The Industrialization of Medicine

Any customer can have a car painted any colour that he wants so long as it is black
~ Henry Ford

Any customer can have a car painted any colour that he wants so long as it is black” Henry Ford

One of my patients just had a newly diagnosed cancer. He said an interesting thing. First let me reassure you he will do well; a bumpy path but he will be fine. I won’t name the cancer because it will distract from the overall point. He, like me and many of you, is, what I call, a ‘data nut.’ Within a week of diagnosis he knew/knows more about his cancer than 99.9% of doctors; and that is not an exaggeration.  After slogging through basic science, primary and secondary medical literature he began to realize how many different ways there were to treat his cancer.

And more worrisome how different his chance of life, death and disability were with the different approaches.  His decision about how to treat his cancer was a matter of life and death. Well, you might say, ‘just go to the experts, you know like Stanford or…whomever.’ The plot thickens just here. This is where Henry Ford’s quote starts to sound less like an anachronistic and whimsical formula from the past and more like medical prophecy.  For good reasons- less chance for charlatanry- and bad- saves money, saves law suits, not lives- there is very little individuation in cancer therapy. A great deal of talk about the genetics of chemotherapy response and drug susceptibility but little actual attempt to precisely match risk and therapy; to match absolute optimal therapy to specific cases.

Remember I said my patient said an interesting thing; I am still getting there. So the more he understood his own anatomy, type of cancer, other health issues, the variety of therapies and diverging paths of any treatment decision tree the more he realized that clarity about his own choice depended on the results of dozens or hundreds of people not the published results of 10’s of thousands; not on the kind of ‘science’ published in ‘peer reviewed medical literature’; not on the kind of therapy he could get by going to ‘the experts’ at Famous U.

His results would depend on precision, on measurable, repeatable mid and end points. He said, aghast I must add, ‘this is all boutique medicine!’ And he is right. What I almost take as a term of slander, ’boutique medicine’, maybe the real ‘gold standard’ of care.  So there you have the alternatives: industrialized medicine or boutique medicine.  A great, clanking, hungry maw of industrialized medicine or real, individualized medicine. I still blanche at the word ’boutique’ as it can also just mean a small personalized standard medical practice; I now hear the word the way my patient used it as a term of approbation indicating a systematic approach to the needs of an individual in the area of their most important purchase; their life.

New England Journal of Medicine (NEJM): Crestor (AstraZeneca) is one of the newer statin class of drugs and as AstraZeneca is funding many of the cardiovascular studies being published these days much has been made about the November 20, 2008 NEJM article that showed starting Crestor in those with cholesterol numbers lower than previously treated but with normal highly sensitive C-Reactive Protein (hsCRP) that then went down had a decrease in stroke, heart attack and other vascular accidents. The study had a mean run time of 1.9 years and involved over 17,000 men and women. Sure enough Crestor lowered hsCRP and independent of effect on LDL reduced vascular events in a linear fashion related to its effect at reducing hsCRP.

Great, very old, news: lower your hsCRP and have fewer strokes and heart attacks. Repeatedly I have shown a larger, faster reduction in hsCRP by my diet and exercise protocols than any statin study has demonstrated. Measure this number, pay attention, lower it and keep it down. You do not need Crestor or Lipitor or any other drug to do this. By the way there was an increase in diabetes in the Crestor group over controls.  Take a pill; get diabetes. Industrialized medicine at its finest.  God Speed, Dr. Mike

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