Overkill - an article in the New Yorker

[Rosie]

An excellent article in the May 11 issue of the New Yorker:

America's Epidemic of Unnecessary Care

Overkill
An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?
By Atul Gawande


Some snippets -- they don't do justice to the full article, but it's a start:

[...]

The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.

The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

[...]

One major problem is what economists call information asymmetry. In 1963, Kenneth Arrow, who went on to win the Nobel Prize in Economics, demonstrated the severe disadvantages that buyers have when they know less about a good than the seller does. His prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.

[...]

Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body. It has been hard for patients and doctors to recognize that tests and scans can be harmful. Why not take a look and see if anything is abnormal? People are discovering why not.

In his later years, my FIL *demanded* every possible test and procedure available so that he could "get better" -- this was an 80+ y.o. man whose body was failing, plain and simple. I suspect often times medical practitioners would prescribe medications or conduct tests in order to cover their a**es (or, to shut him up -- he was high-ranking military and could throw his considerable weight around). The FIL would shrug off the cost, blithely saying "Uncle will pay for it" (he had Medicare plus Tricare for Life). FIL was probably just one of scores of people demanding every means available to somehow reverse the ravages of time on the body. Sad, wasteful, and frustrating.

 

[calmloki]

Not that I disagree with the article or your view of your FIL, but recognizing something in the large or for the masses kind of goes by the wayside when it is your existence that is on the line. All of a sudden any suggestion or test offered that might be of benefit or gain another few days becomes worthwhile.

Watched the movie Dallas Buyer's Club the other night and was struck by clinical tests - 1/2 get a placebo, 1/2 get something that may be a life saver. Proper testing requires that 1/2 may die. Good science, but if you are in the dying group aren't you liable to say screw science - I want to explore anything that may keep me alive.

 

[athena53]

What a great article. Usually I don't have time to read articles of the length the New Yorker typically publishes- but hey, I'm retired! I hope that the proliferation of high-deductible plans makes more people think and research before they agree to expensive tests and procedures. First, of course, we have to know what the potential costs are, all-in, and that's very hard to get.


ETA: the stories of the fainting episodes reminded me of one I had in London. I'd gotten in from Bangalore the day before, having run a teleconference at 10 PM and then taken a flight out at something like 2 or 3 AM. On the way from the airport I'd stopped at a favorite store in London and bought 6 bottles of superb scotch whisky because it was Saturday and they were closed on Sunday and I was heading for the office on Monday. I dragged my luggage and purchases to the hotel on public transportation which left me totally exhausted.

Sunday AM I got up and headed out for some sightseeing. I realized as I stood in the subway car I HAD to sit or I was going to collapse. Fortunately, I found a seat. I got off the car, dragged my rear across to get the subway back to the hotel, and spent the day in bed with the London Times. Monday morning I was my usual cheery self.

My biggest fear was fainting and ending up with a ton of medical costs (not sure how the National Health Service would apply since I'm American). I was in my 50s, grey-haired and clearly a candidate for all kinds of tests to make certain it wasn't a cardiac problem. I was much better off in bed with the Times and a cup of tea.

 

[Meadbh]

Watched the movie Dallas Buyer's Club the other night and was struck by clinical tests - 1/2 get a placebo, 1/2 get something that may be a life saver. Proper testing requires that 1/2 may die. Good science, but if you are in the dying group aren't you liable to say screw science - I want to explore anything that may keep me alive.

Without using scientific methods, medicine would be no better than conjecture.

 

[Bestwifeever]

We can usually choose what level of medical care we want regardless of what everyone else is receiving. The cost shouldn't be the deciding factor.

 

[haha]

Actually head to head treatment comparisons are halted all the time, if it begins to appear that one arm is getting much better results than the other.

Also, no treatment is 100% better such that all the untreated ones die, and all the treated ones survive.

Ha

 

[Meadbh]

We can usually choose what level of medical care we want regardless of what everyone else is receiving. The cost shouldn't be the deciding factor.

Perhaps that might make sense if you are paying for it yourself in a consumer driven market. Want your fourth liver transplant while continuing to drink large quantities of alcohol? Sure. Just find donors, train and hire staff and build hospitals to meet that demand, and pay for it. Money makes the world go around.

However, in any situation where healthcare is regarded as a public good, cost must enter the equation. Taxpayers want value for their money.

 

[calmloki]

Without using scientific methods, medicine would be no better than conjecture.

Totally agree, but again, for the patient, the hope of survival may trump desire to further science for the benefit of others.

I'm currently taking a drug that has a list of side effects that is chilling - and they aren't phrased as "may cause" but as "do cause". OTOH, the guy in the white coat suggests it is proper care and the other option is not desired. He is being paid to know better than I; I'm following instructions. My life though, and while the doctor has an interest it is the patient who may be betting all their chips.

 

[Meadbh]

Totally agree, but again, for the patient, the hope of survival may trump desire to further science for the benefit of others.

I'm currently taking a drug that has a list of side effects that is chilling - and they aren't phrased as "may cause" but as "do cause". OTOH, the guy in the white coat suggests it is proper care and the other option is not desired. He is being paid to know better than I; I'm following instructions. My life though, and while the doctor has an interest it is the patient who may be betting all their chips.

That sounds like amiodarone....

With your history, that is a perfectly rational choice.

 

[MooreBonds]

Not that I disagree with the article or your view of your FIL, but recognizing something in the large or for the masses kind of goes by the wayside when it is your existence that is on the line. All of a sudden any suggestion or test offered that might be of benefit or gain another few days becomes worthwhile.

Your sentiments are true - but in more ways than one.

Imagine being 1 of 12 of your peers on a jury for a medical malpractice case. You hear that a doctor DOESN'T order a _______ test (pick any ol' test). Patient subsequently has health issues directly because said test wasn't ordered and administered, which would have caught this. Patient then dies within 3 days.

If you are a doctor, are you going to put your personal reputation, assets, and future liability insurability on the line for not ordering just 1 test? Let alone 20? or 50? or 100? Even if ordering that test every time "only" benefits 1 out of 100 patients, all it takes is just 1 test to go unadministered and failing to find something to tempt a lawsuit.

Granted, I do agree that some tests may not have much or ANY value (like the article gives an example of an mRI for lower back pain)...how we approach that topic is one thing, but how you handle and address "marginal" tests for EVERYONE, in the hope that a sizable minority of them are helped by the tests is a tough call.

In the 60s/70s, you didn't have the spectre of malpractice lawsuits like you did today, and you didn't have the advances in medicine that you do today. The combination of the two is a very powerful force of inertia to continue proscribing a variety of tests for possible diagnosis.

 

[Meadbh]

The U.S. is well known for "defensive medicine".

What about the situation where the patient dies or is injured because of an unnecessary test?

 

[haha]

like every other "can't go on" spending folly this will go on and likely get worse until diabetes, Alzheimer's, and illnesses related to obesity and poor lifestyle choices will force a painful re-appraisal. Until then, Docs and corporate health providers will go on getting rich, and more nails will be driven in the coffin of the US economy. Nothing is addressed until it absolutely cannot be avoided any longer. Sometime, this will no longer work out "ok".

Ha

 

[Fermion]

Actually head to head treatment comparisons are halted all the time, if it begins to appear that one arm is getting much better results than the other.

And if the treatment arm is the one getting the much better results, you got yourself a 10 bagger stock (if a small biotech).

 

[calmloki]

Yup, and thanks Meadbh. Still hoping to drop it in three months. Great hopes for the efficacy of the RF ablation I had about a month ago for the Afib that developed. Just a bad case of hummingbird heart here!

 

[NW-Bound]

... In his later years, my FIL *demanded* every possible test and procedure available so that he could "get better" -- this was an 80+ y.o. man whose body was failing, plain and simple. I suspect often times medical practitioners would prescribe medications or conduct tests in order to cover their a**es (or, to shut him up -- he was high-ranking military and could throw his considerable weight around). The FIL would shrug off the cost, blithely saying "Uncle will pay for it" (he had Medicare plus Tricare for Life). FIL was probably just one of scores of people demanding every means available to somehow reverse the ravages of time on the body. Sad, wasteful, and frustrating.

My own mother now in her 80s is the same. Once, she said she was going to request a scan or MRI of her head because she had headaches; she wanted to be sure it was not brain cancer. There were also other benign maladies that she went to specialists for. I often have to remind her that doctors are not god, and if she would be willing to go through procedures or take medications that have dubious results for symptoms that often merely come from old age.

Not that I disagree with the article or your view of your FIL, but recognizing something in the large or for the masses kind of goes by the wayside when it is your existence that is on the line. All of a sudden any suggestion or test offered that might be of benefit or gain another few days becomes worthwhile.

Watched the movie Dallas Buyer's Club the other night and was struck by clinical tests - 1/2 get a placebo, 1/2 get something that may be a life saver. Proper testing requires that 1/2 may die. Good science, but if you are in the dying group aren't you liable to say screw science - I want to explore anything that may keep me alive.

Agree. It's just human nature.

Perhaps that might make sense if you are paying for it yourself in a consumer driven market. Want your fourth liver transplant while continuing to drink large quantities of alcohol? Sure. Just find donors, train and hire staff and build hospitals to meet that demand, and pay for it. Money makes the world go around.

However, in any situation where healthcare is regarded as a public good, cost must enter the equation. Taxpayers want value for their money.

Totally agree too. A person is entitled to spend his/her money as seen fit, or to buy expensive insurance supplement. But social medicine has to be rationed. There's no other way.

 

[Meadbh]

Yup, and thanks Meadbh. Still hoping to drop it in three months. Great hopes for the efficacy of the RF ablation I had about a month ago for the Afib that developed. Just a bad case of hummingbird heart here!

I hope you and your heart can get along for many more years, calmloki.

Way back in the early 1980s I looked after a little girl who kept going into Ventricular Fibrillation (the most dangerous arrhythmia there is). Amiodarone was experimental at the time. It saved her life.

 

[Bestwifeever]

Perhaps that might make sense if you are paying for it yourself in a consumer driven market. Want your fourth liver transplant while continuing to drink large quantities of alcohol? Sure. Just find donors, train and hire staff and build hospitals to meet that demand, and pay for it. Money makes the world go around.

However, in any situation where healthcare is regarded as a public good, cost must enter the equation. Taxpayers want value for their money.

I didn't word my post very well--I meant we can choose as little treatment as we want (e.g., no chemo/surgery/radiation for a bleak diagnosis). Even if it were "free," which is why I took cost out of it. I think we all know people who let nature take its course. So articles that talk about what "Everyone does" don't have to apply to us as individuals.

 

[ERhoosier]

Not that I disagree with the article or your view of your FIL, but recognizing something in the large or for the masses kind of goes by the wayside when it is your existence that is on the line. All of a sudden any suggestion or test offered that might be of benefit or gain another few days becomes worthwhile.

Watched the movie Dallas Buyer's Club the other night and was struck by clinical tests - 1/2 get a placebo, 1/2 get something that may be a life saver. Proper testing requires that 1/2 may die. Good science, but if you are in the dying group aren't you liable to say screw science - I want to explore anything that may keep me alive.

Original article really has nothing to do with DBC or being a test subject.
The science is already pretty clear that for many problems MORE testing/care results in WORSE outcomes. Treatment/testing can be WORSE than the disease. Too many folks (and their docs!) just don't get this.
But then, false hope has been the enemy of best medical practice for millennia.

As Hippocrates said........First, DO NO HARM.

 

[Meadbh]

Original article really has nothing to do with DBC or being a test subject.
The science is already pretty clear that for many problems MORE testing/care results in WORSE outcomes. Treatment/testing can be WORSE than the disease. Too many folks (and their docs!) just don't get this.
But then, false hope has been the enemy of best medical practice for millennia.

As Hippocrates said........First, DO NO HARM.

+1000

 

[6miths]

Atul Gawande is a gifted author. I started with 'Being Mortal' and now working my way up the list having just read 'Complications' and 'Better'. Have the audiobook of 'The Checklist Manifesto' next. These should be required reading for all MDs.

'First do no harm...' Too often forgotten.

 

[NW-Bound]

I have read all 3 books by Atul Gawande. I believe doctors already know the limitations of modern medicine and their profession. But when faced with malpractice suits or patient's complaints, they often take the easy way out, and I do not blame them. It's the patients or the public that needs to educate themselves.

PS. A while back, a poster started a thread about how "Doctors die differently". Doctors are human and get the same illness we do, but they know not to pursue uncertain treatments with slim hope when they have to make the choice for themselves.

 

[6miths]

Most doctors learn early in their training that there are things much worse than death.