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.
This problem of inappropriate use or overuse of medical procedures is a difficult nut to crack. For one, physicians, hospitals, and the life science industry are all aligned and incentivized to do more procedures. Even at the subconscious level, as graphically portrayed in Atul Gwande's 2009 New Yorker article, "The Cost Conundrum," patients can be seen as representing an ATM. Certainly not all those procedures are carried out in the patients' best interests; the profound regional variability seen in the use of all sorts of procedures and operations across the United States reinforces the fact that appropriateness and need are not the sole determinants of whether patients are subjected to them. And it isn't just across the United States. 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. Too few in France, or too many in the U.S.? The difference can't simply be attributed to Americans drinking less French red wine.
In the case of my patient, of course, it didn't just start with the unnecessary procedure, but with the initial response to an advertisement, followed by his trust in his original physicians to make objective recommendations about what the proper course of care would be. Similar problems confront anyone trying to navigate all the medical procedures, operations, prescription medications, vitamins, supplements, herbs, alternative treatments, over-the-counter products, and home devices that confront them. The key to the problem is an empowered, knowledgeable patient, but, as we shall see, extra information need not lead to empowerment. Whether information is pushed to consumers (by the news media or by direct-to-consumer advertising) or pulled out of the system by consumers themselves (by, for example, visiting Google Scholar or a social-networking site developed for sufferers of a particular disease), if a consumer can't make the best, most intelligent use of it, all sorts of trouble can unfold.
Reprinted from The Creative Destruction of Medicine, by Eric Topol, by arrangement with Basic Books. Copyright © 2012 by Eric Topol.