Perhaps Preventing Prevention is Prudent

EconTalk Extra
by Amy Willis
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Robert Aronowitz on Risky Medi... Brian Nosek on the Reproducibi...

In his newest book, Risky Medicine, physician Robert Aronowitz calls into question many of the health care norms we've adopted in our lives, including PSA tests for men and routine mammograms for women. In an unusual twist for EconTalk listeners, perhaps, Aronowitz suggests, the biggest problem in health care isn't too little information, but too much.

EconTalk host Russ Roberts also offers a very personal post-script (1:04:44) to this episode, and we're hoping you're willing to be a bit personal this week as well. Let us know how this episode has impacted the way you think about your own health, using the prompts below. As always. we love to hear from you.

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1. How do we confuse the means to good health with actual good health, according to Aronowitz? To what extent have you seen such confusion, either among people you know, or perhaps yourself?

2. What is the "elephant in green pajamas problem," and how does it describe what Aronowitz sees as wrong in medicine today?


3. Aronowitz worries that we'll need to make a "Rawlsian bargain" with ourselves as the quantity of information about our own health grows. What does he mean by this? To what extent should information provided to patients be limited when it comes to screenings and early interventions?

4. Have you ridden the health care "roller coaster?" Were your ups and downs the result of Type I or Type II error? How has your experience changed the way you look at health care?

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COMMENTS (11 to date)
Jonathan Andrews writes:

Very briefly, similar ideas are presented by gerd gigerenzer in "reckoning with risk" and in this video

Morgan Dubiel writes:

IIRC, the First Governor of Hong Kong ordered his government not to collect information on the economy - poverty, income, growth, etc. A lot of data just becomes an excuse to regulate aka "do something". Most problems simply solve themselves because human beings are problem solvers.

Amy Willis writes:

@Morgan, good point...but is there a difference between micro and macro level data collection? That is, SHOULD you want all the info available to regarding your health? Most advice these days suggests yes, while Aronowitz injects some skepticism.

Todd Mora writes:

As I listed to Dr. Roberts most recent podcast, I couldn't help but think about the previous podcast on charities and how they actually do harm. The adage "the road to hell is paved with good intentions" seems very apt in both of these podcast. Well meaning people intend to help and end up doing unintentional harm because they don't focus on the actual outcomes. They are focused on their intentions, which they perceive as good.

Compounding the problem with healthcare issues is the idea that if I eat/exercise/screen, I will never get sick if I do the right stuff. Everyone will die. We need to focus more on what Dr. Roberts talks about when he quotes Adam Smith and says "All men(people) want to be loved and to be lovely." It is a question of the quality you bring to life not just the duration you live.

Overall, I think the new focus of Dr. Roberts podcasts has been inspirational and quite enlightening. Thank you.

p.s. - I would love to hear again from Dr. Michael Munger.

Ben Khammar writes:

My wife and I recently underwent a "wellness screening" (a series of lab tests) in order to qualify for a $700 health savings account credit from my employer. My wife "passed" with flying colors. I, on the other hand, was warned that I am at a high risk for diabetes and heart disease. These warnings were based on my BMI and my total cholesterol. I have lifted weights for 10 years, causing them to confuse my BMI with that of an obese individual. I consume large amounts of fish and other omega-3 fatty acids, causing my good cholesterol, the larger component of my total cholesterol, to be above the "normal" range. I'm still trying to calm my wife down. This "wellness exam" may result in a kale smoothie only diet in my near future. Not worth the $700...

George Gantz writes:

Thanks for the excellent program that gives details on a key existential issue of our times - the challenge of uncertainty and the natural human impulse to control. The epistemic truth is that, in the face of uncertainty, more data does not solve the problem: (e.g.: More Data is Not Enough). Ultimately we have to make choices in the face of uncertainty - a leap of faith is required. This is where the psycho-social dynamics can run amok (e.g. Connected by Christakis and Fowler 2009). Even the ever-skeptical Russ Roberts can get carried away!

The best we can do as decision-makers is to explore and be informed about both dimensions - what is the best science saying about the question at hand? - what are the personal, social and economic drivers at work? This is not exactly an inoculation against angst, but at least our eyes are open.

FYI: I had a radical prostatectomy at the age of 61 - the cancer was first identified by physical exam (and my older brother had been diagnosed the year before) - the PSA was within normal range - the Gleason score from the biopsy was in the 7-8 range. I think this was a good decision! However, in the pre-op testing they did an MRI and found a small nodule in my pancreas. This caused much anxiety as my father had died of pancreatic cancer at the age of 54. Three annual MRI's later, the specialist is telling me - no change - probably not a risk - probably don't need annual MRI screening but they don't know enough about the future risk to change the protocol. She did say "since we have been doing more routine MRI's we are finding lots of these probably benign things that we never saw before."

Oldunshavenone writes:

Thanks to Jonathan Andrews' comment and suggestion to watch Gerd Gigerenzer's talk at UCSB about his new book, "Risk Savvy"! I now plan to read it along with the book by Robert Aronowitz that I just ordered.
I think that one needs to learn much more about how to interpret statistics, including ways to differentiate risk from uncertainty.
I look forward to more EconTalk interviews on this subject.

Jerry Mitchell writes:

Quick thought about Mr. Robert's additional comments at the end of the pod cast. I am an Oncologist and I suspect that the NNT has gone up and the lives saved from screening declined since the time points cited (roughly 1970-1990) because effective adjuvant treatment (treatment after the surgery to prevent recurrence) didn't emerge until after 1990 and really effective treatment for Her-2 positive didn't start until 2005. So, as time has gone it has become less important to find the breast tumors early.

One of the things that has been shockingly happening is the increased number of bilateral mastectomies occurring because more women are requesting them IN SPITE of the evidence demonstrating that in non BRCA positive women the extra disfiguring surgery DOES nothing to reduce recurrence rates. The data suggest that this is fear driven and surgeons aren't refusing because the patient will just leave and the surgeon down the street will do the procedure. This is not just occurring in local or rural hospitals but in major academic centers as well.

Amy Willis writes:

@Jerry- many thanks for adding your experience and perspective! Your comment re: mastectomy rates is fascinating...Do you think these surgeons SHOULD refuse surgery in such instances? I hadn't thought about this aspect...Given the publicity surrounding Angelina Jolie's some time ago, I'm surprised...

Luke J writes:

1. How do we confuse the means to good health with actual good health, according to Aronowitz? To what extent have you seen such confusion, either among people you know, or perhaps yourself?

I do not recall Dr. Aronowitz defining health, but he mentioned that his students at Penn St. have confused the means and ends of good health. Personal interactions have a similar narrative. "I am healthy because I run/eat organics/avoid caffeine." My own idea of health is more about what I can and cannot do. I am inflexible and cannot straighten my legs. I wheeze after half-running half a block. I can bike 10 miles and not puke.

2. What is the "elephant in green pajamas problem," and how does it describe what Aronowitz sees as wrong in medicine today?

"Putative evidence," as Dr. Aronowitz puts it, and no advocate for the counterfactual. On the other hand, a growing body of anecdotal, historical, and empirical evidence supporting alternative narratives with positive health outcomes.


3. Aronowitz worries that we'll need to make a "Rawlsian bargain" with ourselves as the quantity of information about our own health grows. What does he mean by this? To what extent should information provided to patients be limited when it comes to screenings and early interventions?

I had to look this up, having naught read John Rawls, nor studied much in philosophy. We are talking about "Analysis Paralysis," similar to the paradox of choice. Can we make good (perhaps even better) decisions about health without knowing every possible outcome for every possible prevention? Is ignorance a bliss? Yes.

4. Have you ridden the health care "roller coaster?" Were your ups and downs the result of Type I or Type II error? How has your experience changed the way you look at health care?

My wife is 2.5 years through a 5 year naturopathic medicine program. These nearly three years cap a long journey during which our attitudes of health have changed. I have not yet experienced deep anxiety over a Type I or Type II error, but that will come in its own time, I am sure. We all have many reasons to be cynical of health and health providers and there is room for improvement. Right now, I am thankful to be living in this time, in this age, and not 200 years ago, or even 100 years ago. I hold a lot of optimism for my kids and the world that will be available to them.

Jerry Mitchell writes:

@Amy. That is a tough question because it gets at the tension between patient autonomy and paternalism in medical decision making. I might be in the minority but I do think the surgeon should refuse to do procedures that have no demonstrable benefit just as oncologist should not give medicines with no demonstrable benefit (most of us fall short on this). If a patient asks for a leg amputation because they are afraid they will get cancer in their foot every surgeon I know would refuse to perform that procedure (in fact it would be malpractice). Why do we accept mastectomies that have no benefit (of note I am addressing BRCA negative women - Jolie was BRCA positive and prophylactic mastectomy IS indicated)?

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