It's Better to Be Safe Than Sorry — Isn't It?

When deciding where to spend their professional lives, doctors are faced with a basic decision about the type of patient they wish to see. It breaks down like this:

Type 1 Suburban Highly educated White Healthy High SES Overtreated

Type 2 Urban Undereducated Non-white Sick Low SES Undertreated

Of course this is a gross oversimplification, and many patients are a mixture of the two, but as a generality it's pretty accurate. Most doctors will say that they prefer to see a "good mix" of patients, but that's hard to achieve; Type 1 patients don't feel comfortable in offices where Type 2 patients hang out, and vice versa. In addition, when most doctors say they want a mix, what they really mean is that they want mainly one type, but with a smattering of the other thrown in to keep things interesting.

Me, I love taking care of the Type 2s; the Type 1s can drive me nuts. I can't stand having to explain to a Type 1 why this or that test or treatment isn't indicated, but I adore cajoling Type 2s into getting the tests and treatment they desperately need. And I'm good at it. I do have a mix of patients, mainly because people know that I have relatively fancy credentials, and therefore assume that I must be a Type 1 doctor.

Now, it seems to me from my web travels that the vast majority of people on the blogosphere fall squarely into the Type 1 column (the commenters more than the bloggers). If there's a test for something, everyone should get it. Because it would be absolutely terrible for someone to have a medical condition that isn't diagnosed and treated, right?

Well, not necessarily. I think of it as being kind of like the justice system. In the U.S., we'd overall prefer to let a few guilty people go free than to ever imprison an innocent person. In China, the opposite is true (at least from what I've read on the topic). Both systems have their pros and cons. We're horrified to hear about the innocent people imprisoned, possibly tortured, and put to death in China (or at least I am). But I bet they're horrified to hear about people being raped, tortured, and murdered by criminals who were released because of a lack of evidence. In both instances, innocent people suffer and die.

In medicine, testing people for illnesses that they are unlikely to have results in, essentially, false arrests and convictions; people suffer side effects of the tests themselves, and side effects of treatment for a something they may not even have, or if they do have, might never have harmed them. But allowing illnesses to go undetected will result in some people suffering from the illness itself.

There are many studies that examine this very thing, the cost:benefit ratio of a given test or treatment. It's tricky, because you have to put a price on priceless things — health, life — but it can be done. From studies such as these come recommendations about who should be tested. But what you'll find if you compare recommendations to actual practice is that the Type 1s get way more done to them than recommended, while the Type 2s get way less.

For instance: my mother is 65 and in a monogamous (er, I assume) relationship of 25 years. Yet every year, year after year, she gets a Pap smear done. When her risk of cervical cancer is zero. Why does her gynecologist keep putting her up in the stirrups? Well, for one thing, her insurance covers it, but more importantly, her gynecologist probably assumes that my mother expects and wants it. And because, well, yes, her risk is probably zero, but it's better to be safe than sorry, right? Right?

But what would happen if my mother had an abnormal Pap smear? More tests and procedures. Possibly endangering her. And definitely wasting a lot of resources. All for nothing, because if she had an abnormal Pap smear, it would be because of a test error. Who still dies of cervical cancer in this country? Yes, the Type 2s. Because they don't have insurance, or if they do, they don't have doctors who take their type of insurance -- or they don't have doctors, period.

The same thing goes for all the healthy people who get cholesterol tests every year. Or diabetes tests. Or, like my father-in-law, a stress test. The amount of money that is wasted on this kind of nonsense is truly shameful. If my mom could donate her Pap smears even every other year to someone who isn't getting them, a lot of good could be done. (I get a Pap smear every three years. Unfortunately I haven't found a way of donating the ones I don't use.)

There's an annoying saying in medicine that you should treat every patient as if she were your grandmother. I would phrase it a little differently: you should treat your grandmother the way you treat all of your patients, because all of your patients should receive not "VIP" care, but appropriate care.