Correspondence

Geriatrics and the Limits of Medicine

N Engl J Med 1999; 341:768-769September 2, 1999

Article

To the Editor:

In his Sounding Board article (April 22 issue),1 Goodwin wrote, “Modern medicine does not work well for old people.” Goodwin acknowledges that preventing diseases may be desirable but assails the treatment of “proto-illnesses,” such as hypertension, osteoporosis, high cholesterol levels, aortic aneurysm, colonic polyps, and carotid-artery stenosis, which “do not cause symptoms and produce no suffering.” Is there a better way of providing relief from suffering than by preventing it? To view humane care of patients and scientific medicine as opposites is dangerous to good health. Care and cure are not mutually exclusive.

Too many geriatricians see themselves as protecting the elderly from modern medicine. In reality, older adults suffer from too little, not too much, modern medicine. Modern medicine relies on scientific study to determine which interventions benefit more people than they harm. A major problem is the application to the elderly of interventions tested only in younger populations. Past clinical studies have included too few older subjects. To remedy this shortcoming, more elderly people should be included in clinical trials. Goodwin believes that radical prostate surgery offers no proven benefit to many elderly men. He blames over-testing for prostate-specific antigen instead of the use of an inappropriate intervention.

Goodwin confuses the messenger and the message. He concludes that most older men, like the proverbial ostrich, would prefer to live “happily without knowing they had cancer [of the prostate].” The failures of geriatric care are rooted in too little, not too much, basic medical knowledge.

Marc E. Weksler, M.D.
Weill Medical College of Cornell University, New York, NY 10021

1 References

1. 1

   Goodwin JS. Geriatrics and the limits of modern medicine. N Engl J Med 1999;340:1283-1285
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Goodwin replies:

To the Editor: I thank Dr. Weksler for his thoughtful comments. Dr. Weksler appears to be equating science and “modern medicine.” I see science and medicine as being very different from one another. My criticisms concerned the current practice of medicine. A physician is a practitioner, not a scientist. Much of the knowledge base available to physicians comes from scientific investigation. Science provides information about the average behavior of groups — groups of molecules or kidneys or human beings. The practicing physician can use that information in making decisions about the care of individual patients.

As Dr. Weksler notes, medical practitioners should be highly motivated to prevent illness in their patients with actions based mostly on the results of scientific investigations. For example, there is no evidence from randomized, controlled trials that any treatment for local prostate cancer is better than no treatment at all, and there are valid scientific reasons for believing that any treatment of local prostate cancer in men 70 years of age or older might cause more harm than good. Thus, practicing physicians wishing to prevent disease in older men would tend to avoid prostate-specific–antigen testing.

In addition to knowledge of scientific investigation, there are also stores of personal, professional, and cultural wisdom that affect our decision making. Take, for example, an 82-year-old man obsessed with worries about prostate cancer. A wise medical practitioner might well order a prostate-specific–antigen test in the hope that a normal result might allay the patient's anxiety. That decision would not be based on science, and it seems dismissive to call it “art.” It is based on knowledge from sources other than randomized, controlled trials.

I enthusiastically support further scientific investigation with respect to aging. Such investigation will doubtless result in better treatments, better preventive measures, and better health for older patients. This enthusiastic support is not inconsistent with my misgivings regarding modern medicine.

Much of modern medicine seems based not on science but on scientism, a belief system in which the trappings of science — the machines, the digital readouts, the P values — acquire a legitimacy independent of their utility in addressing the actual problems at hand. Scientific dogma can be invoked to justify either undertreatment or overtreatment. Wise, responsive clinical care is something else again.

James S. Goodwin, M.D.
University of Texas Medical Branch, Galveston, TX 77555-0460