The Medical World

By: 
Dr. Michael Bess, MD, FACS

    J.D. Vance, in his book, Hillbilly Elegy, describes his upbringing in a part of society that defies imagination to many people. I can relate to nearly everything he wrote about.  Believe me, health care (and also dental care) was not part of the picture.  
    When I think about promoting health care to as many people as possible, my upbringing makes me very sensitive to the people he describes. There are a lot of good people in that segment of our society and some grow up to be doctors, lawyers, and such – to quote Willie Nelson. Some are just hard headed and have spent their entire lives making bad decisions and are content to continue doing just that.              Those were my role models – tough as nails and the picture of hard living. Most are hardworking, reliable, and accept life as it comes but caring about their health is not on their radar – forget things like vaccinations and screening test.      
    There is little question that widespread vaccinations have nearly wiped out the death and disability associated with things like measles and polio – in spite of what Jenny McCarthy thinks. And with things like Pap smear screening, death from cervical cancer is a rarity. Now currently we are on the cusp of so called liquid biopsies where cancers will be able to be detected with a blood test.  
    From a medical standpoint, the hope is that the simplicity of a blood test will improve our screening rate.  Today our screening rate for colorectal cancer is around 50 percent.  Some say that poor rate is partly because we (unlike the rest of the world) insist on using colonoscopy with its expense and inconvenience.  Breast cancer screening with mammography isn’t much better and has a 20 percent miss rate of cancers along with radiation exposure and expense. We currently screen about 60 percent of eligible women.  
    During my years of doing cancer surgery, some of the angriest people I encountered were women who came in with a palpable breast lump and a normal mammogram. First, they were upset with me because I told them the lump had to be biopsied and then they were understandably angry when that biopsy showed cancer. These were women who had faithfully undergone their screenings but in some cases got a phone or mail result and no physical exam.   No one told them the downside.  They felt they had been misled and often wondered if there isn’t something better.  
    In fact, for breast cancer we already have something better but payment is the main issue. Breast MRI is more accurate than mammography and has no radiation. Of course, it isn’t perfect and you still need a physical exam along with it.  
    I have had this discussion with many women – most with dense breasts which renders the mammogram essentially worthless. I recall one woman in particular who was quite interested in breast MRI because of her dense breast tissue and researched it all out. She asked me if there was some way to get the cost down since insurance wouldn’t cover the $3,000. I suggested she call around to hospitals within a 200 mile radius to see what kind of a cash deal they would cut. I don’t know what she said but the next time I saw her, she said she got it all done for around $300. Maybe the free market has a place in health care screening.    
    So what is the best screening test?      Answer:  It is the one people will use. As I see it, part of our job is to make things simple. Not uncommonly, we fight an uphill battle to get this done. Sometimes because administrative folks push the most profitable screening test and  sometimes because we keep insisting on a more perfect test that unfortunately, few people will use. That is not my definition of success. We will never have a perfect screening test. We will never have a perfect vaccine.  
    The dirty little secret is that among the people I grew up with, an encounter for some sort of screening was, in fact, their (only) entry portal into the medical system. They didn’t have the money or what they considered a proper change of clothes to actually visit a doctor’s office. I can’t begin to tell you how many times I have seen someone brought into an emergency room after an accident and they or someone with them said, “I’ve got this thing I’ve been wanting to ask somebody about.” Once it was a woman with a large fungating breast cancer. She was there because a horse had kicked her in the abdomen.
    These are my people. They have been to rodeos and/or dirt track sprint car races but have never seen the inside of a country club. Good, decent, hardworking people who don’t have the time, inclination, or finances to encounter our health care system.  
    It is not their job to come to us, it is our job to go to them with the best care we can deliver under the circumstances. I think about that as we close more and more of our rural hospitals and it is what drove me during the first years of my surgical career to set up our state-wide trauma care system with air transport into all the rural reaches.          Part of my training was in a big city hospital with an unbelievable number of stabbings and shootings.  We did near miraculous things to put them back on the street alive and yet that level of care wasn’t available to rural farm accident victims. Can we make that rural trauma care as good as the care available to the drug dealer shot a few blocks from a trauma hospital? Probably not, if for no other reason than the distances involved, but we can provide the best we can do under the circumstances.  
    The late Dr. Bob DeClarke and I were chagrined (to say the least) when mobile mammography was essentially done away with following an administrative change at a large hospital in Sioux Falls many years ago. I made several trips to that administrator’s office and tried to make my case that such a move would lead to more advanced stage breast cancers because those women were not going to make the long trip to a large town for their mammograms and, additionally, that mobile unit was their entry into medical care.  
    After about the third meeting he told me in colorful language that those rural women were just going to have to do what he wanted them to do. He scoffed at my ill-tempered retort which was something to the effect that maybe the press would be interested in his position. Within a week, I received a letter from a law firm in Pittsburg informing me that neither the administrator or the hospital were doing anything illegal and they trusted they had heard the last from me on the subject of mammograms.  
    A few years later, I sat next to DeClarke at the weekly cancer conference at that hospital when a young oncologist presented a case of a huge breast cancer in a rural woman. He openly puzzled about why they seemed to be seeing so many late stage breast cancers. DeClarke leaned over to me and said, “We know why, don’t we.”
    Screening is important but it is important for us to remember that to be effective, it has to be delivered and used. It is not about what the test can do for the medical system, it is what the test can do for the patients. It won’t ever be perfect but we can do better than we do now.    
    Michael A Bess MD FACS is a practicing surgeon. He can be reached at sdgensurg@gmail.com
Questions, comments, and suggestions are welcome.

Dr. Bess contributes his view of the medical world to be published in The Review at regular intervals. Subscribe to stay in tune with his column.

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