Although many variations of the Hippocratic Oath hover around graduating medical students today, none of these versions specifically states that the individual patient is to be held in higher regard than public health policy. There’s a reason for this — public health policy didn’t exist 2,400 years ago in ancient Greece, at least not in the way we think of it today. Regardless, an oath of some sort (half of U.S. schools still use a version from Hippocrates) is administered in all of the existing medical schools in the United States, with the implication being that proper care of the individual patient is held above all else.
As straightforward as reverence for the individual patient might seem, there is a concerted effort to plunge a final dagger into the heart of the Hippocratic Oath. Why? The short answer: money. Technology has advanced so rapidly and become so costly that we can no longer think about what is “best” for our individual patients. Society comes first. This, of course, is the basic tenet of socialism, an economic platform with a philosophic foundation, be it right or wrong or somewhere in between.
Gregg Bloche, MD, JD, is a Professor of Law at Georgetown who previously served as a health care advisor to President Obama. His best-selling book raised collective eyebrows in the medical community, though not necessarily due to disagreement. His complete book title is: The Hippocratic Myth: Why Doctors Have to Ration Care, Practice Politics, and Compromise Their Promise to Heal. The author does not call for the death of the Hippocratic Oath; instead, he makes the point that the Oath is already dead, so now, let’s admit it. In a word, limited resources have already prompted a radical change in medicine, and many physicians are practicing for the good of the whole, rather than for individual patients, whether they admit it or not, whether they know it or not.
As it applies to this blog, I was surprised when reading the book to find that Dr. Bloche used screening for breast cancer with MRI as one example, this being a special area of interest and expertise for me. The facts in the book are presented correctly, acknowledging the better sensitivity of MRI in the detection of breast cancer, but pointing out the difficulty in justifying cost, not to mention the arbitrary cut-off for who qualifies and who doesn’t. I can find no fault with breast cancer screening as portrayed by Dr. Bloche in what has become a health care manifesto of sorts.
But here’s where paths diverge. Rather than throwing up my hands and bemoaning the fact “Oh, we can’t afford this or that,” I look for ways to make the superior MRI affordable for society, that is, “cost-effective” in today’s parlance. It’s not that hard if you think about it.
The first problem is the nearly universal belief that the only way to approach aggressive screening with MRI is through risk stratification, offering MRI only to women at the highest levels of risk. All international trials followed this reasoning. Yet, if one reviews cancer yields in the highest of all risks – women positive for mutations in the BRCA genes – only 3 women out of 100 will be found to have cancer on a single screening MRI, missed by mammography. Forgetting costs for a moment, this is actually considered a “high” yield, given that mammography identifies cancer in only 5 women out of 1000 (0.5%) in the general population. Even though 3% with MRI is six-fold the yield in general populations screening, it is not good enough to ensure cost-effectiveness. What now? Curse the insurance companies? The government? ObamaCare? Write books about the death of the Hippocratic Oath?
There are alternatives. First, lower the cost of breast MRI. This transition is in progress now, with the implementation of “fast” MRI for screening. With shorter study times (10 minutes instead of 30 minutes), the cost can be lowered significantly. Rather than several thousand dollars, some are offering the service at less than $500. Now, a Catch-22. Even though insurance covers high-risk screening with MRI, the coding system used universally in billing does not have a different code for screening MRI vs. diagnostic MRI. Therefore, the system shoots itself in the foot as radiologists are ready to lower costs, but can only bill at the higher rate due to the single code. Bottom line: those wanting to take advantage of “fast MRI” for screening must pay cash, and it doesn’t count toward the deductible.
Next, risk-based guidelines need an overhaul. The question should not be, “What is a woman’s breast cancer risk over the course of her lifetime?” Rather, we should be asking, “What is the risk that a woman’s mammogram is harboring an invisible cancer, on the very day of the normal screen?” This may or may not relate to long-term risk. It most certainly relates to the level of breast density on X-ray, a factor not even included in current MRI guidelines! To this end, my research collaborators are focused on computer analysis of subtle asymmetries on “normal” mammograms that currently escape expert radiologists as well as the so-called CAD, “computer-aided detection,” in common use today.
A different approach to the same problem of “current risk” vs. “lifetime risk” would be the development of a blood test to detect mammographically occult breast cancer. I have spent 20 years assisting basic scientists in the ongoing development of a screening blood test in which biomarkers would indicate the presence of cancer independent of mammographic findings. If either the “ultraCAD” approach above or the blood test prove successful, cancer yields on MRI could emerge as 10% or greater (with “missed cancers” very rare), vastly superior to anything remotely possible through risk-stratification, and easily cost-effective.
It speaks to the spirit of individualism that there’s a way to make this work. We already have the remarkable technology of MRI that can decrease the mortality of breast cancer well beyond what mammography can do by itself. So, rather than issuing guidelines that restrict care, it’s up to us to figure out how to make MRI (and other imaging approaches) cost-effective for potential “second tier” use in all women. After all, the majority of newly diagnosed breast cancer patients have no identifiable risks, a fatal flaw for those who trust entirely in risk stratification while proudly espousing “personalized medicine.”
One last point – while 100% of medical schools in the U.S. administer a professional oath of dedication to the individual patient, Hippocratic or not, as noted in the opening paragraph, it is interesting that only 50% of British medical students do the same.
The individual patient is teetering in a precarious balance weighed against societal resources, and there can be no doubt that some tottering is well underway.