By Lambert Strether of Corrente.
Over the past, oh, decade or so I’ve been so consumed with the battle to get everybody into the heatlh care system — “Everybody in, nobody out,” as Quentin Young puts it — that I haven’t put much energy into thinking about the heatlh care itself. After all, just because a house is energy inefficient doesn’t mean that it’s OK to leave people out in the cold. Now that single payer is no longer “never, ever,” but a program that could actually be achieved with (an enormous) level of effort, KHN’s new series, “Treatment Overkill,” which starts with Liz Szabo’s “So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients’ Ills,” provides me with a change to broaden my scope a bit, with a survey post like this one.
So I’m going to look at two issues: (1) Is overtreatment a real problem? and (2) What are the causes of overtreatment? Spoilers: Yes, and it’s complicated.
Confession time: I’m the sort of person who doesn’t get the idea of deductibles at all; I can’t understand why anyone would seek out medical treatment unless they were absolutely sure they needed it. And the reason I fear the heatlh care system is, in fact, the prospect (painful) overtreatment; the dental clinic that was going to give me full anesthesia to remove a wisdom tooth; or my nightmare of “end of life care” hooked up to a machine in a nursing home in a room with a television I can’t turn off.
Overtreatment Is Real Problem
Evidence for overtreatment[1] falls into two categories: Anecdotes, and studies and surveys. I’ll look at anecdotes first.
“Anecdotes” isn’t really a fair word, though; most of the stories are more about entire vertical markets (for example, stents, as we shall see). Szabo starts out with this example:
When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.
“In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.
Medical research published in The New England Journal of Medicine in 2010 — six years before her diagnosis — showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology, which writes medical guidelines, endorsed the shorter course.
In 2013, the society went further and specifically told doctors not to begin radiation on women like Dennison — who was over 50, with a small cancer that hadn’t spread — without considering the shorter therapy.
“It’s disturbing to think that I might have been overtreated,” Dennison said. “I would like to make sure that other women and men know this is an option.”
(Note, sadly, that Dennison immediately puts the onus on the consumer patient to be informed; an obvious tax on time, to be paid with the patient has the least time or energy to spare, instead of looking for the systemic solution she vaguely hints at with “would like to make sure.” This impulse is a topic for another post.)
Nobel Prize Winner Bernard Lowns gives a second example in this interview (after demolishing “bed rest” for heart attack patients as “a form of medieval torture” as well):
[DR. LOWN]: At the Peter Bent Brigham Hospital [now Brigham and Women’s Hospital in Boston] in 1960, I was asked to see a patient who was in her late 70s, demented, and had burns over 60 percent of her body. She had been smoking in bed. They asked me to consult about putting in a pacemaker, which she did not need. Furthermore, she was clearly dying, and implanting a pacemaker would only have increased her suffering without prolonging her life. I was mortified. I wrote a note urging against a pacemaker. It created quite a rumpus. If that were an isolated episode, it would be tragic. But that kind of thing happened daily.
Here is a third, and egregious example, from Health Beat:
Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn’t need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.
The Baltimore Sun broke Dr. Midei’s story in January. In February the U.S. Senate Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the Finance Committee released a 1200-page report..
The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company’s cardiac stents into trusting patients in a single day: “Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei’s home.” Employees from St. Joseph’s attended the feast.
(It may seem that I’m stacking the deck on causality here, but I’m really not, although it would be foolish to deny that such cases exist.)
Note again that these examples all involve treatment: Radiation treatment, a pacemaker, and stents. We’re not talking about ordering a few two many tests. (The American Family Physican supplies numerous classes of overtreatment, not just anecdotes. See Table I.) Now to the studies and surveys.
“Overtreatment in the United States,” by Heather Lyu, et al (from the Public Library of Science, and thus peer-reviewed) has induced a good deal of discusson since its publication in September 2017. From the Findings:
The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures.
Dear me. If one-fifth of all medical care is unnecessary, that does seem like rather a lot of stress and fear induced for no reason. And if one out of every ten treatments is unncessary, that’s rather a lot of people going to Pain City because their number came up, and not for any medical reason. Those odds aren’t quite as bad as Russian roulette, but they’e in the ballpark! I haven’t (yet) been able to find figures on the costs of overtreatment, but there have been studies done on the costs of unnecessay care. Health Affairs:
Current estimates for unnecessary expenditures on overuse range from 10 to 30 percent of total health care spending. Even the lower estimate, from the Institute of Medicine, amounts to nearly $300 billion a year. No specialty is immune from practices that lead to overuse, as a recent spate of papers in medical journals can attest. In cardiology, even using criteria that are relatively permissive, an estimated 11 percent of stents are delivered to “inappropriate patients.” At some hospitals, that rate is closer to 20 percent.
(Note that the figure of 11% unnecessary stents jibes well with Lyu’s figure of 11.1% of all procedures being unnecessary.)
I’m sure none of this is new to any medical professionals in the NC readership, but it was new to me, and may well be new to NC readers — especially those who received treatments that they retrospectively, or just now, understood to be unnecessary.
The Causes of Overtreatment
It’s clear that one cause for overtreatment is the profit motive. (I would speculate that individuals like Midei, the stent dude, are edge cases, and that the real causes are more subtle and systemic.) Quoting again from Lyu, et al.:
The top three cited reasons for overtreatment were “fear of malpractice” (84.7%), “patient pressure/request” (59.0%), and “difficulty accessing prior medical records” (38.2%)… Seventy-one percent of respondents believed that physicians are more likely to perform unnecessary procedures when they profit from them. The interpolated median response for the percentage of physicians who perform unnecessary procedures with a profit motive was 16.7%; 28.1% of respondents believed that at least 30–45% of physicians do so (Fig 2). Respondents who were attending physicians with at least 10 years of experience (OR 1.89 (1.43–2.50) vs trainees) and specialists (OR 1.29 (1.06–1.57)) were more likely to believe that physicians perform unnecessary procedures when they profit from them… Respondents’ compensation method and hospital characteristics were not associated with differences in perceptions on the profit motive associated with unnecessary care.
So, the more experienced the doctor is, the more likely the doctor is to believe that profit drives unnecessary procedures. However, the profit motive imputed to individuals cannot be the sole driver (see “DICE: Nonclinical Causes of Overtreatment” for a model that includes “Economics” without being reductive) as this letter in the British Medical Journal shows:
As a person who follows the evolution of health care policy from the vantage point of the United States, I found BMJ’s May 12 article on “Choosing Wisely in the UK” [see here; CW is an “informed consumer” model] very interesting. The authors ascribe the phenomenon of medical overtreatment in the UK to a culture of “more is better” fostered by such factors as “defensive medicine,” “patient pressures,” “commercial conflicts of interest,” “payment by activity,” and the demands of “pay for performance.”
Many critics of the American health care scene ascribe the problem of irrational overtreatment unsupported by available evidence in the U.S. to precisely the same causes, and argue that the key to rationalizing American medical practice lies in adoption of the UK’s single payer, universal coverage health care system and the UK’s system of civil justice. The fact that a Choosing Wisely program is necessary in the UK, and for most of the same underlying reasons as apply in the U.S., proves that the UK has not found the panacea to achieving rational medical practice and that emulation of the UK methods of health insurance, physician payment, and civil justice will not work as a panacea in the U.S. either.
So, sadly, single payer as such is unlikely to solve overtreatment (although I can’t think of an advocate who ever said it would).
Conclusion
If there were one kind of doctor-patient relationship that I would like to see incentivized when single payer comes to pass, it’s this one. Again Dr. Lown:
U.S. News: Problems with America’s health care system are economic, but they are also human. What’s been lost in modern medicine?
[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I think that you cannot heal the health care system without restoring the art of listening and of compassion. You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be cultured in order to understand where the patient lives, why he lives like that, and also realize that the leading cause of disease in the world is poverty.
Call me Polyanna, but I think if the health care system started treating patients like human beings, that a good deal of overtreatment would be avoided.
NOTES
[1] Overtreatment is not the same as overtesting, or overdiagnosis. Over-treatment involves actual procedures performed on a patient, often surgically. In other words, lots of pain and suffering imposed to no good purpose. (Szabo’s article considers all three, but I am focusing only on overtreatment.) American Family Physicians defines overtreatment as follows: “Treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm. ”
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I worked as a disability advocate for years, which is a high volume practice. I read literally tens of thousands of medical records during that time. I can say, unequivocally, overtreatment is an issue.
Causes are far more difficult to deal with. The high cost of medical care is a reflection of the low quality of life many USAians are living. Listening is a good start, but far from the answer. Getting everyone in the system, so that more preventative medicine can work, avoiding patient demanded surgeries with low-probabilities of success would help as well. But even these two are just the tip of the iceberg.
In disability, chronic physical ailments mix with unemployment to form a deep pool of depressed individuals. Even with access to great healthcare (which few have), the advice to exercise, stretch, and eat healthy that would improve many conditions (spinal stenosis, other arthritis and orthopedic issues, obesity, heart disease) … is worth very little. In a depressed state, changing long term habits into healthy ones is very difficult, and the prevalence of patients seeing a professional to make behavioral adjustments in concert with their disease treatment is few, not counting those that show up to the psychiatrist for medication regularly.
This is why single payer, jobs guarantee, and redistribution tax policy are necessary together.
Excellent comment. The last sentence is a comprehensive statement of actions needed to heal us (U.S.)
Certainly, some will not respond to these actions, but many will and the attempt is magnanimous for a consciously sick nation.
> In a depressed state
I suppose an alternative, and more, er, final solution is opioids. Very profitable!
> single payer, jobs guarantee, and redistribution tax policy are necessary together.
I agree on the first two, but let’s remember that the Federal Government, as the currency issuer, does not require taxes to fund itself. Now, we should tax redistributively to: (1) prevent or destroy an aristocracy of inherited wealth, (2) prevent the 1% from buying the state and civil society with their loose cash, and (3) protect the children of the wealthy from grave psychological and moral harm, but we don’t need to tax them for program funding.
Thank you for this excellent post, Lambert, and for this clarifying comment. I would add one more item to your list of reasons for a redistributive tax system: democracy itself does not depend on a perfect equality of circumstances among the population, but it does require a level of fairness and equal treatment that is simply impossible given the huge disparity between Americans of low and average income — and the squillionaires.
Lambert, exactly why I advocate redistribute tax policy rather than mere “progressive” tax policy. The former is explicit in its intent, the latter falls more into the taxes fund expenditures model, which any good NC reader knows is bullfeathers.
This is a much needed discussion. However, I have a bone to pick. You say that you support re-distributive taxation to ‘(1) prevent or destroy an aristocracy of inherited wealth’.
According to Rob Arnott at Research Affiliates, wealthy Americans tend to run through their money. You don’t see many descendants of 19th Century Robber Barons who are still rich. Europeans are different. Despite high European taxes, you still find rich Fuggers, seven hundred years after their fortune was originally made.
There’s a good book, ‘Wealth’, by Stuart Lucas, a Carnation Instant Breakfast heir, that well describes the problem of keeping a fortune. The Research Affiliate abstract (with a link to the paper) is below:
https://www.researchaffiliates.com/en_us/publications/journal-papers/359_the_myth_of_dynastic_wealth_the_rich_get_poorer.html
Experienced this a couple of years ago.
After a car wreck, both of my parents were hospitalized for a week. During that time, I got a lot of phone calls from the hospital, and many of them related to getting my permission for this, that, and the other test on my mother. Dad had Alzheimers, and, lucky for him, he evaded the endless tests. I guess the doctors figured that he wasn’t going to live much longer, so what was the point? (He died nine months later.)
One of the phone calls really stood out. Mom was anemic, and the doctors wanted to do a colonoscopy to find out why. “Malnutrition!” I said. Loudly.
This had been a problem for years. Mom and Dad simply weren’t eating enough. I’ll get back to that point in a minute. But let me say that I refused the colonoscopy for my mother. In addition to being very invasive, I thought it was unnecessary.
Anyway, Mom got sent home and Dad was discharged to a nursing home. Once he was separated from my mother, he started eating like a horse. Gained 15 pounds in less than three months. Then he started losing weight and the nursing home sent him to hospice. In his case, that was the correct call.
Let’s just say that my mother still has issues with food. Not a new problem. I remember it from my childhood. But she does have caregivers who insist on proper nutrition. And she complies.
Last time I spoke with Mom’s doctor, he didn’t say anything about anemia. Sounds like that’s no longer a problem.
I think specialists are more likely to zero in on the “problem” — the heart or lung or throat, while GP’s are more likely to treat the whole person.
But GP’s are often referral gateways to specialists.
General Practice doctors are hugely important in the healthcare system. They are the traffic cops that direct patients to the appropriate specialist. They do most of the listening.
I think specialists are more likely to zero in on the “problem”
Call me skeptic after being a practioner of Medicine over 40 years! I was a GP before got trained as Diagnostic Radiologist after nearly 5 years of residency. I also worked as ER Physician in early years. I am also licensed to practice in Ontario(Canada) but practiced only in USA after the residency training!
A Diagnostic Radiologist is called ‘ a doctor’s doctor” since the myriad of imaging exists to help the clinical diagnosis. I came across virtually all kind of specialists, medical and surgical kind! Ifound out to whom I wouldn’t even send my ‘dog’ for treatment!
There are ethical and morally conscious docs, but they are in the minority!VERY FEW!
A specialist is like a HAMMER, s/he sees everything as if it is just problem of NAIL! Surgeon thinks through SCALPEL. Go to Pulmonologist, more likely you get bronchoscoped (needed or not), Gastroenterologist – gastro or colonoscopy, so on!
So buyer beware!
S.Nilavar. M.D.
> buyer beware
Or beware being a buyer.
Imagine going to a restaurant where the waiter got to order for you.
“You want the steak? OK better start off with these two appetizers I think you’ll like.
You’ll need some wine too. There’s a 1994 Cabernet that will pair great with this. I’ll mark
that down. The cost? Oh don’t worry about that, your dining insurance will cover it.
Now for dessert. They’re all so good, I have picked out three for you. You don’t need
to finish them. Now I’ll just add in my customary 25% tip (I am highly trained) and we’ll
call it a meal.”
The thing is, a trained, truly professional waiter can make all the difference to your meal. It’s their job to know the food and make your dining experience excellent, unobstrusively. (“None of this “Hi, I’m ______ and I’ll be your server tonight” nonsense). That was at least the theory in France when I was there (sometime ago; it may have changed) and still is in the better restaurants in Quebec. Being a waiter is being a waiter; it’s not a part-time job for actors hoping for their big break.
It comes down to trust. We seem to think that’s no longer important; not on the checklist. I think it’s important, and I bet there are studies that prove the good effects of trust are measurable.
Yes, trust. Essential to enjoying a great restaurant meal, successful medical treatment, and a functioning democracy.
As a regular lurker here, it’s great to see you on this beat Lambert. We’ve been on this for awhile now at the Lown Institute. I refer you and the rest of the commentariat to a series we did in the Lancet which is here:
The Drivers paper is pertinent as a description of the ecosystem of bad care.
FYI it’s a deep problem of modern medicine, part of the reductionism of the Flexner paradigm that needs to change. Over treatment exists in Canada and the UK as well as in an utterly profit driven system like the US.
Single Payer will be necessary but not sufficient for this problem. Monopsony will only go so far without a revolutionary shift in culture and consciousness.
I had the pleasure of meeting Shannon Brownlee (I see she is involved in the Lown Institute) during a month long public health fellowship during my last year of residency about nine years ago. Her book ‘Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer,’ was a pivotal tome that covered many of the issues, especially due to the Fee For service model of medicine practiced in the United States. This came out in 2007, unfortunately it appears the legislators drafting the Affordable Care Act did not seem to pay any attention, as controlling costs and hence volume was not a significant focus of the legislation.
> Single Payer will be necessary but not sufficient for this problem.
That was my takeaway, too. My thought was single payer was necessary because the only way to get leverage over the problem was to put it in the small-democratic arena. I could be wrong, but I don’t see a better alternative. The market will just go on chopping us into smaller and smaller pieces.
If the patient is the one who controls the payment, things may improve. Right now with insurance, there is no one to one relationship between the patient and the health provider. Insurance companies stand between the patient and payment. Even in the case of single payer, if the patient is given incentives to get second opinions and refuse unnecessary treatment, things may work better.
Single payer is likley to require second and if need be third opinions for non emergency surgery. Most insurance pays for a second opinion if you want one (and would be a fool not to get) and if need be a third opinion if the first and second don’t agree.
Kip Sullivan unequivocally disputes the “overtreatment” meme…To the contrary, we are under treated in the US…..
Please read:
“The Health Care Mess: How we got into it and how we’ll get out of it” by Kip Sullivan…..
And Kip is about as smart a person writing about our health care scene as anyone I know.
I tend to agree that we don’t get nearly enough good (think primary) care but n my experience we also get lots of wasted care. I for example have seen ERs repeat CAT scans on a patient more often than weekly for the same condition a practice that should be malpractice but instead is highly profitable.
There are many drivers for such waste and of course single payer is not a panacea for them nor is it meant to be one.
It seems hard to imagine that we might one day make The practice of medicine something that is not entirely commodified the way it is today but indeed that is what needs to happen if we were to change this.
I think we can be undertreated as a polity, and yet overtreated for those who manage to make it through the obstacles to secure care. Too many anecdotes on overtreatment for it not to exist, and the incentives are so obvious…
Over treatment: My mom’s story. From several years ago.
So I was the guardian for my very (VERY) demented mom whom we kept at home, at great cost but also great benefit to her. She had a basal cell tumor on her forehead. About the size of a nickel. She was 90 at the time. I live in one state, she the next state over about 2 hours away. She had full time help at home.
So one of my innumerable trips to help out and oversee, involved taking her to her md appointment at Brigham and Women’s. She had a wonderful gerontologist, who referred me to a dermatologist affiliated with B &W. Her care giver took her a few weeks later and I got a call from the dermatologist, a young woman. Now I’m an old woman but a trained m.d. in Internal Medicine. I also knew (by then ) a great deal about dementia. And especially dementia in my particular mother.
So when the dermatologist called me she said “your mom needs a MOHS procedure”. Well, a Mohs procedure is an 8 hour stop and go procedure. They keep cutting until the margins are clean. They cut, send the specimen to the lab, wait for the result and cut again. Patient is awake the whole time so there’s no anesthesia risk, but 8 hours on a table for a woman with advanced Alzheimer’s was not going to work. I told the dermatologist that there’s no way my mom could tolerate that. The dermatologist got irate. Tried to scare me by saying, “the tumor could grow into her brain!”. I said, “mom’s 90, she’ll be dead b/f the tumor goes anywhere!”
They were so intent on this procedure and challenged my right to speak on mom’s behalf. so…….. I had to fax PROOF of my guardianship for them to let me have the last say. I was pretty discharged. And complained bitterly to the referring doc when we saw him next…. and he mentioned that my complaint wasn’t the first.
Then I found out that the MOHS surgeons get a ton of money at the places they work, like $700,000.00 / year.
Thank you for sharing. It helps to know I am not alone in such experiences.
I often wonder how epidemic stories like yours are. I feel like I could write a whole book based on personal experiences along with those of family and friends. A person really has to educate oneself just to avoid being robbed blind or worse yet harmed, and you at least have the fortune of a medical education. To have to education oneself (trying to filter all the misleading ‘marketing’ information and quacks out there) on complex medical procedures on top of everything else is exasperating beyond words.
How long do we, and those we care about, have to continue suffering the indignities and malfeasance of a broken and corrupt (not worth using euphemisms to debate the issues at this point anymore) healthcare system?
As long as corporations have constitutional rights and can buy the government, which they can do because money = speech: http://www.movetoamend.org
Why am I NOT surprised?
As I have written on many forum, over the years, this was pointed in early 90s by extensive research at RAND Corp and ar Fraser Institute (Canada) that up to 2/3rd of tests/imaging/surgeries have NO clear medical indications and NOT needed. This is also confirmed in my practice over 40 years, in various scenarios ( private,university practice).
It is so sad to observe that it is still going on! Just demonstrates the power of the vested interests in the medical industrial complex.
The topic of this post is overtreatment, not overtesting. I can live with some excess overhead from testing. But I can’t live with being cut open for no good reason other than systemic incentives, often financial.
Unfortunately over testing goes hand in hand with over treatment. There is a thing called an “incidentaloma” that our radiologist friend I’m sure can attest to. These are findings on diagnostic testing that do not answer the question at hand, but cannot be ignored, leading to more testing, usually of the more invasive type including being cut open. This is where physicians must have a grasp of Bayesian analysis, pretest and post test probabilities, etc. to not only know when to order a test, but also when NOT to order a test.
In general I would agree that overtreatment is worse than overtesting, BUT overtesting is also a huge issue. Your assumption is that overtesting doesn’t have serious bad effects but:
1) some tests are dangerous. One of my dogs died after a myelogram (a diagnostic TEST) some years back. A friend’s father had some sort of recommended “test” before surgery to check for something that resulted in an infection which killed him. And, CT scans involve a LOT of radiation (one CT scan is like hundreds of X-rays) and this causes a certain amount of cancer, yes in a very small fraction of those who get them and usually YEARS later (but this still is a hazard and particularly dangerous for children who have a longer lifespan to come). Colonoscopies (a “test”) can on the odd occasion damage people either from a bad reaction to the bowel prep (which, very rarely, can even kill, especially in the elderly) or by perforation of the bowel. None of this makes CT scans or colonoscopies or other tests not frequently useful and absolutely worth the minor risk when really indicated, but, you really do not want overtesting for more reasons than inconvenience and overhead.
2) As someone points out in another comment, overtesting can lead to unnecessary investigations of “incidentalomas” which can be very harmful and damaging.
I’d be surprised if a significant contributor to the “overtreatment” pie wasn’t Pharma advertising
The underlying premise of “modern medicine” is flawed. It dumber than Medieval bloodletting.
Allopathic medicine is brilliant for catastrophic events. In the case of paraplegic injuries, over the last 50 years, their survival rate, in the first two years after the injury, has increased dramatically. However their long term life expectancy is about the same as it was 50 years ago.
Trends in Life Expectancy After Spinal Cord Injury
“Results
Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post–2-year period is small and not statistically significant.”
http://www.sciencedirect.com/science/article/pii/S0003999306004060
We are bamboozled by the “complexity” of the modern medicine model, BUT, “it” is stupidly simple. They define a “normal” range of numbers. This range is arbitrary and always changing. What is normal cholesterol? PSA? Blood sugar? ferritin? vitamin D?
Then they subject the patient to an array of blood tests, x rays, scans, urine tests…
Then, the allopatic doctors use drugs or surgery in order to get your test numbers in the normal range.
Before you know it, the patient is on 15 drugs. They cannot sleep so they are prescribed sleeping pills. Then they are depressed, so anti-psychotics- Finally Oxycontin for the constant unbearable pain.
Allopathic care in NZ is cheap, readily available, but a death trap for the trusting (except for catastrophic events). USAians pays hundreds of thousands of dollars for misery and drug induced ill-health.
If cat poop (feces) were cheap and available in one place (NZ), but outrageously expensive and rationed in another (USA), it is still, basically, just cat shite.
The problem is for profit healthcare. The more tests and treatments, the higher the managers bonuses. There is no regulation except for the insurance companies who are only interested in their own bottom line. The patient is not in a position to rationally oversee their care by themselves. All that matters today is profits; no matter how they are achieved. That is why American life expectancy is decreasing. Besides giving everyone healthcare; a system of primary physicians, government oversight of hospitals and care facilities plus jail time for criminals are also needed.
I have relatives by marriage who live in southern Indiana near the Kentucky border. They are “respectable working class,” and I guess they must have good health insurance. I have never known anyone to have so many surgeries. It is astounding. Cardiac surgeries and orthopedic surgeries, for the most part. The ones I have in mind are 58 and 62 years old; they have never smoked; they go to Mass every Sunday, they have been happily married since they were young and while they don’t eat health food they don’t eat every meal at McDonald’s. But it is surgery after surgery after surgery. They never question the doctors; they never hesitate. And now, unfortunately, some consequences of the surgeries are coming due; the guy is in the hospital with infections both in his pacemaker and in his heart valve (they just replaced both; he’ll probably be okay). No-one else I know has surgeries like this. I think it is a regional scam. It’s true that my dad in CT has had a number of vascular surgeries, but he smoked for decades and the dire need for them has been very apparent.
Here in northern CA, I have a friend whose girlfriend’s son went to the emergency room a number of years ago for a bad finger cut. He was told he needed amputation. Then they found out he had no insurance. He was told to use a salve, and in fact it worked fine. I also have a friend here in Silicon Valley who recently had digestive problems. The MRIs, CAT scans, lab tests and probings under sedation were endless. Finally she was told to stop eating acidic food.
Reducing the profit motive as much as possible is why I would prefer a National Health Service (call it VA for all). Insurance, even if it’s single payer, is still open to fraud and overtreatment. Let’s try to think of medical practitioners as professionals rather than entrepreneurs, and get them to think of themselves that way. I also see it as a possible way to reduce the very high premium given to specialists, so that more would go into primary care.
In modern Medical practice, PROCEDURALISTS ( Surgeons of all kind, Cardiologists, orthopods, Pulmonologists, gastro enterologists anfd of course, invasive and diagnostic Radiologists etc ) always get compensated more than the primary care providers!
There are more CPT codes to charge for specialists than the GPs or FPs
Medicine is business run by 3rd parties! Vested interests won’t allow any challenges to status quo, just the banking system and the FIRE Economy!
> There are more CPT codes to charge for specialists than the GPs or FPs
See here and here at NC on medical coding.
NOTHING, I am NOT aware of, during my practice!
There used to be under 5000, now apparently after the EHR & EMR, there are over 13-16K codes to choose!
With all due respect, if the UK system has embraced, “commercial conflicts of interest,” “payment by activity,” and the demands of “pay for performance” then that means they have a substantial set of profit incentives already in place, rendering their medical system *more*, not *less*, similar to America’s. They may have single payer but that just captures the monopoly rents by regulating the cartel/monopoly/utility or whatever you want to call the medical establisment (it’s per se difficult to even talk about market competition when there’s only one drug or treatment that will save a patient).
The unregulated private provision of public goods like medical care always leads to extortion for profit. If you privatize fire-fighting, entire cities will burn to the ground. If you privatize schools, you get ignorance. If you privatize prisons, you get kidnapping-for-profit and the highest incarceration rate in the civilized world.
If you privatize the military, you get endless war. Why would a for-profit business ever win a war? For that matter, why would they ever lose? The war’s over and they’d be out of money. You think it’s just a coincidence that in the age of corporate personhood (Citizens United) and unlimited bribery of public officials, you’ve had two of the longest, most expensive and least determinative conflicts in our history in Iraq and Afghanistan?
You think it’s a coincidence that the more unregulated “markets” we through at medicine, the more expensive our medical care becomes and the sicker we all get?
Cures don’t make money. Repeat customers do.
Show me a for-profit business that’s in business to go out of business and I’ll show you the perfect company for insuring against social hazards.
It’s simple middle-manager fraud. Politicians love privatizing government because they get to pocket the public budget. When the marines or public school principals hand tax dollars back to politicians and their cronies, everybody goes to prison. Privatize it and then you can have the contractor or charter school give you “campaign donations” – no doubt celebrating your economic genius in the process. They can hire your spouse and cousins. The contractor can even bid up the real estate and then rent it back to themselves at exorbitant prices. There are a million ways to launder the money.
Why do you think there is no transparent public accounting on most of this stuff? The budget disappears into a black hole – which, incidentally, you’ll discover the minute you’re in a hospital, dealing with a pharmacy benefit manager (PBM) or health insurer. That was the true purpose of MERS – to make good mortgage information disappear so CDO purchasers would never know what was in the mystery meat.
This is the great unraveling of Progressive Era controls on public corruption.
If you pay a dotor for every surgical screw he installs, is it any surprise then that a diabetic winds up getting several in his spine he never needed?
This is also how we have set up the aluminum and copper markets, letting speculators buy and horde commodities to drive up the price. It’s also how we run drug distribution under the PBMs. PBMs provide a kickback in the form of a “stocking fee” to pharmacies which would get people sent to prison in other industries. When derivatives traders are not end consumers or producers of a commodity, they bid up prices the same way. We actually give pharmacies a profit incentive to drive cheap, effective, public domain chemicals off the market in favor of expensive, privately patented medicines. Because they are expensive, they pay a greater kickback so the pharmacy has greater incentives to stock and push it.
When railroads charged both farmers and consumers shipping and receiving food, it bankrupted both sides of the transaction by creating incentives to reduce supply in the monopoly transportation network. Reducing rail capacity bid up transportation prices and saved the company on investment. That’s how you raise profits: raise prices, lower expenses. They had no rival to compete. That’s why these kickbacks were outlawed. Imagine if the post office made you buy a stamp for every letter you receive. Oh, wait. We have that with the end of net neutrality. The ISPs get paid both by the service supplier (e.g., Netflix) and by their “customer” (you and I).
You this same “rationing” take place now with drugs. Since legalizing PBM kickbacks, drug prices have soared and we’ve lived through some of the greatest drug shortages since the Soviet Union went bankrupt. Hundreds of chemotherapy patients per year have died because cartels control supply and they don’t like patients getting cheap, efective, public domain treatments. Go look at the availability of methotrexate over the last ten years or your platinum-based compounds. No one tells you this. It’s a blip on the back page of a newspaper (and pretty soon we won’t even have those). Do you think TV “news” – making its profits off drug ads – will ever talk about this?
It’s a new war of enclosure – and it’s far more extensive than simply drug markets. The privatizers are confiscating clean air, potable water, healthy food, public education, public policing and a host of other “general welfare” functions of the government promised us in the preamble. It all traces back to the ideology of for-profit government – which, in technical political science terms, is called fascism – when businesses own and operate the government for private gain.
By the way, we don’t need less testing in medicine. We need more. I don’t know a single idiot in Silicon Valley who ever said we need less data collection. The simple fact is we need to test everything in a patient and compare everything we collect across thousands of diseases. The cost of sensors and DNA sequencing, imaging and protein detection – not to mention data processing – has been falling dramatically and yet “reformers” always stress “rationing” as the cure for health care prices. It’s partly because we ration preventative medicine and diagnostics that we’re in this situation.
Another great place to start would be separating diagnostics (evaluation) and treatment. Would you let the bank’s chief loan officer also serve as the chief auditor? Yet we let the same doctor diagnose, treat and evaluate his own work.
As someone with serious chronic illness from these frauds, listen to me when I tell you we should be practicing medicine thousands of patients at a time with transparent public auditing and big data model building. Building my own private model of genetics from public research saved my life. Nobody does that for you in medicine. Nobody is paid anywhere in the system based on whether you get the cheapest, most effective and safest treatment; in fact, I’ve heard of people getting fired for exactly that.
‘By the way, we don’t need less testing in medicine. We need more. ‘
ah?
No test is 100% accurate! Every test has a potential for a FALSE positive or FALSE negative result.
False + may lead to unnecessary more testing and probably unneeded surgery! False negative gives false sense of relief!
Every test has to stand alone for specificity, sensitivity and accuracy, by statistics!
You’ve answered your own question. No single measurement, in isolation, is 100% accurate. That’s why we need thousands.
We need a cheap gene array chip that measures 10,000 markers in the blood and we need a big data project to match those measurements against a baseline. We need cheap, safe whole body scans. We need measurements of what every cell is up to and how they deviate from the norm.
Nobody’s very angry that cell phone cameras keep getting better, yet somehow we’re always upset that doctors want plenty of tests. That camera is a sensor that measures our environment and the chip gets better and cheaper each year. We need the same attitude in medicine. But then cardiologists might get upset that an immuno-assay shows you’re at risk for atherosclerosis. These guys still don’t want to accept that clogged arteries are an immune system problem and the immune specialists don’t want to accept that it mostly gets started in the gut. And the gut guys don’t want to have anything to do with immunology or cardiology.
Round and round we go…
The future is human genomes for diagnosis and tailoring treatments on individual basis. But that day is yet to come!
> should be practicing medicine thousands of patients at a time with transparent public auditing and big data model building
As long as financial incentives don’t distort the data (and more importantly, which data is collected). Eh?
Does any one in HEALTHCARE system including all kinds of physicians, Hospital Administrators, Insurance executives, health policy pundits or whomever, know:
How much each procedure (of any kind!) or treatment, COSTS ( the REAL-exact, occurred cost) to the provider or the health institution before it is charged (before padding up their profits %) to 3rd party payers or the patient themselves?
There were a few articles in NYT where the hospital CHARGES for Cholecystectomy (gall bladder) varied from $3000 to $10,000 at different zip codes. But none listed the REAL cost occurred!
NONE of them have come forward to reveal that secret, if any b/c it gets ‘charged’ as long as the market bear it!
Cost (?!) over run will added to next year’s premium!
An enigma in Medicine practiced as business, unlike other!
I’ll have to read the post this evening, but I have something to add to the theme:
I was in a meeting where a prominent local single-payer advocate, an emergency room doctor, told us, passionately, that administrative costs were only half the problem,. or less. Overtreatment and overtesting were the bigger part. He blamed the doctors, but of course their billing practices are a big factor.
A big advantage of single-payer is that it creates an institution with the power and motive to change medical practice. Iatrogenic illness is a big factor; overtreatment can kill.
My wife has some chronic health issues and is a regular visitor at–and occasional guest of– the Mayo Clinic, traditionally seen as the home of “integrated medicine” (i.e. the various specialties speak with each other). We count ourselves ridiculously, ridiculously fortunate to be able to so often and easily rely on the oft-named best hospital system in the world. That said, it’s amazing to both of us, even there, how silo-ed medicine has become. This silo-ing HAS to create an inordinate amount of overtreatment. The generalists, however, are left far behind in the community practices, often not able to do much beyond prescribing antibiotics and making referrals. There is a LOT of need for more holistic thinking about the patient that modern western medicine has lost, likely inadvertently, as greater knowledge leads to the need for greater specialization. The gap of some type of “master generalist” (which would of course be another layer of expense in the healthcare system) is filled either by the patient (of patient’s family) or left void. As a result, there’s either a huge tax of time, stress, frustration spent searching internet chat boards and medical reference sites to understand topics because it seems like no single doctor “gets it”, or a hugely inefficient and potentially quite harmful medical treatment experience as each specialty chips away at their corner of the patient. I’m not sure what the answer is, but if this is the experience of a frequent Mayo Clinic patient, I’d wager that the question posed is a pretty fundamental one to the entire practice of modern medicine.
Master Generalist!
You are absolutely right. The primary care provider has to be the THAT coordinator of numerous consultants/specialists (diagnosis & treatments) looking at the (piecemeal) patient through their ‘tunnel vision’ of their respective (organ) specialties but giving less attention to the big picture – the patient as a human being and his or her interest as a top priority.
But currently that is huge responsibility for the primary care provider involving a lot of UNCOMPENSATED (time &money) care, very few can afford. It is a gap yet to be filled in our healthcare system!
For my family, friends and relatives, I have been that ‘master generalist’ for many years. I have been both GP and also specialist in my life time. There has to be a STRONG patient advocate either a family member or a close friend to look after the true interest of that individual. Without that person, a patient is at the risk of under, over or no (neglect) treatment in our healthcare system.
I would add an extra ‘over’ to your list – overdiagnosis.
One of the the few bright spots in published stats for the US compared to other countries is an apparent higher survival rate from cancers. I mentioned this to a relative who is a medical specialist and he just laughed. ‘its not surprising’ he said ‘since an amazing number of those treated in the US for cancer don’t actually have cancer’. Quite simply, overuse of dubious ‘tests’ results in a huge number of false positives for cancer. This leads to ‘successful’ treatments. There are many tests in the US which are simply not permitted in countries with public systems because they produce far too many false positives to justify their use, either because the cancer doesn’t exist, or it is not sufficiently malignant to justify treatment (apparently there are cancers that lie dormant without ever threatening life). I’m not aware, however, if this has ever been quantified, but its certainly true that there are many testing protocols commonly used in the US which are actively recommended against in most European health systems as they are considered not just a waste of money, but actively harmful.
A relative of mine who is a very highly regarded specialist in drug prescribing practice in Europe is currently doing a one year study on practice in the US (focusing on opiates, as it happens). He said that one of the initial findings is that there is a different culture around prescribing in the US to what he is familiar with. Quite simply, US doctors are not taught how to say ‘no’ to patients in a way which doesn’t upset them or feeling they’ve been given a brush off.
Someone mentioned overuse of heart operations above. In Ireland, they developed what are called ‘Sli na Slainte‘ walks, which have spread worldwide. These were developed by the Irish Heart Association following complains that patients were asking for too many drugs and treatments, and not doing the simple thing which was shown to help in the aftermath of heart attacks – exercise. They are way marked walks of set distance – doctors simply prescribe the walk instead of drugs. They are hugely successful. But there is no money in it, so guess where they haven’t been adopted?
*disclaimer* I should say I’m not a medical professional, but I do have an interest in the topic.
‘US doctors are not taught how to say ‘no’ to patients in a way which doesn’t upset them or feeling they’ve been given a brush off.’
But there is always another doctor ‘willing’ to say YES! Shopping for ‘yes’ doctors is NOT usual! They are called ‘DR. Feel good’ ;-)
Remember, Medicine is a business in America!
Thank you, PK. Very interesting, and follows from a thoughtful and insightful post from Lambert, but I guess it makes common sense to strengthen heart muscle and accelerate the body’s natural ability to heal itself through exercise. Pity about the commonness of common sense though, but I digress.
We all know we can live longer and avoid or postpone chronic ailments by maintaining a healthy weight and doing some exercise, particularly cardio. And our arms and legs may look the same over our declining years, but if you don’t use them, you will lose them, those muscles that is.
I post. that such an ideal is too far when you are time and money poor, constantly worried and depressed
Poverty and sickness and lower mortality – they’re all linked to one another. Designed and baked into the dying system
..walking is a curative/extender for people with heart disease….I am a prime example…
in 2000, at age 52 I had a collapsed lung and stopped smoking and started walking….in 2001 I had a massive heart attack and a quad bypass, which I survived due to a year of walking 30″ per day….
in 2010, my lung collapsed again and I was diagnosed with Emhysema (no cure then or now)…..I asked the Pulmonoligist, “How much can I walk, because if I don’t walk, I will soon die as my heart will weaken….”
The Dr. said, “No one has ever asked me that question….they all just go home and walk slow!”
So, I used the oxygen tank with an extended line and “swim noodles” so I could swim and do water exercises……then I tried to stay on my feet for 3-4 hours per day (moving slowly) 6 days a week…..I increased both my heart size and my lung capacity due to this regimen……
I also watch my diet….but, do eat “the good/fun food” in moderation, but avoid salt….
And, I avoid large gatherings during the cold and flu season because they could kill me quickly…..
17 years later, I am finally “slowing down”….BUT, I got all these extra years by JUST KEEPIN’ ON MOVIN’ ON…..
My Pulmunoligist said, “You are unique and we really don’t know what to do for you….just do what you’ve done….you are an inspiration!”
None or too little, or too much, and very occasionally just the right amount of medical care for the lucky few. What a mess.
I’ll add that the elderly, and the poor’s, opinions seem to be discounted by caretakers as if you are lucky enough to be old or unlucky enough to be destitute means you’re soft in the head. So if a patient can understand and communicate what they want and realistically need they have to fight to be listened too.
Four years ago my father who was 78 at the time began having difficulty eating. He had been diagnosed with parkinson’s a couple years earlier but the meds he was on were acceptable and effective for him. He was a brilliant physicist. Well they did a colonoscopy and found tiny tumors. One couldn’t be taken care of at the time and the process to his death began. No one knew how long the tumor had been there or at what speed it would grow but chemo and radiation were prescribed to make it easier to remove. This became a very long sad story which I will not go into detail on right now. The chemo made my Dad horribly sick. The radiation to pin point a tiny area less than the size of a quarter ended damaging all his organs. He died in pain on Thanksgiving morning 2 years ago. The radiation had done too much damage. When he asked questions about treatment he was shuffled to diffident doctors or just not answered. These were very high end NE Medical facilities. The reason he went in for digestive problems never were fixed. Had the tumors never been addressed he could very well be alive today. To date I have over 5 friends who have had a parent die not from the condition they sought help for but the radiation treatment.
> Had the tumors never been addressed he could very well be alive today
I understand that many prostate cancers are cancers you die with and not of.
It’s almost like your body tissues are nothing but sites for rental extraction, if you fall into the wrong hands, which is a Happyville vs. Pain City thing, entirely random….
Clinical and biological behavior of cancers, host response, response to chemo/radiotherapy VARY from individual to other.
some cancers grow slowly and some faster than the others, Specific cytology/histology matters.
Breast cancers in women -30s/40s are aggressive grow faster and metastasize. Same cancer in late 70s or 80s grow very slowly.
There is NO single answer to all cancers and behavior and response to treatments! The inherent individual-host immunity/response also matters!
For me the problems start with the routine physicals which are “free” courtesy of Obamacare. The doctors run tests and find problems with this and that, and after ultrasounds and CT scans and little surgeries to get rid of benign little thingies, before you know it you’ve spent thousands of dollars (courtesy of high deductibles ) for basically nothing. This last time around my GP didn’t like a few things in my lab results and I ended up with a specialist. He started off with “why are you here to see me today?” After questioning me for a little while about my (lack of) symptoms, I finally told him, “I never would have come here on my own if my doctor hadn’t have sent me here.”
Genetic testing will increasingly be a cause of overtreatment:
Lawsuit: Woman had unnecessary mastectomy, hysterectomy based on mistaken diagnosis [Oregonian]
Dr. Lown is on to something:
Medicine is becoming more dehumanizing. This is not only structural due to shorter patient visits, less face to face interaction, fewer family physicians treating the whole family, visiting the patient at their home, to see what their environment/neighborhood is like. It is also the way physicians practice medicine, treating patient’s as mere data sets. I’m not trying to minimize data in medical decision making, but taken out of context from the human element, treating data may be misleading and may not be treating the patient’s ills.
In my experience, when I see a patient coming in over and over for the same complaints, it is likley due to one of three main reasons. One, they are either being misdiagnosed and mistreated, two, they are seeking a special test or drug, or three, their symptoms are not due to an organic medical cause, but due to some sort of somatization secondary to life stressors. Trying to figure out which it is requires the clinician to listen to the patient and understand where they are coming from. Unfortunately, when a primary care physician only has 10 minutes per visit, it is much easier to order a battery of tests to not miss any important diagnoses, or to just capitulate to patient demands than to listen, and in many cases take the time to give the patient some much needed reassurance.
That being said, the patient is not always an innocent bystander in this. There are also many times that the clinician will pick up on the dynamics mentioned above, but reassurance will not satisfy the patient. The patient will demand more be done for a number of reasons. These are mostly anecdotal, such as I read an article and think I need such and such a test, or my friend/family member had this procedure done and I need it two. It sometimes takes me twice as long to explain to a patient why they don’t need something done as it does as to why they do. This is a societal thing and this is linked to the problem of defensive medicine. I like to joke, that physicians always get sued for not ordering a test that may have been indicated, but rarely if ever get sued for over treating someone and then causing harm. Perhaps it has something to do with the ethos that it’s better to do something and look like you’re trying that to do nothing, even though that may be the best course for the patient.
In the end, I think physicians need to be better trained to listen, remember the mantra of “first do no harm”, and treat each patient as if they were their close family member. The incentive structure in medicine has to also change, including the way physicians are reimbursed, as well as the way information and clinical data is sourced and distributed to avoid excess industry bias. And finally, patient’s have to understand that more is not necessarily better, they or their relative do not have a god given right to every experimental, and outrageously expensive treatment available if it does not apply to them clinically and if the chances of it prolonging life are minimal.
Overtreatment can’t possibly be as big a problem as undertreatment, at least certainly not in the world of crappy insurance or subsidized care…our experience was definitely a solid reluctance to order expensive tests or to consider that the problem might be complicated and costly. Which it turned out to be, and the eventual surgery was scheduled as late as possible, as a last resort, and we had to insist on more thorough testing to get a proper diagnosis. They just wanted to save money. The tumor grew all the while this organization was hoping it was something minor. I don’t want to hear about overtreatment, thanks — it seems to always get distorted into blaming the patients for greedily consuming too much healthcare!
My experience as well, though in my cases, thank God, it wasn’t a tumor, “just” ulcers and polyps that were easily treated when they were finally diagnosed.
I hope you came through OK.
Well, you are right, if you are under- or uninsured you are gonna have MUCH more problems with undertreatment and have little reason to be concerned with overtreatment. But, for the well insured, it’s still an enormous problem. Otis Brawley in his excellent book which deals with gross examples of both under-and overtreatment recounts the saga of a well-insured and anxious patient who got radiation for already-treated and not-needing-more-treatment prostate cancer. The radiation caused bowel problems that ended up KILLING him after a couple years of misery.
I had a minor open abscess on my back. Standard treatment is in-office minor surgery, with local anesthesia. I was referred to the head if surgery of a major teaching hospital , who insisted on full OR surgery under general anesthesia. He refused to consider in-office surgery. I refused the full OR overkill. After about a year of argument with my healthcare provider , I was referred to a dermatalogical surgeon for in – office surgery. Took 5 minutes, with local anesthesia. Fixed the problem. But it took a year of war to avoid unnecessary and expensive surgery.
You’ve changed doctors, right?
That’s absolutely insane, and obscene. Good for you for not going along, but terrible!
Healthcare practices, much like bureaucracy, are generally pretty slow on the uptake of new advances. There are little incentives for doctors to advance their practice or to really push for their patient interest, despite the hollow chanting of evidence-based medicine advocates.
When I asked why hypofractionated treatments (shorter course for the breast radiation therapy or prostate) aren’t adapted for radiation treatments, some claimed ignorance while others blamed it on insurance policies only qualify certain on treatment types, few oncologists are interested in pushing for it.
Granted, the price of 25x radiation treatments (5~6weeks) isn’t very different from 20x or 16x(3~4weeks) radiation treatment for the hospital, since it is typically billed by the cancer types, radiation treatment types. I doubt the oncologist received more incentive (by a significant margin) with longer treatment scheme, although this definitely imposes an additional cost on the patient. Overall though, I don’t think differences in treatment duration are an indication of overtreatment itself.
On the other hand, I think the referral system is sometimes causing overtreatment. For example, a prostate cancer patient that is referred through GP > Urologist > Oncologist pathway is far more likely to undergo localized surgery before ADT and radiation therapy, even though, in some case, there is no evidence that this is beneficial to the patient.
Sometimes picture the referral system almost look like a modern highwayman system, where everyone it out for their cut.
background: medical physicist (allied health) experience working in Asian.
Two common threads in these stories seem to be that 1) the overtreatment mostly happens to the elderly; 2) it’s mostly for expensive procedures, not routine ones.
In my teens, 20s and 30s I had a number of easily and inexpensively treated health problems that were only diagnosed when I lived outside the US.
If you are a young person with a $2500 deductible you aren’t getting overtreated.
Excellent points!
Yep true – implications for uk too
‘In my teens, 20s and 30s’
,
Were there:
– CT scans, MRI, Pet scans, ISOTOPE imaging, Ultrasound imaging, Echocardiography? Percutaneous renal drainage?Percutaneous Angioplasty?
-Broncho-scopy , gastroscope, colonoscopy, Linear accelerator (instead of Cobalt machine) to treat cancers?
– advanced/new antibiotics and other medications?
Good OLD days, yep they are OLD for a reason!
I’m in my late 30s.
All those tests have existed but try getting them when you’re at no risk of dying in the next 10 years and have an HMO.
The vast majority of Americans, at least Americans pre-Medicare and especially pre-middle-age, get carefully rationed care with lots of little implied insults that you are whining and need to “buck up.”
My point is, there is a gap in care between tests/treatments (mostly blood tests) that are so cheap that they are widely available, and the super-expensive tests and interventions that get overused because of financial incentives. Try getting anything other than a quickie prescription for most complaints as someone who doesn’t seem like they’re on death’s doorstep. You’d better be a very squeaky wheel.
Highly recommend people read a new book out “Why We Revolt” by Victor Montori MD at the Mayo Clinic. A compassionate clear headed and well written look at what ails modern medicine.
Thanks to readers for the excellent comments on this thread. Adding, “passionate facticity” is a phrase that just popped into my mind.
I was surprised to see psychiatric drug treatment go unmentioned
in examples of unnecessary treatment. Robert Whitaker made a convincing case in his book, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, that drug treatment has been shown to be ineffective compared to supportive, non-drug treatments. Whitaker,
a journalist, convinces by citing studies of treatments done by psychiatrists.
If you look at the top 5 prescribed medications by class, you will see, acid reflux medications, hypertensives, cholesterol lowering, anti depressants and pain medications not necessarily in that order. Theoretically, all but the pain medications (in short duration) can also be treated by lifestyle modifications of diet, exercise, weight loss, and emotional health.
…for most people.
L – Congress is trying to legislate ‘overtreatment’.
https://www.cbo.gov/publication/53241?utm_source=feedblitz&utm_medium=FeedBlitzEmail&utm_content=812526&utm_campaign=Express_2017-10-24_12%3a00
I’ve seen both over treatment and under treatment, both as a nurse and personally, so maybe the problem is Bad Treatment. There seems to be no consistency. Just now I am on the phone, trying to make an appointment with a specialist I saw a few years back. They are not even able to change my address!
And a personal experience:
A couple of years ago, I experienced a “frozen shoulder.” In case you haven’t had this treat, it hurts like unholy h..l, especially if you try to use the arm. And yes, it was the result of overstrain, my own poor judgement.
Long story short: The specialist prescribed physical therapy, which I faithfully pursued, since I’m on Medicare. After a month or so, I realized that it was making the problem WORSE. My arms swelled up all the way to my hands. That called for cortisone, and about that time my therapist ran out of patience.
The frozen shoulder went away after about a year, just as the therapist, in a moment of candor, had said it would. Not perfect, but perfectly usable. As far as I can tell, the best treatment was none, maybe some aspirin to get through the day. Hmmm – could have been an opioid pretext; at least my doctors were good enough not to try that. I hope I would have refused.
I wonder whether physical therapy for frozen shoulder is ALWAYS that harmful?
I don’t know; I do know of a friend who had frozen shoulder and also did not find physical therapy useful and did find it brutally painful; and I heard of someone else whose doctor advised her NOT to get PT until the shoulder had freed itself up some.
You were smart to realize it was hurting not helping and to discontinue the PT.
A comment, offensive or not, will not necessarily get published if it doesn’t add independent content.
When someone habitually uses caps lock or exclamation points, it is the equivalent of shouting in the middle of a conversation – it’s not the worst thing in the world, but it doesn’t do much to build a constructive atmosphere, either.
Just want to say that I appreciate all of your above commentary, Dr. Nilavar, it’s important to have actual Doctors weighing in on such an important subject.
As a cancer patient for quite some time now, I have had to push back on both over testing and over treatment by a world renowned hospital run by Money Men.
Capitalizing the word exactly in many instances, is more appropriate than not, to many of us being abused in Hospitals with utterly no recourse.