Bad Medicine

suggestion.

The implicit assumption of health economics is that it does.

 Let’s imagine a scenario, though: one of your parents is stricken with a rare, rapidly progressive, and invariably fatal cancer that is known to be hereditary in an autosomal dominant fashion.  You have a 50% chance of coming down with that same cancer; there is no cure at any stage of diagnosis and no screening that could be done to identify if you carry the gene.   Average life expectancy from the time of diagnosis is 2 years.  There is, however, a drug that you could take now, and if you were to get the cancer it would add two years of good health to your life expectancy after diagnosis.  The downside is that the drug is relatively toxic – it decreases life expectancy in healthy persons by two years (out of an average of 80, though).  Would you take the drug?

 If you’re like me, that’s a no brainer.  But imagine it’s not a genetic disease, just a random cancer that people get, no identified risk factors.  Try dropping the chances you’ll actually get it down incrementally (from 50%, 25%, 10%, 5%, 1%, &c, &c).  At what point is it no longer worth it to trade two healthy years out of eighty for two healthy years in addition to the two you would have if you get the disease?  Or fix it at 50% but imagine that the two years are filling up with hospital stays, infections, pain control.  What level of discomfort would offset the quality benefit of two extra years in a life that you know is going to end soon?

 It’s clear to me that there are certain conditions in which the value of a year is considerably greater than the value of one healthy year from a reference perspective.�

[Editor’s Note] In theory, I should read before I post, but that’s just not going to happen.

There have been a couple of studies published lately on the the outcomes of patients undergoing bariatric weight loss surgery (off the top of my head, I can’t . One curious and consistent finding is that bariatric surgery patients have a much higher rate of suicide than the rest of the population. One bariatric surgeon I talked to reasoned (based on anecodote) patients who are depressed and obese think overweight is the source of their emotional dysfunction, and when they shed pounds and remain depressed, it’s even harder to cope with.

I can think of other explanations, none of which I’ve bothered to verify, but which I’ve organized in what I’d estimate is decreasing order of probability.

1.) More obese people depressed than age matched population
2.) Hormonal changes with rapid, extreme weight loss cause mood dysfunction
3.) Weight loss energizes depressed people not enough to cure them but enough to do something about it.
4.) Lifestyle modifications of bariatric surgery are fairly significant, perhaps enough to induce mood dysfunction.
5.) Increase in suicide rates limited to patients with adverse outcomes, less weight loss than desired, etc.

I have more to say, but I’ve learned that if I hold off publishing until I’ve finished the thought, I don’t publish it at all.

As the proud owner of a $200,000 debt, this hurts. I’m currently thinking I want to do general medicine, which lends itself nicely to both clinical and research based loan repayment programs, but I’m not eligible until after residency (fellowship, etc). Crushing poverty will probably make it harder to do the things I want to do, academically.

The problem is I don’t know much and don’t have much to say about it. Dum dee dum.