The Myth of Prevention: Letter to the Wall Street Journal

25. June 2009 William Davis (20)




The June 20-21, 2009 Wall Street Journal Weekend Journal featured a provocative front page article written by physician, Dr. Abraham Verghese:

The Myth of Prevention

While eloquently written, I took issue with a few crucial points. Here is the letter I sent to the Editor at Wall Street Journal:


Dear Wall Street Journal Editor,

Re: Dr. Abraham Verghese’s article, The Myth of Prevention in the June 20-21, 2009 Weekend Journal.


I believe a more suitable title for Dr. Verghese’s article would be: “The Myth of What Passes as Prevention.”

As a practicing cardiologist, I, too, have witnessed firsthand the systemic “corruption” described by Dr. Verghese, the doing things “to” people rather than “for” them. Heart care, in particular, is rife with this form of profit-driven health delivery.

There is a fundamental flaw in Dr. Verghese’s otherwise admirable analysis: He assumes that what is called “prevention” in mainstream medicine is truly preventive.

Dr. Verghese makes issue of the apparent minor differences between preventing a condition and just allowing a condition to run its course. Prostate cancer screening is one example: Men subjected to repeated screenings have little length-of-life advantage over men who just allow their prostate to suffer the expected course of disease.

What if, instead, “prevention” as practiced today is nothing more than a solution that has been adopted in mainstream practice to suit yet another doing “to” strategy than doing “for”? In the prostate cancer example, PSA and prostate exam screenings often serve as little more than a means of harvesting procedures for the local urologist.

That’s not prevention. It is a prototypical example of “prevention” being subverted into the cause of revenue-generating procedures.

I submit that Dr. Verghese has fallen victim to the very same system he criticizes. His views have unwittingly been corrupted by the corrupt profit-driven system he describes.

What if, instead, prevention were just that: prevention or elimination of the condition. What if “prevention” of prostate cancer eliminated prostate cancer? What if heart disease “prevention” prevented all heart disease? What if this all proceeded without regard for profit or revenue-generating procedures, but just on results?

Dr. Verghese specifically targets heart scans or coronary calcium scoring, a test he likens to “miracle glow-in-the-dark minnow lures,” calling them “moneymakers.” Yes, when subverted into a corrupt algorithm of stress test, heart catheterization, stent, or bypass, heart scans are indeed a test used wrongly to “prevent” heart disease.

But what if the risk insights provided by heart scans prompt the start of a benign yet effective “prevention” program that inexpensively, safely, and assuredly prevents--in the true sense of the word--or eliminates heart disease? Then I believe the differences in mortality, quality of life, and costs would be substantial. Such strategies exist, yet do not necessarily include prescription drugs and certainly do not include the aftermath of heart catheterization and bypass surgery. Yet such programs fail to seize the limelight of media attention with no new high-tech lifesaving headline nor a big marketing budget to broadcast its message.

The problem in medicine is not prevention and its failure to yield cost- and life-saving results. It is the pervasively profit-driven mindset that keeps true preventive strategies from entering mainstream conversation. It is a repeat of Dr. Ignaz Semmelweis’ late 19th-century pleads for physicians to wash their hands before delivering babies to reduce puerperal sepsis, ignominious advice that earned him life and death in an asylum. We are essentially continuing to deliver children with unwashed hands because there is no revenue-generating procedure to clean them.

No, Dr. Verghese, the economic and medical failings of preventive strategies are not at fault. The failure of the medical system, in which everyone is bent on seizing a piece of the financial action for himself, has resulted in the failure to support the propagation of true preventive strategies that could genuinely save money and lives.

President Obama’s goal of cultivating preventive practices in medicine can work, but only if the profit-motive for “prevention” does not serve as the primary determinant of practice. Results-driven practices that are applied without regard to profit have the potential to yield the sorts of cost-saving and life-saving results that can reduce healthcare costs.


William Davis, MD
Milwaukee, Wisconsin
Medical Director, The Track Your Plaque Program (www.cureality.com)
Blog: http://heartscanblog.blogspot.com
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Comments (20) -

  • Matt B.

    6/25/2009 1:28:37 PM |

    Dr. Davis,

    Well written.  I wish you were on President Obama's panel last night becuase this information needs to filter his way.

  • Anonymous

    6/25/2009 2:10:54 PM |

    The problem for government, the same one it now faces with the finance industry, is how to regulate away the profit motive in a capitalist system. How does the government force physicians to care about their patients and not their wallets? Maybe the only hope is to make these motivations the same thing through shifting incentives, but true prevention's payoff is people living longer, which is impractical to measure, so difficult to reward. It's easier to harness individual motivation to live longer and healthier, ironically, through government educating the public about physicians' and the food and drug industries' profit motives and as such the failures of the government's basic capitalist principles. -keith.

  • Dr. William Davis

    6/25/2009 2:45:48 PM |

    I believe one way to approach the outsized appeal of procedural "solutions" to health is to make reimbursement more on a par with non-procedural solutions.

    In other words, if I put in a stent, I get around $2000. If I coach a patient on how to avoid a stent, I might get between $59 and $178. (Remember that what physicians are paid is not personal payment, but payment to cover costs of operating an office, malpractice costs, etc., all the costs of doing "business.")

    That means that practicing prevention is a way to lose a bunch of money, not sustain a viable practice. Putting in plenty of stents, or putting in knee prostheses, defibrillators, or other procedures will buy you a vacation home in Aspen and a country club membership.

    So the root problem is the perverse excessive reimbursement for procedures, the poor reimbursement for "cerebral" functions like prevention.

  • Anonymous

    6/25/2009 3:06:08 PM |

    Dr. Davis,
    This is Billye once again. You said it all.  I watched the President last night being questioned on the tube about health care.  Not one question was asked relative to the curative power of a Low carb-high fat healthy diet.  As I mentioned before, in just a short nine months I reversed my obesity, diabetes type 2, and stopped most of my medications for heart disease including Staten's.  During a commercial a statistic was flashed on screen that said the following: Heart disease,   diabetes, and obesity was 50% of all health care costs.  I must be living in a parallel universe along with you and a few other brave doctors.  It's amazing how the propaganda job that has been perpetrated on the  American public, which as you know first started with Dr. Ancell Keys fifty years ago and has led to the healthy eating dogma, which continues today, has lemming like led us all over the cliff to bad health.  This has to be stopped and be reversed. Only then will health care become affordable.

    Billye

  • Wil

    6/25/2009 3:26:18 PM |

    Excellent letter Dr. Davis.  I hope the WSJ will publish it.  Allow me to also suggest that you send a copy to the Obama administration and your congressional representatives in Wisconsin.  I plan to forward a copy of your letter to our congressional representatives in Delaware.  

    You have identified a most important issue that is a crucial aspect of the needed reform in our medical services / medical insurance system.  Thank you for that and for all the great info on your blog.

    DT

  • Scott Moore

    6/25/2009 6:02:46 PM |

    Your wonderful post gave me some incentive to write my own letter to the editor. I thoroughly enjoy reading every one of your posts; keep up the good work.

    Here's my letter; you may not agree with the details but I believe you would appreciate its spirit.

    Dear Wall Street Journal Editor,

    While I can see Dr. Verghese's point about the corruption of the system, I think he is missing the broader point about prevention because he is part of the system. Many of our most vexing medical problems can be prevented with non-medical, non-chargeable (or minimally-chargeable) practices:

    * What if the cold and flu season could be made a thing of the past by something as simple as people monitoring their blood level of vitamin D in order to keep it at least 65 ng/ml and took over-the-counter Vitamin D3 gelcaps as a supplement? And what if these gelcaps cost less than $5 per month?
    * What if type II diabetes could be "cured" without medicine but simply by eliminating (or drastically reducing) wheat (bread and pasta), sugar, and potatoes from our diet? This would have been investigated deeply except for the "problem" that the medical profession can't make money off it.
    * What if total cholesterol had very little to do with heart disease? Monitoring it would have very little preventative effect, statins (the world's most profitable drugs) would have their associated revenues cut by 90% or more, and the whole manufactured food industry would have to change their ways -- just as with the diabetes problem above, think of all of the "heart healthy" foods and advertising campaigns that would have to change. What if heart disease could be monitored and predicted better through coronary calcium scans, levels of HbA1c, and the ratio of triglycerides to HDL? What if heart disease could be prevented by lowering our sugar intake and taking inexpensive fish oil supplements? This would mean that doctors would have to retract much of what they have told us for the last 35 years, tell us that they have been wrong, and that they are now right. This is a difficult set of tasks, and one that would challenge their very credibility --- and would reduce their income and the income of the pharmaceutical industry.

    As you might guess, all of the above have been supported by research though the medical industry has been slow to share these findings with us. Prevention isn't a myth --- prevention according to profitable medical practices is the myth.

    Sincerely,

    Scott Moore

  • Anonymous

    6/25/2009 6:31:31 PM |

    Dr. Davis,

    Along the same lines, I think the biggest problem is that the government funds the pharmaceutical to perform ALL the research. As long as the drug industry does all the research, we will never see huge strides in preventative solutions.

    Like you said, most pharmaceutical corporations are more interested in houses in Aspen than they are in looking at things like fish oil and vitamin D, vitamin K and diet adjustments. I can just picture a CEO of a company thinking: "Mmmm...should we use millions of government funds to do research on a new drug, or should we use that money on clinical trial using vitamin D, K, iodine and diet adjustments?" So sad.

  • scall0way

    6/25/2009 7:48:04 PM |

    Interesting article and response. Some of the comments on the article are interesting too, and some make me want to scream, like the one saying:

    " Dairy and meat products do serious health harm... People who live a "raw vegan" eating lifestyle never get diabetes and almost never get cancer or heart disease. Of course people who have high cholesterol will be much more likely to have heart disease. Animal fats solidify on the walls of the bloodstream, clogging them. Plant fats don't do this. Animal protein turns on cancer growth like fertilizer."

  • Kent

    6/25/2009 8:23:13 PM |

    Dr Davis,

    In light of your thoughts that "prostate exam screenings often serve as little more than a means of harvesting procedures for the local urologist", I wanted to get your thoughts on possible similar motives for heart scans.

    I don't have an ebt scan location in my city, however, there is a "hospital" in Oklahoma http://www.integris-health.com/INTEGRIS/en-US/Specialties/HeartCare/HeartHospital/Prevention/EBT+Heart+Scans/ that offers them for $50. Should there be concerns over the extreme low price? Obviously, they are not making their money from the scans. With these scans being offered at a hospital who is well known for "heart procedures", would you feel comfortable with them doing heart scans? Is there a reasonable chance that they could "over read" or alter a scan in order to suggest other procedures?

    Thanks,
    Kent

  • kris

    6/25/2009 9:12:22 PM |

    Dr. David,
    I think the root of the problem starts much early. The amount of time that it takes to complete medical studies and earn degree to become a doctor is lot more than most of the other professions. The whole process kind of justifies a doctor to feel better than the “others”, hence deserve to make more money than the “others””.

    Even the selection process and courses are design only to give favor to the person with great memorization skills not the person who can put two and two together. Even though that there is always a luck of the draw that some individuals are good at both but the ratio suffers. With today’s changing technology, with computers and all that should be able to change the path to the doctor’s degree with open book exams and let the best of the best graduate, not the memorization and nothing else.
    The real “deserving doctors” who really care about humanity, have slim chances to get through the current system. Nor does the current financial commitment is helping them in any ways.

    My older son always good in studies good at memorization always over 95% in biology and it looks like that he can make it all the way to the medicine. But when it comes to the common sense, he has to be explained in a written book fashion. The younger son, not good at the memorization but when it comes to the common sense he is better by miles. He can see and look at the things at the same time but I do know that he can never be a doctor under the current system and he doesn’t have the patience to go through it.
    Older one is already discussing about what the doctors make and how secure the profession is in here in Canada. I may have an idea that when and if he becomes one, what kind of doctor he will be.
    It is hard to change one’s nature. The current system attracts certain kind of nature to get selected as a doctor. Therefore we are seeing the results.

  • homebray

    6/26/2009 3:39:14 AM |

    How to create a virtuous cycle in health care will be a difficult task.

    I'm trying to think of an example on which we could a model --- not easy.  At first I thought dentistry, they are big on preventions with 6 month cleanings and all.  But in the end they are treating the mechanics of your teeth, in a way similar to maintaining a car extends it's life.  They don't (or at least I've never seen one) address underlying issues that lead to problems with the teeth.

    Maybe the closest I can come up with is obstetrics where the prevention is practiced in the form of pre-natal care. Of course the pay day for the doc comes on the big day.

    Can insurance reward doctors for positive outcomes? The heart patient who avoids the need for emergency procedures for examples? I can't see a way for this to work, you don't want doctors who refuse to treat unhealthy patients because there won't be a big pay day.

    Taking the money out of profession would also seem to work against the end goal. You loose the incentive to innovate.

    it's a quandary.

    Dr Davis, perhaps you are leading the way in your practice?

  • Anonymous

    6/26/2009 9:29:23 AM |

    Your letter was excellent.

    And you are right -- what passes for "prevention" in medicine today is nothing but lead-generation.

  • Dr. William Davis

    6/26/2009 2:34:36 PM |

    Great suggestions.

    I don't have the answer to how the system should be changed. But I think that the inequities of outsized procedural payoffs that persists is a source of much of the overuse. It fuels a system of hospitals growing beyond their needs, abuse of procedures, and excessive costs.

    That much at least needs to change.

  • homebray

    6/26/2009 3:43:09 PM |

    Maybe Docs could get paid for positive outcomes or procedures but not both -- -kind of like a wash sale in the stock market.

    That way you can't put off a procedure until after pay day and then do the procedure and collect twice.

    I don't know, Obama needs to do some clever thinking.

  • kris

    6/26/2009 6:14:48 PM |

    I think most of the things that we talk here on the heart scan blog should be a part of the high school curriculum. after all education builds nations. no education is more important than taking care of one's own health. it doesn't have to be unnecessary, no reason, medicine school language. it can be done in an easy make sense beginners language. first prevention is the people themselves should be educated enough to take care of their own bodies. doctors should only be in necessary extreme cases.

  • Wil

    6/26/2009 9:58:31 PM |

    Dr. Davis, your WSJ letter inspired us to write to our congressional reps today.  We included the full text of your letter to the WSJ editor in our own letter, copied below.  Best regards.

    "TO:

    Michael Castle
    Thomas Carper
    Ted Kaufman

    June 26, 2009

    Re:  Medical Care / Medical Insurance Reform

    Gentlemen:

    We will try to keep this message as brief and straightforward as possible.  Very simply, our country badly needs a publicly sponsored medical insurance plan available to all of our fellow citizens at a reasonable cost.  Otherwise we will continue to have the situation where too many families either have no insurance or inadequate coverage.  Our country cannot allow this state of affairs to continue.  We need the public plan feature as part of any “health care” reform so as to provide competition with the private medical insurance industry; an industry which is driven solely by profit for its executives and stockholders.  Clearly, the industry with all its “unhealthy” Wall Street influences cannot be trusted to act in the public interest and, in truth, their business model guarantees they will not.   In fact, the whole idea of profit-driven medical care / medical insurance monopolized by shareholder-owned corporations such as pharmaceutical, medical device and insurance companies is just plain wrong, in our opinion.  

    Our country’s present system for the financing and delivery of medical care has not made American citizens healthier and has given rise to perverse incentives that have made the system outrageously costly and unsustainable.  This must be stopped and Congress must act now in the interests of American citizens and not on behalf of the above-mentioned vested interests that, over time, through lobbying and large campaign contributions, have corrupted public policy and the legislative process.  We hope that any senator or congressman who in the past (or presently) has been accepting campaign contributions from any of these industry “players” will return those contributions and publicly announce that they will no longer accept such contributions.  

    It is our view that each member of Congress needs to begin to think very differently about the way medical services are provided.  As part of the overall reform process we all must ask what it is that will lead to better incentives and more efficient methods for improving the health and well-being of our fellow citizens.  To that end we draw to your attention a recent letter from Dr. William Davis, a practicing cardiologist from Milwaukee, Wisconsin, to the Wall Street Journal.  Dr. Davis has raised a crucial issue that all policymakers should be thinking about as they address medical care reform.  His letter reads as follows:

    [Dr. Davis, here we inserted the text of your WSJ letter]

    Mike, Tom and Ted:  We hope each of you will think seriously about these matters after severing whatever ties you may have to the vested interests that will spend millions on their lobbyists and on stealth advertising to prevent meaningful reform from being enacted by Congress.

    Sincerely,
    etc.

  • Dr. William Davis

    6/27/2009 12:41:23 AM |

    Hi, Wil--

    Well said.

    If enough of us stand up and shout, perhaps we can eventually out-shout the voices of Big Pharma, the hospital lobbies, and preservers of the status quo.

    I believe that we need to continue to fight, including opposing this crazed notion that prevention is a waste. Unintentionally (?), Dr. Varghese has performed the country a grave disservice.

  • Tanya

    6/27/2009 7:37:15 PM |

    Dr. Davis,

    Did the WSJ publish your letter?  I took a look at their site and it looks as though it wasn't picked up.

    Can I humbly make a suggestion?  I've spent a lot of time in politics and therefore know the value of getting into the Letters page.  It is very important to keep letters fairly short.  Long letters are not often published.  Your perspective is so important and you write very well, that it would be a shame if your letters are not published simply because newspapers need to include a number of letters and to do so on no more than one page.

  • Dr. William Davis

    6/27/2009 7:39:14 PM |

    Hi, Tanya--

    No, it looks like they didn't.

    Thanks for the helpful suggestion. Next time!

  • Trinkwasser

    7/14/2009 4:09:37 PM |

    Be careful what you wish for, here's our (UK) Government's view of prevention

    http://www.nhs.uk/Change4Life/Pages/default.aspx

    sponsored by Kelloggs and Tescos

    http://www.satfatnav.com/

    sponsored by Unilever

    http://www.diabetes.org.uk/Guide-to-diabetes/Food_and_recipes/Eating-well-with-Type-2-diabetes/A-healthy-balance/

    our only Diabetes Charity's opinion

    sponsored by

    http://www.diabetes.org.uk/Get_involved/Corporate/Acknowledgements/

    money doesn't talk, it SHOUTS

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