As we anticipate a new year characterized by unprecedented interest in healthcare innovation, pay particular attention to the following three emerging tensions in the space.
Tension 1: Preventive Health vs Excessive Medicalization
A core tenet of medicine is that it’s better to prevent a disease (or at least catch it early) than to treat it after it has firmly taken hold. This is the rationale for both our interest in screening exams (such as mammography) as well as the focus on risk factor reduction (e.g. treating high blood pressure and high cholesterol to prevent heart attacks).
The problem, however, is that intervention itself carries a risk, which is sometimes well-characterized (e.g. in the case of a low-dose aspirin for some patients with a history of heart disease) but more often incompletely understood.
As both Eric Topol and Nassim Taleb have argued, there’s a powerful tendency to underestimate the risk associated with interventions. Topol, for example, has highlighted the potential risk of using statins to treat patients who have never had heart disease (i.e. primary prevention), a danger he worries may exceed the “relatively small benefit that can be derived.” (Other cardiologists disagree – see this piece by colleague Matt Herper).
In his new book Antifragile, Taleb focuses extensively on iatrogenics, arguing “we should not take risks with near-healthy people” though he adds “we should take a lot, a lot more, with those deemed in danger.”
Both Topol and Taleb are right that we tend to underestimate iatrogenicity in general, and often fail to factor in the small but real possibility of potential harm.
At the same time, I also worry about external experts deciding categorically what sort of risk is or isn’t “worth it” for an individual patient – a particular problem in oncology, where it now seems fashionable to declare the possibility of a few more months of life a marginal or insignificant benefit.
Even less dramatically, a treatment benefit that some might view as trivial (for hemorrhoids, say) might be life-altering for others. For these sufferers, a theoretical risk that some (like Taleb) find prohibitive might be worth the likelihood of symptom relief. Ideally, this decision would ultimately belong to patients, not experts asserting to act on patients’ behalf.
Patient monitoring outside the hospital has been a hot topic (and also a not so hot topic) for the past 15 years.
A clever little study was published last month in the Archives of Internal Medicine, and it – plus the fact that I’ve just started a stint as ward attending – prompted me to think about the importance of managing a set of tasks in the hospital. In my quarter-century of mentoring residents and faculty, I can’t think of an area in which the gulf between what people should do and what they actually do is larger, nor one in which improving performance yields more tangible rewards.
At 5am, Mr. A rolls onto the medicine floor: the fifth and final new patient to be admitted that night. The 70-year-old is well-known to our institution from his near-monthly hospitalizations and his primary care doctor, cardiologist, podiatrist, ophthalmologist, and both of his endocrinologists all work in-house. Unfortunately, for the intern admitting him (and for Mr. A), this translates into a few hours-worth of prior blood test results, MRI reports, visit notes, and discharge summaries to peruse. Where to begin? How to find the key details buried in this hoard of information?
When you or a loved one enters a hospital, it is easy to feel powerless. The hospital has its own protocols and procedures. It is a “system” and now you find yourself part of that system.
A recent report by the New York Times contained 
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