America's Epidemic of Unnecessary Care
May 7, 2015 8:15 AM   Subscribe

 
Excellent takeaway:
It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care. And that is the hidden harm: unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative.

A common example is the case of low back pain. It can take nearly an hour of in-office counsel and discussion to help a patient understand why an MRI will do nothing to advance their management for back pain if the symptoms are not indicative of a surgically correctable issue. Time like that is like gold in the bigger picture, because it is precisely those educated individuals who will help propagate proper management further into the general population much better than physicians can. The same type of counsel, i.e. time-consuming but ultimately quite effective over years at improving care, is education regarding appropriate antibiotic usage. There are many others. I think the combined effects of physician fatigue, risk aversion, time constraints all make the likelihood of reducing unnecessary care quite low, as none of these issues are going to change soon. What does impact the issue are more educated patients and patients being on the hook financially for more of their care, which tends to drive more of a discussion about the need for many tests or procedures.
posted by docpops at 8:37 AM on May 7, 2015 [14 favorites]


That reminds me, I need a referral to an opthalmologist who specializes in the treatment of prolonged reading of white text on blue background.
posted by fairmettle at 8:39 AM on May 7, 2015 [7 favorites]


I think the combined effects of physician fatigue, risk aversion, time constraints all make the likelihood of reducing unnecessary care quite low, as none of these issues are going to change soon. What does impact the issue are more educated patients and patients being on the hook financially for more of their care, which tends to drive more of a discussion about the need for many tests or procedures.

I think the article explained how some of the structural issues that lead to physician fatigue and time constraints are, in fact, changing. Hospitals and insurance companies have a lot of money and influence, but large employers who fund the heathcare system with their insurance premiums have started to realize that they're on the hook not just for the excessive diagnostic procedures but also for the negative fallout of mis/overdiagnosis, and the ACA appears to have put in place some supports for exactly the kind of practices that can do that in-office counsel and discussion you're talking about. It's not a perfect solution by any means, but having large and powerful institutions to act as a countervailing force to some of the excesses of the healthcare industry instead of just shutting up and paying whatever to whoever is something that could actually work toward the benefit of patients.
posted by Copronymus at 8:50 AM on May 7, 2015


Remove the profit motive from healthcare.

Of course there is that, but as the article points out, some of the reason that unnecessary care gets done is because when you have a scalpel, you want to cut. Surgeons want to fix things surgically, not with physical therapy, and vice versa. Doctors believe that they're helping, whether not they actually are. Ultimately, it requires physicians to reconsider their biases or have some sort of check on their decision. The former is difficult, and the latter is intensely distasteful to doctors (and impractical besides). This part of it is quite hard.

If anything, the profit motive can help solve the problem. Tests aren't free and if hospitals are forced to understand that tests have costs to them, then they are incentivized to reduce unnecessary treatment.
posted by TypographicalError at 8:53 AM on May 7, 2015 [1 favorite]


I'd be interested to know what the rates of unnecessary treatment are in Canada, or basically the rest of the Western world. I seem to recall reading before that they are orders of magnitude less than in the USA. Doctors are the same everywhere--surgeons want to cut--so the only difference is profit, far as I can tell.
posted by feckless fecal fear mongering at 8:55 AM on May 7, 2015


Just an fyi, lower back pain can be a symptom of lung cancer. I learned that not too long ago.
posted by I-baLL at 8:59 AM on May 7, 2015 [1 favorite]


I think one problem in the US is that health insurance typically funds medical interventions but not necessarily other things that might be cheaper and more effective. I have an old shoulder/ upper-back injury that caused me problems for years, and I finally (knock wood) seem to have tackled it with a combination of short-term physical therapy, getting a more ergonomic desk set-up, and regular exercise. But my health insurance only paid for the physical therapy. I'm lucky that my workplace wellness program will pay for part of my gym membership and for an ergonomic work station, but I don't think that's necessarily typical in the US. If I'd had surgery, which likely wouldn't have been effective, that would have been paid for, but for the most part you're on your own if you're going to make lifestyle changes that ultimately might be more effective.
posted by ArbitraryAndCapricious at 8:59 AM on May 7, 2015 [3 favorites]


I enjoyed the article; Dr Gawande is an excellent thinker and a creditable writer. I believe it's less of a problem in the UK; an NHS doctor is salaried and receives no compensation of any sort for your treatment. They're more likely to refuse an unwarranted procedure on those grounds, but I imagine that the rate of doctors approving unnecessary treatments out of fatigue or unwillingness to argue with a stubborn patient is probably quite similar to that of the US.
posted by The Zeroth Law at 9:00 AM on May 7, 2015 [2 favorites]


Quality metrics are just another iteration of bullshit that won't result in better outcomes. See 'managed care' from 1-2 decades hence. And believe me, patient volumes and throughput are more critical than ever to remuneration, it's just that not meeting quality benchmarks can lead to financial penalties or small rewards, but those metrics are often so asinine it would make your head spin (and often finessed behind the scenes via database management). Cost reductions will come, if ever, when the doors are flung open to all of the population for basic care and better education of managing one's health combine to reduce the need for nursing along the chronic miserable health of your average American. In a typical month I would be surprised if more than 5% of my visits are for the treatment of acute or worrisome issues that weren't foreseeable or easily preventable (i.e. an unexpected pneumonia, acute injury, a new diagnosis of cancer). It's just the same dozen things ad infinitum in most cases. State sponsored health plans are often somewhat easier to deal with because they are often the only ones that use evidence based standards for approving treatment. So you have an ally (or really a scapegoat) when it comes to not ordering unnecessary tests or treatments.
posted by docpops at 9:07 AM on May 7, 2015 [7 favorites]


This is the correct diagnosis of a disease that is never going to bother you in your lifetime.

But the thing is - I'd be much more uncomfortable with a doctor saying 'Welp, you've got a problem, but I'm not going to deal with it, because you're probably fine.' If I have a disease, I want to know, and I want it fixed, even if it's not necessarily going to lead to death. Death is not the only metric!
posted by corb at 9:22 AM on May 7, 2015 [3 favorites]


docpops, if I might pose a question: if you had plenary authority over public funds and could pass any laws you wanted to, what would you do to improve the health care system in America?
posted by clockzero at 9:40 AM on May 7, 2015


If I have a disease, I want to know, and I want it fixed, even if it's not necessarily going to lead to death. Death is not the only metric!

Death is not the only metric, but surgery is also not the only fix.

I don't know a single doctor who would be that dismissive - in my experience, it's been more like "Welp, you've got a problem, but I'm not going to operate because you can also fix this by just not wearing high-heeled shoes and getting 30 minutes of exercise 4 times a week" or something like that. There are cases where the condition is so slight and so minimal that actual medical intervention would cause more damage than the condition itself - I had a doctor once explain that she was reluctant to do a follow-up biopsy on an abnormal colposcopy I had, because "the abnormality is extremely slight, and the biopsy would actually do more damage than just waiting 6 months and checking again to see if it just goes away on its own." So we decided to wait, and sure enough, it did go away - and moreover, I also didn't have to recover from having part of my cervix surgically excised, nor did I have to pay for it.
posted by EmpressCallipygos at 9:41 AM on May 7, 2015 [9 favorites]


Doctors are the same everywhere--surgeons want to cut--so the only difference is profit, far as I can tell.

I'm not sure what the rates are in Canada or elsewhere, but doctors work for profit here, too. Most healthcare is provided by doctors in private practice or privately-owned for profit organizations (e.g. blood and imaging labs). It's health insurance that is public, not health care.

That said, I can always get a same-day appointment with my family doctor and I've never felt rushed during an appointment.
posted by If only I had a penguin... at 9:41 AM on May 7, 2015 [1 favorite]


I'm not going to operate because you can also fix this by just not wearing high-heeled shoes and getting 30 minutes of exercise 4 times a week

Alright, given that example, I'm going to take it a little further. This is not even a hypothetical for me : I have excess weight to the point that it is negatively impacting my health, particularly given that I have a family history of some crappy medical conditions. Doctors know that my weight needs to reduce in order to increase my life expectancy.

I work a busy and stressful life. I do not have the time or the spoons for 30 minutes of exercise 4 times a week or the massive diet changes suggested. I would like medical intervention. I even know which medical intervention has, in the past, been helpful for me (metabolism-increasing drugs).

But because people judge metabolism-increasing drugs to have risk of addiction, or because they know that weight loss CAN be accomplished through diet and exercise and view it as the least harm, doctors don't prescribe me said metabolism increasing drugs. They offer to set me up with dieticians which are useless for me, or exercise consultants that are equally useless for me.

This is not an optimal outcome. Because doctors think they're being so great by avoiding medical intervention, I'm probably going to die at least ten years earlier than I ordinarily would. But they rest on the fact that if I were a totally different person, with a totally different life, there would be a solution.

How is this good for anyone? Just because the drugs that would massively help my life are expensive?
posted by corb at 9:50 AM on May 7, 2015 [2 favorites]


docpops, if I might pose a question: if you had plenary authority over public funds and could pass any laws you wanted to, what would you do to improve the health care system in America?
posted by clockzero at 9:40 AM on May 7 [+] [!]


Off the top of my head I would allow physicians who are repaying debt to the government to go into schools and nursing homes and candidly tell the public all the stuff that goes on in the heads and offices of their physicians, and educate them about what works and what is worthless as far as their health goes, and start it early, like second grade and every year after. We just don't have even the most basic discussions about nutrition, exercise, the limits of antibiotics, how to age with some hope of not being miserable, etc when they could actually effect outcomes, i.e. not in your doctor's office when you find out you have diabetes. I would also push for community health clinics staffed by nurse practitioners who did nothing but manage basic issues like asthma, hypertension, diabetes, and chronic stable pain so that the few primary care doctors could really focus on more complex illnesses.
posted by docpops at 10:08 AM on May 7, 2015 [19 favorites]


A common example is the case of low back pain. It can take nearly an hour of in-office counsel and discussion to help a patient understand why an MRI will do nothing to advance their management for back pain if the symptoms are not indicative of a surgically correctable issue.

Funny you should bring this up. Here is what treatment for my "lower back pain" looked like:

A) back goes out doing strenuous physical labor, am out of work for about 6 weeks. no insurance, can't go to a doctor

B) eventually recover, get on essentially medicaid which allows me to go to clinic. talk to nurse practitioner about back injury. NP quickly does diagnostics which show that I am mobile with a normal range of motion but ignores the fact that I can't do strenuous activity and experience periodic pain. no diagnosis, no treatment

C) back goes out again. immobilized. wait three weeks for NP appointment, after which I am able to move and do things that an elderly person would be able to do (i'm not elderly). diagnosis of non-specific back pain. they say they can't get me an MRI unless I am referred to physical therapy with no specific diagnosis. physical therapists have me do exercises which hurt my back and in the process max out my yearly physical therapy allowance.

D) back goes out again. go to emergency occupational medicine clinic. finally get referral for MRI to discover I have two degenerating disks. clinic where I was going to goes under, have to go find a different clinic. no treatment... but at least I know what's wrong.

Surgeons like Dr. Gawande, respectfully, know fuck-all about how medicine actually works as a system in this country. But, talking about 'unnecessary procedures' will totally get the attention of the health insurance gnomes and get you an article in the New Yorker, regardless of how nuanced your view may actually be. Why is that? It's this sort of talk which made it take years for me to get a MRI to find out what was actually wrong with my back.
posted by ennui.bz at 10:08 AM on May 7, 2015 [2 favorites]


Corb, a more honest answer is simply that those drugs are primarily appetite suppressants and although they do produce small weight decrements in many people they are a cruel ruse and the weight comes back in every instance. So the least paternalistic thing you can do is tell a patient, hey, your blood pressure may go up and any weight loss you achieve from this is completely due to reduced intake, same as if you had done it yourself, but you seem genuinely aware of the shortcomings and risk and who am I to say it isn't going to help you in some small way (not flippantly but sincerely). That approach seems to help most people understand why those medications aren't really in their best interest, and that it isn't because we are trying to punish them. I wish it was possible to get across how ominous the words "medical intervention" really are. The instant you embark on any 'medical intervention' you run the risk of permanent damage to your health. It needs to be worth it.
posted by docpops at 10:11 AM on May 7, 2015 [13 favorites]


Dr. Gawande has a master's in public health as well as an MD, and has a joint appointment in a medical school and a public health school, so I suspect that he does not in fact know fuck-all about how medicine actually works in this country.
posted by ArbitraryAndCapricious at 10:13 AM on May 7, 2015 [27 favorites]


ennui.bz, hopefully it has been made clear that degenerative disc disease is essentially a normal finding in nearly every upright biped over 30 years of age and very rarely is the single source of pain. More to the point, if it is the cause, the treatment is no different in the long run.
posted by docpops at 10:19 AM on May 7, 2015 [7 favorites]


Who by very slow decay
posted by bukvich at 10:22 AM on May 7, 2015 [4 favorites]


hopefully it has been made clear that degenerative disc disease is essentially a normal finding in nearly every upright biped over 30 years of age and very rarely is the single source of pain. More to the point, if it is the cause, the treatment is no different in the long run.

no, it hasn't because no doctor has actually tried to treat me because I am too poor to actually have an incentive to treat. do you have any idea how that feels? i know that someday I will die because I am too poor to get the attention of anyone.

the system is built around interlocking flow-charts for not actually treating people but passing them along to some other part of the system.

Dr. Gawande has a master's in public health as well as an MD, and has a joint appointment in a medical school and a public health school, so I suspect that he does not in fact know fuck-all about how medicine actually works in this country.

which makes him someone paid to not actually understand how the system works.
posted by ennui.bz at 10:25 AM on May 7, 2015 [2 favorites]


I'm not sure. As somehow who had inexplicable bouts of terrible immobilizing pain... It took a long time and."unnessicary"procedures to produce no answers. But I and my doctor are certian it isn't going to kill me whatever it is, and I'm on maintenance med that can decrease the pain bouts (not a narcotic) and I live my life okay.

My almost broken portible nebulizer is concidered unnessisary by my insurance now, because I haven't been in the hospital for asthma in a very long time (like ten years) so replacing it is unnecessary. But it is the thing that allowed me to work in my job when I'm having a bout of asthma and it keeps me out of the hospital because nebulizers work. The medical intervention that had kept me safe is now unnecessary because is effective.
posted by AlexiaSky at 10:26 AM on May 7, 2015 [1 favorite]


How is this good for anyone? Just because the drugs that would massively help my life are expensive?

I don't think the question should be whether a given intervention's good for anyone -- it should be whether it's good for you, in your particular case. With any medical intervention, the biggest issue is balancing risks and benefits; it's not just that these drugs are addictive, it's that they come with a boatload of side effects, addiction included. For one, they could make you even more hypertensive than you are now, which will markedly increase the risks of strokes, aneurysms, and all sorts of fun stuff. They usually increase anxiety, and in turn, your stress levels, which could in itself negate any benefits you get. They can mess with your endocrine system and your blood sugar levels, which could give you diabetes down the road. And so on. Not to mention that when you stop taking these drugs, the weight usually comes back.

Lifestyle modification is the current standard of care in your case for a reason: the risks are close to nil, and the changes you make have a better chance of sticking. It's not a matter of prescribing something that has seemed to work for you so far -- no competent physician, having a better picture of the risk-benefit ratio of these interventions, would prescribe these drugs as a first-line treatment, knowing full well that, in the back of their minds, they're exposing you to the full spectrum of these possible risks. That doesn't even get into the issue of the potential liability, both legal and professional, were they to cause you harm by not following the current guidelines. Frankly, no physician I know would ever want to willingly expose their patients to possible harm -- it's not even a question of liability, but doing what they feel is best for their patients, and sometimes that means saying no.
posted by un petit cadeau at 10:29 AM on May 7, 2015 [7 favorites]


And frankly, no physician I know would want to willingly expose their patients to possible harm -- it's not even a question of liability, but doing what they feel is best for their patients, and sometimes that means saying no.

And that is precisely the paternalistic bullshit that makes some of us have serious problems with articles like that, that pose doctors as The Enlightened Ones that should get to be gatekeepers because they think they know best, regardless of what their patient actually wants.
posted by corb at 10:34 AM on May 7, 2015


just to add something here. the fact that I am now on medicaid doesn't change the fact that no doctor actually wants to treat me. are you a doctor? does this sound shocking? it shouldn't because this is the basic fact of American medicine if you have very low income. medicaid rates are too low to actually motivate equal treatment in our system.

ennui.bz, hopefully it has been made clear that degenerative disc disease is essentially a normal finding in nearly every upright biped over 30 years of age and very rarely is the single source of pain. More to the point, if it is the cause, the treatment is no different in the long run.

i'm sorry, i just can't get past this. you are a physician and yet you somehow don't understand that it is totally normal for someone at my income level to receive no medical care even if they have been through a clinic.

but this level of naivete is totally normal (in my experience) for medical doctors in the US.
posted by ennui.bz at 10:34 AM on May 7, 2015 [1 favorite]


How is this good for anyone? Just because the drugs that would massively help my life are expensive?

For the record, I was not speaking of your personal situation, I was speaking of hypotheticals that were more like my own. I was speaking strictly to your assertion that doctors would say "well, this is a problem but I'm going to sit here and not do anything".

But that's precisely it - there are cases where surgical intervention is indeed the best option, and there are also cases where surgical intervention is not the best option. And as frustrating as it is for you to not be given the intervention that would help you best, it is equally as frustrating for someone who would be best served by a non-surgical intervention to be told "it's surgery or nothing".
posted by EmpressCallipygos at 10:54 AM on May 7, 2015 [1 favorite]


"Off the top of my head I would allow physicians who are repaying debt to the government to go into schools and nursing homes and candidly tell the public all the stuff that goes on in the heads and offices of their physicians, and educate them about what works and what is worthless as far as their health goes, and start it early, like second grade and every year after."

As you probably know, I have an extremely rare collagenopathy and I and most of my family have had a constant relationship with medical care our entire lives. Not only that, but we have the problems that come from an extremely rare and poorly understood condition -- our doctors usually rely on us for a lot of information (in my experience, that's been true not only with PCPs, but even with the specialists). And my mom is an RN, for whatever that's worth. Basically, what my experience and observation have been is that an informed and actively involved patient is absolutely crucial and, sadly, this is pretty much the opposite of most patients. People have vastly unrealistic ideas about medicine (and, again, I couldn't avoid understanding this, given that I have a genetic illness, present in my family for generations, that was only properly diagnosed, and only partially, from my own case when I was a child) and they expect their doctors to a) be nearly omniscient at diagnosis, and b) be able to immediately and effectively treat an illness. And when that's not true -- as it often isn't true -- they assume incompetence.

This produces a lot of interlocking pressures for unnecessary treatment. Patients demand testing that really won't help, they demand treatments that won't help. Physicians accommodate this for a number of reasons. Patients specifically demand these things, often, but they also just implicitly demand them because there's an expectation of doing something. Shouldn't we get more tests, shouldn't we try a treatment, shouldn't we try another treatment, etc. And people everywhere have stories of how something is diagnosed only after years of examinations and testing and multiple doctors, where the moral of the story is that someone screwed up, the diagnosis should have happened right away. And then there are all the idiopathic stuff that just starts and ends and most likely no one was ever going to be able to diagnose the issues, much less treat it. But that isn't possible, either, according to how most people think about medicine. Everything is diagnosable and treatable, they think.

I've watched this dynamic with other people, I've experienced it myself with regard to other illnesses I've had (that is to say, most doctors I've seen for other stuff just do the things they do, because they're expected by most patients to do them), and I've experienced it with my collagenopathy because it presents in many different ways and, you know, orthopedics are prone to just getting out their toolbox, anyway, because that's what they do and they have fancy equipment and techniques available.

"And that is precisely the paternalistic bullshit that makes some of us have serious problems with articles like that, that pose doctors as The Enlightened Ones that should get to be gatekeepers because they think they know best, regardless of what their patient actually wants."

If patients actually were informed, then they'd likely make the same decision. Usually they aren't, and so you get the attitude you just exhibited, which is the worst of all possible worlds. Doctors know, generally, a lot more than I do and I trust them in this respect. They don't know my own body better than I do, and they mostly don't even know much more about my own illness than I do. But, you know, I have never had any trouble with any of my doctors in the way that you describe. They're not paternalistic with me because I am not expecting them to be gods and then getting angry at them for not making everything better. I work with them as a partner in my own health care, where I defer to their vast expertise in medicine and they defer to my expertise in my own body and illness and knowledge and awareness of the conditions from which I suffer. It works out pretty well.

"it shouldn't because this is the basic fact of American medicine if you have very low income. medicaid rates are too low to actually motivate equal treatment in our system."

This greatly varies from state-to-state. States that put everyone into the same pool and where Medicaid patients aren't very specifically Medicaid, tend to have much greater availability of care for Medicaid patients because hospitals and doctors are enrolled in the larger program. Where this isn't the case, and you have to try to find specific providers that will take Medicaid, then it can be very difficult in some states and areas to find any health care at all. I don't know if that's your situation, but I've observed with other people (I've never been on Medicaid) a huge variety of experiences in what you're describing. But it can be very difficult for some Medicaid patients in some areas to get care. Other places, it's not a problem at all.
posted by Ivan Fyodorovich at 10:55 AM on May 7, 2015 [19 favorites]


The thing is, ennui.bz, you did get a medical intervention: you got an MRI that cost thousands and thousands of dollars and, at least according to the article, probably didn't provide information that would change what treatment should be provided to you. Now you can't get treatment. If that money had been spent on effective treatment instead of the unnecessary MRI, then everyone would be better off. That's the whole point about the American healthcare system: it's both extremely expensive and extremely unequal. If we spent less money on unnecessary testing and treatment, we would have more than enough money to give everyone adequate medical care.
posted by ArbitraryAndCapricious at 10:56 AM on May 7, 2015 [11 favorites]


Hopefully, we as a society will eventually absorb the lessons underlying false positives and harm. Just because we can image something, doesn't always improve health.

For 1000 women given mammograms, a 1% rate of cancer, and a 9% false positive rate (1):
990 don't have breast cancer. 10 do.

Of those 10, 9 will test positive. 1 will test negative.
Of the 990, 89 will test positive. 901 will test negative.

The change of having breast cancer GIVEN A POSITIVE TEST is 9 / (89+9) = 0.09.
89 women will be exposed to further testing, and the harms that Gawande points out.

(1) Woloshin and Schwartz, BMJ 2012.
posted by Dashy at 10:58 AM on May 7, 2015 [4 favorites]


as frustrating as it is for you to not be given the intervention that would help you best, it is equally as frustrating for someone who would be best served by a non-surgical intervention to be told "it's surgery or nothing".

I completely agree. That's why I wish the doctors could simply present the risks and benefits of all treatment options, rather than withholding some because they think the patients can't possibly understand, or couldn't possibly make the right decision if they did.
posted by corb at 11:01 AM on May 7, 2015 [1 favorite]


My gut estimate, feebly informed by my proximity to health research, is that 50¢ of every $1 spent on health care in the US is for ineffective or harmful interventions. We could cut medical costs in half if we could only identify them with certainty and eliminate their use. The number of highly expensive, unproven therapies is enormous and their impact not only on the cost of healthcare but also on the perception of how medical care should be practiced and improved is detrimental to us all.

The sad excuse is given that we can't afford to do the careful outcomes research because it's too expensive, but Scott Ramsey of the Fred Hutchinson Cancer Center estimates that the results of the Women's Health Initiative, which cost $260 million, had a net economic return of $37 billion, or $140 for every dollar spent on the trial. Most often new drugs or devices are tested only acutely and only for impact on surrogate outcomes and the companies try every trick in the book to get out of the cost of proving actual clinical efficacy. They are often abetted by physicians who are convinced by "clinical judgement" that they work. A good example is Class I antiarrhythmics like encainide and flecainide that were given for post-MI rhythm disturbances for a long time. The Cardiac Arrhythmia Suppression Trial, which was originally designed without a placebo group because the physicians running the study violently opposed it, eventually illustrated that the drugs were killing patients, but not until after a lot of deaths had occurred.

Surgeries aren't even required to be proven, but are vetted by the opinions of other surgeons. This led, for example, to widespread use of PE tubes for ear infections, unnecessary tonsillectomies, and endarterectomies that killed more often than healed. You wouldn't think so, but neither by-pass surgery, nor stents, nor solid organ transplantation have ever been tested in randomized trials.

You will hear a lot of excuses by proponents of these interventions, but they boil down to the solid belief that they are effective and so the observational data are sufficient. But keep in mind that these same arguments were used for every other widely used therapy eventually shown to be ineffective or harmful by randomized trials.
posted by Mental Wimp at 12:02 PM on May 7, 2015 [5 favorites]


He should guest on Dr. Oz to get the word out to more people.
posted by Renoroc at 12:14 PM on May 7, 2015 [2 favorites]


Every time I read about doctors ordering "unnecessary tests," I wonder where those doctors are and how can I see one. I don't seem to be able to find any doctors willing to so much as look at me, much less put a hand on me or run a test of any kind. Everything thing will go away on its own so just take some aspirin and come back for more of the same if it doesn't change.
posted by 3.2.3 at 12:29 PM on May 7, 2015 [1 favorite]


That's why I wish the doctors could simply present the risks and benefits of all treatment options, rather than withholding some because they think the patients can't possibly understand, or couldn't possibly make the right decision if they did.

....But....I'm not certain that that's what we're talking about in the first place, we're talking about cases where the doctors jump straight to "yes, let's do [blah]".
posted by EmpressCallipygos at 1:02 PM on May 7, 2015


That's why I wish the doctors could simply present the risks and benefits of all treatment options, rather than withholding some because they think the patients can't possibly understand, or couldn't possibly make the right decision if they did.

PATIENT: Doctor, it hurts when I do this
DOCTOR: Here are hundreds of pages worth of information on dozens of treatment options!
posted by aubilenon at 1:03 PM on May 7, 2015 [1 favorite]


Yeah, I agree with you a bit there 3.2.3

I had a recent ACL replacement which quickly, too quickly for that to really be the problem, turned into 4 blood clots in my calf. After 3 months of anti-coagulation, (normal time is 6 months), the doctor relayed the message that if I were a symptomatic, I could stop.

WAT?

I had to call back and emphasize that I wasn't thrilled with this answer, my leg is all fried, how do I know if that's normal or being caused by the clots still being there? Finally, they decided they would order another ultrasound...

And of course, I still have them more than I should, so why don't you stay on the anti-coag for another 3 months. How expensive are ultrasounds that I have to twist your arm to check out something inside my body that you can't actually see?

I think doctors tend to go with, "what treatments/tests look appropriate for what this set of symptoms is most likely to be", rather than what it might be. Which is bad if your condition isn't typical.
posted by Windopaene at 1:06 PM on May 7, 2015


I think instead of using words like "unnecessary care" (how can care ever be unnecessary?) and "over-testing" which ring bells like "Overfed millenials and their helicopter parents demand non-stop coddling for their little boo-boos and their toxic self-esteem" this article should have been about how doctors don't know what the F they're doing 80% of the time. Either they're prescribing procedures that have no hope of working, or writing you off completely as "obese" or "stressed" or "a woman". I had strep throat once that was visible all over my mouth and got a prescription for a stomach x-ray.
posted by bleep at 1:17 PM on May 7, 2015 [13 favorites]


Like I think the problem we should actually be looking at is why doctors don't know what they're doing. Forget patients, they're always going to be there, they're always going to be scared, sick, illogical humans. Doctors are supposed to know better but it seems like they don't.
posted by bleep at 1:20 PM on May 7, 2015 [1 favorite]


I would simply like to know exactly what a procedure or test my doctor suggest would cost me before I undergo it, rather than finding out via a litany of incomprehensible bills dribbled out for months afterwards. I could then look at each of the procedures to determine if I should actually get them.
posted by Blue Meanie at 2:03 PM on May 7, 2015 [9 favorites]


My prescription is to read the earlier comments and call me in the morning.
posted by sneebler at 2:08 PM on May 7, 2015


Doctors are supposed to know better but it seems like they don't.

One of the reasons I adore my current pediatrician is that when he's stumped by something going on with one of my kids (one of them has an unusual and only-recently-diagnosable digestive disorder that there isn't a lot known about, the other has subtle-but-definitely-present neurological quirks), he says flat out "I got nothing but a hunch" or "I was stumped, so I did some research, and this is what I found" or "my guess is X but I don't have a lot of confidence in that, let me get you a referral to a specialist" or even "I have no idea, my literature search came up blank, I asked some experts and got contradictory and unsupported guesses, so at this point I'm going to say go with your gut and tell me how it worked out." (That last, I hasten to say, was for a non-critical health management type issue.) It means that when he says "The answer is X" or "We shouldn't bother testing for that because of Y*" or "I know it seems counterintuitive, but Z," I am much, much more likely to believe him.

*For example: my son has a significant history of severe croup, poor/low muscle tone all over his entire body, and recently had about 6 weeks of nighttime cough and stridor with no other symptoms. It's possible that he has laryngomalacia. Our ped has recommended against testing for it though, because the test would require sedation, the only treatment is surgery, and apart from the croup he doesn't have any severe consequences from it. Since the croup appears to be getting to be less of a problem, there's no point in putting him through the testing if we aren't going to do anything with that information.
posted by KathrynT at 2:33 PM on May 7, 2015 [11 favorites]


Very few of the doctors I have dealt with have had what I would call a great bedside manner, but the comments in this thread make me feel sorry for them. People seem to have one bad experience and decide that the entire profession (responsible, along with civil engineering, for most of our modern quality of life) is worthless and knows nothing of value.
posted by Steely-eyed Missile Man at 2:44 PM on May 7, 2015 [7 favorites]


One bad experience that they're sharing in a thread, because everyone sharing every bad experience would be really boring. A thread discussing an article that's about a doctor describing the shortcomings of his own profession.
posted by bleep at 2:50 PM on May 7, 2015


I can only imagine the miserable opinion many people have of our profession, since so often there is nothing useful we have to offer. But I assure you, for the majority of people (not the Metafilter n=1+), the reasons that we hector you endlessly to eat right, exercise regularly, and not accumulate weight unnecessarily is that nothing brings out the limits of medicine and the accompanying sense of time wasted with an idiot MD as the misery of the living with an aging, inactive and poorly-fed body that wants solutions that don't exist.
posted by docpops at 3:09 PM on May 7, 2015 [18 favorites]


As a morbidly obese woman whose father has barely-managed type II diabetes and whose mother recently underwent a hip replacement, docpops, I hear you loud and clear and agree completely. My mom knew she was going to need her hip replaced, and spent five years getting ready for the surgery; reducing her excess weight as much as she could, doing weightbearing exercises to increase her bone density, doing yoga and Pilates to strengthen the muscles around her hip to better support the joint, and doing distance cycling to help keep the connective tissues as flexible and mobile as possible even given her limited range of motion from her arthritis. I mean, she trained for that surgery, really. And it really paid off.

As a patient, though, what I would like -- and what I have appreciated from my physicians -- is an acknowledgment that the things you ask for are frequently quite a big deal. If there was a medical treatment for obesity -- say, a drug that had to be infused intravenously -- that required an hour or more of dedicated time every day, dramatic changes to cultural and social participation, and a constant feeling of hunger with the associated fatigue and mood effects, nobody would be surprised if patient compliance was poor. And yet so often, people expect people who already have a lot of demands on their time and resources to just magically "make it work" when it comes to diet and exercise.

In 2006, my husband decided to attack his weight problem by commuting to work via bicycle instead of car. It was a good decision; his cholesterol was 283, his blood pressure was 145/95, he weighed 250 pounds, and his father had nearly dropped dead of a heart attack six years earlier at the age of 58. He's been doing it ever since, and it's worked out GREAT for him -- now he weighs 190, his cholesterol is 179, his blood pressure is 110/70. But it's only possible because he has a wife at home who can run all his errands for him, who takes care of the kids so he doesn't have to take them to daycare, who does all the teacher meetings and banking and grocery shopping and everything else that requires nipping out in the middle of the day, who can go and pick him up if he gets sick at work or if he gets a flat tire, and who has dinner ready when he gets home so he doesn't have to deal with cooking a healthy meal for himself and his children after his lengthened commute. On the days where I'm not available to do those things, or when he has an appointment that I can't do for him? He has to drive. So where does that leave people who don't have a full-time Support Adult in their lives? Where does that leave the Support Adult?
posted by KathrynT at 4:32 PM on May 7, 2015 [27 favorites]


ennui.bz: I feel super bad for you - for me at least, there's no question you got completely screwed over by the medical system.

But that absolutely isn't inconsistent with the article - not at all.

It is undeniable that the US government spends more money on healthcare than any other government in the world. Where's that money going? It ain't going to fix your back!

> People seem to have one bad experience and decide that the entire profession (responsible, along with civil engineering, for most of our modern quality of life) is worthless and knows nothing of value.

You're completely misrepresenting this. No rational person doesn't value modern medicine. ennui.bz, for example, isn't complaining because of "one bad experience" - he's experienced years of pain and endless run-arounds that have savaged his ability to make a living.

The issue is that the United States spends an astonishing, unprecedented, inconceivably vast amount of money on health care, both through the government, through insurers, and though private payers, and yet gets surprisingly mediocre results overall.

And the reason is that a fairly large segment of the population gets blue-chip treatment that includes a huge amount of padding and unnecessary testing, and an even larger segment of the population gets the bargain-basement remains, delivered grudgingly and late - and also with a lot of padding and unnecessary testing.

(I should add that I personally have gotten very good treatment and have had a good relationship with pretty well all the doctors I ever had... but I attribute that to the fact that I can talk science well and be convincing. If I say something like, "Given that I don't eat meat and have enjoyed good health for a long time, I feel that for me the benefits of a colonoscopy in reducing mortality are outweighed by the very small but non-zero mortality from the procedure itself," I'll always get a good response from a doctor - something I expect I would not get if I were a guy with dreads saying exactly the same thing using less sesquipedalian verbiage...)
posted by lupus_yonderboy at 4:56 PM on May 7, 2015 [4 favorites]


I thought it was a great article about a serious issue. The attitude in some of the coments is a bit odd to me. I totally understand that it is healthy to recognize one's doctor is fallible, but it totally does not follow that I, with no medical training, would be able to judge the accuracy of a diagnosis. It's like recognizing the New York Times can be wrong and then just believing stuff people post on Facebook.
posted by snofoam at 6:28 PM on May 7, 2015 [5 favorites]


Kaiser Permanente calls and writes, writes and calls trying to get me to "choose a doctor". Guess what KP, I am never going to respond. The only time I would even consider going near a doctor would be for a broken limb or serious infection. Doctors are like cops, best avoided if at all possible.
posted by telstar at 6:53 PM on May 7, 2015


Man, nothing brings out the broad over-generalizations and I-had-a-bad-experience anecdotes like threads on medical care. Doctors are humans. Some are terrible, many are fantastic, and most truthfully want what's best for their patients. You HAVE to do your homework, and if your doctor does not suit your needs you have to find another one you can work with. They are also not by-request pharmacists. You must advocate for your own care, but a doctor is not required to give you what you demand if they feel it is not indicated. It is a working relationship that demands trust and respect from BOTH sides.

Conflation of doctors and the fucked up nature of insurance and reimbursement, particularly in the good ol USA, further muddies the waters. Doctors have to live with the fucked up health system as much as patients.
posted by Existential Dread at 8:36 PM on May 7, 2015 [8 favorites]


And yet so often, people expect people who already have a lot of demands on their time and resources to just magically "make it work" when it comes to diet and exercise.

In audiology, we talk a lot about how the most predictive factor for a patient being successful and satisfied with a hearing aid or cochlear implant is their motivation. We talk a lot of 'stages of change,' which is a hot topic in most medical fields, where you recognize that only a small percentage of the patient's outcome has to do with your professional intervention, and most of it is their willingness to bring something to the table, where they are along the gradient of denial of a problem to motivated to improve.

And we do talk about ways to try and help empower and motivate our patients - but at the end of the day, that part is really on the patient. Doctors are scientists. They are experts in diagnosing and advising. But they aren't magicians, and it's not their job to try and convince you to follow their advice or get on board with a plan of treatment.

It's hard. I see my patients' frustrations. But hearing aids and cochlear implants aren't magic pills. Such interventions are rare in any branch of medicine. Getting healthy - whether it's managing weight or training your brain to use an implant - is really hard work, and at the end of the day, no one can do that work but the patient.

I find myself in the clinic saying "I understand" a lot. It's like a mantra. And I do understand that changing your life is hard. And I understand that your expectations for how much some intervention can help you may be out of line with what is realistic. But that is completely out of my control, that's the kicker. I can only do what I can do - I can diagnose you, I can give you the proper treatment - but I can't make it any easier than it is. And when my patients get mad at me for that - what am I supposed to do with that? I say that I understand, and I move on, even if I don't understand.
posted by Lutoslawski at 8:52 PM on May 7, 2015 [8 favorites]


Oh man, it took me all day to get to this thread. I was fucking overwhelmed with fighting the good fight with my patients to get through the whole article and all of the comments in this thread. I pretty much agree whole heartedly with Drs. Gawande and Docpops. I'm a doc that sees Medicaid, Medicare, and uninsured almost exclusively. In our current climate, there are so many pressures to do things quickly and thinking about medical problems and discussing them with patients is so disincentived financially that I myself have have not infrequently ordered the unhelpful test or treatment simply because not doing so means missing yet another family dinner or pissing off my waiting room full of patients by running further behind. Doing the thing I know in my heart is right is something that takes time I don't have and there is little disincentive to do the wrong thing. Too often, the patient expects it, the consultant wants it, and the insurance company will pay for it, and my business organization just wants me to move more patients through the clinic. The only thing that gives me pause is the knowledge that as a primary care physician, if I fail to resolve a problem, the patient will keep coming back to me. But man, it takes way less time to fill out the MRI referral than it does to explain to the anxious patient why the MRI isn't going to make a difference and to discuss the things that will make a difference, which often falls on deaf ears.

No one but me cares if I do the right thing medically, but there's a huge apparatus that cares if I move patients through quickly and that I make sure the "customer" is "satisfied" with my "care."
posted by Slarty Bartfast at 11:07 PM on May 7, 2015 [14 favorites]


It's hard. I see my patients' frustrations. But hearing aids and cochlear implants aren't magic pills. Such interventions are rare in any branch of medicine. Getting healthy - whether it's managing weight or training your brain to use an implant - is really hard work, and at the end of the day, no one can do that work but the patient.

So I think part of the problem, for me, is that it seems very similar to my own industry - social work dealing with the homeless. Much like getting healthy all around is a process that involves a lot of lifestyle changes, getting fully stably housed is also a process that involves a lot of change. When I see a client present with his current situation (homelessness) I know that he will be much better off if my intervention also involves a lot of other things - if he gets counseling, alcohol treatment, fixes up his credit, repairs relationships with family, cuts ties with destructive friends, etc. And if I think the client is open to those things, I will offer them and try to make them easier. But the thing that I don't do is say, "Well, we're going to leave you on the streets unless you go through steps XYZ." Because at the end of the day, either the client is willing and able to do those things or they're not, and they still need not to be sleeping on the street.

Likewise, at the end of the day, either your patients are going to make lifestyle changes or they're not - and if they're not and you know they're not, depriving them of medical interventions just because you think the path you already know they're not going to take would be better seems kind of jacked up. Like, I'm sure that my health would be radically improved if I had the time and spoons to exercise an hour daily - but I'm not going to be able to. It would be great if doctors would listen to their patients when they tell them that their life needs preclude the changes that are being recommended, and the doctors could then say, "Okay, given that, X is your best option."
posted by corb at 10:10 AM on May 8, 2015


Also, spoons = energy, if anyone else was momentarily confused.
posted by Steely-eyed Missile Man at 10:44 AM on May 8, 2015


Bad patients, bad doctors. It gets tedious. What I see is a great asymmetry of information and power leading to sourness all around. As patients we are advised to "do our research, be strong advocates for care" and simultaneously subjected to the equivalent of eyerolling by most of the medical establishment. Its pretty obvious how the mechanics of the business of medicine result in a surfiet of unnecessary tests and procedures however that seems like an uncomfortable subject so the story often seems to become one of unresonably demanding patients who are considered kind of stupid.

As with all of Gawandi's writing this article is extremely lucid and compelling. The only criticism of his work I have is that it comes from the standpoint of someone who is experienced with the absolutely best care there is. He often picks examples, (the walmart man for example,) that seem to be the acme of how the system should work and yet reading it I feel like he is describing some fantasy land forever unobtainable for 99 percent of the population, a land that he seems to be saying is only kept from us by the lack of insight in the medical world. I feel like he should go undercover to understand better from the patients side what it is like to navigate the system without the benefits of network and prestige without having to resort to imagination or interview.
posted by Pembquist at 11:48 AM on May 8, 2015 [1 favorite]


Yes at the same time you have to be informed and advocate for yourself but god forbid you read something on the Internet, never ever do that. And if you're not already thin then you're a lost cause anyway.
posted by bleep at 12:16 PM on May 8, 2015 [4 favorites]


Re: reading things on the internet, there's a right way and a wrong way. I speak as a patient, not a doctor. If you go to WebMD and diagnose yourself with an extremely rare condition only found in three spots on the planet, or one known to be associated with malingerers (e.g. chronic lyme disease), then yeah, you might get the brush off. If you cite some peer reviewed research or accepted medical bodies, you still might get the brush off from bad docs, but the good ones will work with you.

In my example, I had to advocate strongly for a correct diagnosis for my cancer; I had a campus doc who was extremely lazy and generally would only see healthy college kids, and so he just gave me the most cursory examination. When I bullied my way to an ultrasound and got a correct diagnosis, I then did my research on the National Comprehensive Cancer Network and presented my understanding to my oncologist teams. I have had amazing docs who gave me reams of papers to read up on, and I have had oncologists (cough Stanford cough) who could not have given less of a shit. I dropped the bad docs post-haste.
posted by Existential Dread at 12:34 PM on May 8, 2015 [2 favorites]


I think, though, that a person's ability to be taken seriously is often pretty contingent on factors like class, education level, gender, whether they're thin, etc. Also, depending on how your insurance works, you can't always just drop a bad doctor, because there may not be another available doctor who takes your insurance.

But I really think this needs to be treated as a systemic problem, not as a problem with individual patients or doctors. Some patients are unreasonable. Some doctors are jerks. We're all people, and people are typically not perfect. Any workable system has to be able to function even if patients and doctors are flawed human beings.
posted by ArbitraryAndCapricious at 12:59 PM on May 8, 2015 [6 favorites]


The unwillingness of people to accept any possibility of lifestyle change

You know, at this point, I don't know any other way to see statements like this other than class-and ablist- based blindness. The idea that everyone has the ability to engage in radical lifestyle change but it's just that they're not morally upright enough to do so is frankly offensive as hell.

Would you tell someone in a wheelchair for crippling pain that they'd be better off if they just got up and run more often? No? Then why would you tell someone with a mental health issue that may be just as debilitating to do it?

Would you tell someone poor to just 'go get a job'? No? Then why would you tell someone already working long hours to just make time out of their copious free time to make lifestyle changes that you think are advisable, when they may already be suffering from the effects of a sleep deficit and possible double shifts? And that's not even beginning to tackle frankly how fucking expensive it is to eat healthy.
posted by corb at 1:13 PM on May 8, 2015 [7 favorites]


Would you tell someone in a wheelchair for crippling pain that they'd be better off if they just got up and run more often?

Yes, preferably short bursts of sprinting or trampoline workouts with a personal trainer, ideally of east Asian provenance, but short of that, light jogging on an indoor track.
posted by docpops at 2:32 PM on May 8, 2015 [1 favorite]


Existential dread's story explicates the crux of some kind of problem. The negligent doctor she went to first...there should be a public record of their failure, and I don't mean some stupid crowdsourced add vending website. How many patients have had to reinvent the wheel, learning first how to research medical literature and then researching it?
posted by Pembquist at 2:56 PM on May 8, 2015 [2 favorites]


a person's ability to be taken seriously is often pretty contingent on factors like class, education level, gender, whether they're thin, etc.

You forgot to mention race - the one and only factor here that a patient generally cannot ever change about themselves. It's only folks with "normal" BMIs who are truly safe from the proverbial exam room side eye (and I don't mean by the doctors). My local clinic has an alert that pops up on the medical professionals' computer screens whenever a patient's BMI measures "underweight," "overweight," or "obese"-- the latter 2 of which show up on screen the vast majority of the time. The insurers and the US government all want it this way, so that's how it is. Most of the local MDs I know at this clinic would rather not be so obviously prompted to discuss the fact of a patient not having a "normal" BMI -- it is too triggering for too many folks, it leads to bad reviews, it wastes precious time, and it is often highly irrelevant to the particulars of any given patient/doctor discussion.

Make no mistake though: a person with a "normal" BMI does not necessarily equal a person who is "thin." Something like 68 percent of US adults are considered to be either of "overweight" BMI or "obese" BMI, and issues of fat shaming in health care are thankfully getting press. But what we don't often hear about are the patients who have an "underweight" BMI and are also often not taken seriously enough by medical professionals, especially those patients who are "underweight" women. The status quo the insurers want to enforce basically boils down to: be "normal" or you will face some additional hurdles. Post-ACA, they can no longer get you on pre-existing conditions, so this is the future of how they will get you.
posted by hush at 3:46 PM on May 8, 2015 [1 favorite]


I have a friend who is, right now, probably dying-for-real in a critical care unit of a malady that nobody seems to be able to accurately diagnose or decide how to treat. She has specialists issuing contradictory orders and yelling at her for not following them, she's been accused of lying about everything from being compliant about her medication to whether or not she's diabetic. (They actually woke her up in the middle of the night to do a "surprise" blood sugar check.) She's been in and out of the hospital for the better part of a year, because she keeps being discharged directly from the CCU and then having to be brought back by ambulance a few weeks or days later.

She is smart, well educated, charming, well informed, and a fierce advocate for her own health, when she's conscious. But she's also fat and on Medicaid. And while there are a ton of wonderful doctors doing yeoman's work with Medicaid patients (hat tip to Slarty Bartfast), I can't help but think she would be getting better care if she was thin and/or on private insurance.
posted by KathrynT at 6:19 PM on May 8, 2015 [3 favorites]


While it's always gratifying to use anecdotes to bring those arrogant doctors down a peg or two, the fact that you or your friend got unsatisfactory medical care doesn't really argue against the article's main point:

it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful.

Surely we don't want ourselves and our loved ones to get tests or treatments that have consistently been shown to have no benefit or to be outright harmful?
posted by kevinsp8 at 9:11 PM on May 8, 2015 [2 favorites]


I'm pretty confident that nobody wants that. People want to be listened to, to get appropriate care and not be treated like crap.
posted by bleep at 9:22 PM on May 8, 2015 [2 favorites]


A British version in the Guardian:
The Academy of Medical Royal Colleges wants to bring an end to a culture of “too much medicine” in which “more is better” and doctors feel compelled to always “do something”, often because they feel under pressure from the patient, even though they know that the treatment recommended will probably not work.
posted by ellieBOA at 3:32 AM on May 13, 2015


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