In early 2010, roughly one year after his inauguration, Barack Obama saw the White House physician. The circumstances of his visit led to days of testing using high-powered scans, invasive procedures and evaluations under anesthesia. This, the presidential check-up, may be an ideal symbol -- and a starting point -- for what ails American medicine.
To screen the then 48-year-old for colon cancer, Obama's doctors performed a colonoscopy. This was two years before the test would be medically appropriate. Prior to age 50, the mathematical chance of reaping benefits from a colonoscopy is eclipsed by the larger chance of a potentially fatal complication like intestinal perforation or severe bleeding.
They also checked his prostate specific antigen, a discredited test that does not save lives, but does sometimes spur unnecessary surgeries that can leave men incontinent and impotent.
For his heart, Obama underwent a coronary artery scan, a test that guidelines and specialty groups have declared useless, and a source of false positives, when performed in the absence of symptoms. Obama is and was physically fit, exercising regularly without indications of heart disease.
The over-testing Obama experienced is frustratingly common, and the great hazard is the "positive" result. While radiation exposure is risky, and invasive tests can be dangerous, for generally healthy people false positives are by far the most common mishap of medical testing. With mammograms, for instance, 97 percent of positive findings are false, and these results lead to unnecessary and sometimes perilous treatments or tests like surgical biopsies. That risk may be worth taking when a test is proven to save lives, but for colonoscopies in young people, PSA tests and heart scans for those without symptoms, this isn't the case. And yet Obama, whose test results were largely normal, was luckier than his predecessor.
After a stress test performed during his checkup in 2013, George W. Bush was rushed to cardiac surgery. Recommendations by the American College of Cardiology suggest that Bush, an avid cycler and outdoorsman with no heart symptoms, should never have had the test. Worse yet, a host of studies shows that under these circumstances coronary stenting, the surgery Bush underwent, is chancy, invasive, and utterly ineffective. The stent in Bush's artery will neither prevent future heart attacks nor extend his life. (The fact that Bush's blockage was 95 percent -- a detail released to defend the procedure -- is both typical and unrelated to a stent's effectiveness).
Why are presidents routinely theￂﾠvictims of such medical exuberance? Perhaps because no doctor wants to be accused of doing too little in such cases. Or, perhaps because of a predilection for doing something, even when that something may be more risky than helpful. But despite editorials lamenting the practice, there is a flourishing market for the president's brand of care. A Web search on the term "executive physical" yields advertisements from a star-studded line up, including the likes of Johns Hopkins and the Mayo Clinic. In one typical example, a video from the Cleveland Clinic promises a spa-like day of examinations including prostate blood testing, stress tests, and chest X-rays. Each of these is either a proven failure or (at best) unsupported by evidence.
Executive physicals are both artifact and symbol of failure, in my opinion. In a nation of overflowing emergency rooms and packed offices the wealthy buy up care like a precious commodity, indulging to harmful excess. Meanwhile, hospitals and doctors reap the bounty, rational actors in a system of misaligned incentives and dubious science.ￂﾠIn the end, the less fortunate stand outside the gate, waiting and hoping for care that is essential, while the wealthy are fleeced, overpaying and suffering for care that is excessive. Everyone loses.
How do we right-size care of the wealthy and celebrated, while opening the gates to all? This is the fundamental puzzle that Obamacare must solve.
In the meantime, we're approaching the calendar date for another presidential checkup.