Sunday, June 10, 2012

Choose Wisely Takes Aim at Unneccessary Medical Tests. Shooting Blanks?

Low Hanging Fruit

As I write this, it is months away from the election. The election season has been fascinating. I watched many of the Republican ‘debates’ which ranged from informative to entertaining to absurd. Candidates came and candidates went. Many enjoyed short lived surges, only to flame out afterwards. I was drawn early on to Jon Huntsman, but it seems that decent folks who tell the truth without pandering can’t succeed.

So, now we are left with Romney vs Obama, a contest that at present seems too close to call.  The continued anemic job creation statistics, which may not be the president's fault, will hurt him.  If the economy appears to creep forward in the months ahead, and there are no unforeseen events to sandbag the president, then I think he will prevail. It is the unforeseen that worries the Democrats. If several economies in Europe implode and drag us to the edge of the cliff, it will have a political impact here in November.

Neither candidate is ideal. Romney can be rightfully criticized for is ‘evolving’ political views and for lacking a real connection with everyday Americans, many of whom are suffering. Obama has resorted to classic class warfare, aiming his populist message to exploit envy for votes. His legislative triumph, Obamacare, is deeply flawed and was rammed through the legislature. Soon, the Supreme Court of the United States will decide if the law, particularly the individual mandate, is unconstitutional.

My advice? Choose wisely.

A new program called Choose Wisely was launched earlier this year, which deserves our close attention and support. It aims to eliminate unnecessary medical testing which accomplishes two important goals. It saves money and improves medical quality. The effort is under the aegis of the American Board of Internal Medicine Foundation and will continue for several years. Numerous medical societies and Consumer Reports will each identify medical tests and treatments that are being over utilized and should be curtailed. I am pleased that the American Gastroenterological Association is participating.

I’ll paraphrase some of the recommendations from the various participating societies.

  • Don’t give cancer patients chemo if it won’t do them any good.
  • Don’t subject patients to unnecessary colonoscopies.
  • Do not perform routine preventive medical tests on dialysis patients who don’t have long to live.
  • Do not perform electrocardiograms (EKGs) each year on healthy patients who don’t need them.
  • Do not perform cardiac stress tests on patients who do not need them.
Yeah, these suggestions sound absurd, but I guess we have to start somewhere. The medical societies are not just picking low hanging fruit, they’re picking fallen fruit that's on the ground. These initial recommendations are not controversial. At present, there is no surgical society participating. If there were, we could expect a bold recommendation such as ‘do not remove a gallbladder just because it’s there’.

Choose Wisely will confront obstacles and push back once the low fruit has been cleared. It will be very difficult to reach the fruit hanging on the higher branches. Physicians, pharmaceutical folks, medical device companies and hospitals have never been inclined to sacrifice their incomes to serve the greater good. This is why comparative effectiveness research (CER), a feature of Obamacare that I do support, will have great difficulty gaining traction. Any reform that saves health care dollars reduces some group’s income. Guess what happens then.

I support Choose Wisely, but I don’t find the opening recommendations to be all that wise. Shouldn’t we physicians already know not to perform unnecessary medical tests and treatments that patients don’t need? At least now, the public will be armed with official information to enable them to advocate more effectively for themselves.

As the program matures, the choices will become more controversial. There will be spirited disagreement over whether a medical intervention is unnecessary. I predict that those who stand to lose economically will take positions that protect their revenue stream. Indeed, voters may do the same thing this November.



8 comments:

Unknown said...

Michael,

Thank you for your thoughts; I enjoy your blog and agree with a great deal of what you said. I am an anesthesiologist and physician executive, and I certainly see a great deal of unnecessary testing and procedures. As a profession, we owe it to our patients to reduce this in a thoughtful fashion, and the initial recommendations you mention do seem a little weak.

There is however, danger in these waters. The reason that I have time to write this today is that I am home recovering from a prostatectomy. That journey began with a screening PSA last December and were it not for that test my life expectancy would be considerably reduced. I am 55.

I underwent two biopsies to find the cancer; both of which resulted in inconvenient but not harmful bleeding. I had only local anesthesia for them and there was little post procedural pain. The reason I had a second biopsy is that a few atypical cells (PIN) were found in the first but no cancer, and my urologist wisely guided me to a second biopsy.

I had a small and early (Gleason 6) cancer on the second biopsy. I delayed surgery 3 1/2 months to allow the tissues to heal after the biopsies and to take care of some personal matters. In that time I advanced from a Gleason 6 to a 7, and the cancer was bilateral and at the margins of the gland. Fortunately, there is no evidence that it spread beyond the prostate. This was a case of catching it just in time.

My personal story is relevant in the face of the recent recommendations from the US Preventive Services Task Force suggesting that the PSA is a “harmful” test. The task force is chaired by a (female) pediatrician and no urologist sits on it. They suggest that PSA harms patients because it leads to biopsies and perhaps treatment for a cancer that is slow growing and may not need to be treated.

Taken in context there is probably a lot of truth in that. If I were 75 or 80 with multiple other diseases; I could have been harmed by the workup or the surgery, and it would be much more likely that I die of something else.

Little in our world is taken in context however, and for a man my age, the risk of death and serious morbidity from the cancer far outweighs the treatment risk. Had I not had the PSA, it is very possible that my first signal of trouble would have been pain from bony metastases. A blanket recommendation against PSA testing is irresponsible in a world that communicates in 30 second sound bites, instant YouTube fame, and Facebook “likes”. I hope this recommendation is not taken seriously.

What IS needed, is thoughtful, honest discussion between physicians and patients taking into account ALL relevant factors. Because of time and increasing economic pressure however; physicians are finding themselves with less and less time to engage in such activities. Much of this time pressure is created by government agencies like the task force which make irresponsible pronouncements; many of which result in mandates requiring considerable physician effort and time and yet are uncompensated.

Let’s make progress by all means. Let’s stop doing unnecessary tests and procedures. First though, let’s get government OUT of the physician-patient relationship.

Never Again said...

How about leaving out the "sedation?" It adds enormous cost and really, does EVERYBODY need amnesia? This is such a bad drug for so many people. I didn't get amnesia, and it completely SCATTERED my thought processes and I haven't returned to normal. I don't expect to at this point, I have a "new normal" in which my formerly high IQ brain functions at a much lower level. Of course it was profitable for the hospital to give me this drug. Plus it was profitable for the counselor I had to see for years. It's profitable for the Lexapro people, and the Amitiriptiline manufacturers as well. Do I have to tell you that I will never have any of the tests where Versed is routinely used? Saving for me, for a while.

Michael Kirsch, M.D. said...

To my anesthesia colleague, the government and insurance companies are already interfering with our relationships with patients, and it will only be getting worse. the profession is changing and I fear, that physicians and the public will face great challenges. The Supreme Court may issue its Obamacare ruling today.

Payam said...

To my GI and anesthesia colleagues, you both raise great points. As an interventional cardiologist, i can tell you that perhaps no other field of medicine is being scrutinized more than mine, with the recent slew of "unnecessary stenting." The elephant in the room: we spend more healthcare dollars per person than any other developed country, and we are the unhealthiest people. The one thing that will definitely drive US debt higher than GDP is uncontrolled healthcare spending. I think all docs can point to anecdotal stories about how catastrophe was averted by ordering a test or doing a procedure (no offense to your personal prostate cancer story) . But there is no denying the evidence that more is not always better. Patients (and even docs) cannot understand why a 70% mid LAD stenosis does not necessarily need a stent, especially if asymptomatic. But, as it stands, the whole system is geared towards "doing more." Patients want that MRI for back pain, hospitals want the MRI for revenue, and docs want the MRI because they don't get paid for tobacco counseling and diet education. It's a model thats unsustainable.

Chris Cantilena said...

No argument that reducing unnecessary tests and procedures is a good thing to do. My argument is that the decision properly rests in the physician-patient relationship. It is not the purview of government or its advisory bodies, or the media to frighten patients away from something that MAY be immensely beneficial.

I am the anesthesiologist above, btw...I didn't mean to post anonymously but couldn't figure out how to put my name on it.

As for the elephant in the room...I think that beast is patient responsibility.

Michael Kirsch, M.D. said...

Thanks, Chris. I agree that the decision should be left in the exam room with the patient and the physician. Do you agree that patients and physicians each can be driving forces for excessive medical care?

Anonymous said...

I am an OT. My friend a PT. We have worked in therapy 25+ years each.
A friend of hers had colon polyps removed. The physician decided a future subsequent check up test time. When this 3 year time arrived insurance refused to pay for it stating: "Non conclusive evidence for need of the test". At the 3rd submission to insurance the test was accepted for payment. Post testing found a malignant polyp! The physicians on the medical review boards appear heartless and incompetent at times. Cancer should never wait...
Another case in point:
My husband currently has disc degeneration/arthritis and was forced to retire early. He operated vibrating heavy equipment for years. It causes this damage. He has had 2 neck fusions so far.
We have an ongoing frustration with a physician insurance surgical medical review (SMRB) board who approves procedures for our insurance.
We see a Orthopedic spine specialist, a man we trust for 20+ years. He has first prescribed a conservative pain management program(for initially a larger pain area). We sent us to his friend; a chiropractor for spinal adjustments, pain pills PRN, local anesthetic cream and muscle relaxers PRN, rest, motion,ice. The pain area reduced more to one palatable area. Post 3 Dr. visits,3 wks. post conservative management w/compliance to the physicians program the results were discussed with our Dr. My husband is still not functional with the pain level and it is excessive.
The Dr's plan was to continue on with a his protocol that has worked for patients in the past. He ordered a spinal pain anesthesia shot (in a surgery setting) as a conclusive diagnostic test. This is followed up by a subsequent office appointment to ask the patient if pain relief is finally achieved (from numbing that nerve root area).
This is a very painful shot. there is no anesthesia for the needle. It is a slow process to get the medicine in and it burns. The patient must be awake to talk to the Dr. yet not move if he is in pain.
If you agree to this shot you are really in a desperate need for pain relief.
Our Dr explained he has a conclusive MRI report showing arthritic bone spurs, disc degeneration and stenosis at a disc level. He has subjective reports of his patients failure with conservative management.
We have been denied 3 times by our IMRB to get the shot! They keep asking for another letter from the Dr. that states "more conclusive wording" is needed before they can approve this cost. They previously approved the MRI.
The Dr's precert office shared this denial history started to be constant for surgery's since April, since the insurance hired a SMRB for precert.
Each time it is rescheduled and canceled. The rescheduling adds more time to our waiting. This has added 2 more months to this persons life of pain. This has physiologically added more damage to that nerve area, not to mention the stress that pain can put on a person of heart attack age.
If the diagnostic test works as the Dr. plans he will next burn off the nerve root with a scheduled 2nd shot.
We pay $600. a month for insurance. What are we paying insurance for? I am sure the Dr. is not getting enough! He has to dictate 3 more letters & pay additionally for transcription & scheduling staff to do added work. It puts cancellations into his schedule. The surgical staff building has to cancel and remake appointments. It costs the medical teams more money every time the SMRB cancels!
I agree with you Michael, we are not stupid. Many consumers are also in the medical field. We can see what is going on.

Michael Kirsch, M.D. said...

@anonymous, I am so sorry to hear of your frustration. I am sure that your saga is not unique. Do you think that Obamacare will improve your situation?

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