Monday, August 15, 2011

Newsweek - Just Say No! - One Word Can Save Your Life. Too Simplistic. Doctors Need to Help.

Newsweek has a very provocative and yet incredibly too simplistic piece for the public and patients on its cover story - One Word Can Save Your Life: No! - New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good.

The piece is actually well written and highlights facts that have been apparent for some time.  More intervention and treatment isn't necessarily better.  Having a cardiac catheterization or open heart surgery for patients with stable heart disease and mild chest pain isn't better than diet, exercise, and the prescription medication treatment.  PSA, the blood test previously suggested by many professional organizations, isn't helpful to screen for prostate cancer, even though the value of the test was questioned years ago.  Antibiotics for sinus infection?  Usually not helpful.

Certainly doctors do bear part of the blame.  If patients are getting routine colonoscopies sooner than every 10 years or are getting them despite being quite a bit older (80 and older) and frail, then clearly patients should say no to more care.  More isn't better.  (Whether a patient has the conviction to do so is another story.  When my auto mechanic says it is time to change the brakes or change the oil, who am I to say no?)

But the overtreatment and overuse of medical technology does not just fall on the doctors.  It is also the patients' and the public's perception of what is the right care.  Whether this perception was shaped by doctors, the media, movies and television shows, or patients comparing notes is hard to say, but the reality is patients have a certain expectation of what should be done which often is in stark contrast to the right thing to do.  For low back pain, many patients simply want a MRI and avoid an examination or visit.  After all, isn't the truth in the MRI?  Isn't talking to a patient and examining his back, knee and ankle reflexes, evaluating for joint strength and sensation simply from a by-gone era that is antiquated in the 21st century?  Do patients know the limitations of our understanding not in the history or physical examination honed by generations of doctors before us, but the shiny new piece of technology rolled out annually by General Electric?  As Dr. Michael Lauer, a cardiologist of the National Heart, Lung, and Blood Institute noted in the piece, “Our imaging and diagnostic tests are so good, we can see things we couldn’t see before...But our ability to understand what we’re seeing and to know if we should intervene hasn’t kept up.”

Doctors who do provide the right care, which often is low tech and common sense, might be viewed as denying care.  If a patient has chest pain which is easily treated with a statin (cholesterol lowering) drug and beta-blocker and a cardiologist is not needed for further intervention, do you think the patient or the family will feel more relieved or more anxious?  If a stress test isn't offered to an otherwise healthy middle aged man as part of a physical (or at a minimum an EKG) and yet is offered the identical tests as part of an executive physical, do you think the public at large will feel better or worse in not having the tests, which are correctly noted in the article not proven to save lives?  (It is ironic that although fantastic experts are quoted in the piece including Dr. Steven Nissen, a cardiologist at Cleveland Clinic, his organization offers executive physicals, which you guessed it provide many of these tests and interventions to paying clients.  Though the results of the majority of the tests are normal it is that remote possibility that something might be wrong and the basis of the testimonials on the website that have the public clamoring for more testing and treatments).

In today's society where news is disseminated as sound bites or tweets, I am concerned about the unintended implications this Newsweek story will bring: patients will say no to everything.  Based on a well written, though not entirely balanced article, patients will anchor their decisions to default to no based on this small piece of information.  It has already occurred with vaccinations.  As the National Committee for Quality Assurance noted in its 2010 State of Health Care Quality report, childhood immunization rates for those in private insurance has actually fallen compared to those in public insurance (Medicaid) plans.

Childhood vaccination rates in 2009 declined by almost four percentage points in commercial plans.
A possible cause of this drop is commercial plan parents may refuse vaccines for their children based on the unproven, but increasingly popular, notion that vaccines cause autism. Celebrity activists are outspoken advocates of this view. Interestingly, we see vaccination rates in Medicaid – the program serving the poor – continuing to steadily improve.  
“The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation,” said NCQA President Margaret E. O’Kane. “All of us in health care need to work together to get better information to the public.”
The State of Health Care Quality Report examined quality data from over 1,000 health plans that collectively cover 118 million Americans.

Because of the complexity, nuances, and ever changing nature of medicine, patients more than ever need doctors to lead and be firm on what works and what does not.  The anecdotal quote by a doctor who opted not to have a mammogram should be taken as one person's opinion and not a recommendation for all women to do the same.  Having patients say no or expecting them to make the right decisions for themselves and family is not how the country will get better care.  A recent NY Times piece by Dr. Pauline Chen titled Letting Doctors Make Tough Decisions could not have been more timely.

... a new study reveals that too much physician restraint may not be all that good for the patient — and perhaps may even be unethical. While doctors might equate letting patients make their own decisions with respect, a large number of patients don’t see it that way. In fact, it appears that a majority of patients are being left to make decisions that they never wanted to in the first place….

The challenges appear to arise not when the medical choices are obvious, but when the best option for a patient is uncertain. In these situations, when doctors pass the burden of decision-making to a patient or family, it can exacerbate an already stressful situation. “If a physician with all of his or her clinical experience is feeling that much uncertainty,” Dr. Curlin said, “imagine what kind of serious anxiety and confusion the patient and family may be feeling.”

Medical choices are not as obvious.  Today the vast amount of information and choices are overwhelming.  The easy and natural thing to do is to run away or bury our heads in the sand, or simply say no when decisions are complex. 

The Newsweek article concludes -

Many doctors don’t seem to be getting the message about useless and harmful health care. Medicare pays them more than $100 million a year for screening colonoscopies; some 40 percent are for people in whom they will almost certainly harm more than help. Arthroscopic knee surgery for osteoarthritis is performed about 650,000 times a year; studies show that it, too, is no more effective than placebo treatment, yet taxpayers and private insurers pay for it. And although several large studies, including the Occluded Artery Trial in 2006, have shown that inserting a stent to prop open a blocked artery more than 24 hours after a heart attack does not improve survival rates or reduce the risk of another coronary compared with drugs alone, the practice continues at a rate of 100,000 such procedures a year, estimate researchers led by Dr. Judith Hochman, a cardiologist at New York University. “We’re killing more people than we’re saving with these procedures,” says UT’s Goodwin. “It’s as simple as that.”

Actually, I think doctors are getting the message as Dr. Atul Gawande noted in the June 2009, New Yorker piece Cost Conundrum.  Doctors are compensated more to do more.  Even medical students get the message.  Increasingly more are becoming specialists as reimbursement is far more lucrative in doing procedures than it is to simply talk and counsel patients.

The Newsweek piece tries to simplify the problem too easily by hinting to patients that saying no is a good thing rather than challenging patients to have an open-minded, important and thoughtful conversation about the advantages and disadvantages of having certain tests or treatments with their primary care doctor.  Of course since fewer medical students want to do primary care, my job and those of my colleagues in family medicine and internal medicine just got a lot harder.

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