Doctoring General Medicine Knowledge

Forgotten Concepts in Medical Practice

A reader asked an excellent question on my last post. Roy wondered if further research in elderly patients would identify a subset of patients that would benefit more from anti-coagulation.

My answer is… not likely. The reasons involve three oft-forgotten concepts. See below.

To Roy, I say it is unlikely that further research will address the very elderly. The problem is vested interests. There are few industries willing to fund such studies because it is unlikely to result in positive results for something they can sell. Also, the government isn’t much interested in funding life-prolonging studies in the elderly– because of futility.

Two reasons for this are the law of diminishing returns plus our immortality. Humans do not live forever. Our lifespans are fixed. When we become older, there are many diseases that can end our life. Diminishing returns holds that even If we could decrease our risk of stroke, it would not matter much because old age also increases the odds of cancer, heart disease, falls, infection, car accidents etc.

The third oft-forgotten concept is competing causes of death. It’s why cancer screening does not reduce overall mortality.

Screening for breast cancer in the general public may slightly decrease the rate of dying from breast cancer; screening for colon cancer may slightly decrease the risk of dying from colon cancer. But, my gosh, there are oodles of other diseases one can die from.

Trying to avoid one form of death is pure folly. (The caveat of course is if you have a major familial predilection for one type of disease; most people lining up for colonoscopies do not have this family history.)

Dr Ben Mazer and I wrote about the downside of cancer screening for WBUR. Link is here> Does Cancer Screening Save More Lives Overall? Not Necessarily

Our fixed lifespans, the law of diminishing returns and competing causes of death are the reasons we don’t put defibrillators in older people who have other serious diseases. It makes no sense to protect one from sudden death, when there are many other ways of dying.

One of THE most important questions to ask yourself and your doctor/clinician: what is the risk of me dying with or without this test or treatment. Often the answer is no difference. And if that is the case, you can avoid the potential harm of the test or treatment.

Remember…we doctors hardly control as many outcomes as we think we do.


4 replies on “Forgotten Concepts in Medical Practice”

You make sense to me.I wonder why more doctors dont think like you! Your reasoning on afib is why I’m not 100 percent sold on getting ablation.Ive lost 20 pounds and will lose another 20 when I see my e.p. I’m wanting to know the underlying cause of this afib.Really I want to reverse it!

Pure science and common sense. Disagree though on one point. I fear a stroke that disables me. Would rather die from many other things. Strokes cost so much money. More research is needed not to avoid death but to avoid massive disabilities

You are a voice that needs to be heard. Please keep posting. Too many seniors spend their days visiting Drs and taking pills instead of lolling about doing something fun. Time is short. Enjoy and spread joy when/while you can. Your happy face is still needed.

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