Earlier this month, an article was published by the New Yorker that questioned the mounds of unnecessary medical care doctors prescribe and the physical and financial effects on patients. “Overkill” by Atul Gawande, a surgeon, highlights the many patients and situations he’s seen that have been subjected to overtesting and overtreatment.
We know that some medical imaging can be unnecessary, and it’s estimated that a third of all CT scans are, costing patients and taxpayers money all while exposing the patient to additional radiation. It’s estimated that 2% of cancers, which lead to approximately 15,000 deaths per year, are directly caused from the radiation exposure of CT scans. The FDA has even created the Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging, which asks that imaging only be done when absolutely necessary, and that when imaging is taken, the least amount of radiation be used.
Overkill is a lengthy but very good article, which you can read here. If you’re pressed for time, keep reading below as I touch on the main points.
Gawande is inspired to write this article after a news article catches his eye. The article discusses a study that took place covering more than a million Medicare patients, and uncovered that a huge proportion of the care they received had been a huge waste. The study specifically targeted 26 tests and treatments that have been proven to provide no benefit to the patient, sometimes even causing more harm than good (these include doing an EEG for headaches or MRIs for lower back pain).
A 2010 report from the Institute of Medicine found that 30% of health care spending, which comes out to about 750 billion per year, was a waste. Higher prices, admin expense, and fraud accounted for half of this waste, but more than anything, that waste was due to unnecessary health care.
In his own practice, Gawande decided to take a closer look at the history of some of his new patients, and how much of their past care seemed unnecessary. That day, he saw eight patients with enough history for him to critique. “To my surprise, it appeared that seven of those eight had received unnecessary care,” he writes, “Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage.”
So why does this keep happening? Why are doctors doing it, and why are patients spending so much money and putting themselves through unnecessary treatments?
Gawande breaks it down. To begin with, for doctors, it usually feels better to do more than to not do enough. As Gawande states, it’s that test he should have done that sticks with him–sometimes for years to come. For the patient, something called information asymmetry comes into play. As a patient, you may feel as if the doctor knows much more than you, so of course you should listen to what they advise.
As for excessive testing, the anxious patient and doctor are usually thinking, ‘Why not? What’s the harm to taking a closer look?’ But sometimes these tests lead to over diagnosis, and in turn the treatment of a ‘problem’ that wasn’t really ever a problem, and probably would never turn into a problem in the future.
Some surprising facts that Gawande presents:
1. In the United States, the number of thyroid cancers that have been detected and removed has doubled, yet the death rate hasn’t been reduced at all.
2. In South Korea, the common use of ultrasound screening has led to a fifteen-fold increase in the detection of small thyroid cancers. It’s now the number one cancer diagnosed and treated in South Korea, but the death rate hasn’t dropped at all.
This isn’t the first time Gawande is hearing about unnecessary care. In 2006, he created turmoil when he wrote an article, The Cost Conundrum, which uncovered the disparity between two towns in Texas. McAllen, which has some of the highest per-capita costs for Medicare in the nation, and El Paso, which has the same poor health and poverty as McAllen, but with half the Medicare costs and the same to better results.
The key factor in this discrepancy was the reward system that gave profits to the doctors for the quantity of care provided, regardless of the result. The doctors in McAllen took advantage of this, and existed in a “profit-maximizing world.” They even owned stake in health services around the city. After publishing the piece, Gawande watched the backlash unfold. He’s told there was a lot of finger pointing and anger. The medical community had felt singled out by his article. But through this came change. Medicare costs dropped about three thousand per patient. The taxpayers saved almost half a billion dollars.
Fortunately, providing quality care can be rewarded. Gawande writes of Armando Osio, a 63-year old primary care physician in McAllen, TX. He hadn’t participated in the over treatment of his patients, and was making a modest income compared to the specialty doctors in the area. A group called WellMed contacted him, wanting to establish a practice with him. WellMed said that if he improved quality of care, and ultimately saved money, he would receive bonuses based on that. He agreed and began to practice the way he wished, spending a longer amount of time with patients and improving customer satisfaction, and being rewarded for doing right by the patient.
In one case, Osio worked with an older man with diabetes. The man had some misunderstandings about his medication, the complications of diabetes, and how to care for himself. Although the man didn’t look sick, his vitals showed his body was in panic. Previously, Osio would have had to send him to the hospital, where they would have done tests, given him medication, and sent him on his way–no better than he was before, and thousands of dollars spent. Osio’s new focus of quality of care gave him the time to educate the man, and connect him with their diabetes educator to discuss his medications and set up weekly checkup calls. The man could now live a much healthier, more manageable life with diabetes. And not only that, but Osio was rewarded, and began making much more than he had prior to WellMed. This model works–after speaking more with WellMed about their practice, Gawande learned that although the population that WellMed was serving included older and sicker patients, the death rate of their patients was half that of other clinics in the Texas area.
While the trend is leading towards a focus on quality over quantity, Gawande wonders, could there be proponents against this type of healthcare, could there be backlash? This model values eliminating unnecessary spending, but what if a surgery goes undone or images aren’t taken, and it turns out it should have? “It’s possible that we will calibrate things wrongly, and skate past the point where conservative care becomes inadequate care,” Gawande writes.
In the end, Gawande believes that we’re headed in the right direction, “As long as a more thoughtful, more measured style of medicine keeps improving outcomes, change should be easy to cheer for.”