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Thursday, April 12, 2007

"Freakonomics" Stephen Dubner Gets To The "Heart" Of The Matter

Stephen Dubner's, co-author of the best selling book, "Freakonomics," makes some dead-on comments in response to recent information about how coronary stenting is no more effective typically than heart drugs, even though it is far more invasive, and far more profitable for the medical personnel involved. He writes:
An editorial in the current British Medical Journal makes a very sharp point that many of us have probably been thinking about in the last few weeks while reading the latest medical news in the papers:
It’s easy to feel contempt for deluded practitioners of the past who advocated bloodletting and tonsillectomies for all. Easy, that is, until one considers emerging evidence that coronary stenting and postmenopausal hormone replacement therapy may well be the contemporary equivalents of those now discredited practices.
This recent New York Times article tells of the compelling study which found that coronary stenting is typically no more effective than heart drugs, even though it is far more invasive — and, to be sure, profitable for the medical personnel involved.
Indeed, another article in the same issue of BMJ suggests that stenting is less common in Europe than in the U.S. mainly because “there have not been the same financial incentives to carry out some stenting.”
FWIW, we mentioned this subject briefly in Freakonomics:
If you were to assume that many experts use their information to your detriment, you’d be right. Experts depend on the fact that you don’t have the information they do. Or that you are so befuddled by the complexity of their operation that you wouldn’t know what to do with the information if you had it. Or that you are so in awe of their expertise that you wouldn’t dare challenge them. If your doctor suggests that you have angioplasty—even though some current research suggests that angioplasty does little to prevent heart attacks—you aren’t likely to think that the doctor is using his informational advantage to make a few thousand dollars for himself or his buddy. But as David Hillis, an interventional cardiologist at the University of Texas Southwestern Medical Center in Dallas, explained to the New York Times, a doctor may have the same economic incentives as a car salesman or a funeral director or a mutual-fund manager: “If you’re an invasive cardiologist and Joe Smith, the local internist, is sending you patients, and if you tell them they don’t need the procedure, pretty soon Joe Smith doesn’t send patients anymore.”
The BMJ editorial also asks a wise question. Perhaps some of you can offer an answer: “What other medical orthodoxies might join hormone replacement therapy and stenting on the ever-growing list of discredited interventions?”
I have one prediction: late-stage chemotherapy for many types of cancer.

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