Sight unseen

In the midst of the controversy surrounding the recommendations for breast cancer screening from the U.S. Preventive Services Task Force, a section of the Agency for Healthcare Research and Quality, I received a two-page letter from my primary care physician reminding me that it was time for me to have my screening colonoscopy. Included with the two-page letter was the equipment for me to first perform a hemoccult test, complete with a pre-paid addressed envelope for returning my specimen.

Sounds reasonable except that, to my knowledge, I have never set eyes on my PCP and certainly have never provided a history or presented for a physical examination. The PCP was selected for me a few months ago by my insurance carrier after my former PCP left the system.

In fairness, I must quickly add that my doctor has probably never seen the letter that arrived in my mail, and it was certainly not hand signed. However, I did appreciate the closing sentence: “As we approach the holidays, give yourself and your family the most special gift of all: peace of mind with respect to caring for your health and well-being.”

Should I conclude from this that there is a priori knowledge that my colonoscopy will be normal?

As an endocrinologist most of my clinical activity is devoted to preventive medicine:

optimizing glycemic control in patients with diabetes, making sure that they are up to date with visits to the ophthalmologist and podiatrist;
preventing the first or subsequent fractures in patients with low bone density or osteoporosis;
managing dyslipidemia or hypertension to prevent adverse health outcomes;
and minimizing the risk of future kidney stones in patients who have already suffered the agony of their first one.

I certainly have no beef with preventive medicine. What gets my juices flowing is what I call “cookie cutter” medicine where the needs of the individual patient take second-place precedence over making doctors sure that they don’t run afoul of AHRQ or any other government or insurance agency.

Since I am in a sounding-off mood, there is one more item I want to get off my chest. The therapy we prescribe for our patients only works if it is taken as prescribed at least most of the time, but the literature is replete with documentation of poor adherence with almost all classes of preventive therapy such as the list I gave above.

In my community, it is common for the pharmacist to provide a detailed description of all potential side effects when they hand the patient the medication. I have yet to see labeling describing why the drug has been prescribed. My all-time favorite was the patient who refused to take raloxifene when she read the pharmacist’s label indicating that the drug may have an effect on her cholesterol level. Indeed it does — it increases HDL and lowers LDL and total cholesterol, a favorable effect. When I contacted the pharmacist to inquire where he got his information he told me that it came from “head office,” and he didn’t have time to check the labeling on every drug he prescribes!

Preventive medicine is perhaps the most important aspect of our health care system — let’s not mess it up with rules, regulations, and behaviors that make no sense at all!