Imagine two men in their early 60s. A year from now, both men will be dead.
Changing how doctors, patients and the media perceive prevention could save lives and billions of health care dollars.
Today, each is scheduled for an initial consultation with an orthopedic surgeon and will undergo hip replacement surgery. Patient A will die on the operating table from a surgical complication. Patient B will undergo the procedure without incident. But within 12 months he will die from colon cancer that could have been detected as part of today’s visit and removed before it spread.
Patient A’s death, caused by the surgical complication, will be considered a medical catastrophe. Hospital officials will step in. The surgeon will need to defend his actions. If that surgeon is found negligent, there will be professional consequences and damage to his reputation.
Patient B’s death from a preventable colon cancer will be viewed very differently.
The health care world doesn’t view errors of omission and commission the same. The reasons comprise a mix of medical culture, patient and media bias, and health care economics. Let’s explore each of the perspectives involved in the consistently high dosage of preventable deaths in America.
The Doctor and prevention
On the whole, physicians undervalue the importance of achieving the highest levels of prevention. It’s a habit they form in medical school and throughout their specialty training. Medical students and residents absorb long-held beliefs and values from more senior trainees and attending physicians. By the time they start practicing medicine, they know which activities are valued and which are merely an afterthought.
Prevention is merely an afterthought.
Physicians are rewarded well, both professionally and personally, for intervening during a crisis – much more than for preventing a life-threatening condition in the first place.
When a patient who’s suffering from a heart attack is brought to the emergency room, the cardiologist who unclogs the artery becomes a hero for saving the patient’s life. The cardiologist’s clinical skill is praised by colleagues and the patient.
Compare this to saving a life through prevention. Of course, physicians are pleased they have the ability to lower their patients’ blood lipids and control their high blood pressure. But unlike the cardiologist, they can’t be sure which of their patients avoided a heart attack or stroke through prevention measures.
As a result, there are no kudos from colleagues or thank-you letters from grateful family members. The doctor’s clinical excellence goes unrecognized and unrewarded.
This culture of valuing intervention over prevention is reflected in how doctors are paid. Surgeons and medical subspecialists who do procedures sit at the top of the income pyramid. Those primary care physicians who focus on prevention stand near the bottom.
The patient and prevention
Since patients can’t ever be sure whether they would have developed cancer or experienced a heart attack, few place a high value on all the tests and prevention advice their physicians recommend.
As a result, they don’t understand how much work and diligence are involved in successfully preventing disease. They assume all physicians are equally skilled in this area. While that assumption proves incorrect, the culture of health care and the media reinforce this misconception.
When patients are told they have a heart condition and need a procedure, they jump through hoops to find “the best” specialist for their problem. What they don’t recognize is that the difference in clinical outcomes among well-trained interventional cardiologists is relatively small.
Almost no one asks, “Who can achieve the highest levels of prevention for me and my family?” But in terms of clinical outcomes, the variation among doctors in this area is much greater.
The media and prevention
When a new drug is found to extend the average person’s life by a few weeks, the pharmaceutical company touts it as a scientific breakthrough. The media jump all over it. It’s a banner headline.
And although prevention can reduce the likelihood of stroke, heart attack or cancer by up to 30 percent, the media rarely report on the medical industry’s failure to maximize prevention for all.
Drug and device companies spend millions on television and magazine ads to promote their newest products – particularly those that generate the biggest profits. In contrast, no one advertises approaches for prevention, which are relatively inexpensive.
For example, there are four generic medications on the market that can dramatically reduce the risk of heart attack in patients with diabetes, kidney failure, peripheral vascular disease or those who suffered a previous heart attack. Yet few drug companies encourage doctors to prescribe these inexpensive medications. Instead, their detail sales people push newer patent-protected drugs, which sell at significantly higher prices.
All this information is readily available but relatively absent from media coverage. Unnecessary deaths from preventable diseases just aren’t as newsworthy.
Medical culture, patients and media contribute to the lack of medical prevention and the resulting suboptimal outcomes. Half of the 68 million adults with high blood pressure today are not achieving adequate control. An estimated 71 million adults have high cholesterol. Only 1 in 3 has it under control.
Those facts contribute to even more alarming statistics. An estimated 715,000 people suffer a heart attack each year and 795,000 experience a stroke. As a result, 7 in 10 deaths every year in the U.S. are caused by chronic – often preventable – diseases. Stroke, cancer and heart disease account for more than half. Through prevention and screening, the incidences of these diseases, along with the suffering and expense associated with them, could be reduced significantly.
Information on the differences in prevention performance is available. In fact, we know some doctors and medical groups help 30 percent more patients achieve blood pressure control or complete cancer screening than their peers, based on the Medicare Star Rating system and National Committee for Quality Assurance (NCQA) data.
If every insured American received care from higher performers, as many as 200,000 heart attacks and strokes could be prevented each year, according to analysis done by quality experts at Kaiser Permanente.
The future of prevention
The Affordable Care Act will increase prevention rates. Health insurance will become available to more people and companies will be required to fully cover the cost of preventive services. At least in the first few years, payments for primary care will increase. But reducing the economic barriers to preventive care won’t be enough.
Doctors, the people that patients trust the most, must play a role in motivating everyone to seek and follow prevention measures. And those prevention measures must be an integral part of the medical training and ongoing education doctors undergo.
Furthermore, all physicians — regardless of specialty — need to accept responsibility for talking to patients about gaps in their preventive services. Doing so will help those with chronic conditions minimize the risk of complications.
In any given year, many patients won’t seek care from their primary care physician. But they may see a specialist. If every physician – not just primary care physicians – took prevention seriously, the rate of blood pressure control could rise from 55 percent to close to 90 percent. The incident of strokes could drop dramatically, as well.
Consider this: Colon cancer usually begins as a benign polyp and takes 10 years to progress to invasive cancer. However, once the cancer penetrates the intestinal wall, the chance of cure drops quickly. When patients are cared for by the highest-performing physicians and medical groups in the country, 80 percent of patients in the appropriate age groups are screened. In contrast, the national rate hovers around 60 percent.
Physicians know how to reduce the incidence of heart disease, strokes and cancer. They just don’t do it often enough. If we can change how doctors, patients and the media perceive prevention, the nation could achieve cost savings in the billions while positively impacting the lives of patients and their families.
One day, we will be as concerned about the patient who dies from lack of preventive care as we are about the patient who dies from a surgical complication.
Until then, people will die needlessly.