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Mar. 06, 2015

There Is Such a Thing As Too Much Medical Care

by H. Gilbert Welch

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The following is an excerpt from Less Medicine, More Health by H. Gilbert Welch. Listen to SciFri on Friday, March 6, to hear Welch talk about the misconceptions of medical care.
 
We Americans consume a lot of medical care. By some metrics, we are the most medicalized society in the world. To be sure, there is an increasing amount of competition on this front as more and more of the developed world gives us a run for our money.
 
You might think that the biggest problem in medical care is that it costs too much. Or that health insurance is too expensive, too uneven, too complicated—and gives you too many forms to fill out. But the central problem is that too much medical care has too little value.
 
That’s right, there can be too much medical care. Obviously this is not a problem for everyone, and it certainly isn’t meant to deny that some people get too little medical care. But there has been a growing recognition that the conventional concern about “too little” needs to be balanced with a concern about “too much.”
 
In a recent national survey of primary care physicians published by Archives of Internal Medicine, nearly one-half said their patients received too much medical care. Don’t miss the fact that’s the doctors talking.
 
Can you imagine the dentists saying that? Or the small animal vets?
 
And too much is not simply meant to imply wasteful care, but also harmful care.
 
I’ve been trying to raise physician consciousness about this problem for years. But some doctors don’t need their consciousness raised—they know the problem better than I. After giving medical grand rounds at the University of Cincinnati, one came up to tell me a story. Not about one of his patients, but about his father.
 
Mr. Nadeau was eighty-five and in excellent health. He went to see his doctor simply for a routine checkup. The doctor performed a careful physical exam. Everything looked good, except for a bulge he thought he felt in Mr. Nadeau’s belly—a bulge that might be an abdominal aortic aneurysm. An aneurysm is a ballooning of a blood vessel. As the blood vessel balloons, the vessel wall stretches, thins, and can rupture. The aorta is the largest blood vessel in the body. It originates in the heart, travels upwards in the chest (to supply blood to the head and arms), and then curves downwards into the abdomen (to supply blood to the digestive tract, kidneys, and legs). A ruptured abdominal aorta can cause massive blood loss and sudden death. That’s worrisome.
 
So the doctor ordered an abdominal ultrasound, the same technology used to show expectant mothers their baby. The ultrasound showed that Mr. Nadeau’s aorta was normal—there was no abdominal aortic aneurysm. But the ultrasound found something else to worry about. It found something abnormal on Mr. Nadeau’s pancreas. The radiologist thought it was a small growth. It had nothing to do with what the doctor felt on the physical exam; it was way too small to be felt. But it still could be cancer.
 
She recommended a CT scan of the abdomen, an exam that combines X-rays and computing power to produce a more detailed picture than ultrasound. The CT scan showed the pancreas was normal.
 
But the CT scan found something else to worry about. It found a nodule on Mr. Nadeau’s liver. The radiologist recommended a liver biopsy to see what the nodule was (it could be cancer too). To biopsy a liver nodule a gastroenterologist inserts a needle through the skin, through the liver, and into the nodule. To cut out a piece of tissue big enough for a pathologist to examine under a microscope, the gastroenterologist has to use a good-sized needle, roughly the caliber of a small knitting needle.
 
The pathologic diagnosis was hemangioma, a benign growth made up of lots of blood vessels. Given that a small knitting needle was cutting through a growth full of blood vessels, you won’t be surprised by what happened next.
 
Bleeding. Mr. Nadeau was in the hospital for a week. He needed about ten units of blood (his physician son had a hard time keeping count). He was in a lot of pain and was given morphine. Once patients are on pain medications and bedridden in the hospital, other things happen. Mr. Nadeau was no exception: he became unable to pee. He had to have a urinary catheter put in. It was an ordeal. Although Mr. Nadeau did not die, he could have.
 
That’s too much medicine.
 
It’s tempting to look for someone to blame here—someone who has made a mistake. Maybe the gastroenterologist should have decided to watch the nodule, instead of biopsying it. Maybe the radiologist should have recognized that the nodule was a hemangioma. Maybe the primary care doctor should not have examined Mr. Nadeau’s abdomen. Maybe Mr. Nadeau should not have gone in for a checkup in the first place.
 
Or maybe all of us should reconsider our assumptions and expectations for medical care.
 
If you wonder whether Mr. Nadeau’s story of harmful medical care is one of a kind, I suggest you see a doctor. Ask him or her. I bet you’ll hear another story.
 
Too many people are being made to worry about diseases they don’t have and are at only average risk to get. You may not consider that a harm, but remember health is not simply a state of physical being—it’s also a state of mind.
 
Too many people are being tested and exposed to the harmful effects of the testing process: the anxiety of false alarms and the vulnerability caused by ambiguous findings (“you don’t have the disease, but you aren’t normal”). Not to mention the complications of diagnostic procedures.
 
Too many people are being treated with treatments they don’t need or can’t benefit from. Treatment interventions can have substantial physical harms such as medication reactions, surgical complications, even death.
 
How did we get here?
 
The doctors’ standard answer to the question is: lawyers. We call it defensive medicine. Fear of malpractice does influence our behavior, but it’s clearly not the whole story. I ask my colleagues who blame lawyers to consider this thought experiment: Would the problems of overuse simply disappear if the lawyers simply disappeared? That tends to help them understand that a myriad of forces are at play.
 
The economists’ standard answer to the question is (surprise) economics. Here’s how they see it: physicians are paid more to do more, and insurance, not the patient, foots most of the bill. Paying physicians a fee every time they provide a service encourages them to order more tests and procedures. Because patients are shielded from the cost by a third party (the insurer), they have little incentive to scrutinize the value of the services. In other words, economists see the combination of fee for service and third-party payment as a powerful recipe for too much care.
 
I think of it as the free food problem. In my younger days, hospitals routinely gave doctors in training, even lowly medical students, free food. Not that it was that good; this was the era when the term “hospital food” was right up there with “school lunch.” But it was free. Instead of deciding between two entrees, I just got both. And I’d eat both. Plus, since somewhere in the hospital there always seemed to be a staff member having a birthday, I could always manage to find free dessert at a nursing station.
 
Now my problem is at medical conferences. To be sure, the food has gotten healthier—less fat, less sugar, less processed—but it’s still free (more precisely, wrapped into the registration fee). But the end result is the same. I eat too much.
 
And don’t get me started on “all you can eat” buffets.
 
Note that the free food problem exists even without the fee for service incentive. Imagine free food and paying food-service workers more to put more food on your plate. Can you say gluttony? So the economists have a point: incentives matter. But there is a wrinkle. You can’t just grab some medical care to go. It takes time—and can have some annoying qualities. Plus it generally doesn’t taste that good. So the source of too much medical care must be more complicated than free food.
 
The recipe of adding fee for service to third-party payment to cook up too much medical care would not work without strong underlying beliefs about the value of the product. The general public harbors assumptions about medical care that encourage overuse. Assumptions like: it’s always better to fix the problem, sooner (or newer) is always better, or it never hurts to get more information.
 
I’m not blaming the public; many of these assumptions flow directly from information provided to them, be it from the news media, talk shows, advertising, PR campaigns, disease advocacy groups, public service announcements, or doctors themselves.
 
Regardless of their source, these assumptions lead individuals to have an excessively optimistic view of medical care. That leads them to seek—some would say to demand, others to accept—too much care. These assumptions also drive public policy in the same direction, to our detriment.
 
A growing number of doctors understand that the prevailing assumptions drive too much medical care. Some of them have contributed to this book through their writing and research. And while more and more doctors recognize that these assumptions are erroneous, they still assume it’s what their patients assume, and so they act accordingly. The truth is that doctors find it’s much harder to challenge the assumptions than to go with the flow.
 
This book is about challenging these assumptions—and helping us all avoid too much medical care.
 
 

Excerpted from Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care by Dr. H. Gilbert Welch, (Beacon Press, 2015 ). Reprinted with permission by Beacon Press.

 
Author photo by Mark Washburn
About H. Gilbert Welch

Dr. H. Gilbert Welch is an academic physician, a professor at Dartmouth Medical School, and a nationally recognized expert on the effects of medical testing. Dr. Welch is the author of three previous books.

The views expressed are those of the author and are not necessarily those of Science Friday.

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