A friendly chat at Starbucks wandered into the topic of what my friend termed the "medical-industrial complex."
That sounds like a creepy conspiracy theory-loaded realm found on the dark nets, doesn't it?
For those of us with suspicious minds: Calm down. There's nothing all that nefarious going on. (Or is there?) It's just an attention-grabbing rubric for the network of corporations which supply health-care services and products for a profit.
What got us into it: A few days earlier, I'd been scheduled to undergo an elective outpatient surgical procedure. Languishing in pre-op for over two hours as my doctor attended his first patient of the day, I had plenty of time to reconsider my options. Growing more anxious and uneasy as the minutes ticked by, I asked myself: Is this really necessary?
Deciding it wasn't, I announced I was leaving, untied my gown, tossed the hospital-supplied skid-proof socks onto the bed, got dressed, and bolted for the door. From the look on the attending nurse's face, I'm pretty sure she feared I was having a panic attack. In a way, I guess I was.
My Starbucks friend was sympathetic to my sudden--and absolute--need to get out of there. That's when we started talking about the increasing number of knee and hip replacements she's seeing among baby boomers. She's not convinced that all such procedures are necessary, let alone successful.
She might be right (she usually is). According to the website for the Orthopedic Institute of Pennsylvania, over the last 10 years there has been a threefold increase in knee replacements for those ages 45 to 64. In part, that's because this age group is more active than previous generations, and they want to continue to participate in the sports they've pursued throughout their lives. So some opt for hip and knee replacements as a preventative measure, before troublesome afflictions like osteoarthiritis show up to slow them down.
And, since excess weight adds significant stress to our joints, it's not surprising that many obese patients--39.5 percent of adults in this country--are lining up for hip and knee replacements as well.
There are plenty of physicians and providers ready and willing to help them out; among them are proprietary hospitals, many owned by physicians in order to provide a workshop for their practices.
As my friend's father is a doctor, I was surprised that she wasn't all-in when it came to health-care services. But no. "My dad says that the top third of any medical school graduating class makes the best researchers," she told me. "The middle third are the best with patients, and the bottom third make the most money."
She's not a denier; people who don't vaccinate their children cause her distress.
"But you can't catch a bad knee from somebody else," she said. Having knee or hip replacement only matters to the person choosing to do so.
That led us to the subject of mammograms. My friend is not a fan. I'm on the fence.
Obviously mammograms save lives. It's estimated that these screenings reduce cancer rates by 15 percent. And they're especially relevant for those with family histories of breast cancer.
But women, including those who are healthy, feel pressure from those in the medical community to get a mammogram every year. It's troubling enough to be exposed to radiation--admittedly small doses, but still--that might not be necessary, but many of us have encountered the psychological upheaval of false positive findings.
Even when a follow-up exam turns out to be negative, the initial finding worms its way into one's self-perception, thereby perpetuating the desire to continue getting yearly exams.
Here's where the medical-industrial complex comes in. Since September 2010, the Affordable Care Act requires health insurance plans to cover screening mammograms every one or two years with no out-of-pocket costs for women ages 40 and older. That's for a routine screening, which amounts to a lot of income for screening providers.
It's also confusing that many mammogram providers ask their patients if they want an enhanced 3D mammogram, which may be covered by insurance, or may not (Medicare, for example, doesn't pay for them). So the patient will be billed. Again, this benefits the providers.
According to information on the Mayo Clinic website: There isn't enough evidence to conclude that 3D mammograms can reduce the risk of dying of breast cancer more than a standard mammogram alone. For this reason, most guidelines for breast cancer screening don't specify that women should choose 3D mammograms over standard mammograms alone.
So what to do?
Here's advice from Dr. Rachel Freedman, a medical oncologist in the breast oncology center at Dana Farber Cancer Institute: "For women with no history of cancer, U.S. screening guidelines recommend that all women start receiving mammograms when they turn 40 or 50 and to continue getting one every one or two years. This routine continues until they turn about 75 years of age or if, for whatever reason, they have limited life expectancy. At that point, whether a woman continues to have mammograms depends on thoughtful discussion between the woman and her health-care team about what is appropriate for her specific situation."
If that doesn't suit you, there's this from Dr. Robert Shmerling. faculty editor of Harvard Health Publishing: "We want tests that actually improve longevity or quality of life. On the other side, we don't want too many false alarms (or 'false positive' results) that suggest disease when in fact no disease is present. ... There's another downside to false alarms: worry. If you're told your screening test for cancer is abnormal, the time it takes to figure out that it's a false alarm can be terribly frightening. And it can seem like forever."
I think I'll skip the screening this year. Maybe by next year, guidelines will be clearer.
Karen Martin is senior editor of Perspective.
Editorial on 09/15/2019