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Who owns medical technology?
THE LANCET 8958
Who
owns
medical
technology?
In his book The Diffusion of Innovations, Rogers chronicles what happened when the snowmobile was introduced to an isolated community of Lapps living in northern Finland. The economy and social structure of this community centred on the reindeer, which provided food, clothing, and transport. The Lapps thought of themselves as reindeer herders. They felt a close relationship with their semi-domesticated animals and treated them with care and kindness. In this egalitarian society each family owned about the same number of animals. In 1961, one of the schoolteachers purchased a snowmobile for recreational travel, and the vehicle rapidly gained a use hauling wood and supplies. A trip to the nearest town that took 3 days by reindeer sled was reduced to a mere 5 hours by snowmobile. 10 years after the first snowmobile was introduced, almost every household owned one. The machine came to be seen as a necessity; it completely replaced travel by ski and sled for herding reindeer. Unfortunately, the animals were frightened by the speed and noise of the snowmobile. They were driven into a near wild state and their fertility declined. Families needed to sell more reindeer to pay for the fuel and maintenance of their machines and, because fewer reindeer calves were born each year, their resources became overstretched. Many were forced out of reindeer-raising; a few families built up very large herds. Two points emerge from this story quite apart from the obvious one that the introduction of technology may have costs that outweigh its benefits. The first is that technology brings much more than hardware. When the Lapps swapped their skis and reindeer sleds for snowmobiles, they
May 6, 1995
exchanged autonomy in transport and energy for dependency on external supplies of gasoline. There was a shift in social values. High status in the community had previously been accorded to men with good strings of draught animals; now it was ownership of a machine that brought prestige. The second point is that the Lapps had no way of predicting the consequences of adopting the snowmobile. At no time during the process of diffusion of the new technology through the community were they able to find a way of studying and discussing the likely outcomes. The possibility that the introduction of snowmobiles could be resisted or checked never arose. Are doctors about to go the same way as the Lapps? And for similar reasons? Two recent articles in the Economist have warned how bleak the future looks for doctors.2,3 They analyse the loss of power of the medical profession and the increasing managerial influence on decisions formerly thought to be the exclusive preserve of doctors. A large part of the reason has to do with medicine’s increasing
dependence
on
technology.
Technological
innovation is making investigation of patients simpler and safer. At the same time, these technological tests yield better and more complex information. The Economist predicts a diminishing role for doctors and an increasing one for technicians. Technology, as the Lapps found to their cost, cannot be separated from the social and economic values of the society that produced it. Views about restriction of availability of medical technologies are changing. Legislation previously deemed necessary to safeguard an uninformed population from
1125
dangerous charlatans is now more likely to be seen as serving the needs of the profession than protecting patients. The governments, insurance companies, and employers who pay the bill for health care are demanding more say in decisions about when it shall be used and by whom. They are likely to find that technicians are cheaper to employ than doctors. But the change in views is driven by more than the desire to get value for money. Consumers want control or, what amounts to the same thing, the illusion of control, of their life and health. They may not have read Foucault4 but they still have doubts about whether modern medicine will help them achieve this. We can hear this ambivalence articulated every day in our clinics. Patients tell us that they do not believe in taking tablets; simultaneously, they demand more rather than less treatment. A survey of American adults found that, in the previous year, one in three had used unorthodox therapies.s Educated young white people with high incomes were the group who used unconventional treatment most. Such people form a large market to be exploited by interests, not always commercial, that seldom run parallel with those of the medical profession. If examples are needed, think of the rising sales of herbal medicines and doit-yourself kits for pregnancy testing or for measuring plasma cholesterol. Read the health pages in magazines and newspapers. Explore cyberspace to observe the numbers of disease selfhelp groups available on the Internet. Buy one of
the
computer programs designed to help you diagnose your own ailments. The Economist criticises doctors for interpreting their function too narrowly.3 They have seen their job as sifting symptoms, deciding what is wrong, and prescribing treatment. This mechanistic be could duplicated by the approach are If doctors to survive they need microprocessor. to relinquish their role as the guardians and gatekeepers of a technological fountain whose elixir grants eternal health. They must stop toeing questionable lines about what constitutes a healthy lifestyle. Instead, they should return to their roots as healers and teachers. They will be sought out as much for their counsel and wisdom as for their knowledge of therapeutics. There is a good deal of nonsense in the preface that Shaw wrote to his play The Doctor’s Dilemma, but one of his conclusions is inescapably right-"Do not try to live for ever. You will not succeed". Advances in medical technology have not diminished its truth. The Lancet 1 2
3 4 5
Rogers EM. Diffusion of innovations. 3rd ed. New York: Free Press, Macmillan, 1983: 370-431. Anon. Tomorrow’s doctoring: patient, heal thyself. Economist Feb 4, 1995: 19-21. Anon. Science and technology: why doctors? Economist Dec 10, 1994: 117-18. Foucault M. The birth of the clinic. London: Tavistock Publications, 1973. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993; 328: 246-52.
COMMENTARY
Colorectal adenomas on follow-up colonoscopy: is the cancer risk unchanged? Colorectal adenomas are associated with an increased risk of colon cancer by at least three-fold over the general population, and by six-fold if they are multiple.’ Much time and effort is now expended by colonoscopists world wide in removing adenomas with the expectation of reducing the cancer risk. Support for this notion came from the US National Polyp Study of 1418 patients who had both complete colonoscopy as well as removal of at least one adenoma from the colon or rectum. The cancer risk in this group was less than 1% after 7 years of observation compared with up to 4% in historical controls over the same period.2 The assumption has been that the reduction in cancer risk is due to removal of adenomas. However, an equally important factor for reducing individual risk may be the index colonoscopy itself, which establishes the absence of cancer anywhere in the colon and so places such patients in a much lower risk category than those in an unscreened group. The addition of polypectomy may further reduce the risk for individuals whose polyps are already large enough to contain a focus of cancer, or with growth potential to achieve a size that is likely to undergo
1126
5 mm, and especially those idea how much of the risk exclusion of cancer as opposed to
malignant change3 (polyps >1 cm). Overall, we have
no
reduction is due to removal of adenomas. Against this background Neugut and colleagues5 in New York determined the occurrence (incidence) rate of adenomas on follow-up colonoscopy in individuals whose index examination was adenoma free by comparison with the recurrence rate when the initial colonoscopy showed either single or multiple adenomas. Patients underwent colonoscopy because of occult or gross bleeding or because of a family history of colon cancer. Not surprisingly, the researchers found that the number of adenomas at the index colonoscopy was related to the likelihood of additional polyps at follow-up 36 months later (recurrence rate), especially if three of more polyps were present. For these individuals the recurrence rate was 65% vs 41-9% and 48-5%, respectively, for individuals with one or two adenomas on the index colonoscopy. The lowest risk of polyps at 36 months16%-was in individuals whose initial colonoscopy showed no polyps. Nevertheless, after 63 months’ followup the cumulative rate of adenomas was the same irrespective of the initial findings, with 76% of patients having adenomas, while by 72 months the rate
Who
owns
medical
technology?
In his book The Diffusion of Innovations, Rogers chronicles what happened when the snowmobile was introduced to an isolated community of Lapps living in northern Finland. The economy and social structure of this community centred on the reindeer, which provided food, clothing, and transport. The Lapps thought of themselves as reindeer herders. They felt a close relationship with their semi-domesticated animals and treated them with care and kindness. In this egalitarian society each family owned about the same number of animals. In 1961, one of the schoolteachers purchased a snowmobile for recreational travel, and the vehicle rapidly gained a use hauling wood and supplies. A trip to the nearest town that took 3 days by reindeer sled was reduced to a mere 5 hours by snowmobile. 10 years after the first snowmobile was introduced, almost every household owned one. The machine came to be seen as a necessity; it completely replaced travel by ski and sled for herding reindeer. Unfortunately, the animals were frightened by the speed and noise of the snowmobile. They were driven into a near wild state and their fertility declined. Families needed to sell more reindeer to pay for the fuel and maintenance of their machines and, because fewer reindeer calves were born each year, their resources became overstretched. Many were forced out of reindeer-raising; a few families built up very large herds. Two points emerge from this story quite apart from the obvious one that the introduction of technology may have costs that outweigh its benefits. The first is that technology brings much more than hardware. When the Lapps swapped their skis and reindeer sleds for snowmobiles, they
May 6, 1995
exchanged autonomy in transport and energy for dependency on external supplies of gasoline. There was a shift in social values. High status in the community had previously been accorded to men with good strings of draught animals; now it was ownership of a machine that brought prestige. The second point is that the Lapps had no way of predicting the consequences of adopting the snowmobile. At no time during the process of diffusion of the new technology through the community were they able to find a way of studying and discussing the likely outcomes. The possibility that the introduction of snowmobiles could be resisted or checked never arose. Are doctors about to go the same way as the Lapps? And for similar reasons? Two recent articles in the Economist have warned how bleak the future looks for doctors.2,3 They analyse the loss of power of the medical profession and the increasing managerial influence on decisions formerly thought to be the exclusive preserve of doctors. A large part of the reason has to do with medicine’s increasing
dependence
on
technology.
Technological
innovation is making investigation of patients simpler and safer. At the same time, these technological tests yield better and more complex information. The Economist predicts a diminishing role for doctors and an increasing one for technicians. Technology, as the Lapps found to their cost, cannot be separated from the social and economic values of the society that produced it. Views about restriction of availability of medical technologies are changing. Legislation previously deemed necessary to safeguard an uninformed population from
1125
dangerous charlatans is now more likely to be seen as serving the needs of the profession than protecting patients. The governments, insurance companies, and employers who pay the bill for health care are demanding more say in decisions about when it shall be used and by whom. They are likely to find that technicians are cheaper to employ than doctors. But the change in views is driven by more than the desire to get value for money. Consumers want control or, what amounts to the same thing, the illusion of control, of their life and health. They may not have read Foucault4 but they still have doubts about whether modern medicine will help them achieve this. We can hear this ambivalence articulated every day in our clinics. Patients tell us that they do not believe in taking tablets; simultaneously, they demand more rather than less treatment. A survey of American adults found that, in the previous year, one in three had used unorthodox therapies.s Educated young white people with high incomes were the group who used unconventional treatment most. Such people form a large market to be exploited by interests, not always commercial, that seldom run parallel with those of the medical profession. If examples are needed, think of the rising sales of herbal medicines and doit-yourself kits for pregnancy testing or for measuring plasma cholesterol. Read the health pages in magazines and newspapers. Explore cyberspace to observe the numbers of disease selfhelp groups available on the Internet. Buy one of
the
computer programs designed to help you diagnose your own ailments. The Economist criticises doctors for interpreting their function too narrowly.3 They have seen their job as sifting symptoms, deciding what is wrong, and prescribing treatment. This mechanistic be could duplicated by the approach are If doctors to survive they need microprocessor. to relinquish their role as the guardians and gatekeepers of a technological fountain whose elixir grants eternal health. They must stop toeing questionable lines about what constitutes a healthy lifestyle. Instead, they should return to their roots as healers and teachers. They will be sought out as much for their counsel and wisdom as for their knowledge of therapeutics. There is a good deal of nonsense in the preface that Shaw wrote to his play The Doctor’s Dilemma, but one of his conclusions is inescapably right-"Do not try to live for ever. You will not succeed". Advances in medical technology have not diminished its truth. The Lancet 1 2
3 4 5
Rogers EM. Diffusion of innovations. 3rd ed. New York: Free Press, Macmillan, 1983: 370-431. Anon. Tomorrow’s doctoring: patient, heal thyself. Economist Feb 4, 1995: 19-21. Anon. Science and technology: why doctors? Economist Dec 10, 1994: 117-18. Foucault M. The birth of the clinic. London: Tavistock Publications, 1973. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. N Engl J Med 1993; 328: 246-52.
COMMENTARY
Colorectal adenomas on follow-up colonoscopy: is the cancer risk unchanged? Colorectal adenomas are associated with an increased risk of colon cancer by at least three-fold over the general population, and by six-fold if they are multiple.’ Much time and effort is now expended by colonoscopists world wide in removing adenomas with the expectation of reducing the cancer risk. Support for this notion came from the US National Polyp Study of 1418 patients who had both complete colonoscopy as well as removal of at least one adenoma from the colon or rectum. The cancer risk in this group was less than 1% after 7 years of observation compared with up to 4% in historical controls over the same period.2 The assumption has been that the reduction in cancer risk is due to removal of adenomas. However, an equally important factor for reducing individual risk may be the index colonoscopy itself, which establishes the absence of cancer anywhere in the colon and so places such patients in a much lower risk category than those in an unscreened group. The addition of polypectomy may further reduce the risk for individuals whose polyps are already large enough to contain a focus of cancer, or with growth potential to achieve a size that is likely to undergo
1126
5 mm, and especially those idea how much of the risk exclusion of cancer as opposed to
malignant change3 (polyps >1 cm). Overall, we have
no
reduction is due to removal of adenomas. Against this background Neugut and colleagues5 in New York determined the occurrence (incidence) rate of adenomas on follow-up colonoscopy in individuals whose index examination was adenoma free by comparison with the recurrence rate when the initial colonoscopy showed either single or multiple adenomas. Patients underwent colonoscopy because of occult or gross bleeding or because of a family history of colon cancer. Not surprisingly, the researchers found that the number of adenomas at the index colonoscopy was related to the likelihood of additional polyps at follow-up 36 months later (recurrence rate), especially if three of more polyps were present. For these individuals the recurrence rate was 65% vs 41-9% and 48-5%, respectively, for individuals with one or two adenomas on the index colonoscopy. The lowest risk of polyps at 36 months16%-was in individuals whose initial colonoscopy showed no polyps. Nevertheless, after 63 months’ followup the cumulative rate of adenomas was the same irrespective of the initial findings, with 76% of patients having adenomas, while by 72 months the rate