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TEDMED 2012

Ivan Oransky: Are we over-medicalized?

April 11, 2012

Reuters health editor Ivan Oransky warns that we’re suffering from an epidemic of preposterous preconditions -- pre-diabetes, pre-cancer, and many more. In this engaging talk from TEDMED he shows how health care can find a solution... by taking an important lesson from baseball.

Ivan Oransky - Health reporter
Ivan Oransky is the executive editor of Reuters Health, and has done pioneering work in covering scientific retractions. Full bio

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Double-click the English subtitles below to play the video.
Those of you who have seen the film "Moneyball,"
00:15
or have read the book by Michael Lewis,
00:19
will be familiar with the story of Billy Beane.
00:21
Billy was supposed to be a tremendous ballplayer; all the scouts told him so.
00:24
They told his parents that
00:29
they predicted that he was going to be a star.
00:30
But what actually happened when he signed the contract -- and by the way, he didn't
00:32
want to sign that contract, he wanted to go to
college --
00:37
which is what my mother, who actually does
love me,
00:39
said that I should do too, and I did --
00:42
well, he didn't do very well. He struggled
mightily.
00:45
He got traded a couple of times, he ended up in the Minors for most of his career,
00:48
and he actually ended up in management. He ended up as a General Manager of the
00:53
Oakland A's.
00:57
Now for many of you in this room, ending up in management, which is also what I've done,
00:57
is seen as a success.
01:02
I can assure you that for a kid trying to make it in the Bigs,
01:03
going into management ain't no success story. It's a failure.
01:07
And what I want to talk to you about today, and share with you, is that our
01:11
healthcare system, our medical system, is
just as bad at predicting
01:16
what happens to people in it -- patients,
others --
01:20
as those scouts were at predicting what would happen to Billy Beane.
01:24
And yet, every day
01:29
thousands of people in this country
01:32
are diagnosed with preconditions.
01:34
We hear about pre-hypertension, we hear about pre-dementia,
01:38
we hear about pre-anxiety, and I'm pretty sure that I diagnosed myself with
01:42
that in the green room.
01:47
We also refer to subclinical conditions.
01:49
There's subclinical atherosclerosis, subclinical hardening of the arteries,
01:53
obviously linked to heart attacks, potentially.
01:57
One of my favorites is called
subclinical acne.
02:01
If you look up subclinical acne, you may find a website, which I did,
02:04
which says that this is the easiest type of acne to treat.
02:08
You don't have the pustules or the redness and inflammation.
02:12
Maybe that's because you don't actually
have acne.
02:19
I have a name for all of these conditions, it's another precondition:
02:23
I call them preposterous.
02:29
In baseball, the game follows the pre-game.
02:31
Season follows the pre-season.
02:37
But with a lot of these conditions, that actually isn't the case, or at least it isn't the
02:40
case all the time. It's as if there's a rain delay, every single time in many cases.
02:44
We have pre-cancerous lesions,
02:49
which often don't turn into cancer.
02:51
And yet,
02:54
if you take, for example, subclinical
osteoporosis, a bone thinning disease,
02:56
the precondition,
03:00
otherwise known as osteopenia,
03:01
you would have to treat 270
women for three years
03:04
in order to prevent one broken bone.
03:08
That's an awful lot of women
03:10
when you multiply by the number of women
who were diagnosed
03:11
with this osteopenia.
03:14
And so is it any wonder,
03:16
given all of the costs and the side effects
03:18
of the drugs that we're using to treat these preconditions, that every year
03:21
we're spending more than two trillion dollars on healthcare and yet
03:25
100,000 people a year -- and that's a conservative estimate -- are dying
03:29
not because of the conditions they have,
03:32
but because of the treatments that we're giving them and the complications of those treatments?
03:34
We've medicalized everything
03:38
in this country.
03:41
Women in the audience, I have
some
03:42
pretty bad news that you already know,
03:45
and that's that every aspect of your
life
03:47
has been medicalized.
03:50
Strike one is when you hit puberty.
03:51
You now have something that happens to you once a month that has been medicalized.
03:54
It's a condition;
03:58
it has to be treated. Strike two
03:59
is if you get pregnant.
04:00
That's been medicalized as
well.
04:02
You have to have a high-tech experience
04:05
of pregnancy, otherwise something might go wrong.
04:07
Strike three is menopause.
04:10
We all know what happened when millions of women were given hormone replacement therapy
04:13
for menopausal symptoms
04:18
for decades until all of a sudden we realized, because a study came out, a big one,
04:21
NIH-funded.
04:25
It said,
04:26
actually, a lot of that hormone replacement therapy may be doing more harm than good
04:27
for many of those women.
04:32
Just in case,
04:34
I don't want to leave the men out --
04:36
I am one, after all --
04:37
I have really bad news for all of you in
this room,
04:39
and for everyone
04:42
listening and watching elsewhere:
04:43
You all have
04:44
a universally fatal condition.
04:46
So, just take a moment.
04:49
It's called pre-death.
04:52
Every single one of you has it, because
you have the risk factor for it,
04:53
which is being alive.
04:58
But I have some good news for you,
because
05:00
I'm a journalist, I like to end things in a happy way or a forward-thinking way.
05:03
And that good news is that if you can survive to the end of my talk, which
05:07
we'll see if that happens for everyone,
05:11
you will be a pre-vivor.
05:14
I made up pre-death.
05:17
If I used someone else's pre-death, I apologize,
05:22
I think I made it up.
05:26
I didn't make up pre-vivor.
05:27
Pre-vivor is what a particular cancer advocacy group would like everyone who
05:29
just has a risk factor,
05:34
but hasn't actually had that cancer,
05:36
to call themselves.
05:38
You are a pre-vivor.
05:40
We've had HBO here this morning. I'm wondering if Mark Burnett is anywhere in the
05:41
audience, I'd like to suggest
05:46
a reality TV show called "Pre-vivor."
05:47
If you develop a disease, you're off
the island.
05:51
But the problem is, we have a system
05:55
that is completely --
06:00
basically promoted this.
06:02
We've selected, at every point in this system,
06:04
to do what we do, and to give everyone a
precondition and then eventually
06:07
a condition, in some cases.
06:11
Start with the doctor-patient
relationship. Doctors, most of them,
06:13
are in a fee-for-service system. They are
basically incentivized to do more --
06:17
procedures, tests,
06:22
prescribe medications.
06:24
Patients come to them,
06:26
they want to do something. We're
Americans, we can't just stand
06:27
there, we have to do something. And so
they want a drug.
06:31
They want a treatment. They want to be told, this is what you have and this is how
06:34
you treat it. If the doctor
doesn't give you that,
06:38
you go somewhere else.
06:40
That's not very good for doctors'
business.
06:42
Or even worse,
06:44
if you are diagnosed with something
eventually, and the doctor didn't order that test,
06:45
you get sued.
06:49
We have pharmaceutical companies that are
constantly trying to expand
06:51
the indications, expand the number of people who are eligible for a given treatment,
06:54
because that obviously helps their bottom line.
We have advocacy groups,
07:00
like the one that's come up with
pre-vivor,
07:03
who want to make more and more people feel they are at risk, or might have a condition,
07:05
so that they can raise more funds
07:09
and raise visibility, et cetera.
07:11
But this isn't actually,
07:14
despite what journalists typically do,
this isn't actually about blaming
07:16
particular players.
07:19
We are all responsible.
07:20
I'm responsible.
07:22
I actually root for the Yankees, I mean talk
about
07:23
rooting for the worst
possible
07:26
offender when it comes to doing
everything you can do.
07:30
Thank you.
07:32
But everyone is responsible.
07:34
I went to medical school,
07:38
and I didn't have a course called How to Think Skeptically,
07:41
or How Not to Order Tests.
07:45
We have this system
07:47
where that's what you do.
07:50
And it actually took being a journalist
07:52
to understand all these incentives. You know, economists like to say,
07:55
there are no bad people,
07:59
there are just bad incentives.
08:00
And that's actually true.
08:02
Because what we've created is a sort of Field of Dreams, when it comes to medical technology.
08:03
So when you put another MRI in
every corner, you put a robot
08:07
in every hospital saying that everyone has to have robotic surgery.
08:12
Well, we've created a system where if you
build it, they will come.
08:16
But you can actually perversely
08:19
tell people to come, convince them
08:23
that they have to come.
08:26
It was when I became a journalist that I really realized how I was part of this problem,
08:27
and how we all are part of this problem.
08:32
I was medicalizing every risk factor, I was writing stories, commissioning stories,
08:34
every day, that were trying to,
08:38
not necessarily make people worried, although that was what often happened.
08:41
But, you know, there are ways out.
08:44
I saw my own internist last week,
08:47
and he said to me,
08:49
"You know," and he told me something that
08:52
everyone in this audience could have
told me for free,
08:54
but I paid him for the privilege, which
is that
08:57
I need to lose some weight.
08:59
Well, he's right. I've had honest-to-goodness high blood pressure
09:01
for a dozen years now, same
09:05
age my father got it,
09:07
and it's a real disease. It's not pre-hypertension, it's actual
09:09
hypertension, high blood pressure.
09:13
Well, he's right,
09:15
but he didn't say to me,
09:16
well, you have pre-obesity or
09:19
you have pre-diabetes, or anything like that. He didn't say,
09:20
better start taking this Statin, you need to lower your cholesterol.
09:24
No, he said, "Go out and lose some weight. Come back and see me in a bit,
09:27
or just give me a call and let me know how you're doing."
09:30
So that's, to me,
09:32
a way forward.
09:34
Billy Beane, by the way, learned the same
thing.
09:36
He learned,
09:38
from watching this kid who he eventually hired, who was really successful for him,
09:40
that it wasn't swinging for the fences, it
wasn't swinging at every pitch
09:43
like the sluggers do, which is what all the expensive teams like the Yankees like to --
09:48
they like to pick up those guys.
09:53
This kid told him, you know, you gotta watch the guys, and you gotta go out and find
09:54
the guys who like to walk,
09:59
because getting on base by a walk
10:00
is just as good, and in our healthcare
system
10:02
we need to figure out,
10:05
is that really a good pitch
10:06
or should we let it go by and not swing at everything?
10:08
Thanks.
10:11

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Ivan Oransky - Health reporter
Ivan Oransky is the executive editor of Reuters Health, and has done pioneering work in covering scientific retractions.

Why you should listen

Ivan Oransky is a doctor-turned reporter. With an MD and an internship completed, he left to cover heath and health care, bringing the insight of a trained doctor to the beat. He is now executive editor of Reuters Health, and also teaches journalism and medicine at New York University.

He is also the co-founder of Retraction Watch a blog that tracks and investigates retractions in scientific journals, and it's sister-site, Embargo Watch, doing the same for reporting on scientific papers.

The original video is available on TED.com
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