Thursday, May 7, 2015


We all agree that it’s possible to have too much of a good thing. Do we also agree that it’s possible to have too much medical care?

America spends much more than any other country on medical care, but, strangely, the extra expense does not produce notably better results.

So says Dr. Atul Gawande. He argues the point in a long and detailed New Yorker essay.

He places the blame on greedy physicians, misinformed consumers and a system that doles out rewards for the number of procedures, not the quality of the results.

In his words:

The forces that have led to a global epidemic of overtesting, overdiagnosis, and overtreatment are easy to grasp. Doctors get paid for doing more, not less. We’re more afraid of doing too little than of doing too much. And patients often feel the same way. They’re likely to be grateful for the extra test done in the name of “being thorough”—and then for the procedure to address what’s found.

Strangely, Gawande has nothing to say about the influence of malpractice lawsuits. The omission is striking. We suspect that a physician is more likely to be sued for having stinted on treatment than for having overtreated his patient.

A patient who feels that he is being deprived of treatment is more likely to sue than a patient who receives too much treatment.

When it doesn’t cost the patient anything, he is also likely to insist on the procedure or the test. After all, what harm can come from one more blood test or MRI.

Americans believe that they have a constitutional right to medical treatment and they consume it happily, regardless of whether it makes them appreciably better.

Gawande also omits all mention of mental health treatment. Psychiatry is not his bailiwick, so he cannot judge from his personal experience whether psychoactive medication is overprescribed or whether patients too often mistake everyday mental anguish for mental illness.

Be that as it may, all physicians face the challenge of finding a mean between too much and not enough.

Gawande explains that overtesting and overtreatment are pervasive and very expensive problems:

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

The United States is a country of three hundred million people who annually undergo around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests. Often, these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little nodule that can’t be completely explained, a lab result that is a bit off, a heart tracing that doesn’t look quite right.

As testing becomes more thorough, physicians are more likely to find something that is not quite normal. But, does that mean that they should always intervene to solve the problem? What if the problem is not likely to pose any real danger and if the procedure comports definite risks?

Gawande continues:

Excessive testing is a problem for a number of reasons. For one thing, some diagnostic studies are harmful in themselves—we’re doing so many CT scans and other forms of imaging that rely on radiation that they are believed to be increasing the population’s cancer rates. These direct risks are often greater than we account for.

And also:

Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.

He continues:

H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on overdiagnosis, and in his excellent new book, “Less Medicine, More Health,” he explains the phenomenon this way: we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference.

Not all cancerous tumors are dangerous:

A recent review concludes that, depending on the organ involved, anywhere from fifteen to seventy-five per cent of cancers found are indolent tumors—turtles—that have stopped growing or are growing too slowly to be life-threatening. Cervical and colon cancers are rarely indolent; screening and early treatment have been associated with a notable reduction in deaths from those cancers. Prostate and breast cancers are more like thyroid cancers. Imaging tends to uncover a substantial reservoir of indolent disease and relatively few rabbit-like cancers that are life-threatening but treatable.

Some of the problem derives from the fact that physicians are in the business of managing their patients’ anxiety. Many patients feel a measure of relief for having undergone a procedure, regardless of its medical effectiveness. This is true, Gawande notes, even when there are unforeseen complications. They are happy to know that someone cares about their lives and their health. Besides, they believe that it costs them nothing:

Waste is not just consuming a third of health-care spending; it’s costing people’s lives. As long as a more thoughtful, more measured style of medicine keeps improving outcomes, change should be easy to cheer for. Still, when it’s your turn to sit across from a doctor, in the white glare of a clinic, with your back aching, or your head throbbing, or a scan showing some small possible abnormality, what are you going to fear more—the prospect of doing too little or of doing too much?

Unfortunately, the medical system has helped to produce the anxiety.

All the same, she thanked me profusely for relieving her anxiety. I couldn’t help reflect on how that anxiety had been created. The medical system had done what it so often does: performed tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk. Meanwhile, we avoid taking adequate care of the biggest problems that people face—problems like diabetes, high blood pressure, or any number of less technologically intensive conditions. An entire health-care system has been devoted to this game.

Yet, if physicians themselves are anxious about being sued for malpractice or if they need to generate more income to pay their malpractice premiums, perhaps they are communicating that anxiety to their patients.


Sam L. said...

I'm seeing this as a superregenerative circuit--a positive feedback is sent to the circuit, resulting in amplification, and on, and on, and on. No way to damp it out.

Larry Sheldon said...

Sorry--I cannot join you in blaming the doctors.

There are three culprits. You, me, and the lawyers, all driving a frenzy of defensive medicine.