ObamaCare, Evidence Based Medicine and Me

The cornerstone of ObamaCare is something called "Evidence Based Medicine" (EBM). A recent New York Times article stated that fully half of the two thousand odd pages of the recently enacted healthcare bill dealt with programs of research to reduce the cost of healthcare by use of EBM.

EBM attempts "to apply the best scientific evidence gained from research to medical decision making". It "seeks to assess the quality of evidence of the risks and benefits and treatments (including lack of treatment)" (Wikipedia, Evidence Based Medicine). In other words, it uses a risk based model in determining treatment options. This results in protocols, or clinical treatment plans, being developed which address the higher payoffs first, and then the next highest, etc.

Notice that when they are assessing risks, they are using a combination of probability (what is the likelihood that a diagnosis is correct) and outcome (what is the impact if the diagnosis is correct). They are not looking at what the potential worst outcome is and treating that first. My own case clearly illustrates this point.

When I presented myself to my Primary Care Physician, Dr. X, my symptoms had all of the hallmarks of a problem with the sacroiliac joint, which is the joint where the spine and the hips come together. The doctor did a brief (approximately ten minute) examination where he asked me to describe the pain and where it was, did a neurological exam (looking to see whether nerves were directly being affected) and palpated the area, looking for masses which he did not find.

The protocol for treating had several steps: first, a combination of anti-inflammatory drugs and physical therapy for a period of months. If this is not successful, assessment and treatment by a spinal specialist. The spinal specialist also has several treatment options, including direct injection of affected areas with steroids to improve mobility, mobilization of the joint and more advanced imaging.

Now a much clearer diagnosis could have been found by ordering an MRI. This would likely have definitively shown where my problem lay. Why wasn't an MRI taken? Because the cost of the MRI was not justified by the likelihood that impact was as severe as mine turned out to be.

The MRI that finally diagnosed my cancer cost approximately $2000. While literally millions of patients with my symptoms go the doctor each year, a very, very, very small fraction turn out to have cancer. I have found statistics that suggest that there are fewer than 1000 adult cases of osteo-sarcoma in the US, and only a fraction of those would have had symptoms that matched mine. A larger population of patients with severely herniated or ruptured discs present (approximately 2%), but they typically present with neurological symptoms that I simply did not have. There are other problems that can present with similar symptoms, some with dire impact, but again they are very low probability events.

It is simply extremely costly to MRI every patient presenting with my symptoms, on the off chance that they might have cancer. Say that 1% of population of the US presents to their doctor with lower back symptoms in a year. This would yield a population of three million people. Let's say that 250 cases of osteo sarcoma could be found this way. That means that the cost of finding those cases would be ((3,000,000/250)*$2000) or twenty-four million dollars each. It is much cheaper to treat the most likely cause and see if they get better. If they don't, then treat the next more likely cause, etc. I would bet that it is only when you get multiple standard deviations from the mean that you get to cases that require the MRI to diagnose and treat. The savings are, quite simply, enormous.

(Please note that I am making a lot of these statistics up - I have no idea how many patients present with lower back pain each year, nor do I know what percentage of those cases turn out to be cancer. The actual number will differ wildly from what I have shown here, which is strictly for illustrative purposes).

The fact is that I went completely through both tier one (Physical Therapy) and tier two (examination and treatment by a spinal specialist) before they got to the point where my Primary Care Physician decided to get an MRI, and that is only because he found me writhing in pain on his examination room floor after he kept my waiting for an hour. During that time I was examined by no fewer than four doctors, not including the ones who examined the x-rays that the spinal specialist had taken and the physical therapist who treated me. In addition to the x-rays, I also had several ultra-sounds, none of which found a tumor the size of a medium potato.

A more aggressive doctor might have ordered the MRI anyway, particularly when I reported repeatedly that my pain was increasing week-to-week, despite treatment. It is very likely that if the MRI had been taken at the beginning of my treatment, my cancer would not have metastasized, nor would it have grown into my sacrum, both of which would have had dramatic impact on my current prognosis. In other words, if I had been treated by what ObamaCare and EBM would consider a "bad" doctor, one who runs unnecessary procedures, both my life expectancy and my quality of life would be a lot better right now.

So how do I feel about all this? First of all, I recognize that I am, first and foremost, incredibly unlucky. The odds of someone my age getting what I have gotten are really spectacularly low. I recognize that treating with an MRI would be prohibitively expensive. $24 million dollars will pay for an awful lot of health-care for somebody. Yet, at the same time, I recognize that I am a hidden part of the cost of ObamaCare and EBM. Some people are definitely going to get sicker and die that wouldn't otherwise because of EBM. However, I also recognize that a vastly larger population are going to be treated and get well that otherwise would not. The payoff to society is clear.

So I feel resigned to my fate. I am not particularly angry at my doctors for not giving me an MRI sooner, because I feel that I understand the reasons why they didn't. I am just very, very unlucky. I do question whether they should have examined me sooner when physical therapy failed, though.

And yet, and yet, I look out the window on a beautiful Spring morning, and I wonder, what if?