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Medicine Science

Why Doctors Hate Science 1064

Posted by kdawson
from the comparative-effectiveness-research dept.
theodp writes "A 2004 study found some 10 million women lacking a cervix were still getting Pap tests. Only problem is, a Pap test screens for cervical cancer — no cervix, no cancer. With this tale, Newsweek's Sharon Begley makes her case for comparative-effectiveness research (CER), which is receiving $1 billion under the stimulus bill for studies to determine which treatments, including drugs, are more medically sound and cost-effective than others for a given ailment. Physicians, Begley says, must stop treatments that are rooted more in local medical culture than in medical science, embrace practices that have been shown scientifically to be superior to others, and ignore critics who paint CER as government control of doctors' decision-making."
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Why Doctors Hate Science

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  • Smart move (Score:5, Insightful)

    by mc1138 (718275) on Sunday March 01, 2009 @11:32PM (#27035959) Homepage
    While I am all for people being able to make their own calls and decisions, this sort of research could very well help to streamline more basic medical procedures and help bring to light both new medicines and treatments that might not be able to afford the same advertising as the crap that gets shoved in front of consumers every ten minutes on tv, radio and internet.
    • Re:Smart move (Score:5, Insightful)

      by Chonnawonga (1025364) on Sunday March 01, 2009 @11:51PM (#27036121)
      Even worse is the advertising that gets shoved in the faces of the doctors! There was another study recently (I'd link to it, but I'm too lazy to go search for it) that found that doctors were making a lot of choices about which drugs to prescribe based on all the advertising and free samples they're regularly bombarded with. Then there was another study that found that drug companies were spending twice as much on marketing as on research. Sadly, family physicians just don't have a whole lot of extra time to be reading up fully on every drug that hits the market. Having a way to distil research and make it more accessible to doctors could go a long way to countering that.
      • by cayenne8 (626475) on Monday March 02, 2009 @12:25AM (#27036423) Homepage Journal
        Hell, it isn't so much the Dr's making the decisions now...for the past decades, we've had the beancounters in HMO's and like dictating what tx the physicians, clinics and hospitals can give.

        Couple that with having to do unnecessary tests many times just to CYA to fight off bloodsucking lawyers and malpractice cases....well, that explains a lot of it away.

        • by mi (197448) <slashdot-2012@virtual-estates.net> on Monday March 02, 2009 @01:46AM (#27037071) Homepage

          for the past decades, we've had the beancounters in HMO's and like dictating what tx the physicians, clinics and hospitals can give.

          The current evil incarnation of HMOs et al were the result of a misguided and illiberal government policy: let's insure people through their employers. No employer meant either you are too rich for the government to care, or poor enough to be eligible for Medicaid. Self-employed? Sho-sho-shoo, we don't like these people — they are harder to corral.

          Losing a job meant losing health-insurance, and switching employer often meant having to switch an insurer, along with the "network" of doctors. Why exactly the two completely unrelated things (job and health insurance) had to be bundled together by government regulation (employers were given a tax-credit for insuring the employees) remains unclear.

          Last fall, however, during the elections, two alternatives were put forth. One of them, from Mr. Change, was the old and tried (elsewhere) "single-payer". He said, it is his top choice, but promised not to push for it, although health-related parts [yahoo.com] of the "stimulus" bill suggest the opposite.

          The other proposal came from McCain, who wanted to eliminate the employer's tax-credit (the part Obama emphasized during debates) in favor of giving each individual a tax-credit (the part Obama never acknowledged) to be spent on their own health care. This would've created the same kind of market for health insurance as exists for, say, auto, term-life, house, and other insurances. The decoupling of health care from employment would've been much more fare, and the prices would've come down because of genuine competition.

          The benefit would've been enormous, because the exelsior ("ever upwards" lat.) health care costs (and the associated evilness of health-insurers) are primarily explained by the fact, that consumers of care aren't the ones paying neither for the care itself, nor even for the insurance. This creates a lot of waste, and leads to — inefficient, but alienating — attempts to control it. Nobody is happy and we may end up with something worse (like government-provided health care), just because it will be different ("Change" is good, right?).

          In closing I'd like to offer a real-life example... A doctor gave us a prescription recently for our newborn's acid reflux with the words: "try this, see if it helps her". The prescription was for 30 tablets (30 days). When I got to the pharmacy, I learned, that the 30 tablets cost $190, and that insurance will only cover $120 (for some reason or the other). Here is the point, where different people would think different things:

          1. Crap, this is an outrage! When are we going to have free health care — and free medicines? Maybe, Obama will deliver on this.
          2. Khm, doctor said: "try it", so let's buy 15 instead of 30 (for half the price) and come for more only if it actually helps.
          3. Must be some drug — if prices for medicines were regulated and capped, no one would bother investing into making it.

          As you could guess, my thoughts were 2 and 3. But you, likely, know quite a few people, who would think 1 — and, maybe, 2 as well, but angrily.

          • by samkass (174571) on Monday March 02, 2009 @02:23AM (#27037267) Homepage Journal

            The other proposal came from McCain, who wanted to eliminate the employer's tax-credit (the part Obama emphasized during debates) in favor of giving each individual a tax-credit (the part Obama never acknowledged) to be spent on their own health care. This would've created the same kind of market for health insurance as exists for, say, auto, term-life, house, and other insurances. The decoupling of health care from employment would've been much more fare, and the prices would've come down because of genuine competition.

            "fare" is right! What kind of negotiating position does someone who needs life-saving care have versus an insurance company? A poor one. The only people who would be able to afford health insurance in that plan are people who don't need it. You'll note that McCain himself didn't seem to eager to buy his own insurance rather than take his employers.

            The most efficiently run medical payment service in this country right now is medicare with over 95% efficiency in terms of money going to treatment vs. overhead.

            • by cayenne8 (626475) on Monday March 02, 2009 @11:17AM (#27040199) Homepage Journal
              ""fare" is right! What kind of negotiating position does someone who needs life-saving care have versus an insurance company? A poor one. The only people who would be able to afford health insurance in that plan are people who don't need it. You'll note that McCain himself didn't seem to eager to buy his own insurance rather than take his employers."

              Well, not so much...IF we went back to thinking of medical insurance as INSURANCE. Something to only be there as a safety net, in case of catastrophic medical emergency (ie heart attack, serious injury, cancer...etc).

              But for day to day things....routine office visits, and meds....that needs to be planned out in your budget as another part of living within your means.

              As a self employed person, I do the high deductible policy ($1200)...and couple that with a Health Savings Account, which for a single person last year...you could load up with $2900 pre-tax. I pay my routine medical needs (including dental and eyesight and supplies) out of this pre-tax money. The HSA earns interest, and when the market is better, can also be invested to grow. The monies remaining in the HSA after retirement can be transfered as retirement $$ to you, much like and IRA.

              I find when the Dr. knows I am paying....I generally get about a 15% discount off visits and procedures over what they'd charge insurance.

              I wisht they'd expand the HSA program and let you sock a lot more money into it. I'd rather keep this type deal even when I sometimes go back to W2 hourly, or something closer to being an employee some place. But this bastardization we've come to..where you have 'insurance' pay for everything, and co-pays and the like is a bunch of bunk.

              Why not let the Feds let US put money away (like we do for rainy days and any other needs) pre-tax....and loosen up insurance for coverage for catastrophic needs.

          • by Grym (725290) * on Monday March 02, 2009 @04:15AM (#27037789)

            The current evil incarnation of HMOs et al were the result of a misguided and illiberal government policy: let's insure people through their employers. No employer meant either you are too rich for the government to care, or poor enough to be eligible for Medicaid. Self-employed? Sho-sho-shoo, we don't like these people -- they are harder to corral.

            HMOs and federally mandated employer-based healthcare was proposed and signed into law by President Nixon. In fact, there is an infamous tape [youtube.com] of Nixon and his adviser discussing the plan as proposed by Edgar Kaiser of Kaiser Permanente where they blatantly talked about how the emphasis would be on profit (for the HMO) and "providing less care."

            What we have today wasn't the result of some master-plan hatched in a secret lair in the lower recesses of an evil University by bleeding heart liberals or whatever you've been told. No, our entire employer based healthcare system is the result of special interest pork legislation written by the industry and pushed upon the public by a Republican administration. It's the DMCA of 1971.

            With regard to your child's heartburn, you need to start asserting yourself as a patient and parent. Take an active role in your child's health and specifically ASK your doctor for generic prescriptions. I'm going to go out on a limb and guess that your doctor prescribed Nexium or some other namebrand Proton Pump Inhibitor. The generic, Omeprazole, is available Over-The-Counter, costs a fraction of the price, and works virtually identically. Call your doctor and ask him or her if this is appropriate for your daughter. No doctor I've ever met would mind a call such as this. In fact, I think most would welcome it. Fifteen seconds of his or her time for one potentially satisfied, engaged patient is what you call a clinical no-brainer.

            -Grym

          • by EWAdams (953502) on Monday March 02, 2009 @08:29AM (#27038843) Homepage

            I've experienced both systems first-hand -- I'm an American living in Britain. Government-provided health care is FAR superior to what I received in the USA. Easier to get, cheaper, and of equivalent quality. No comparison.

      • Re:Smart move (Score:4, Informative)

        by Anonymous Coward on Monday March 02, 2009 @01:05AM (#27036755)

        There are a few reasons for what you're talking about. I am a primary care provider myself, a nurse practitioner, and the BIGGEST reason we give out the drugs the reps bring us is because when we give out the drugs we get as samples there is no cost to the patient. You would probably be shocked at how many people can't afford a $4 wal-mart prescription. If this means I give aciphex instead of prilosec I'm going to jump on that pretty quickly.

        That said, there was a recent ethics thing where drug reps can't give us pharma schwag (I'll miss getting my viagra clock every year...) anymore, nor can they take us out to dinner at expensive restaurants. *sniffle*

        In conclusion, even if you don't have a cervix it makes sense to get a pap of that area, because if you don't have one it probably means that you had all those bits removed for some reason, and the dysplasia or cancer may be present in the areas immediately adjacent to what was removed. Sometimes it doesn't make sense, but sometimes it does.

      • Re:Smart move (Score:5, Interesting)

        by MagikSlinger (259969) on Monday March 02, 2009 @01:24AM (#27036909) Homepage Journal

        I had an unfortunate incident of that. I came in with depression/anxiety, and my doctor put me on Paxil. Not because it was the best choice, but because it was the NEWEST one, and the lovely dinner the pharamceutical company paid for had these nice salesmen who told all the doctors how safe and effective with it.

        After one night on it, I stopped it and made another appointment with the doctor. To say I had a bad reaction would be an understatement. I'd describe it as extreme anxiety with hot sweats and other wonderful symptoms. Cut to a few years later, I start reading in the news about "unreported" side-effects of Paxil and the drug maker being forced to issue updated clinical notes. Now the warnings [medicinenet.com] list all these things.

        The appallingly bad knowledge, especially about new drugs, family doctors have is downright frightening.

        If you want to know how my story turned out, I got a referral to a psychiatrist who had many, many years of experience and helped me figure out my problem was a combination of biology, a sleeping disorder I'd recently been diagnosed with and really bad work environment. He helped me figure out which drug worked better for me (one that was new, but was relatively less marketed), talked me through how to make the appropriate changes in my thinking and lifestyle to survive bad times and then after the appropriate monitoring time, sent me on my way, and I've been overall pretty good.

        The lesson here is our doctors need real medical knowledge to draw on--not just what the marketers and sales people tell them. Family doctors are usually over worked trying to pay the office rent, the receptionist, the malpractice insurance, etc. And they don't have the time or energy to keep learning anymore, and what they do have time for is usually not of high quality to begin with.

        I for one am looking forward to this. It doesn't just benefit America--it could benefit everybody.

        • Re:Smart move (Score:4, Informative)

          by Stanislav_J (947290) on Monday March 02, 2009 @07:20AM (#27038489)

          The appallingly bad knowledge, especially about new drugs, family doctors have is downright frightening.

          All the points being made here are very pertinent, but one factor I have been dealing with (handling my elderly mother's medical care as she is no longer capable of keeping track of things) is that doctors today just have too heavy of a workload. They are juggling so many patients that they cannot possibly devote the time they really need to every individual case. The tendency is to just diagnose and order tests/prescribe drugs based on the most common knee-jerk diagnosis that comes to mind. The House M.D. depiction of a group of doctors having the time to sit around and debate diagnoses with intricate knowledge of every exotic possibility and with ready knowledge of all the latest medical research simply does not happen in most hospitals.

          Example: for over two decades, my mother has dealt with achalasia, a swallowing disorder. It is not a common problem, but certainly not some exotic rare disease that no one has heard of. She does have a very capable gastroenterologist, and the problem is currently under control, but it does rear its ugly head now and then. When my mother has been hospitalized and treated for other problems, the achalsia is still a factor as it affects her diet and eating schedule. You would be amazed at the number of attending physicians to whom I have had to explain and define what achalsia is and how it should be handled. Different doctors will all come and go in the course of her stay, none of whom seem to talk to each other at all, or have any inclination to inquire of her gastro doc about the problem, and all of them skeptical at best and disdainful at most of this "layman" son of hers trying to tell them how to do their job. When the achalasia begins to manifest (usually because they ignore or are clueless about the standard recommendations for diet), they keep automatically attributing it to nausea or reflux or some other unrelated condition and try to treat her for that. I can't sit in her room 24/7 waiting to intercept any random new doctor that happens to breeze in at odd times for one of their brief drive-by visits to "educate" them about achalasia (and somehow this information either never gets into her chart, or gets overlooked by these doctors in their overworked haste), so she ends up getting unnecessary treatment for problems she doesn't have. And this is not in some hellhole of a hospital -- this is in the highest-rated, most modern facility in our metro area.

          Much as I would like to see some form of universal health care soon, this phenomenon will just be exacerbated by suddenly adding 30 or 40 million new formerly uninsured patients into the system. Doctors already do not have the time to give each patient the time and care they need. Unless they train or import a whole lot of new medical talent quickly, it's just going to jam up the system even more, and there will be an even greater tendency for doctors to make diagnoses and treatment decisions "on the fly" as they breeze through on their way to their next patient.

    • Re:Smart move (Score:5, Insightful)

      by fuzzyfuzzyfungus (1223518) on Sunday March 01, 2009 @11:55PM (#27036165) Journal
      In addition, the dreaded "rationing" of healthcare is already here, brought to you by the private sector. I work, I have insurance, I pay my premiums; but the insurance company, obviously, makes more money when they deny a claim than when they pay it. A system where procedures are paid or denied based on their expected benefit, as established by actual research, would be a considerable improvement.

      In reality, "choice" in medicine is already an illusion for virtually everybody. Unless you can absorb arbitrarily high out-of-pocket expenses, or have extraordinarily generous insurance coverage, your medical choices are already circumscribed by what you can afford, or convince your insurer to pay for. Better data would, hopefully, more closely align people's options with what is actually effective, and increase overall quality.
      • Re:Smart move (Score:5, Insightful)

        by wellingj (1030460) on Monday March 02, 2009 @12:07AM (#27036255)
        I see where you are coming from, but I still can't agree that people should eat food and drive cars that they can't afford. I don't to see how health care should be any different.

        I think the whole problem there stems from how health insurance morphed to health care. If you want to go see a doctor every year, pay for it. If you get run over by a truck, that's what insurance is for. Insurance is for the unforseable, not the routine. The problem is the line that has to be drawn, and it becomes a pretty grey area, so it's ended up that the insurance company is expected to pay for everything, which of course drives up the cost.

        Wondered off on a tangent there... oops.
        • Re: (Score:3, Insightful)

          I don't think you wandered off topic, I think you are directly ontarget.
        • Re:Smart move (Score:5, Insightful)

          by causality (777677) on Monday March 02, 2009 @12:23AM (#27036409)

          I see where you are coming from, but I still can't agree that people should eat food and drive cars that they can't afford. I don't to see how health care should be any different. I think the whole problem there stems from how health insurance morphed to health care. If you want to go see a doctor every year, pay for it. If you get run over by a truck, that's what insurance is for. Insurance is for the unforseable, not the routine. The problem is the line that has to be drawn, and it becomes a pretty grey area, so it's ended up that the insurance company is expected to pay for everything, which of course drives up the cost. Wondered off on a tangent there... oops.

          Indeed. I can't remember where I heard this, but this is an explanation I've heard: if car insurance worked like health insurance, then every time you put gas in your tank or get an oil change or replace the tires you would file a new claim.

          • by shermo (1284310) on Monday March 02, 2009 @12:37AM (#27036529)

            Don't give them ideas.

          • Re:Smart move (Score:5, Insightful)

            by CodeBuster (516420) on Monday March 02, 2009 @03:16AM (#27037513)

            MOD THIS THREAD UP PLEASE.

            The parent and grandparent are EXACTLY right. The problem with health insurance is that it pays a little bit on everything whereas every other type of insurance on the market: flood, earthquake, fire, auto, etc...is all designed to protect from unforeseen and large expenses that are infrequent or unlikely, but can be very expensive when they do happen. That is what insurance is all about. Do you insure your house against the cost of mowing the lawn? Do you, as the grandparent suggests, split the cost of an oil change or a fill up with your auto insurance company as a "co-pay"? Certainly not, so why then should health insurance be peculiar among all other types? Why can't people save enough money or alter their spending so that they can simply pay for routine care and expenses out of their own pocket as they do for other necessary things in their lives? IMHO, the burden is on the socialized medicine people to explain why health insurance is UNIQUE among all other types of insurance and cannot be left in the hands of private insurance and instead must be provided by the government making regular third-party (i.e. the worst and least efficient kind) payments on routine citizen needs. After all, if the government was or is so efficient at providing health care then why not have them provide other things too like cars, vacations, computers, designer clothing, and everything else that people want.

            If people really want to learn about How To Cure Health Care [hoover.org] then they should read the linked article.

            • Re:Smart move (Score:5, Interesting)

              by ahabswhale (1189519) on Monday March 02, 2009 @03:40AM (#27037617)

              Sorry but you are massively uninformed. There are different kinds of health insurance just like there's different kinds of auto and disability insurance. What you are talking about is a "major medical" policy that only kicks in when your costs exceed ~$2k. This is the exact kind of policy I have. Why do I have this kind of policy? Because to get a policy that starts at $0 would cost me over a $1k a month. So, these policies already exist and they are already VERY common. The fact that you and the parent poster don't know about them is utterly fucking shocking to me. Even with major medical, I still have to pay over $200 a month for health insurance just for myself (non-smoker, non-obese).

              The bottom line is that the cost of health care has skyrocketed compared to average income. It becomes less and less affordable and is becoming a greater and greater burden on the economy. In fact, the idiots that perpetuate the system we have today are driving us into socialized medicine (their worst fear) just because there will be no other way to deal with the costs. Frankly, I can't wait just so I can laugh my fucking ass off. Most doctors fucking suck anyway. Like everything else, 90% of them are worthless. Too bad you don't have time to shop around while you're in the middle of a heart attack.

              "After all, if the government was or is so efficient at providing health care then why not have them provide other things too like cars, vacations, computers, designer clothing, and everything else that people want."

              You must be fucking kidding me. It would be impossible for even the government to be less efficient than what we have today. Socialized systems in other western countries are far more efficient. We spend TWICE what England and Canada do per capita on health care.

              Seriously, you need to actually READ about this stuff before you spout your mouth off. You have no idea what you're talking about.

              • Re:Smart move (Score:5, Insightful)

                by CodeBuster (516420) on Monday March 02, 2009 @04:37AM (#27037871)
                Just because I was talking about a particular aspect of health insurance, one that is common in America, doesn't mean that that is the only type available. You should not interpret the absence of a particular topic in health insurance in this thread as evidence that we don't know about it. I have a high deductible health plan with a health savings account myself (although my deductible is somewhat higher than 2k and I pay a bit less than you do per month every three months or quarterly). However, we are in the EXTREME minority of Americans with health care coverage. Most Americans, those who have coverage anyway, select family HMO plans through their employer with effectively much lower deductibles, although it is not an apples and apples comparison because the HMO plans are structured differently with no lifetime maximums in exchange for more constrained care and escalation choices and procedures.

                The bottom line is that the cost of health care has skyrocketed compared to average income. It becomes less and less affordable and is becoming a greater and greater burden on the economy.

                Care that in many cases wasn't available for most of the previous century. If you want 3d computer assisted MRIs and other fancy tests and cutting edge drugs to treat your condition or extend your lifespan then you are going to have to pay for them. I have no problem paying for basic health care and if people are stupid enough to go to the emergency room instead of calling their doctor or going to an urgent care clinic (the kind that are open all night and can do most things up to and including minor surgeries for reasonable prices) then they have nobody but themselves to blame. Emergency rooms are for life threatening emergencies most other needs can either wait until morning or you could go to urgent care clinic instead.

                You must be fucking kidding me. It would be impossible for even the government to be less efficient than what we have today. Socialized systems in other western countries are far more efficient. We spend TWICE what England and Canada do per capita on health care.

                In a manner of speaking you are right, government provided single payer health care is less expensive than the present US system (which almost nobody likes for different reasons). HOWEVER, the single payer system achieves these lower costs with some combination of higher taxes for everyone (taxing is a whole different topic, but suffice it to say that it never works to single out a single group and just tax them without effecting anything or anyone else in the economy) OR rationing of care or both. There is no free lunch, and costs can take on many forms not just money out of pocket. For example, there could be longer lines, or unavailable drugs (like those cancer drugs that NHS refused to pay for in England), or other general economic costs of higher taxes necessary to support the single payer government healthcare system. I would like to go in the opposite direction, towards private pay for everything except expensive life saving care which would be covered as private insurance covers many other risks in our lives. We both agree that the US health care system is broken, but that is not really a revelation nor is it particularly controversial. Everyone knows its broken. Your mistake was to assume that because I don't want government provided single payer health care that I was in favor of the status quo, as if there were only ever two choices: exactly what we have right now OR single payer.

                Like everything else, 90% of them are worthless. Too bad you don't have time to shop around while you're in the middle of a heart attack.

                Don't know where you have been going, but I suggest that you find a new primary care physician if you are so dissatisfied. The heat attack isn't what I am talking about. If you have a heart attack then the paramedics are probably going to send you to the emergency room anyway if they cannot get you s

        • Re:Smart move (Score:5, Insightful)

          by Estanislao Martínez (203477) on Monday March 02, 2009 @01:15AM (#27036841) Homepage

          I think the whole problem there stems from how health insurance morphed to health care. If you want to go see a doctor every year, pay for it. If you get run over by a truck, that's what insurance is for. Insurance is for the unforseable, not the routine. The problem is the line that has to be drawn, and it becomes a pretty grey area, so it's ended up that the insurance company is expected to pay for everything, which of course drives up the cost.

          The problem with what you're saying is that the sort of routine care you say insurance shouldn't cover actually doesn't cost much to provide. Health care expenditures are really one of those 80/20 phenomena: the vast majority of the cost is spent on the health care of a small number of people.

          By making people pay for it out of pocket, all you do is disincentivize routine care (which is cheap to provide). You don't put a dent on the major sources of health costs, and what's worse, you prevent people from getting treated early on, while it's still relatively cheap to do so.

          • Re:Smart move (Score:4, Insightful)

            by CodeBuster (516420) on Monday March 02, 2009 @03:25AM (#27037551)
            I have a health savings account [wikipedia.org] and high deductible insurance plan. I pay out of pocket for all routine expenses such as doctor visits and prescriptions with the exception of one physical which I get free per year and of course high costs that exceed the deductible (i.e. I get run over by a bus and end up hospitalized for major surgery). I do not avoid routine care and my doctor loves seeing me because he knows that he will not have to bill insurance and wait six months for his money, I simply pay him out of the money which I have saved in my health savings account. Why would you avoid routine care when you have purposefully and diligently saved money ahead of time in a tax advantaged savings account specifically to pay for routine health care expenses? I think the answer is that you wouldn't. Now, is this plan for everyone? No, probably not everyone, but for many ordinary Americans this type of plan could work and work well, especially because it incentives people to seek out good quality routine medical care at reasonable prices since they are paying out of their own pocket.
        • by copponex (13876) on Monday March 02, 2009 @01:19AM (#27036875) Homepage

          The problem is that the market has come up with an awful solution to medical liability, which is pitting malpractice insurance against health insurance. Much of the cost of health care can be traced back to either. The other source of cost is that health care is sold as any other product on the free market, which is unfortunately very stupid. Deregulation of health care has led to the closure of hundreds of hospitals around the country, and pushed the costs out of the reach of much of the population. This is actually based on market principle, since the question moved from how much it costs to provide adequate health care, to how much people are willing to pay for it. Of course the upper sector of society is loving life with 3d pictures of their unborn child and access to obscure specialists at the drop of the hat, while the rest of the population struggles to pay for pills and basic care.

          Now you have people dropping dead of overdoses and mixed prescriptions since the doctor is motivated to treat instead of heal, and billions of dollars are invested in figuring out how to sustain erections instead of preventing cancer. Hopefully the current economic situation will provide enough pressure to put an end to the ridiculous and unfounded belief that the market works for everything. Health care is no different than any other bit of infrastructure. You pay taxes and share risks for the benefit of the whole population.

          • by GNT (319794) on Monday March 02, 2009 @01:44AM (#27037057)

            What f'ing deregulation? YOU DO NOT HAVE A FREE MARKET IN HEALTHCARE. YOU HAVE the MOST regulated market short of universal useless healthcare.

            Understand this -- there's no moore law associated with healthcare. NOthing has f'ing changed in 20 years since I first practiced in any significant way.

            Cancer survival is measured in 5-year survival patterns and the approval process for a treatment runs up 15 years. Thank you FDA regs. Give me a break. You have no understanding whatsoever of economics in general and healthcare in particular.

            This is the end of the road of the inflation that started with Medicaid and Medicare in the 60's.

        • Re:Smart move (Score:5, Interesting)

          by FrankieBaby1986 (1035596) on Monday March 02, 2009 @01:32AM (#27036963)
          I thought insurance companies helped pay for regular checkups and the like because it helped prevent worse illnesses that would potentially be much more costly?
        • Re:Smart move (Score:4, Insightful)

          by evilviper (135110) on Monday March 02, 2009 @01:52AM (#27037101) Journal

          If you want to go see a doctor every year, pay for it. If you get run over by a truck, that's what insurance is for.

          Unfortunately, that is the current practice with health care, and we know what that leads to... Emergency rooms with 4 hour wait times....

          It's a bit like saying, if you want to change your oil every 6 months, you should pay for it, your warranty is only for when your car has mechanical problems.

          In both cases, if you skip the preventative step, you will end up having to go with the corrective step, which costs vastly, vastly more.

          I've often thought that the most inexpensive health insurance, would be the one that REQUIRES you to get a full annual check-up, and accept early preventative care for any conditions found, or else you forfeit your insurance coverage for anything that could have been found and corrected earlier, at much less expense.

          As an added bonus, more people would simply be healthier, live longer, and miss less work, all resulting in more money, for you (the health insurance provider).

        • Re:Smart move (Score:5, Insightful)

          by bluephone (200451) <grey.burntelectrons@org> on Monday March 02, 2009 @02:09AM (#27037197) Homepage Journal

          I don't to see how health care should be any different.

          Because I can live without $50 steaks and $100,000 cars. I for one would be dead without a simple medication. I had a medical emergency last year that is relatively simple to perform by a surgeon, took all of 45 minutes under the knife, but I'd have DIED without it. That's why it should be different.

        • Re:Smart move (Score:5, Insightful)

          by twostix (1277166) on Monday March 02, 2009 @02:22AM (#27037259)

          How strange,

          In your country if you're accused of a crime you consider it a natural right to have access to a free lawyer and access to free legal advice is enshrined in the highest law of the land. The spirit of socialism at its finest! But oddly there's no "socialism" conflict in that area, even from the "libertarians".

          But when it comes to the right to some basic level of healthcare, no go. If you're poor you and your children can suffer.

          It's an interesting paradox actually, because generally the poor commit more crime. So people are happy to fund legal representation for lower class criminals. But are definitely not happy to help fund a basic level of health care for themselves. Which is somewhat odd as the vast majority of people will be affected by health issues in their life, not criminal courts. And the costs associated with the two are about the same.

          A strange but interesting culture.

          (Yes I'm aware of the low quality of public defenders - due to a lack of funding more than anything. But it's better than nothing, just like public hospitals)

        • Re:Smart move (Score:5, Interesting)

          by dokebi (624663) on Monday March 02, 2009 @02:54AM (#27037411)

          You are seriously misinformed. There are two important things wrong with what you're saying.

          First, the cost of providing emergency care for accidents isn't something that can be reduced, period. What we can do to reduce health care cost is to increase participation in early detection and treatment of disease, which is *FAAAR* more effective (and cheaper) than treatment later on. It's like a city providing free needle exchanges, because that's are far cheaper than treating someone who contracts HIV or some other horrible disease.

          Of course, US health care doesn't run on logic, but rather puritan morals and vague capitalist ideology. The most effective way to prevent teen pregnancy, as determined empirically, is early sex education and free condoms, not home schooling and regular church attendance. But we can't use the most effective method.

          Secondly, health care is something that people need throughout their lives. As our population gets older, it's not "insurance" for accidents, but rather an on-going part of their care. Which means there is a continuous, fixed cost that must be paid to take care of someone. Therefore, an "insurance" scheme, where risk/profit is calculated to determine premiums doesn't really work. It's much better to spread the risk to the whole population, and have full benefits for everyone.

          The reason health care system in the US is so broken is because it's dominated by interest groups that want a continuous supply of "sick" but rich people. Think of the drug and insurance companies, the plastic surgeons and viagra peddlers. Nobody is really interested in the well-being of the people, and those who should--the citizens of this country--can only imagine a world they see in commercials made by drug and insurance companies. Sad indeed.

        • Re:Smart move (Score:4, Insightful)

          by Eivind (15695) <eivindorama@gmail.com> on Monday March 02, 2009 @04:40AM (#27037881) Homepage

          There's a difference between healthcare and car-ownership.

          If someone, trough bad-luck, bad-planning, silly-choices or other circumstances end up not owning a car, we as a society are generally willing to say: "So walk then, or take the bus."

          Not so if someone trough bad luck, bad planning, silly choices or other circumstances end up broke, uninsured and with cancer. We -don't- typically say; "so do without treatment, then."

  • by UltimApe (991552) on Sunday March 01, 2009 @11:34PM (#27035977)

    I bet next they give mandatory prostate exams to women too!

  • by popo (107611) on Sunday March 01, 2009 @11:39PM (#27036013) Homepage

    the assumption here is that wasteful procedures are due to the profit motives of physicians.

    anyone who knows anything about health-care will tell you that the primary cause of most non-cost-effective procedures is fear of legal consequences.

    want cheaper healthcare? reform the legal system and get the hmo's out of the game.

    • by db32 (862117) on Monday March 02, 2009 @12:07AM (#27036257) Journal
      This isn't entirely true, but it isn't exactly off the mark either. There are simply a stupid number of factors involved here that allow nonsense like this to happen. Insurance companies will frequently pull garbage like "we won't pay for X unless Y has already been done". So then doctors are forced into doing Y before doing X so that the patient doesn't get saddled with an insane bill. Also, before anyone here goes "well the doctor could just not charge" I will point out that these things are RARELY interelated. Doctors don't generally do any of the work themselves. You go to the family doctor for joint pain for example. He says go get an X-ray. Typically only specialists will have their own x-ray equipment (podiatrist/orthopedics/etc). So...either you get refered to a hospital or specialist and go get your x-ray. Bill #2 is now generated. So then that x-ray gets sent off to a radiologist who reads the x-ray into a dictation machine. Bill #3 is generated. Now, as an expense somewhere in bill #2 or #3 is going to be the cost of some transcriptionist group taking that dictation and typing it up. THEN! If you have to fix that joint surgically you go to a hospital...now you are paying an anesthesiologist (who is typically his own practice rather than a hospital employee), you are paying the hospital for your time in their OR and Recovery and supplies used, you are paying a surgeon (who may or may not be working for whoever did your x-rays). Now, at each stage of this process the insurance company gets to dictate terms of what will and won't be paid for. You are still dealing with the profit motivation of the various doctors in that chain (hey, not all of them are good docs, most are, but there are always assholes in every field) and you are dealing with the stupid lawsuits. People have managed to turn honest mistakes into malpractice which I think is fucking insane. Doctors should be held to high standards, but when you say they can't make a mistake without losing their ass the costs of healthcare goes through the f'ing roof. If they remove a lung when you were supposed to be getting a kidney removed...malpractice. If you come out with brain damage after a brain surgery...unless they were just running around with a blender in your head this is just one of the risks of having brain surgery....not fucking malpractice.

      All of this doesn't even begin to cover all of the lobbying that the insurance companies and pharma companies do to rig the game in their favor. Everyone bitches about these evil "socalists" trying to screw up medical services, but the real issue is that the die hard capitalists have already fucked it all the hell up in their favor and they are scared to death of losing the kickbacks. (Disclaimer: Go talk to someone in the military about that whole free government provided healthcare...you get what you pay for...)
  • by blahplusplus (757119) on Sunday March 01, 2009 @11:45PM (#27036071)

    ... as the title of this entry suggest. Not all doctors are created equal, and lets get this straight - all human beings, no matter how educated are very fallible and human.

    I had one young doctor think I should have my moles checked out that "looked cancerous" and another doctor whom I'm also freinds with that tells me "that doctor is full of shit". I also had my GP (general practitioner) suggest I had a part of my foot cut off after a series of infections after many an ingrown nail, needless to say I rejected his suggestion and did the work on the foot myself and still have everything all intact and normal as ever.

    Just because someone suggests something who is in a position of recognized credentialed authority, does not mean it is a license to take their judgments and advice without scrutiny and a grain of salt.

    Knowing how to do this and when is the hard part, but this is something that only people who've lived long enough and have the wherewithal to gain by experience - mankind is extremely fallible. Therefore critical skepticism must be employed when decisions can have significant consequences.

    It's easy for experts to suggest something to someone else when they don't have to bear the risk and consequences of going through with it.

  • I'm torn on this (Score:4, Insightful)

    by DesScorp (410532) <DesScorpNO@SPAMGmail.com> on Sunday March 01, 2009 @11:51PM (#27036125) Homepage Journal

    While I like the idea of reinforcing what works and discouraging what doesn't, the fact is, this is a federal study, and likely the well-intentioned results will be some government panel or body controlling what doctors can and cannot do, regardless of the patient's circumstances, all in the name of "science" and "efficiency". They may well make some things better. But they'll inevitably make more things worse.

    I want to aid in better treatments, but I can also easily see some overreaching federal agency micromanaging physicians. Sorry, but find me one federal agency that never tried to expand their power exponentially, often in the name of "the public good".

    • Re: (Score:3, Funny)

      by SecurityGuy (217807)

      find me one federal agency that never tried to expand their power exponentially, often in the name of "the public good".

      The IRS. At least, they don't claim it's for the public good. :P

    • The vast majority of procedures are highly constrained by insurance rules: either the government in the case of Medicare, or private industry in the case of various HMOs and insurance plans, have complex rules about what must be done in what order to get reimbursement. Doctors already have to follow that, so it'd at least be an improvement if those rules had some basis in scientific evidence indicating what treatments really are better.

    • Re: (Score:3, Informative)

      by TubeSteak (669689)

      While I like the idea of reinforcing what works and discouraging what doesn't, the fact is, this is a federal study, and likely the well-intentioned results will be some government panel or body controlling what doctors can and cannot do, regardless of the patient's circumstances, all in the name of "science" and "efficiency".

      I think you're confusing "federal studies" with "federally funded studies".
      The reality is that most trials are done by pharmaceutical companies and not impartial non-government organizations.

      You can call the status quo a success, if you want the winners to be big pharma's profit margin. Unfortunately, big pharma has one goal: to get the next blockbuster drug (or variation of a previous one) approved by the FDA. Personally, I can't help but observe that the 'free' market has obviously failed "we the people"

  • by macraig (621737) <(mark.a.craig) (at) (gmail.com)> on Sunday March 01, 2009 @11:54PM (#27036159)

    Why do you folks think Big Pharma is so successful? One of the prongs of their attack on medical knowledge (and ultimately research also) is mis-education and indoctrination of physicians themselves, through both subtle whispering in their ears as well as brute-force constant bombardment. The knowledge of physicians is pretty much under attack from the day they toss that cap in the air, if not sooner.

    BTW, I've heard from a family member who is a Kaiser HMO patient that Kaiser does not allow Big Pharma reps direct access to its staff phyicians, and instead funnels them to some sort of departmental liaison; if that's true, that is certainly one good thing that an HMO is doing.

  • by neoshmengi (466784) on Sunday March 01, 2009 @11:58PM (#27036183) Journal

    I practice evidence based medicine as much as possible. The trouble is that patients have a very hard time understanding it, let alone appreciating it.

    I don't give antibiotics for colds, but those patients often go see other doctors to get their antibiotics. When they get their inappropriate prescription, ironically I come across as a bad doctor for not prescribing it in the first place.

    When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it. Parents hate that.

    I have a cranky baby at home. My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work. They stared at me like I had three heads. After all, they tried it and it worked for them!

    People come in with back pain. My job is to rule out the dangerous causes, and once that's done give them some analgesia and tell them to weight a few weeks for it to improve. Any serious pathology will reveal itself over time if there are no red flags during the initial history and physical. Patients hate that. They want the xray. So they go to their chiropractor who orders a bunch of xrays (placebo 'tests' are very therapeutic to patients actually). "Well, your xray looks fine!"

    EBM is hard on the practitioners. The old school of medicine is to say, "This is what you have and this is what you need to do to fix it."

    Now we say, "It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?"
    Very dissatisfying to a lot of patients.

    Everyone wants all the scans and tests even when it doesn't make sense, because they all know the guy who was told that his problem wasn't serious and it turned out to be cancer etc.

    The previous party line was that all diabetics should be on aspirin to decrease their chances of having a heart attack. A recent study came out showing very little evidence for primary prevention of heart attacks with aspirin. What to do now? How to integrate every little bit of often conflicting evidence into clinical practice? It's very hard to stay up to date, let alone sift the wheat from the chaffe.

    EBM is the gold standard of how we should practice medicine. Yet it is immensely frustrating to put into actual practice.

  • by ducomputergeek (595742) on Monday March 02, 2009 @12:00AM (#27036203)

    http://www.amazon.com/Critical-What-About-Health-Care-Crisis/dp/0312383010/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1235966206&sr=8-1 [amazon.com]

    And modeled on the UK system where a review board develops a formula the determines if the cost-benefit is worth it or not.

    Sounds all good and all, but basically this is what HMO's try to do now.

    Only difference I can tell is that the government will be the ones telling you what treatments you can/cannot get instead of the HMO's.

    • by ColdWetDog (752185) * on Monday March 02, 2009 @02:06AM (#27037181) Homepage

      Sounds all good and all, but basically this is what HMO's try to do now.

      Not exactly. Insurance companies historically do not try to make the difficult judgment of how effective a particular procedure or test has to be, or whether one procedure is better than another. All they really want to do is to limit their costs. If they can find some supporting evidence that backs up not paying something, all the better. They are not set up to be, and cannot ever hope to be, "honest brokers". They go to great pains not to publish their results and schedules.

      Obviously, the next question is whether or not a governmental entity can be open enough so the public and the medical community can feel that the guidelines they put out are believable. You can, however, craft it so that the decision trees and supporting data are open to public scrutiny. You will still have people rending garments and wailing over specific cutoffs and decisions - it will never be a cut and dry activity. However, you cannot leave it to any for profit entity. The temptation to cheat is simply too large.

  • Misleading Title (Score:5, Insightful)

    by LightPhoenix7 (1070028) on Monday March 02, 2009 @12:11AM (#27036297)
    While I understand the need to have a catchy title, it's grossly mis-representative of the problem. Doctors don't hate science - doctors hate the misapplication of science and the failure to apply common sense. Hence, pap smears for patients without a cervix.
    • by Daniel Dvorkin (106857) * on Monday March 02, 2009 @02:48AM (#27037377) Homepage Journal

      Did you RTFA? The whole point is that many physicians are doing things, such as pap smears for women without cervixes, which are contrary to both science and common sense -- and they react badly when informed that what they're doing is unscientific and nonensical. "Hate science" may be a bit strong, but there's no question that a lot of physicians don't care much for it when it interferes with their preconceived notions.

  • I figure I might as well throw in my two cents:

    Last summer, I hurt one of my shoulders bad. It was somehow dislocated before it slipped back into place. I'm well aware that this does a good job fucking up the joint. For the first week, it was a dull ache that got acute when I moved my right side at all. I couldn't swing my arm backwards past straight out, to say nothing of doing any pushups. It's been about 4 months now and I can finally just about lay down on my back arms-straight-up without any nagging pain.

    We can't afford health insurance so I never even considered seeing a doctor. Why risk getting raped for half a semester's tuition just so they can either say "you'll get better" or recommend more things we can't afford?

    Now go ahead, tell me it's my fault for not working hard enough to have insurance or that I'd have to wait in line in England. At least there someone will eventually take a look at it.
    • by PCM2 (4486) on Monday March 02, 2009 @02:30AM (#27037297) Homepage

      Where are you getting this "half a semester's tuition" figure? A visit to a doctor's office doesn't cost any more than a visit to a hair stylist, and it takes a lot less time. You can fill a prescription for three months' worth of painkillers at Wal-Mart for $10.

      I honestly don't get it. If your car got a bad flat you'd buy a new tire. You'd tell yourself "I have no choice." But when it's your own body that breaks down, instead of paying to get it repaired, you'd rather complain about it and act like you're a hero for enduring the injury. As a result, you'll probably end up with advanced arthritis at a young age and you'll never regain full physical function. Way to go.

  • by aswang (92825) <aswang@@@fatoprofugus...net> on Monday March 02, 2009 @12:43AM (#27036579) Homepage
    1. Private insurance will not pay for a woman's well visit if they don't have a Pap smear. They don't care that the woman doesn't have a cervix. If you don't do it, you don't get paid, and it's just easier to do it no matter how nonsensical it is than it is to get on the phone with someone who is not medically trained and argue that, yes, you did do a well woman exam even though you didn't do a Pap smear.

    2. There is a case to be made for anal Pap smears, because HSV also causes anorectal cancer in people who participate in anal sex. Unfortunately, because it's not standard of care, private insurance won't pay for that either. (We don't even need to talk about Medicare or Medicaid because they don't pay for preventative visits.)
  • If you want my opinion, the article sounded suspiciously like insurance company propaganda. The doctor is the one person in the equation who basically has the same vested interest the patient has -- keeping the patient alive.

    The cost effectiveness arguments she makes are bunk. E.g., if the old line drugs for schizophrenia are so great, why haven't they worked? And why is dehydrating someone the best way of treating high blood pressure? Give me a break.

    Politicians may hate science, and certainly the health insurance companies hate science, and both like to think in terms of cost effectiveness, unless of course it's their own health that's at stake, in which case they want the best "science" available. And maybe some journalists hate science if they've absorbed enough behind the scenes insurance lobby propaganda.

    But of all the groups mentioned in the article, it is the doctors who hate science least, and who are most about trying to find the right answer, the right answer meaning the one that is best for the patient's health, as opposed to the insurance company's bank account.

    (And in case you're wondering, I'm not a doctor, and have never even had any relative or personal friend who is a doctor; but I do remember my first doctor, who had, under a large glass dome, a giant gold microscope, which occupied the central place of honor in his office... a clear homage to his love and reverence for Science. And in practice he cared for the lives of his patients as though they were his own. And I guess they were.).
  • EBM vs. the Art (Score:5, Insightful)

    by Stickerboy (61554) on Monday March 02, 2009 @12:57AM (#27036695) Homepage

    If practicing medicine consisted of a video game or a board test, then yes, doctors could suspend their own judgement in favor of strict evidence-based medicine. Unfortunately, this is the Real World, and doctors frequently have to approach EBM with a healthy dose of skepticism.

    The problem with EBM is threefold: the evidence record is necessarily incomplete; many real-world patients have very little in common to patients that make it through selection criteria into randomized clinical trials (RCTs); it is very easy to skew studies in minute ways through endpoints, study design, and a thousand other ways that are difficult for busy practicing physicians to catch.

    Want some examples? A recent multicenter study (in worldwide sites) of blood pressure medications funded by the maker of Lotrel found that their combination ACE inhibitor/calcium channel antagonist (CCA) had slightly better morbidity/mortality outcomes over a given period of time than patients who were placed on a combination of the ACE inhibitor and a thiazide diuretic, with similar reductions in blood pressure. The data is fantastic, and the outcomes are probably real. But when you check closely into the outcomes criteria, one of the "bad" endpoints is "hospitalization for unstable angina" (new or worsening chest pain). One of the indications that CCAs have that diuretics do not is the treatment of angina. CCAs, through the mechanisms of its action, can prevent anginal episodes or make them better. A thiazide diuretic will not treat angina directly. Out of the room of ~20 doctors this study was being presented to, apparently I was the only one who thought of this. And since many of the patients involved in the study had prior cardiac history with ostensible angina, it made perfect sense why CCAs would perform better for these patients. But this study is not being billed as that - the study is being presented as evidence of the possible superiority of using one drug over another in the general population with high blood pressure.

    And then there's the Nexium/Prilosec fiasco. Nexium was developed by the makers of Prilosec when patent protection for Prilosec began running out. (You can buy generic Prilosec (omeprazole) over the counter.) Nexium (ESomeprazole [emphasis mine]) is filtered Prilosec - the biologically active enantiomer of Prilosec's racemic mixture. Nexium is on average six times more expensive, mg for mg, than generic omeprazole. The only study I know of (and that is certainly being quoted in wide circulation) comparing the effectiveness of the two was funded by the makers of Prilosec and Nexium, comparing healing rates of acid-reflux esophagitis with "typical" doses of Prilosec and Nexium. Nexium outperformed Prilosec in healing the worst grades of esophagitis - grades C and D. The "typical" doses used were 20 mg of Prilosec and 40 mg of Nexium. As this is the evidence out there, many doctors consider Nexium to be a "stronger" or "better" acid suppressor than Prilosec. I'll let the reader make the logical conclusions.

    And let's talk about "typical" patients and the dearth of them in the evidence record. On an inpatient service today, I saw a "typical" patient hospitalized for a hypertensive emergency. He was a type 2 diabetic (DM)(uncontrolled) who came in with a blood pressure of 180s/120s. He has diastolic congestive heart failure (CHF) from his long-term uncontrolled hypertension (HTN). He also has chronic kidney disease probably due to a combination of his smoking, his DM, and his HTN. He also has an exacerbation of his bad chronic obstructive pulmonary disease (COPD) from his smoking. Now the evidence suggests that I place him on a beta-blocker to treat his HTN and his CHF concurrently. But beta-blockers are relatively contraindicated in acute exacerbations of COPD. The evidence suggests that I place him on an ACE inhibitor to treat his DM and HTN, but that would decrease his kidney function, and he's already at the tipping point of needing dialysis so

  • by Secret Rabbit (914973) on Monday March 02, 2009 @04:03AM (#27037733) Journal

    Yes, we all know that (arguably) most docs don't keep up with the literature. Or they choose a treatment and stick with that because it worked the best at one point and they like it because they trust it. Problem is, that research is ongoing and new things are found all the time. In fact, on one of my clicking adventures on-line, I found out that Lithium Carbonate was being used to treat refractory depression (as an adjunct), OCD, cluster headaches and even ALS (the one that Stephen Hawkins has) to name a few. All that in *low* doses. Yet, most docs still consider this a horrid drug refusing to realise that in low doses Lithium Carbonate does _not_ require close monitoring.

    So, this sort of study could be very beneficial.

    HOWEVER, it's things like this that HMO's really *really* like. They'll probably use it to force doctors into treatments that are cheaper alternatives regardless of that particular patient. Because, as with many things, certain disorders, etc, have different drugs to treat them. Different drugs for different sets of symptoms, different severity of symptoms, etc, etc, etc. So, patients will likely get cheated out of drugs that would be more effective for them simply because there HMO won't pay for the one that is best for them and the one that is best for them isn't in there price range. Especially, for the more complicated disorders.

    And what happens when next week happens and this changes. How often is this list going to be updated? How often are the HMO's going to be updating from the research?

    Quite frankly, while I fully believe that this thing is undertaken with the best of intentions, it is ripe for abuse. In the end, it is my opinion, that it'll likely lead to more harm than good.

  • A few facts first:
    1) Pap smears still make sense in women after a hysterectomy. It is then called a vaginal vault smear. It is meaningful at the very least in women who had abnormal smears prior to hysterectomy, because abnormal cells can have spread to the surrounding vaginal wall

    2) Some surgeons leave a stump of the cervix behind when they perform a subtotal hysterectomy. Not common practice any more, but used to be very common in many countries and can have some advantages for the stability of the pelvic floor. Not all women who had a hysterectomy know whether they still have a cervix stump or not.

    3) When the hysterectomy was performed for malignancy, eg cancer of the uterus, the vaginal vault smear can be useful to detect early recurrence

    Hence. some women may not need pap smears after a total hysterectomy - but in many women this is still a meaningful and cost effective procedure - which is why even public health systems are still happy to pay for them.

    The article does not seem to take this properly into account - because most scientists have only a very limited insight into medical problems. I should know - I did a science degree first before becoming a MD.

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