Doctors Weigh in on Low-Value Care

Pam Linn

Some of my relatives and friends think I’ve gone bonkers, but I’ve told them all I don’t ever want to go to the emergency room or any other part of the hospital. It’s been two or three years since I saw a doctor, and then it was because my daughter insisted.

The results were mixed. If I had known then what I know now about vertigo, I would have refused. 

As it was, the doctor wasn’t in, so her two assistants saw me. That was when I realized they didn’t know much more than I did. They wrote two prescriptions: one for a patch behind my ear to stop the whirling and one for nausea. Well, that was overkill. Nausea is caused by the room twirling around wildly, so if the patch works, then no more nausea, right? Turned out I was allergic to the patch, and, after three days, I broke out in such a vicious rash I looked as though I’d rolled naked in poison ivy.

Recently, my favorite doctor and author Atul Gawande wrote another piece for The New Yorker on May 11, 2015 titled “Overkill,” with the subtitle “An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?”

A study of more than a million Medicare patients suggested that a huge proportion had received care that was simply a waste, called by researchers “low-value care.” Gawande called it no-value care.

The study revealed how often people received one of 26 tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. The list included unnecessary EEGs, CT or MRI scans or putting a coronary-artery stent in patients with stable cardiac disease. In just a single year, the researchers reported 25 to 42 percent of Medicare patients received at least one of the 26 useless tests and treatments.

“Some diagnostic studies are harmful in themselves,” Gawande wrote. “We’re doing so many CT scans and other forms of imaging that rely on radiation that they are believed to be increasing the population’s cancer rates.”

Gawande cites another reason overtesting is a problem: overdiagnosis (not misdiagnosis), the erroneous diagnosis of a disease. “This is the correct diagnosis of a disease that is never going to bother you in your lifetime,” he wrote. “We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted.”

In H. Gilbert Welch’s new book, “Less Medicine, More Health,” he explained the phenomenon this way: We’ve assumed that cancers are all like rabbits, that you want to catch before they escape the barnyard pen. But some are more like birds, the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots more are like turtles. They aren’t going anywhere. Removing them won’t make any difference.

Gawande added, “Over the past two decades, we’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all.”

Nationwide, we spend more money on spinal fusions, for instance, than on any other operation — $13 billion in 2011 alone.

What may be partially to blame is our high technology and specialty-intensive health system. Countries that have higher proportions of general practitioners have better medical outcomes, better patient experiences and, according to a European study, lower cost growth.

While the Affordable Care Act (ACA) has slowed the galloping escalation of medical costs, we could still do better. Included in the ACA are opportunities for physicians to practice the kind of dedicated care that may improve outcomes. The law allows any group of physicians with 5,000 or more Medicare patients to contract directly with the government as an “accountable care organization,” Gawande noted.

And medical schools are beginning to recognize that education hasn’t caught up with reality. An article by Melinda Beck in the Wall Street Journal said the care structure of medical school — two years of basic science followed by two years of clinical work — has been in place since 1910. But a wave of innovation is now sweeping through medical schools, much of it aimed at producing young doctors who are better prepared to meet the demands of our changing health-care system. 

Another MD recently wrote that he would stop going to see a doctor after age 75. Now, perhaps he can tell us how to get our relatives and friends to quit demanding we go only to be told we have this or that anomaly (usually non-life threatening) that can be corrected by surgery or drugs. Probably not.