Public Health: Self-Inflicted Stupidity

In truth, some people don’t learn from mistakes. They simply repeat them.

In the early days of Covid, government officials — including those in public health — put out an array of messages, apparently because they felt the need to say something, even though key facts about the disease were unknown at that time. Covid was a “meeting engagement” as a military historian might call it. We needed to learn about the enemy before we could offer sound advice.

The misinformation that was put out helped to create the anti-mask and anti-vaccine movements and contributed to the massive US death toll. Now those movements probably would have come into being without the help of inept public health experts, but they helped nurture stupidity just the same.

Did the public health community learn anything from this? Apparently not.

The new example is an article by Paul Pinsky of the National Cancer Institute entitled “Putting Cancer Screening in Perspective.”(1) If I may summarize his argument: Early detection of disease is usually a good thing, unless what we find is something that either (a) shouldn’t be treated or (b) we don’t know how to treat. In either of these cases, we worry the patient and sometimes an inept doctor will commit to a treatment that actually does more harm than good.

Technically, this is a reasonable statement. “Watchful waiting” is an accepted approach to prostate cancer given that in some cases, the patient will be dead from some other cause long before the tumor gets large enough to be an issue. The burden is on the doctor to know when watchful waiting is the best course and when a more active treatment is required.

The patient doesn’t have the knowledge to make that decision.

How does not knowing a problem exists help? (My uncle had both early stage dementia and cancer, and opted not to treat the cancer to avoid inflicting the dementia on his loved ones. To me, that’s a valid choice that he couldn’t have made without knowledge of what was happening to him.)

Another possibility that might explain this article is that the NIH thinks that no one from the general public or the media looks at the NIH website. Not true, and it would be sad if it were.

Pinsky’s recommendation is to limit screening to situations in which there is a reasonable expectation of a problem. That however would be a death sentence for people who acquire esophageal cancer. By the time someone knows they have a problem with that disease, it’s Stage IV and there’s only the smallest likelihood of survival. Endoscopic inspection is really the only way to head this cancer off.

What we don’t want is for patients to interpret Pinsky’s advice as an excuse to avoid regular physical exams and screenings. In fact, we could make the case that we should conduct colonoscopies starting at much younger ages than we do today. The growing incidence of colon cancer among people in their 20s and 30s would support more screening, not less.(6)

In my view, the entire point of the Affordable Care Act was to reduce America’s spending on healthcare by promoting early detection and treatment. Not only are the outcomes from early detection better for patients, but the cost of treatment is very substantially less.

Instead, there are two issues we really need to address:

1. Conflicts of Interest: The tendency for some doctors to be motivated by compensation in making decisions about whether and how to treat a condition. Medscape has covered this topic in the past and even conducted a survey in which a majority of respondents admitted to being influenced by money in making diagnosis and treatment recommendations. More recent articles address how payments from drug companies influence what doctors prescribe.(2,3) The conflict of interest problem is sufficiently common that various professional organizations and formulated rules about them, but it’s clear that not every doctor pays attention to the rules.(4)
2. Failure to refer: Doctors vary in what they know. By one account, there’s 1,500 pages of new medical research published daily, and it would be a strain to try to keep up. Some doctors do, some don’t. This problem arises when a doctor doesn’t have the most up-to-date information about a patient condition or treatment, but fails to refer the patient to another doctor with that expertise. Money can be a root cause of this problem, but the potential for harm to the patient is very real.

Bottom line: we don’t need to scare people away from getting check-ups. We do need to deal with the issues that can lead to misuse of the results of screening exams.

Sources:

1. https://www.nih.gov/about-nih/what-we-do/science-health-public-trust/perspectives/science-health-public-trust/putting-cancer-screening-perspective
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6308758/
3. https://www.usatoday.com/story/news/investigations/2019/08/07/biologic-drug-makers-pay-doctors-prescriptions/1943331001/
4. https://www.ncbi.nlm.nih.gov/books/NBK22944/
5. https://www.standardsofcare.org/medical-malpractice/types/failure-to-refer/
6. https://www.cancer.gov/news-events/cancer-currents-blog/2020/colorectal-cancer-rising-younger-adults

People are crazy