We continued to discuss some other issues including the potential benefit of Vitamin D supplementation, maintaining a healthy weight and exercise regimen along with some other screening tests for various health conditions. Then it came out that she was paying for an alternative “cleansing” therapy that involved soaking in a liquid that changed colour as more “toxins” were “leached” from her feet.

She was convinced that this “detoxification” was helpful for her overall health and well-being and that it had positive effect on how she felt and on her energy. To be honest with her, I mentioned my scepticism and described the various methods the body uses to eliminate waste products and toxins, but the feet were not one of them. I explained that there was no scientific literature that I could direct her to that would prove she was spending her money wisely.

She asked: Why then, did the water change colour when she soaked her feet? To her this meant that some active, beneficial process was taking place. Since other people soaking their feet had the water turn a different colour, she perceived that they must eliminating different toxins. The visible colour was enough to convince her that something substantial was happening.

We discussed the possibility that a change in pH may have been changing the colour of the water. Different people may harbour different bacteria that could affect the pH of the water and perhaps something had been added to the water to change it different colours for the various clients depending on the pH.

In any case, I doubted very much that she was receiving any actual physical benefit from the process. I had no evidence of what toxin was being removed or how this would be accomplished or what benefit to her health could be expected. We ended the discussion with her insistence that I should try this myself and with me suggesting that placebo effect is quite common.

If she wanted to spend her money on this kind of “care” because it made her feel good then so be it, just as long as there was no substantial risk to her health, possibly only to her pocket book.

In this patient’s case, the preventative measure of accurately diagnosing the breast lump as benign or malignant has a substantial impact on the patient’s health and productivity. Failure to screen the breast lump adequately could have resulted in a poor outcome and many years of a productive life being lost. However, the same cannot be said of the “detoxifying” foot bath treatment. And yet the patient wanted to persist spending her money on this because she felt it had some value for her. Did it actually prevent disease or save future medical expenses covered by tax payers or herself: Probably not.

The whole point of this vignette is to highlight the difficulties surrounding the perception of preventative care at an individual level and as an overall cost savings endeavour.

In a recent New England Journal of Medicine article from February 14, 2008, “Does Preventative Care Save Money? Health Economics and the Presidential Candidates", by Joshua T. Cohen, Ph.D., Peter J. Neumann, Sc.D., and Milton C. Weinstein, Ph.D., the authors consider the popular component of the various presidential candidates’ platforms which focus on prevention to decrease spiralling health care costs in the US.

They write:

“The first element in Hillary Clinton’s plan is to “focus on prevention: wellness not sickness.” John Edwards has stated that “study after study shows that primary and preventative care greatly reduces future health care costs, as well as increasing patients’ health”. Mike Huckabee has said that a focus on prevention “would save countless lives, pain and suffering by the victims of chronic conditions, and billions of dollars.” Barack Obama has argued that “too little is spent on prevention and public health.”

Indeed, some evidence does suggest that there are opportunities to save money and improve health through prevention. Preventable causes of death, such as tobacco smoking, poor diet and physical inactivity, and misuse of alcohol have been estimated to be responsible for 900,000 deaths annually-nearly 40% of total yearly mortality in the US. Moreover, some of the measures identified by the U.S. Preventative Services Task Force, such as counselling adults to quit smoking, screening for colorectal cancer, and providing influenza vaccination, reduce mortality either at low cost or at a cost savings.”

However, they go on to say that sweeping statements about the cost-saving potential of prevention are overreaching. Preventing illness can in some cases save money, but in other cases it can add to health care costs. The vast majority of preventative measures reviewed in the health economics literature did not save money according to this report.

They conclude that, “In the face of increasingly constrained resources, there is a realistic way of achieving better health results: conduct careful analysis to identify evidence-based opportunities for more efficient delivery of health care—whether prevention or treatment—and then restructure the system to create incentives that encourage the appropriate delivery of efficient interventions.”

We should be careful how we spend our finite health care resources in Canada too. But should my patient, who seems to find individual benefit in spending on unproven preventative modalities, be stopped from doing so? If not, then should she be able to spend on proven preventative modalities even if they are not shown to be cost-effective for a government funded system but are still seen as beneficial and cost-effective to her? I think the answer is “yes”.