I have a personal confession to make. My father is a prostate cancer survivor. One month after he retired at the age of 68, he was diagnosed with advanced prostate cancer. After undergoing radiation seed implants and hormonal therapy, he was in remission, until a couple of years ago. That’s when his addiction to health care began.
The Nightmare Begins
Starting a few years back, my father’s PSA would spike up all of a sudden. When this happened, he underwent several rounds of bone scans, CTs, and blood tests. He ended up receiving cryotherapy, and later, stereotactic radiosurgery. More recently, he underwent chemotherapy. The problem is that his PSA is still very high, but his physicians have no idea where the cancer is hiding. There’s no obvious growth in his prostate, and his bone scans always come back normal. Still upon his physician’s recommendation, my father undergoes his CT, bone scans and blood tests every 6 months or so.
One day, as we were talking during dinner, my father mentioned that his doctors billed his insurance company "a lot of money for the hormonal implants" as stated on his insurance claim’s Explanation of Benefits (EOB’s). He’d noticed that these claims were denied payment more often than not by his insurance carrier, which concerned him a great deal since he felt that this would sour his relationship with his doctor. He was just as surprised to find out many months later, that these claims would get paid, but after multiple claim submissions and denials, and at a much reduced, discounted rate. Suffice it to say that this experience rattled his illusion of me getting wealthy as a physician.
Seeing how expensive these tests were, my father also felt guilty for being such a burden to the health care system, undergoing test after test every 6 months, with no obvious origin of his cancer. Just the same, his doctors keep telling him that by all measures, his life expectancy looks grim as long as the numbers show evidence of cancer, and so still recommend testing as a precaution.
One time, after seeing my father undergo an extensive battery of tests and radiation treatment that almost put him under, I tried using reverse psychology to get him to stop. Reasoning with him hadn’t worked until then, as what his doctors told him always trumped what I, or anyone else who loved him, said. I sarcastically told my father that it’s his obligation as an American citizen to continue undergoing the testing and the treatments, as long as his physicians recommended it, since this is what drives our health care system. I added that massive consumption of healthcare is a major foundation of our economy. Without it, how else could we spend 17% of our GDP? Little did I realize at that time that he would take me seriously.
What More Could You Want?
A recent op-ed in the New York Times commented on using prostate cancer as a bell-weather for how we structure our healthcare system. Study after study has shown that overall, aggressive testing and treatment for prostate cancer doesn’t really change the overall life-expectancy compared with no treatment at all. Yes, there are some very aggressive tumors, but in comparison, there are much more incidental, benign-behaving growths that don’t grow or cause any problems. Just like thyroid cancer, prostate cancer is very common as men age. Only some behave aggressively.
The op-ed writer’s argument is that how we deal with similar medical conditions can make a major impact on not only cost containment issues, but also in many quality of life issues. He’s not saying we should just ignore it, but for most "routine" prostate cancers, follow it closely, but treat it very conservatively, intervening only when absolutely necessary. Since there’s no difference on life expectancy, what’s the point of spending millions or even billions on tests and treatment options that ultimately don’t make any difference in the long term?
I explained all of this to my father whose doctors recently recommended another round of radiation despite the fact that his stress test showed his cardiovascular functioning was that of someone 10 years younger. My father justifies continuing his current regimen for the following reason: Many of his close friends died of advanced metastatic prostate cancer, and clearly, doing something is better than not doing anything at all. When emotions are involved, logic, financial considerations and common sense all go out the window. It’s only natural, since it’s human nature. His doctors also feel compelled to do everything possible to give him and themselves peace of mind, in knowing every few months that that there’s no obvious return of the cancer.
Despite the cancer diagnosis, my father is healthier, more vibrant and youthful than many of his peers let alone his doctors. He takes undergraduate courses at Hunter College, plays a mean game of tennis, swims regularly, sings in his church choir, hikes on Hunter mountain with those that are 20 years his junior, and goes to the symphony and opera every chance he gets. He even played King Lear recently in a local theater production. Currently, he’s rehearsing for a role in The Fantastics. Although he’s living with a "life threatening" disease, this doesn’t prevent him from living the life he’s always dreamed of at the ripe old age of 78.
When More Is Not Always Better
According to Wikipedia, addiction is characterized as follows: "the continued use of a substance despite its detrimental effects, impaired control over the use of a drug (compulsive behavior), and preoccupation with a drug’s use for non-therapeutic purposes (i.e. craving the drug)."
I’ll be the first to admit that I’m just as guilty in bringing about this healthcare crisis as anyone else. Up until a few years back, I was the same as anyone else-performing surgery, rendering treatment and dispensing medication according to the model standard of care. But over the last decade, the threshhold for what’s considered standard care has spiraled out of control. In the case of my wife, for instance, who recently delivered our third child 10 years after our first, she had to undergo double the amount of tests and check ups, all the while spending countless hours negotiating multiple disruptions in her continuity of care (see the article Health Scare Crisis). Infant vaccinations have also doubled in the last 10 years, so if I choose to get just 1 shot rather than the recommended 2-3 shots per pediatric visit for Brennan, my newborn, I’d have to pay out of pocket for this expense since my insurance only covers for "routine visits".
In a 20 minute documentary video, The Story of Stuff, (www.storyofstuff.com), Annie Leonard details how as a society, we’ve become addicted to consumption. I highly recommend everyone watch this video. Similarly, we’ve also become addicted to consuming healthcare. It makes us feel good to have more tests, not because there’s any absolute proof it works, but "just because" it’s there. A day doesn’t go by when I don’t consult with a patient who’s on at least 10-20 different medications per day. When I ask them if they think any of it is making a difference, they’ll say "not really, but at least it’s keeping the (i.e. cholesterol, blood sugar, PH etc) numbers down". Despite dubious evidence that many pills or surgical procedures make any difference in the long run, doctors perform procedures or order more tests rather than spend time with patients or counseling them to help change their habits–especially when there’s zero compensation from insurance companies for doing the latter.
In another documentary, The Corporation (www.thecorporation.com) the narrator describes how a business entity that was created for the right economic reasons can morph into a paranoid schizophrenic monster. It’s not that the individuals within the corporation are malicious, greedy or even evil, but that the corporation itself takes on the personality traits of a greedy, delusional, psychopathic maniac. As I see it, this is what’s also happened to our health care system in the United States. Despite the good intentions we all had at the outset in providing affordable and accessible healthcare to Americans, our relationship to healthcare has morphed into a skewed dependency. Why should we eat right and exercise, which is so difficult to maintain, when there’s a pill for every ill imaginable and unimaginable?
The Only Thing To Fear is Fear Itself
Everywhere you look these days, there’s one fear mongering message after another being reeled into our consciousness. From the time you’re an infant to the time you’re old as my father, you’re told to protect yourself from encounter after near fatal encounter with every possible disease you can think of. At a picnic recently with some friends and family at a Westchester park about an hours drive from the city, a tiny tick barely the size of a pin-head was found on my friends’ young son. Instantly, everyone who attended was alerted to the possibility of Lyme disease and we begrudgingly woke up our three very sleepy children to comb through every nook and cranny despite the baths they took earlier. The thought going through my mind at the time was: you can never be too sure.
As such, healthcare is a major revenue generator, and as long as fear is what’s driving everyone, and as long as someone else (the government or your employer) is paying for to accommodate this fear, things are not looking too good for our future, despite all the proposed changes.
As for me, I’ve come to terms with my father’s illness. As long as my father continues to stay active and has a positive outlook on life, I’m not concerned about whether or not his cancer returns. My only fear is that if his cancer does return, the "prognosis" that he may be given by his doctors will ultimately come true as a self-fulfilling prophesy. In the meantime, I refrain all judgement of my father who now takes prides in the fact that he can continue to contribute to the health care system and to the economy by undergoing more tests.