The first experts were shamans, an occupational category that eventually divided into doctors and priests. As the Catholic Church became more and more powerful, abuses of priestly power became more and more apparent and upsetting, leading to the Protestant Reformation.
Now — half a millennium later — doctors are under much greater scrutiny. The results of that scrutiny are unfavorable — perhaps highly unfavorable. A RAND study suggested that the overall benefit of a substantial amount of health care was small, except in certain special cases such as eyeglass prescription. A large fraction of surgeries are unnecessary, says one critic–and by large he means large:
Stanford University urologist Thomas A. Stamey, M.D., generally regarded as the father of PSA testing, says that 90 percent of all the prostatectomies performed at the Stanford hospital over the past 5 years have been unnecessary.
Earlier post on this topic.
Addendum: According to Biotech Blog,
There’s been a shift in the past 50 years away from the doctor-centric model of healthcare to one in which patients expect, and demand, better information and control over their treatments.
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A 70-293 is a much better choice than 70-296 for someone who plans to do 70-291 later. If the future plans revolve around 70-526, it is alright otherwise.
Thanks for the Shaw recommendation. If I’m too pessimistic, tell me the serious flaws of the RAND study that I link to — it found little benefit of additional medical treatment.
Vaccination works, sure — it is public health, not medicine. Better nutrition works, clean water works — all that is public health. Not smoking works.
Broken bones fix themselves, so your “serious broken bones” example isn’t impressive. There may have been a minor advantage to what the doctors did. And fixing broken bones is a special area of medicine — one where it is easy to see the benefits.
Heart disease, cancer, diabetes, stroke — I think it is easy to see that most of the time, doctors can do little about these things. As one doctor told me: “The truth is that for most problems we see, we can’t do much.” When it comes to everyday illnesses our immune systems do the work. So where is the great benefit?
I wonder if anyone is seriously attempting to determine the morbidity and mortality benefits of “medicine” as opposed to just “public health”. It would require huge meta analyses of particular areas of medicine, and then aggregating them in some way, I would guess. My own medical treatment is based on extremely crude correlational science. I’ve had my blood pressure and cholesterol lowered by drugs (prior to my weight loss); it’s clear that high cholesterol and blood pressure correlate with greater mortality, but I’m not sure we know that lowering them with drugs helps that much.
My doctor tells me that no one needs to die now from colon cancer. If everyone got colonoscopies at the right age, then all colon cancer would be detected early and when detected early can be “cured”. My impression is that cancers like leukemia and others are far more treatable.
Or take AIDs — surely medical treatment is extending the lives of AID’s patients enormously.
But I may be an innocent victim of hype; I don’t think about these things rigorously. It’s confusing to me. There are apparently serious scientists now claiming that in the next century or longevity will be radically expanded. I am extremely skeptical when I hear this.
My question to Seth is: Do we really have the scientific knowledge to justify his claim? Is there any intuition/ideology etc., in his claim? The Rand study would have to be very fine-grained about the specific treatments that the 7000 people got and then sort out the effects — which it did not do. It would have to show which medications were given to whom at what stage of development in pathologies, differences in diagnostic testing, etc. I don’t take it very seriously — but I defer to others in evaluating studies. It’s probably true that a lot of medical treatment does little good, but we may not know which is useless until it’s tried out for a while…
The RAND study did look at different treatments; it found that eyeglasses were clearly effective but that most treatments were not. Surely the RAND study has its problems — but is there a better study?
My own experience with doctors has been good. I had hernia surgery, which was obviously both necessary and helpful. When I had a kidney stone (very painful), a shot of morphine really worked. Sure, there are cases when medicine helps. But attempts to look at the big picture, counting costs along with benefits, have not been favorable, as far as I know. If there is evidence I am leaving out, please let me know.
All the evidence that is left out would presumably not be meta-evidence, since I assume the requisite meta evidence has not been done. There is a lot of research on particular treatments showing some are not that good and some are very good.
My point would be that to speak as a scientist the best thing to say is that we don’t really know how much medical treatment helps, and may never know a lot. The Rand study may be interesting but way too limited in value.
We can’t ethically take say 10,000 people at birth, and randomly provide half with stellar medical treatment and half with zero treatment for 100 years, while each receives the same “public health” benefits (however the distinction is drawn) — which would tell us a lot. Short of that, we can look at particular treatments that have been scientifically shown to help and see how much they add up to increased longevity, lower morbidity, etc… and weigh them against things like the Rand study…
Read the May 16 comment by Toby on the article you point to. The study does *not* say that health care is useless. Rather, it suggests that more health care *at the margin* is may not be very helpful. There is an *enormous* difference between these two statements.
If you want to measure the benefits of health care, the proper control group is people who have *NO* access to health care, not people who have health care but have to pay for it. The RAND study measured the benefits of *free* health care as compared to care that people pay for or have covered by insurance.
Look at the gains in lifespan in the 20th century alone that have come from the development of antibiotics. Diabetics have health care to thank for synthetic insulin. People with heart disease have statins and angioplasties and coronary bypasses and heart transplants. People with cancer have chemotherapy and radiation and surgery – cancer mortality rates have been falling substantially over recent years.
I understand that you don’t agree with everything in the world of modern medicine, but arguing that health care provides no benefit is, to put it charitably, silly. Without health care, it’s quite possible that you’d be dead or seriously disabled from that kidney stone.
I don’t “argue that health care provides no benefit.” No benefit is much too strong. Perhaps I should have made that clearer — that is, in addition to my eyeglasses example and the 10% of prostatectomies that the Stanford doctor believed are helpful. What I am trying to say is that the increased scrutiny given doctors has not turned out well for them. The RAND study, of course, is limited — but is there a better attempt to figure out the overall value of medicine? I don’t know of one. if you can point me to a study that shows the more-than-minor value of modern medicine I’d love to look at it.
Lifespan gains in the 20th century are often attributed to public health measures, such as clean drinking water and vaccinations. They do not make a strong case for the value of medicine.
Why do you attribute the decline in cancer mortality to medicine rather than lifestyle changes (e.g., less smoking, better nutrition)? Perhaps the improvement is due to 90% lifestyle change, 10% medicine. I don’t know what the correct percentage is, but you seem to.
Diabetics have been helped by synthetic insulin, indeed. But they administer it themselves. It’s a special case, between medicine and prevention. And in spite of this help, diabetes is a major cause of death and disability. No doubt because of obesity, which doctors have done nothing to help with.
My kidney stone passed in a day or so without help from doctors. The morphine reduced the pain it caused.
Here you go: https://www.economics.harvard.edu/faculty/dcutler/papers/cutler_meara_boulders_2001_final.pdf
While public health measures and improved nutrition dominated in the early part of the 20th century, antibiotics contributed to a big decline in mortality in the middle of the 20th century. Medical treatment is playing an increasingly important role in reducing mortality, particularly in dealing with cardiovascular disease.
Andrew, my point is that when the overall effectiveness of medicine has come under scrutiny, it has not fared well — and the RAND study is a good example. Whatever its flaws or various interpretations, I don’t think it can be dismissed. I don’t believe that medicine is completely ineffective — far from it. But how effective is it compared to the existing big effects on health — such as clean water? And adequate nutrition? As far as I can tell, not very — which is why I didn’t bother to put qualifications around the straightforward conclusion from the RAND study. (I might have said, “According to a RAND study. . . ” or “If you believe this study . . . “) The sheer difficulty of making a convincing case for the great overall efficacy of medicine is a sign of that, I think. The mother of a friend was near death — and then she recovered when all of her medicines were stopped. Her prescribed drugs were killing her.
Geoff, thanks for pointing me to the Cutler paper. I am very interested in the evidence for the other side. My take on that paper was that the argument for the importance of medicine in reducing heart disease was completely unconvincing. Sure, there may be a small effect. But the graph of heart disease mortality shows a steady decline starting around 1960. Did something happen around 1960 to make heart disease research all of a sudden effective? Not that I know of. Yet the shape of the graph — a long steady decline — suggests a single cause that became more and more effective. Around 1960, Americans became more interested in physical fitness. JFK dramatized this with his 50-Mile Hikes. This interest in fitness has slowly grown ever since.
A small NET statistical effect does not necessarily indicate small GROSS causal effects. A large benefit of medicine may be counterbalanced by medical errors, deaths under general anesthesia or from unnecessary surgery, diseases caught in the hospital, unknown side effects of drug combinations… many are talking as if the bold hypothesis under consideration is that medicine is a null-op. This is not the bold hypothesis. The bold hypothesis is actually a spectrum of hypotheses under which the marginal benefits of medicine, and its marginal harms, range in unison from low to high – any point in this spectrum accounts for the RAND data. For every bright anecdote that pops up in your mind about how modern medicine cured your uncle’s skin cancer (which I’m quite willing to accept it did) consider the anecdote someone else posted to Overcoming Bias about an uncle who went under general anesthesia for knee surgery and never woke up.
I think there is probably an even simpler explanation for the RAND study: it’s comparing health care that people would pay for on their own to free health care. Free or not, most people will obtain treatments that have obvious benefits: having a broken leg set, antibiotics for an acute infection, visits to an obstetrician while giving birth, and so on. It’s things that are less obviously beneficial that people might choose to forgo – maybe things like brand name drugs instead of generics, frequent checkups, extra tests, etc. So perhaps the RAND study just shows that treatments that do not have benefits that are obvious to patients do not pay off in reduced mortality. That doesn’t seem very surprising, nor does it discredit medical professionals to my way of thinking.
“Heart disease, cancer, diabetes, stroke — I think it is easy to see that most of the time, doctors can do little about these things. As one doctor told me: “The truth is that for most problems we see, we can’t do much.” When it comes to everyday illnesses our immune systems do the work. So where is the great benefit? ”
There may not be a cure for diabetes, but certainly treatments such as insulin therapy are effective in regulating blood sugar levels which reduces complications due to diabetes. Hemoglobin A1c is a measure of blood sugar levels over the past 3 months. High A1c is strongly associated with many of the complications of diabetes such as retinopathy, heart disease, and limb amputations, and death just to name a few. You are either IGNORANT or an IDIOT if you can’t see the great benefits of medicine for treating diabetes.
In regards to cancer, in some cases, early detection is the key to successful treatment.
Reductions in heart disease have been shown to be associated with various medicines.
Your doctor’s quote should perhaps be restated as follows: by the time that patients seek help, there is sometimes not much that the doctor can do to treat the disease, or in the case of diabetes cure it (no cure yet). However, that is not to say that some of the symptoms cannot be treated with meds. In the case of type II diabetics, many of them have spent years over-eating and not exercising and a doctor cannot fix the strain you have put on your body by not taking care of yourself. At the onset of type II diabetes, all the doc can do is attempt to regulate your blood sugar levels with meds or insulin therapy, but both are far from a cure.
Your statement
“Heart disease, cancer, diabetes, stroke — I think it is easy to see that most of the time, doctors can do little about these things.”
is very IGNORANT, especially when it comes to diabetes. Medicines have made a huge impact on the treatment of diabetes… without insulin, type I diabetics DIE.
Seth,
After visiting Bangladesh, I would have to disagree with you. There are plenty of people walking around with what seemed to be treatable problems. They probably would value any doctoring…even if it doesn’t hold up to your standards.
I would also argue with your definitions. All of vacines and most public health stuff is most strongly driven by doctors. They should get credit for that.
Lastly, everyone’s prize evidence; an annecdote. (hey wait doesn’t this stinking comments section have a spell checker?)
My wife had a mysterious infection that distroyed her vistibular nerves. She lost much of her sense of balance. There was nothing that could be done. But after much much testing and expense, they did figure out what had happened.
The neurologist had no cure, but his explanation of what had happened and his discussion about the sort of accomadations and changes she needed to make in her life style allowed her to get on with her life. Up until then she was floundering and unable to work or even to function very much.
So the point is, what would a study of effectiveness make of this. In one way we spent a lot of money on doctors and in the end they could do nothing. On the other hand, the information about what had happened and how to go forward kind of saved her life.
I’m not saying doctors have no effect. I’m not saying they’re not comforting — “palliative” is the technical term. I’m saying that the effects of American medicine, in America, that when scrutinized seem overall — not in every case — to be minor compared to the big effects in health — for example, the effects of high-Vitamin-C foods on scurvy, the effects of clean water on infectious diseases, the effects of morphine on pain.
As I mentioned earlier, insulin is a special case, halfway between prevention and treatment.
You seem to have a very narrowly defined definition of medicine, which actually does not seem very clear.
If a doctor diagnoses me with diabetes and tells me to take insulin, is he not in some way responsible for improving my condition? I believe doctors play a very critical role in the diagnosis of disease, to which they at least earn some credit in a less narrowly defined view of medicine.
“Diabetics have been helped by synthetic insulin, indeed. But they administer it themselves. It’s a special case, between medicine and prevention. And in spite of this help, diabetes is a major cause of death and disability. No doubt because of obesity, which doctors have done nothing to help with.”
You are right. Doctors do not yet have a magical cure for diabetes that enables patients to not have to take care of themselves. But whose fault is that really? The doctor’s fault, or the patient’s fault?
If a doctor tells me to take an antibiotic, and then I self-administer it, does this also fall in between medicine and treatment?
Doctors improve many conditions, absolutely. And one of them is diabetes. But compared to the treatment of scurvy with Vitamin C, is the improvement major or minor? In practice?
“Whose fault is that?” I’m trying to describe the situation. Since you ask I don’t blame either the doctor or the patient. I blame human nature.
You’re right, to say the special thing about insulin is that patients “adminster it themselves” is confusing. As you say most drugs are self-administered. I should have said that insulin is special in two ways: it replaces something missing from the body; and the administration (to be effective) has to be remarkably careful and intricate. It is true that in the right hands, insulin is a major medical success story. Those “right hands” however are few. Perhaps they will become more common in the future. Self-experimentation played a very big role in showing how insulin could be used most effectively. Something else that sets insulin apart from other treatments.
Geoff,
The RAND study was surprising to many people, including me. All health care is supposed to help; the study found that a lot of it did not clearly help. I think there is something to be learned from that.
Seth, see my comments at Gelman’s website about interpreting the results from the Rand study and why I am not surprised to not see much of a difference. https://www.stat.columbia.edu/~cook/movabletype/archives/2007/06/total_vs_margin.html
Thanks for the link. I have commented over there.
Seth,
Why is every medicine supposed to have a big impact? Won’t some have a larger effect? For the meds that are truly important, don’t you think that most groups received those, and the less important, those that don’t have as large of an impact, were probably what were used more in the free group.
Though there may not have been noticeable overall health benefits from going to see the doctor more, as was done in the treatment group, who is to say that they didn’t recover from illness faster? For most common ailments, our immune system can fight them off slowly and your health overall won’t be affected much by not going to the doctor. However, how much of a benefit is there to taking a drug that speeds up the recovery process, though it may not be a benefit to your overall health. Factors such as this don’t show up in the Rand study results.
Also, let’s say I’m in the free group, is there a benefit to going to the doctor at some of the first signs of getting sick? Even if I find out that if I have a virus that can’t be treated by antibiotics, should I not have gone? Should I have used less free health services because my immune system would have most likely been able to handle the ailment? Going to the doctor more often does not necessarily mean that they received more meds… a lot of the times were probably because they were being cautious and because they could for free. When you have to pay, people aren’t usually willing to seek care until they get really sick and know that they need to be seen. However, even at this point if they do have something treatable, their overall health is not going to be affected by having waited to see if their immune system could handle it.
Seth, smaller studies are fine for if you want to concentrate on a population of people who are sick and you are going to randomly give half the cure as in your scurvy example.
The point about the most necessary medicines is that those are where the biggest benefits are seen. Not every drug or every treatment will make a big impact in your overall health. For any treatments that do make a large impact on your health, I assure you that even people who had to pay received the necessary treatments.
Big effects in healthcare can be seen for those who are sick… it is much harder to see effects of medicine when you take a sample from the general population, thus you should need an even bigger sample if you want to see a benefit.
Unfortunately, as medicines become better and better, it becomes harder and harder to improve upon the standard of care. This is one of the reasons why clinical trials require so many patients to see the positive benefits of a new drug. In addition, even when the population in your study is sick, it can still be difficult to see the benefits when looking at events with low incidence rates…. and this is even when your population is sick. Can you imagine how woefully underpowered you must be when looking at a group of healthy people.
By the way, for those of you who are interested, the study looked at 2750 families, the mean age was ONLY 33, the youngest person was 14, and the maximum age at time of enrollment was 61.
“All of vacines and most public health stuff is most strongly driven by doctors. They should get credit for that.”
Actually, it started in the U.S. with public health nurses and insurance companies. Doctors actually went out and got that stopped.
That they are behind it now, due to the fact that they collect payment for administering it when nurses used to go door to door and provide the service for free, doesn’t tell me anything that makes me want to give them credit.