In the midst of the controversy surrounding
recommendations for breast cancer screening from the U.S. Preventive Services
Task Force, a section of the Agency for Healthcare Research and Quality, I
received a two-page letter from my primary care physician reminding me that it
was time for me to have my screening colonoscopy. Included with the two-page
letter was the equipment for me to first perform a hemoccult test, complete
with a pre-paid addressed envelope for returning my specimen.
Sounds reasonable except that, to my knowledge, I have never set eyes on
my PCP and certainly have never provided a history or presented for a physical
examination. The PCP was selected for me a few months ago by my insurance
carrier after my former PCP left the system.
In fairness, I must quickly add that my doctor has probably never seen
the letter that arrived in my mail, and it was certainly not hand signed.
However, I did appreciate the closing sentence: As we approach the
holidays, give yourself and your family the most special gift of all: peace of
mind with respect to caring for your health and well-being.
Should I conclude from this that there is a priori knowledge that
my colonoscopy will be normal?
As an endocrinologist most of my clinical activity is devoted to
- optimizing glycemic control in patients with diabetes, making sure
that they are up to date with visits to the ophthalmologist and
- preventing the first or subsequent fractures in patients with low
bone density or osteoporosis;
- managing dyslipidemia or hypertension to prevent adverse health
- and minimizing the risk of future kidney stones in patients who have
already suffered the agony of their first one.
I certainly have no beef with preventive medicine. What gets my juices
flowing is what I call cookie cutter medicine where the needs of
the individual patient take second-place precedence over making doctors sure
that they dont run afoul of AHRQ or any other government or insurance
Since I am in a sounding-off mood, there is one more item I want to get
off my chest. The therapy we prescribe for our patients only works if it is
taken as prescribed at least most of the time, but the literature is replete
with documentation of poor adherence with almost all classes of preventive
therapy such as the list I gave above.
In my community, it is common for the pharmacist to provide a detailed
description of all potential side effects when they hand the patient the
medication. I have yet to see labeling describing why the drug has been
prescribed. My all-time favorite was the patient who refused to take raloxifene
when she read the pharmacists label indicating that the drug may have an
effect on her cholesterol level. Indeed it does it increases HDL and
lowers LDL and total cholesterol, a favorable effect. When I contacted the
pharmacist to inquire where he got his information he told me that it came from
head office, and he didnt have time to check the labeling on
every drug he prescribes!
Preventive medicine is perhaps the most important aspect of our health
care system lets not mess it up with rules, regulations, and
behaviors that make no sense at all!