Medical Progress: Creative Destruction vs. Destructive Creation
The phrase "creative destruction" hovering between a cliché and a profundity, is often used as a throwaway line, especially among entrepreneurs and investors. In Silicon Valley-speak, as applied to product development, it describes progress as disruptive technologies. One frequently cited example is the smartphone, which all but killed the market for regular cell phones and fatally injured the recording business (CD's, MP3 players), PDA's, point-and-shoot cameras, wrist watches, calculators and voice recorders. Further examples abound, think: railroad and the automobile vs. horse and carriage, radio vs. the telegraph, email vs. the post office, social networks and the Internet vs. the publishing industry, Netflix vs. ...who knows?
Creative destruction, then, occurs when invention or imagination lays waste to established forms of manufacturing and distribution, revolutionizing, annihilating or causing replacement of whatever existed before.
Joseph Schumpeter, the pioneering economist, though not the originator of the phrase, developed this concept into a powerful economic principle, the vital force of innovation behind capitalism's business cycle of boom and bust. The concept enjoys a long and vivid history. Karl Marx prefigured him in The Communist Manifesto with "...the enforced destruction of ... productive forces" and capitalism "...sowing the seeds of its own destruction." In non-economic realms the idea of replacing old moralities with new ones, like "God is dead" goes back to Nietzsche who argues that every creative act has it destructive consequence. In Hinduism, the god Shiva is simultaneously destroyer and creator, another source of our idea of creative destruction.
We need only reverse the phrase to see the crossover point of creative destruction and its obverse: dead and dying industries and small businesses, downsizing, economic recession, job loss, with all the associated human costs of unemployment, foreclosures, and homelessness. More examples of destructive creation come to mind, such as consumer and commercial software upgrades killing off perfectly good software to force consumers and industry alike into upgrading or compelling us to search for alternatives. Consider the cost we endure for the replacement rate. By discarding our household goods, cars, old TV's, computers, and mobile phones, we "destructively" increase toxic and other waste. These results of creative destruction have long been foreseen, and continue to be actively encouraged to promote our economic well being.
Destructive Creation and Medicine
Medical Progress in the form of immunization, antibiotics, cardiac surgery, revolutionary imaging, etc. has been a colossal success story over the past century, conferring on our age extravagant improvement in health and longevity. Yet from time to time, we suffer disillusion when we learn, often long after the fact, that some promising new drugs are so dangerous they've been taken off the market, that uncountable cardiac procedures, such as catheterization, stent placement, implantable pacemakers were not indicated, that tens of thousands of joint replacement need never have been performed.
Dr. Eric Topol, in his 2011 book, "The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care", rhapsodizes over our smart phone detecting cancer cells, monitoring your brain waves, or warning you of an imminent heart attack. Could this be overshooting the runway? At the same time Topol was on the money when he predicted our vital signs could be monitored continuously, perhaps even your blood glucose and other blood chemistries. After all, we now have the soaring stock price of the new IPO, Fitbit, "which tracks every part of your day—including activity, exercise, food, weight and sleep—to help you find your fit, stay motivated, and see how small steps make a big impact." Then there's TV's Jeopardy with its IBM expert system, Dr. Watson, answering all your questions, and IBM, according to the New York Times, seriously considering widespread applications in health care. Does this mean we can now commodify the medical profession, as well as healthcare itself, by simply replacing them with digital technology and mobile devices?
The Electronic Medical Record (EMR)
In order to make a medical appointment with some specialists at Pennsylvania Hospital in Philadelphia you must activate your account at their website in order to be provided with "secure, confidential, and convenient access to your personal medical record." For convenience, an app is available for your iPhone or Android users through their website. But what if you're one of three Americans who don't own a cell phone or else belong to the 47% of those over 65 who don't use the Internet and try to get an appointment?
Increasing numbers of physicians and patients pay a price for the unintended consequences of EMR. Sen. Lamar Alexander (R. Tenn), Senate health committee chair, reminds us we've already spent $28 billion in taxpayer dollars subsidizing it. "Physicians don't like these electronic medical systems and say they disrupt workflow, interrupt the doctor-patient relationship, and haven't been worth the effort."
Speaking of relating to your doctor, have you experienced shorter visits while your doctor is busy looking at his computer more and more and having eye contact less and less? If you've been hospitalized lately, have you noticed nurses spending fewer minutes talking to you or being in the room, and more and more time typing into their handset or looking at the monitor?
Here are two other glaring examples of destructive creation in medicine; obviously, there are more waiting to be revealed.
The PSA Test
Dr. Richard J. Ablin, Research Professor of Immunobiology at the University of Arizona College of Medicine in a New York Times Op-Ed, the man who invented the PSA test 45 years ago, observes that while 16% of men have a lifetime chance of receiving a diagnosis of prostate cancer, they have only a 3% chance of dying from the disease. "The fact is, that infections, ... drugs like ibuprofen and simple prostatic enlargement occurring in the majority of older men, can all falsely elevate PSA. Moreover, the test ...cannot distinguish between the cancers that kill and the vast majority which grow so slowly that 97% of men will die of something else" Cancer phobia amplified by uncritical professional panels and commercial interests have caused hundreds of thousands of men to have radical prostate cancer surgery or radiation, resulting in a tragically high percentage of permanent impotence, incontinence of urine, or both. The New England Journal of Medicine published the two largest studies of the screening procedure, one in Europe which showed that 48 men would have to be treated to save one life. As Dr. Ablin reiterates, "That's 47 men who, in all likelihood, can no longer function sexually or stay out of the bathroom for long." The American study showed that over a period of 7 to 10 years, screening did not reduce the death rate in men 55 and over.
Finally something has been done by the profession. Various new recommendations have been issued since 2012 for PSA screening, when The U.S. Preventive services Task Force, a government-appointed panel advised against the routine use of the PSA. This was followed by The American Urological Association, The American Cancer Society ("Last Medical Review: 10/17/2014 Last Revised: 01/01/06/2015") and even a summary on WebMD.
Because these recommendations for screening are complicated by variables such as patient, age, history, and preferences, it is not surprising that many general physicians remain confused. Overall, things have improved, after these wake-up calls.
Upper Endoscopy (EGD) and the Disappearing GI Series
It is surely one of medicine's greatest ironies and blind infatuations that routine imaging of the upper GI tract has changed so profoundly in the past 40 years. The introduction of the fiber optic gastroscope in 1963 initiated this sea change in diagnosis, catching the medical profession and patients in an undertow of fashionable technology.
The procedure, EGD, is so unpleasant that, in order to prevent struggling, coughing, and gagging, over 97% of patients receive "conscious sedation," light general anesthesia sufficient, as is any level of anesthesia, to result in complications, misadventures, even death. Though the numbers seem very small, can they be considered insignificant if they result from a diagnostic procedure performed on millions of patients? "Unplanned events" occurred in one study in 1.6% with cardiovascular problems (arrhythmia, chest pain or angina, hypotension, or myocardial infarction) occurred in 0.6%. In another study complication occurring within 24 hours after endoscopy) has been reported as 3 per 1000 procedures. Mortality has been reported as high as 1 in 2,000 in some series, but by the Mayo Clinic as 1 in 9,000 procedures. Also see this article. The numbers seem small, but consider that every year 20 million or more American undergo the procedure. While up to 10% of the procedures are indicated to treat complications, internal bleeding or remove a foreign body, that leaves an estimated 18 million, of which 1800 will die and 60,000 will have a complication.
Yet the use of X-rays and barium, the esophagogram and upper GI series, a procedure without risk or complications, to outline the esophagus, stomach and intestine, has been increasingly abandoned by the medical profession over the past 40 years. This despite the fact that the upper GI series gives invaluable information regarding upper GI function, such as swallowing, esophageal reflux, stomach irritability, transit time to the bowel, etc, information, arguably, which EGD cannot give, since it only visualizes structure, not function.
The cost of EGD, incidentally, averages $3000 per procedure, the upper GI series, less than $600. This disparity, not counting, deaths and complications, amounts to over $43 billion spent yearly, if not needlessly, for health care.
I've covered only a fraction of medical examples of destructive creation, or its mirror image, creative destruction, however you define it. Many examples of advancement in the health sciences prove ultimately to be illusory, yet politically correct, the result of misplaced enthusiasm and uncritical public and professional acceptance. We remain seduced by the conviction that established ways can be easily overturned when something new comes along in the costume of progress. This belief is supported and heralded unceasingly by the media and their advertisers, if not also the medical literature.
Our maxim should remain, "Be not the first nor the last" to embrace progress in diagnosis and treatment of human suffering. As for the present status of medical progress, we are reminded of Gandhi when asked what he thought of Western civilization: "I think," he remarked "it would be a very good idea."
Martin F. Sturman, MD, FACP
Copyright 2015, Mathemedics, Inc.
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