Sunday, February 13, 2011

Overtreatment and Unnecessary Medical Care: Healthcare's Biggest Threat

My daughter, Elana, home from college on winter break, offered me a book to peruse from one of her classes. She correctly suspected that her father, the Whistleblower, would enjoy reading a book authored by a Whistleblower pro.

The book, Overtreated, by Shannon Brownlee, should be required reading for first year medical students, who have not yet acquired views and habits that promulgate excessive medical care and treatment. For those of us already in practice, this book should be a required element of board recertification. The theme of the book appears as a subtitle on the cover.

Why Too Much Medicine is Making us Sicker and Poorer

Brownlee understands the medical system well and describes a culture of excess, conflicts of interests, absence of universal quality control mechanisms and fractured and disorganized care with no one in charge of a particular patient. She presents some chilling anecdotes of medical tragedies that have occurred at our most prestigious medical institutions. And she introduces us to reform leaders who understand the system’s inherent deficiencies and their proposals to remedy them.

Brownlee states that explanations for waste in the health care system include:
  • Cost of a gargantuan bureaucracy
  • Medical malpractice fear and defensive medicine
  • Incentives for patients with medical insurance to overutilize care
  • Rising medical costs
The most important cause, she argues, is unnecessary medical care, which costs the nations hundreds of billions of dollars and exposes patients to the risk of harm from medical complications. She writes: If overtreatment were a disease, there would be a patient advocacy group out there raising money for a cure. She points out numerous conflicts of interest in the system where medical incomes rise when medical outcomes decline. She shares the views of early medical reformers, iconoclasts, who are now firmly in the mainstream of medical reform efforts. She gives the history the development of the understanding of geographic variability in medical costs and outcomes. She explains why spending more on health care oven leads to worse health for patients. The reader will see the familiar statistics comparing the United States to other nations who spend far less than we do and enjoy better health.

The book was published in 2007, before the divisive national debate on Obamacare took place. But, the book is not dated and the issues are highly relevant. The book reminded me of Atul Gawande’s remarkable and influential essay published in New Yorker Magazine in 2009. Gawande’s piece impressed one reader so powerfully, that he required his entire presidential cabinet to read the article.

I haven’t finished the book yet, but I intend to. I award Brownlee’s book with the coveted Whistleblower Seal of Excellence. Even a perusal of the first few chapters would be worthwhile.

I hope that you will consider reading it and recommending it to others. Why not leave a copy in your medical office waiting room or on your coffee table at home? You might consult it before you sign up for the total body scan being advertised in your newspaper.

My deep concern is that Overtreated will be Underread.

13 comments:

marilynmann said...

I generally agree with Brownlee that there is a lot of overtreatment in this country, but I don't always agree with her on specifics. On the issue of flu vaccines, for example. See this November 2009 article in the Atlantic: Does the vaccine matter? by Shannon Brownlee and Jeanne Lenzer.
http://www.theatlantic.com/magazine/toc/2009/11/

A problem closely related to overtreatment is overdiagnosis. Here's another book to put on your reading list, if you have not already done so:

Overdiagnosed: Making People Sick in the Pursuit of Health, by H. Gilbert Welch, Lisa Schwartz, Steve Woloshin

A. Bailey said...

None of this is new, of course.

Thus saith the Rules of the House, verse 13:

THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

I was brought up on this as a house officer, and it did me well right up to the day I entered fee-for-service medicine.

Anyway, may I share a question that has bothered me for the last several months as I contemplate the behavior of a "colleague"?

Can we tell the difference between someone who churns, vs. someone who is very compulsive, vs. someone who is profoundly risk-adversive, vs. someone who is very insecure and hasn't learned to trust themselves enough not to repeat colonoscopies every six months in order not to miss anything?

I used to think I could, but now I don't think I can.

Doc, do you know people who do way too many colonoscopies but are motivated by factors other than the profit motive?

Jaime K. said...

I also recently read Brownlee's book and couldn't agree with you more. I am sharing it with my nephew who is currently a med student and I hope he passes it along too. We have a lot to learn from Brownlee and the failings of our medical system. Thanks, Doc, for putting it on the forefront.

Anonymous said...

A young friend of mine went off to medical school a couple of years ago. I had just finished doing a lot of reading as I helped hubby research his own book "Too Profitable to Cure." Despite the wealth of insight I learned during my research, I gifted my young friend with a copy of "Hippocrates' Shadow" by David H. Newman, MD as she began her arduous journey. I might suggest THIS as required reading, as it emphasizes (among other things) the lost art of listening and patient-doctor partnership.

Melody

Michael Kirsch, M.D. said...

Great comments, all. @A Bailey, tough questions you pose. There are many reasons why physicians order procedures. Often, I think we blend several of these reasons when we recommend a test. We may do so because of medical need, litigation fear, patient demand, insecurity or for profit, among other reasons.

The Medical Contrarian said...

Great post! Sounds like a number of must reads here. Regarding the risk of over use of medical technology, you should read Bob Wachtner's blog on the risks of imaging.

http://community.the-hospitalist.org/blogs/wachters_world/archive/2011/02/11/a-game-changing-statistic-1-in-250.aspx

BobbyG said...

See also "Overdo$ed America." And, many of Dr. Robert Burton's writings regarding "the Worried Well." Joe Flower also has some spot-on commentary in his "Five Frameworks..." series.

A. Bailey said...

What we need is massive amounts of Federal legislation controlling the ordering of tests and therapy in order to rein in escalating health care costs.

Anonymous said...

Dear MD Whistleblower,


My name is Barbara O’Brien and I am a political blogger. Just had a question about your blog and couldn’t find an email—please get back to me as soon as you can (barbaraobrien(at)maacenter.org)

Thanks,
Barbara

Michael Kirsch, M.D. said...

@A. Bailey, sarcasm noted and appreciated!

Shannon said...

Dr. Kirsch,

Thanks for your kind words about Overtreated. I enjoyed your podcasts, too. One doctor told me that there would always be defensive medicine until the patient's right to sue was completely eliminated!

Here's a thought about tort reform: what if we changed the standard of informed consent to ensure that patients really are informed about tradeoffs involved in elective procedures and tests, and that physicians share the decision more?

Shannon Brownlee
(If you'd like to email me, just google Brownlee and New America Foundation.)

Susan said...

"Incentives for patients with medical insurance to over-utilize care...." Exactly why we must empower people to question their providers. This has some ideas: http://whatstherealcost.org/video.php?post=five-questions

Merr Hap said...

over-treatment that's dangerous. we actually suspected that my grandfather died because of over-treatment but there's no way we can prove it. we don't know anything, we just put our faith in the hands of the medical team whose handling my grand.

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