Nothing is more pervasive in our medical consciousness than the idea that seeing a doctor, getting regular tests and cancer screens, and treating/fixing problems will keep us healthier. Up to a point this is correct; if we have symptoms of illness or are impaired medically there are certain tests and treatments that can help. But we have taken this notion too far, with the result being a financial collapse of our health care delivery system, harm needlessly inflicted on older people, and financial benefit to certain segments of our society (including many administators and specialiasts). Over-treatment is an epidemic in this country, spurred on by the discredited illusion that we can find and fix problems with certainty, and that such probing/treating will improve our well being and allow us to live longer. The Institute of Medicine estimates that 30% of all medical tests, medicines, and procedures are unnecessary at a cost of $750 billion a year. Meanwhile, if we look at Blue Zones in the world, places where people live the longest, most have virtually no reliance on modern medical care. Instead they look to themselves and their communities to stay healthy.
We have spent much time in this blog dismissing many certainties about medical intervention, showing that the relative benefits touted by the press and many doctors translate to negligible absolute benefits, and that many “standard of care” interventions actually cause substantial harm. In my other website at www.doc-patient-talk.com Erik Rifkin and I use BRCTs to show the actual risks and benefits of many interventions, few of which are truly impactful to an individual’s health. Our recent blog on cardiac stents demonstrates just how dangerous and ineffective this well-compensated and over-done medical procedure is (CLICK HERE to see the blog) despite public perception to the contrary. We show that very few cardiologists actually discuss the risks and benefits of stenting before performing the test. When they do discuss it, virtually no patients opt to get stents. When they do not discuss it, virtually all patients get stents.
Such a revelation should open eyes and point to what is likely the most onerous cause of our current medical over-treatment crisis: the failure of medical practitioners and the press to provide patients with actual risk/benefit information that they can understand and which leads to individualized provider-patient discourse about medical interventions. Medicare’s quality indicators discourage such discussions; by simply grading practitioners on how many numbers they fix and how many tests they order, Medicare is dissuading doctors and nurse practitioners from giving patients any choice. A patient who looks at actual risks and benefits and decides not to take Warfarin for afib, or not to lower blood pressure below 120, or not to get a mammogram, or not to get bone density screening, will reflect badly on the practitioner’s measures of quality, which insist that certain numbers must be righted and certain tests must be ordered. And progressively, under the banner of health care reform, such measures of quality directly impact physician and nurse practitioner reimbursement. Why have the discussion and encourage shared decision making, which is time consuming and requires independent thought, when the patient may well decide to follow a course that makes the practitioner look “bad” in the eyes of quality indicators? Why not just follow the script and tell the patient what to do, order tests and medicines, and keep the visit safe and simple? Better to over-medicate and over-test, despite the potentially harmful effects on the patient (such as dropping blood pressure too low which can cause a hip fracture, dizziness, memory loss, feinting, but which adheres to quality guidelines), then to take the risk of discussing issues.
Many patients too believe that tests and medicines and procedures are going to be helpful; it is a myth sewn into their thinking by society’s incessant messaging. Afterall, it makes sense that if an artery in the heart is 80% narrowed we should put in a stent and open it; that looking for blockages in carotid arteries can’t do any harm and may reveal a silent problem that could otherwise cause a stroke if left unfixed (see BRCT showing the false positive rate, leading to potentially harmful tests and treatments);
that performing preventive tests like cholesterol screening, mammograms, PSAs, bone density tests, and lung cancer screens may similarly find problems before they become untreatable; that pushing blood pressure and sugars as low as possible can only be helpful; that looking for a cause of dementia and giving maximum drugs to fix it is the most thorough way to address this terrible disease. As I show in my book and in the blog, none of this is true. In fact, many such interventions are typically minimally effective at best and often potentially harmful. As we throw medicines and tests and procedures one after another upon the backs of our elderly, stress intensifies, side effects increase, and the benefits diminish. Aggressive care, despite the illusion to the contrary, can be much more harmful than helpful to so many people, while it drains Medicare of its funding at a rapid rate.
Perhaps the most damaging ramification of the myth of medical intervention is that it removes the onus of medical care from the patient and puts it on the lap of the practitioner. We no longer believe that we have the capacity or the need to heal ourselves; there are pills and tests and treatments that can keep us healthy. No wonder that people are getting fatter and lazier, no wonder that life expectancy among white Americans is actually decreasing. Nothing symbolizes that myth more than the use of artificial sweeteners. We know that consuming too much sugar is bad, but we can still have our cake and cookies and sweet coffee just by putting in spenda and not changing our actual behavior. In fact, recent studies show that the use of these sweeteners actually increases obesity and the chance of getting diabetes, with a plausible biologic reason to explain it. Will this convince people to make real changes in diet rather than trying to cheat the system by using fake sugar? Very unlikely! We do not have to make difficult choices to improve our health when there is a chemical that can do it for us. Such a fallacious assumption is entwined in all medical thinking as well.
Many patients with memory loss advocate for aggressive strategies to find the cause of their dementia, and then to treat it equally aggressively. We know that the search for any reversible triggers of dementia is basically futile; out of 1000 people who undergo such testing, only 3 find treatable causes (see BRCT), and virtually all of those problems are found by the primary care providers with basic tests.
That does not stop my patients and their families from seeing specialist after specialist, getting test after test, to pin down the reason for their loved one’s memory loss. Similarly, many specialist doctors throw pills into the guts of these patients, often at high doses and in high numbers, despite a paucity of evidence to suggest that these medicines have any meaningful impact on memory, and despite evidence that shows they can cause substantial harm. In reality, while memory pills can minimally help people do better on a 70 point memory test (30% of people with placebo improve, an additional 9% of people on the drugs improve), this “improvement” does not translate into anything clinically meaningful, it wears off within a year, and it is no better in combination or higher dosage than lower dose. Most importantly, it does nothing to actually treat the dementia, and it can lead to serious side effects far too frequently, such as 10% of patients who have severe weight loss.
A recent study showed that among people who exercise regularly compared to people who do not exercise, memory loss can be delayed by 10 years. We know that physical exercise helps prevent and treat memory loss. We know that brain exercises and socialization do as well. But few patients choose to purse these easy self-help strategies we know are effective. They look to “experts” in memory loss who order tests and medicines, all of which Medicare will pay for; Medicare does not help pay for gym membership or home daycare. And so instead of working to help themselves, instead of accommodating to the disease and devising strategies to mitigate its progression, they enter the realm of medical fantasy, something pushed on them by “experts” and by the media and internet, and take drugs and undergo tests in the hope of being aggressive and thorough in confronting their disease. None of this works much beyond that of placebo. And by taking this dangerous and expensive road, they are turning their backs on self-reliance and common sense.
This is no different than people who get regular heart stress tests and take statin cholesterol medicines instead of losing weight and exercising as they try to avoid a heart attack. Than people who undergo lung CT scans rather than quitting smoking in the hope they will avoid lung cancer. Than people who take medicines to drop their sugars and blood pressures as low as possible, even to the point of being weak and dizzy, rather than change their lifestyle and accept more sensible numerical objectives. We think that the harder we push, the more we rely on health care practitioners to extirpate disease and stamp out bad humors, then the less we have to do for ourselves, and the healthier we will be. And the unfortunate news is that Medicare will not only pay patients and doctors to engage in that quixotic pursuit, but it will reward practitioners with high grades of quality when they turn their backs on shared decision making and over-treat their patients. Outcome means nothing. Checking off the right boxes is where medical care has moved under the umbrella of health care reform.
In the end, we must push back, both as health care providers and patients. We must insist that reason and sense rise up and squelch the grand illusion that has infiltrated our medical thinking. Medicare can be a tool to help make this happen. It can pay less for tests and procedures, and pay more for practitioner-patient discourse. It can change quality indicators so that they judge practitioners by whether they have meaningful discussions using reliable measures of benefit and risk, and not concern themselves with which paths patients choose to follow. Ultimately, when patients move back to being in charge of their own health, when they can transcend the grand illusion by acquiring reliable medical knowledge and be afforded the opportunity to speak to their health care providers about which interventions seem most beneficial to them, then over-treatment will diminish, cost will drop, outcomes will improve, and satisfaction for both practitioner and patient will increase. We don’t need complicated solutions to the Medicare mess to save it from itself. We just need a very small change in direction. It is up to us to make sure this gets done.
The True Value of Primary Care
March 22, 2015
changing the fate of primary care
October 10, 2014
The Great Myth: Why Health Care Reform is Failing both Patients and Practitioners