Preventive Medicine Column
Dr. David L. Katz
A recent study in JAMA, featured in a NY Times opinion piece of April 4, shows that complication rates for bariatric surgery since 2006 do not differ between designated Centers of Excellence, and their counterparts. The Times column concludes that if bariatric surgery is every bit as excellent at centers with, and without, such a designation-the designation is at best useless, and at worst misleading. But in my opinion, there is far more wrong here than a label of ‘excellence’ that outlives its utility.
First, the rate of bariatric operations rose “exponentially” before systematic study and publication of outcomes and complications. How do we account for this in an age of so-called “evidence-based” medicine?
Most colleagues with whom I’ve discussed this tend to concur- we don’t really have evidence-based medicine; we have reimbursement-based medicine. What gets studied is what gets done; and what gets done is what gets paid for. We like to think we figure out what works, and then cover it. But we can’t figure out that something works if it never gets any traction in the first place. In the pursuit of evidence, cart and horse routinely swap positions- and money cracks the whip.
A tendency to medicalize, symptomatic no doubt of living in an age of technology and pharmacology advancing much faster than wisdom, is a matter of increasing attention and concern. A poignant column in the NY Times of April 1st made that very point about attention deficit disorder. I have long lamented the modern inclination to bolt normally rambunctious children to chairs all day long, then prescribe Ritalin when they can’t sit still. Yes, there really is ADD/ADHD that warrants medication. But the proper remedy for rambunctiousness in young children is recess, not Ritalin. And yes, we have actual data to show the substitution can work.
The related myopia is that once we medicalize everything from restlessness to weight gain, we tend to look for solutions within the walls of medicine- and neglect the world of opportunity outside that box.
So, for instance: why is it that bariatric surgery was routinely reimbursed long before data collection was robust, but a boarding school that can produce comparable or better results at lower overall cost won’t be? Because our culture has told us that all health problems are medical problems, and medical problems warrant medical solutions. We are culturally indoctrinated to presume that drugs and operations are the right ways to fix health problems. They are to some extent presumed effective until proven otherwise.
The very opposite is true of non-medical, lifestyle-based interventions that are ultimately far more powerful. One good example is the widely known heart disease reversal program developed by my friend, Dr. Dean Ornish. Some 15 years of study were required to establish this as a reimbursable alternative to coronary bypass surgery. In contrast, coronary bypass surgery was reimbursed from the start. There are many other examples- but no need to belabor the point.
The second great conundrum here is a potentially massive misallocation of money. It’s not just that we reimburse for surgery while neglecting non-medical approaches that could work as well or better. It’s that our entire system of biomedical advance, and the investments that underlie it, favor the…well, biomedical.
What I mean is that the somewhat-more-than $30 billion annual budget of the National Institutes of Health is overwhelmingly directed at promoting basic science advances, and clinical intervention trials. Another huge sum of money is provided by pharmaceutical and device companies to study- you guessed it- drugs and devices.
A vanishingly tiny portion of the NIH budget is allocated to figuring out how to turn what we already know into what we routinely do. Since what we already know would allow us to eliminate fully 80% or more of all chronic disease– heart disease, cancer, stroke, diabetes, dementia- that seems a potentially serious oversight.
The restriction of Medicare reimbursement for bariatric surgery to Centers of Excellence may well be obsolete, and that’s a problem. But fussing over which centers to reimburse for weight loss surgery while neglecting the opportunities to prevent that weight gain in the first place is a far bigger problem. Worrying about how best to direct scalpels while neglecting opportunities to make better use of feet and forks routine is a far bigger problem. Choosing among biomedical solutions while ignoring all options outside that box is a far bigger problem.
The bad news is bigger problems. The good news is corresponding solutions. But we will find our way to them only if we climb the entanglements of money and medicine, overcome our prevailing myopia- and take in the landscape of neglected opportunity outside the box.
Dr. David L. Katz; www.davidkatzmd.com