Introduction

Reviews

Does Your Doctor Know When to Intervene? (And When Not to?)

Timothy B. McCall, M.D.

In the early 20th century, doctors had little to offer patients other than sympathy and morphine. In recent decades we’ve become accustomed to miracles. We have witnessed the development of open heart surgery, cures for childhood leukemias, vaccines for once deadly diseases. As a result, doctors are increasingly expected to provide answers and effective therapies for every problem that comes along. But according to the New England Journal of Medicine around 90 percent of the time patients visit doctors with conditions that will either improve on their own without treatment or that are out of reach of modern medicine’s powers.

To make matters worse, many interventions employed by physicians over the years have proven to be utterly worthless, some frankly dangerous. We don’t need to think back to the age of leeches and blood lettings to find examples. In the 1950s and 60s, millions of children had their tonsils removed for no good reason; hundreds of babies were born without arms and legs because of the drug Thalidomide; thousands of people received X-ray therapy for acne or for unwanted facial hair and are now turning up with thyroid cancer. The list goes on and on.

These horror stories are not just historical curiosities. Many of the interventions commonly employed today are similarly suspect. The C-section rate has skyrocketed, without a corresponding improvement in the health of mothers or their infants. Dozens of common surgical procedures have never been proven effective. Chemotherapy saves many lives but is also given to patients with no realistic hope of improvement. The terminally ill are hooked up to tubes and wires and breathing machines only to prolong the process of dying.

The biggest variable in the rate of intervention is the individual physician. Doctors vary in their philosophies of practice. Some are prone to intervene. Others are much more wary of potential side effects and will only recommend intervention when the likely benefits clearly outweigh the risks.

These days, of course, money plays a big role. If you have traditional insurance doctors get paid every time they do something like a test or operation. In HMOs and other forms of managed care, the incentives are reversed: doctors often earn more by doing less (see Follow The Money).

Consider the results of a New England Journal of Medicine study which looked at the individual doctor’s role in unnecessary C-sections. Researchers at Wayne State University in Detroit investigated the role of differences in the practice styles of physicians on the rate of Cesarean sections. They studied over 1500 affluent women at low risk of birth complications.

Overall, 26.9 percent of the women had C-sections but the rate varied from 19 percent to 42 percent depending on the doctor. For women who had never before had a C-section, the C-section rates for different doctors ranged from 9.6 to 31.8 percent. Variation in the rate of C-sections was not attributable the degree of risk of the pregnancy. Babies delivered by doctors who did lots of C-sections were not any healthier than those delivered by doctors who did few.

Why are some doctors more anxious to do C-sections than others? Consider the opinion of one doctor who believes all women should give birth by C-section. “Why should the modern woman,” he writes in a letter to the Journal of the American Medical Association, “undergo the sweaty, gut-wrenching ordeal of labor that may last 12 to 24 hours or more?” He continues, “And let’s face it—the female perineum [pelvic tissues including the vagina and anus] never returns to its original state after two or more vaginal deliveries.”

Imagine having a doctor like that deciding what was going to happen with your body—yet another reason to make sure to talk with your doctor about his or her opinions and assert your preferences.

Next: Sometimes the Best Treatment is No Treatment

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