Monday, January 23, 2012

The shamans knew

Thanks to Kevin, MD for reprinting an excellent column by Joe Kosterich entitled, "There is scope for harm when ordering tests."  Dr. Kosterich notes:
  1. Most symptoms that we experience are not due to disease. A cough may be a symptom of lung cancer but hardly anyone who coughs has lung cancer. Likewise with a headache and brain tumors.
  2. Most conditions we see today are not acute emergencies and hence can be given time to resolve themselves. You do not always have to run to the doctor at the first sign of any symptom. Listen to your body.
  3. Tests and treatments have an important role but are never free from potential harm. We must always balance the benefits against the risks.
  4. We need to get back to treating people and not numbers so as to please governments and academics.
  5. The process of setting guidelines needs to be cleaned up.
All of this reminds me of some advice I received from an internist a few years ago.  He said that the main job of a primary care doctors is to decide not to treat someone's symptoms.  I may get the numbers wrong, but I recall him saying that 85% of symptoms just go away after a short time; another 10% can be treated, either simply or in a more complicated manner; and the remaining 5% will not go away even with treatment.

I conclude from this that the shamans and medicine men of olden days had things figured out pretty well.  A person shows up with symptoms.  In most cases, if you just talk to them, sing some songs, beat a drum or jiggle a rattle, and burn some incense, 85% will get over their symptoms.  In other cases, if you administer some herbal remedies -- purgatives, muscle relaxants, anti-anxiety drugs, or anti-emetics -- another 10% will get better.  And for the final 5%, you blame a lack of progress on the "evil spirits" or other supernatural forces.

With a 95% success rate, your career and livelihood is assured!

For more on this and related topics, check a new website called The Naked Doctor.  An excerpt:

Naked Doctor aims to encourage discussion and awareness of the opportunities to do more for health by doing less. It is a compilation of articles, books and other works that highlight overdiagnosis and overtreatment. 

It is a project of Dr Justin Coleman, a GP who works in Aboriginal and Torres Strait Islander health in Brisbane. He holds a Masters in Public Health, and is President of the Australasian Medical Writers Association.


Marilyn said...

From Facebook:

Marilyn Morrissey
I agree with this basic premise. However, being able to distinguish between mundane and worrisome symptoms is dependent upon exquisite clinical judgement, a sixth sense, if you will. That kind of judgement only comes with LOTS of clinical experience and plenty of supervision. Sadly, I've seen too many serious, even deadly, conditions missed due to inexperience, minimalization of symptoms or excessive concern for the bottom line.

Anonymous said...

Being an old school former surgeon I remember two sayings of my elder colleagues:
1. Courage is never needed for immediately operating a patient, it is needed for NOT immediately operating the patient.
2. Only snooty doctors say that they've ever cured even one of their patients, the maximum they were able to do was creating optimal circumstances for natural healing processes, or in a less favorable situation, didn't work against them.

Experimental Mouse

Paul Levy said...


Anonymous said...

Dr. Kosterich's essay is excellent. The other fallacy that potential patients (as well as some doctors) fall into is that there is a thin bright line between health and disease. In my field of pathology, one can often trace a progression of more severe atypia over time which finally crosses an arbitrarily-defined line into what we call cancer. We quickly learned that if we used the term 'carcinoma in situ' for some tissue types, as opposed to 'severe atypia', the clinician would feel obligated to treat it. It was that word 'carcinoma', no matter the modifier.
As do many doctors, I think long and hard before I go to the doctor with symptoms and put myself on the medical treadmill.


James M. O'Brien, Jr., M.D., M.S. said...

I understand the comments as they relate to acute complaints - and, in fact, this may reflect our backward approach to treating disease ratehr than maintaining health. But, in fact, our greatest opportunity for saving lives is likely in treating conditions for which acute complaints are infrequent - hypertension, diabetes, obesity, sedentary lifestyle, tobacco addiction, algochol abuse and dependence. I also think some of the comments by Dr Kosterich suggest a normal huam condition - we values losses more than gains. So, while better blood pressure control has been shown on average to reduce morbidity and mortality, "adding more tablets...can expose people to risks on the downside such as falling due to fainting." This is a classic omission bias.