library at the health & hospital system where I am a regular patient, and conducted hours of research. I understood everything I read. Darn good thing I did that, too; because I learned that I would have to take Immunosuppressant drugs to avoid rejection of the grafted tissue; which I had not been told during the consultation with the surgeon. There is no way that I wanted to suppress my immune system; so I declined to have the operation. Thus, I made an informed & educated choice for my own well-being.
Reply | Report Abuse | Link to thisYour statement that "it is useless to give printed details with every medicine" is way off base, and ill-advised. You should be well-aware that each medicine is different - and as such, each one carries different dosage levels and times; and each one has it's own unique interaction & allergic reaction information & potential side effect info. As well, all of the people who are taking those medicines have individual differences unique to them. What one patient can take; perhaps the next one can't - so it is critical that they be provided with data outlining potential allergic reaction info, side effect info, and interaction info. Not to mention that the information provided with each medication provides a disclaimer, of sorts, to release the manufacturer from liability; should the patient take something the paper advises against.
What would really be a waste would be the life that is taken because the patient was not informed about interaction info, dosage info, side effect info, etc. on the paperwork that is wisely provided with the medicine.
In closing, I believe that the good patient is one who takes an interest in their own health & treatment; and who is well-informed enough about their own health condition that they pay attention to the cues their body gives them to alert them to a problem. I absolutely cannot fathom demonstrating zero interest in my own health state.
I don't know how true this is--does anyone know?--but if ever real it was an interesting healthcare system. The story I heard said that the system was used long ago in ancient China. Clients came from those who could afford a low-fee "insurance policy" which avoided a middleman. They paid their doctor a small but regular fee to keep them healthy. If they became ill the doctor furnished healing herbs and treatments while the patients got money back for the sick days they were too ill to do regular tasks, and stopped paying until they got well--which amounted to comprehensive health treatment & medication insurance. If they died from the illness their heirs received a substantial percentage of their money back from the doctor, so it was life insurance, too.
Reply | Report Abuse | Link to thisAny comments? I'm a Medieval historian, but of Europe, not the Chinese empire. It sounds idealistically mythic, rather easy to fake if someone wanted to extend days of non-payment--they just stayed in bed--and the payments out would ruin a doctor in a widespread plague. But if it were ever reality, it was a lot more humane than the greedy system that European privatized medicine has been since the days of shamans, and still is still in cumbersome and expensive use in the United States where too many persons have been conned into worshiping privateers.
It was my observation,and my experience.I am glad you differ.
Reply | Report Abuse | Link to thisIn my opinion, such a wonderful Eric Topol's paper has to be read by both laymen and physicians, including cardiologists, around the world, aiming to the GOOD of mankind! As regards myself, from now on I shall referr to it, writing that it is from "The Creative Destruction of Medicine, by Eric Topol, by arrangement with Basic Books. Copyright © 2012 by Eric Topol",as an example of oustanding information on the Medicine field. I thanks very much my skilled Colleague, and I would be delighted with being allowd - after receiving his mail address - to stay in contact with him.
Reply | Report Abuse | Link to thisSincerely.
Sergio Stagnaro
Sergio Stagnaro MD
Via Erasmo Piaggio 23/8
16039 Riva Trigoso (Genoa) Italy
Founder of Quantum Biophysical Semeiotics
Who's Who in the World (and America)
since 1996
Honorary President of International Society of
Quantum Biophysical Semeiotics
Ph 0039-0185-42315
Cell. 3338631439
www.semeioticabiofisica.it
www.sisbq.org
dottsergio@semeioticabiofisica.it
www.sergiostagnarowordpress.com
There is no patient advantage in soliciting drugs and procedures directly to the patient. That is designed to increase sales with only financial motivations. The practice of advertising medication used to be illegal, and it should be again. This country is over medicated compared to other countries, with no gains in longevity or improved health to show for it. Procedures are a cash cow for hospitals and specialists. There is no limit to how much can be charged for procedures and prices go up faster than any other segment of the economy. Two main reasons are greed and defensive medicine to avoid being accused of missing something.
Reply | Report Abuse | Link to thisDoctors should determine if a patient needs medicine and procedures, not brainwashing with constant advertising.
I think patients deserve full disclosure of information. The doctor will have to make a judgment as to how detailed the info is to suit the individual. A previous commenter assumes everyone but him is incapable of understanding, obviously there is a range of intelligence.
These issues are covered very well in the book "Overdiagnosed: Making People Sick in the Pursuit of Health."
Reply | Report Abuse | Link to thisaligatorhardt, you are absolutely correct in stating, "There is no patient advantage in soliciting drugs and procedures directly to the patient."
Reply | Report Abuse | Link to thisEspecially in the area of psychotropic drugs. At a mere 4.48% of the world's population, the U.S. uses 60% of the worlds psychotropic drugs. This is as a result of DTC (Direct to Consumer) advertising.
I was given benzodiazepines for a seizure disorder (migraines) and the anxiety caused by them. I was NEVER once told that benzos are, in fact, tranquilizers. If I had been told they were tranquilizers I would have absolutely refused them. I knew tranks were addictive! I was on benzos for over 15 years. These meds carry a host of 'side effects' - side effects are (in reality) "direct effects" which no-one wants to acknowledge (unless, of course, they are prescribing additional drugs to counter side effects - each with its OWN list of side effects). The resulting poly-drugging quickly gets out of hand and the patient begins to wonder why they are not getting better, but instead, are feeling more sick.
It makes sense that if a 'side effect' is listed in the package insert - the longer a patient is on the drug, the more likely they will develop them. Here is a partial list of benzo side effects and symptoms.
http://en.wikipedia.org/wiki/Benzodiazepine_withdrawal_syndrome
I was Iatrogenically Addicted to benzos and didn't know it!
After some time on benzos, I developed high blood pressure (along with other symptoms on this list). But that's OK they have a pill for high blood pressure ... Lisinopril ... http://en.wikipedia.org/wiki/Lisinopril ... to which I developed dry cough, joint pain, decreased liver function, and more.
Iatrogenic Insult added to Iatrogenic Injury.
My doc kept asking me if I was having hallucinations - another "side effect" of benzo addiction. I never did, so I always said, "NO." My doc seemed disappointed at my reply. I did become extremely depressed and overly anxious as long term benzo addiction tends to create or exacerbate both physical and mental health conditions.
All of this is common knowledge to the drug manufacturers and to the physicians who prescribe these drugs. The smoking gun is that when you are taken off the drug too abruptly, you are prescribed anti-seizure drugs in order to prevent seizure, coma or death.
This Iatrogenic Addiction is, truly, Choreographed Insanity!
Docs can accurately diagnose addiction in patients, but if they can't accurately diagnose Iatrogenic Addiction, they need to get out of the business.
There is nothing new in this book. Ivan Illich said this a generation ago. "Medical Nemesis, the Expropriation of Health" 1975. What is new is to see that it should take 37 years for well known, very well connnected doctors like Mr Topol to understand a book.
Reply | Report Abuse | Link to thisThe parient became lethatgic after Lipitor intake. What a surprise! The stuff knocked me out in 24 hours after three tries so I had to feel it was not the right thing for me. For some it may be a good drug but for me it was no good and made me feel terrible. If any doctor prescribes a drug and does not check later with the patient to see the results Dr.he/she is not doing his job. Many don't check. Such is life. It is up to the patient to use his head and if things get worse with treatment then check and ask a lot of questions... a lot of questions.
Reply | Report Abuse | Link to this1. The question itself is malformed. Since to be fully informed respects a patient's dignity and a physician's self respect, there can't be too much information.
Reply | Report Abuse | Link to this2. Much of what passes for information to uninformed patients is not information but unverified opinions, or misinformation.
3. If the medical industry and its practitioners are profit-driven, as many critics have pointed out, it follows that the patient is a just a means to maximizing profits. If this seems to be the case, BUYER BEWARE!
Doctors need to keep up with their reading of advances, etc., in their field. Or take the more disclipined approach, continuing education classes. At least flip through the magazines in their offices. Several times I mentioned new advances re some of the medical problems my mother has and the doctor looked surprised.
Reply | Report Abuse | Link to thisI don't see this story as a problem of too much information but too little education of the patient and the common attitude of treating doctors like little gods that know best for us. They don't, necessarily. Some are even downright incompetent (are you reading this, Dr. Cohen?). People need to take responsibility for their own health and employ their doctors as consultants instead of taking their advice blindly.
Reply | Report Abuse | Link to thisIn my opinion, to keep the good mentality in treaty for the rest of life is more important than other else.
Reply | Report Abuse | Link to thisTo the author:
Reply | Report Abuse | Link to thisthis statistic seems extremely high--
"For every 1,000 people in France, 192 will have an angioplasty or stent procedure. In the United States, the number is more than double at 437. "
This means, I infer, that by the time they die nearly half of all Americans have had angioplasty or a stent procedure.
The only statistic I could (quickly) find online was an estimate of between 600,000 and 1 million angioplasties per year in the US. This was in a USA Today article on the declining frequency of such procedures. But clearly, even at 1 million per year, getting half of the 330M persons in the US angioplastied would take a while...
Can it be accurate?
What a load of rubbish. All physicians are paid to be 'straight shooters' with their customers. Those that do not do so need fired as unfit.
Reply | Report Abuse | Link to thisTopol:
Reply | Report Abuse | Link to thisUnfortunately, this individual's story is not so uncommon. Think predator and prey: the physicians and hospital advertise, leading to a high volume of heart scans, billed directly to the patients at some $500 each.
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A Dynamical Model of General Intelligence: The Positive Manifold of Intelligence by Mutualism
Han L. J. van der Maas, Conor V. Dolan, Raoul P. P. P. Grasman, Jelte M. Wicherts, Hilde M. Huizenga, and Maartje E. J. Raijmakers University of Amsterdam
http://wicherts.socsci.uva.nl/maas2006.pdf
Abstract
Scores on cognitive tasks used in intelligence tests correlate positively with each other, that is, they display a positive manifold of correlations. The positive manifold is often explained by positing a dominant latent variable, the g factor, associated with a single quantitative cognitive or biological process or capacity. In this article, a new explanation of the positive manifold based on a dynamical model is proposed, in which reciprocal causation or mutualism plays a central role. It is shown that the positive manifold emerges purely by positive beneficial interactions between cognitive processes during development. A single underlying g factor plays no role in the model. The model offers explanations of important findings in intelligence research, such as the hierarchical factor structure of intelligence, the low predictability of intelligence from early childhood performance, the integration/differentiation effect, the increase in heritability of g, and the Jensen effect, and is consistent with current explanations of the Flynn effect.
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van der Maas, et al used the Lotka-Volterra prey–predator model to pose an alternative explanation to the positive manifold of general intelligence in IQ test scores. Topol's mention of a predator-prey relationship in the context of current American medical leads me to suspect the Lotka-Volterra model might also be used to confirm his assessment of American medical practice and health insurance in a methodical way.
http://query.nytimes.com/gst/fullpage.html?res=980DE4DA133FF935A35755C0A9669D8B63&ref=hannahfairfield
Reply | Report Abuse | Link to thisThe figures for stents should be per 100,000 people not per 1,000. His source is linked above -- read the correction.
I am late to come to this discussion, but would like to add that, as a physicians, I see my job is to interprete the significance of a patient's clinical presentation and to discuss options open to him: no treatment, life style modifications, or treatments (medical, surgical). Often times, conservative monitoring is the best option. Pushing patients towards treatment modalities for profit is unprofessional and unethical.
Reply | Report Abuse | Link to thisThis practice is rampant in dentistry and other areas of healthcare. Patients are victimized because they have limited ability to determine what is quality care and what is not. The lack of a patients knowledge added to the authority of the "White Coat" of authority has opened the door to less than ethical to talk patients into unneeded care.
Reply | Report Abuse | Link to thisPhysicians have always to remember that they prescribe usually drugs, whose precise action mechanisms they do not know, to human body they know in distressing way.
Reply | Report Abuse | Link to thisIn my opinion, the first information to patients, physicians have to prefer absolutely, must regard patients Quantum Biophysical Constitutions and dependent Inherited Real Risks in a precise site of a whatever biological system. This is the question: "Is in this patient CAD Inherited Real Risk, Diabetic Constituion, Oncological Terrain-Dependent, Inherited Real Risk). Less expense and better therapy quality.