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Saturday, March 9, 2013

No Dear, Bigger Is Not Always Better: How Doing Nothing Is Often Better Than Getting Defensive Medicine

 "The delivery of medical care is to do as much nothing as possible."

-Stephen Bergman known as "Dr. Samuel Shem," Rule Number 13, The House of God

Website for information on The House of God:

Heads up! Physicians -- Your first rule is "to do no harm."

Dr. Sanjay Gupta reports American doctors perform far more tests and procedures and hand our more prescriptions than in other industrialized nations, and far more than they once did. Since 1996, the percentage of doctor visits leading to at least five drugs’ being prescribed has nearly tripled, and the number of M.R.I. scans quadrupled.
More -- more procedures, more testing, more treatment, more drugs -- is not always better. According to Gupta, in a recent anonymous survey, orthopedic surgeons said 24 percent of the tests they ordered were medically unnecessary.
Americans must begin to question some very common methods used by doctors because of the following reasons:
(1) Unnecessary actions can be potentially harmful, and
(2) Unnecessary actions are exceedingly expensive. 
According to a 1999 report by the Institute of Medicine, as many as 98,000 Americans were dying every year because of medical mistakes. Today, exact figures are hard to come by because states don’t abide by the same reporting guidelines.
Consider the case of a 40-year-old mom who sought treatment for heartburn. Even though neither she nor her doctors thought she was having a heart attack, it was a remote possibility. Miss that diagnosis, and the doctors could be sued. She was admitted for “non-specific” EKG changes, had an “equivocal” stress test, and then underwent coronary cauterisation, which perforated an artery and killed her.

Or consider Jack the 33-year-old dentist and father of three, who fell and bumped his head when he was 13. He “felt a little funny” but he never lost consciousness. He had a normal neurological exam. He had no confusion, nausea or vomiting. The ER doctor ordered a CT scan. The radiation damaged the DNA in Jack’s brain and 20 years later the mutated DNA developed into an untreatable glioma (brain tumor). Why did the doctor order the CT scan? He had a very rational fear of being sued.
(BirdStrike M.D., "A Nameless Faceless Killer," Emergency Physicians Monthly)
Defensive Medicine
Tamer Mahrous, the Happy Hospitalist writes, “Some doctors and patients may be willing to experience some anxiety for the unknown. But most won’t, especially since neither party is directly paying for the testing. This selfish interest is rooted in moral hazard, at the expense of national economic security.”

Tamer is a board certified internist who graduated from medical school (UNMC) in 2000, completed my internal medicine residency from the University of Nebraska Medical Center in 2003 and practice as a board certified internist at a world class hospital as part of the largest independent private practice hospitalist group in the state, Inpatient Physician Associates. Happy is a character he created in 2007 to allow the reader to experience what hospitalist medicine is really like.

Check out the Happy Hospitalist Blog:
A survey by Mount Sinai School of Medicine researchers has found that 91 percent of physicians believe concerns over malpractice lawsuits result in "defensive medicine." Defensive medicine is defined as "the practice of ordering medical tests, procedures, or consultations of doubtful clinical value in order to protect the prescribing physician from malpractice suits."
This kind of treatment is meant less to protect the patient than to protect the doctor or hospital against potential lawsuits. Read that last sentence again. Isn't this "concern for protection" ironic? So, the root of the practice of defensive medicine is really all about coverage -- covering the assets and bare asses of  health care providers.
Yet, a consumer group Public Citizen, a national, nonprofit consumer advocacy organization, says that medical malpractice payments in 2011 were at a record low and have fallen for eight straight years. That's right. Malpractice payments are not to blame for the rising cost of health care.

The group’s report says that the number of medical payments and the inflation-adjusted value of such payments were at their lowest levels since 1991, the earliest full year for which such data is available.

In the report, “Malpractice Payments Sunk to Record Low in 2011,” Public Citizen analyzed data from the federal government’s National Practitioner Data Bank, which tracks malpractice payments on behalf of doctors.

Let's make this clear. Patients are not becoming rich because of the malpractice of doctors. Just the opposite -- patients are the ones who pay not only the physical and mental costs of bad doctoring but also the tremendous monetary costs.

“Contrary to the promises of policymakers and leaders of physician groups who have spent the past two decades championing efforts to restrict patients’ legal rights, there is no evidence that patients receive any benefits in exchange for ceding their legal remedies,” said Taylor Lincoln, research director of Public Citizen’s Congress Watch division and author of the report. “Instead, malpractice victims and ordinary patients end up absorbing significant costs for uncompensated medical errors.”
("Learn When to Say ‘Whoa!’ to Your Doctor," Consumer Reports, June 2012)

In contrast to the hundreds of thousands of injuries (and tens or hundreds of thousands of deaths) that major studies attribute annually to medical mistakes, fewer than 10,000 medical malpractice payments were made on behalf of doctors in 2011, demonstrating that the vast majority of patients injured by medical malpractice are not being compensated, the Public Citizen report says.

 (Click image to enlarge.)

"The Good, the Bad, and the Ugly"
To be fair, let's acknowledge that certainly most procedures, tests and prescriptions are based on legitimate need. Yet, the sad irony is that many are not. The whole thing reminds me of my favorite Sergio Leone Spaghetti Western:    
"The Good": Defensive medicine is rooted in the goal of avoiding mistakes.
"The Bad":  Each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error.
"The Ugly": More procedures, more testing, and more treatment are not always better.
But, the beat goes on. Nearly half of primary-care physicians say their own patients get too much medical care, according to a survey published in 2011 by researchers at Dartmouth College.
What Procedures? What Risks? What the...?
Let's talk about some of the major culprits involved in defensive medicine:
* Pills and pills and more pills...

(a) When people show up complaining that something hurts, the easiest way for a doctor to get them out of the office is to send the patients off with a prescription for a pain medication that contains a narcotic (like Vicodin or OxyContin). You should never use them for chronic pain — and if you're on them already, work hard to get off them.

(b) Millions of Americans take statins to lower their cholesterol. Common side effects from these drugs include muscle pain and soreness. Usually those effects are just annoying, but some patients suffer muscle weakness as well, especially around the haunches, which can be debilitating.

The side effects don't always go away when you patients stop taking the pills. Orthopedists see this all the time and say it is a concern, but most docs downplay it. Be vigilant if you're starting a statin regimen, and talk to your doctor about switching or discontinuing drugs immediately if you develop severe or disabling symptoms.

(c) Many patients have been on medicines for years without change. No one tells them that many drugs, especially antihypertensives, anticoagulants and antidepressants, may no longer be necessary after a year or two. It's also often possible to lower doses of these medications — which also lowers the risk of side effects. So, make it a habit to revisit your list of medicines with your doc, and see if you can't pare it down once in a while.
(Dr. Scott Haig, "10 Medical Missteps," Time, October 6 2008)
* An EKG—which records the heart’s electrical activity through electrodes attached to the chest—is a standard part of a routine exam. Some also regularly get an exercise stress test, which is an EKG done as they walk on a treadmill. Both are key if you have symptoms of heart disease or are at high risk of it. But for other people, the tests are not as accurate and can lead to unnecessary follow-up and treatment such as CT angiograms, which expose you to a radiation dose equal to 600 to 800 chest X-rays, and coronary angiography, which exposes you to further radiation.
* Getting an X-ray, CT scan, or MRI  for back pain can seem like a good idea. But back pain usually subsides in about a month, with or without testing. In fact, the American Academy of Family Physicians (AAFP) recommends that unless red flags are present, doctors should wait six weeks to order imaging for low back pain. Back-pain sufferers in a 2010 study who had an MRI within the first month didn’t recover any faster than those who didn’t have the test -- but were exposed to radiation and were eight times as likely to have surgery. Plus, they had a five-fold increase in medical costs.
One study projected 1,200 new cancer cases based on the 2.2 million CT scans done for lower-back pain in the U.S. in 2007. CT scans and X-rays of the lower back are especially worrisome for men and women of childbearing age, because they can expose testicles and ovaries to substantial radiation. Finally, the tests often reveal abnormalities that are unrelated to the pain but can prompt needless worry and lead to unnecessary follow-up tests and treatment, sometimes including even surgery.

Sanjay Gupta reports: "CT and M.R.I. scans can lead to false positives and unnecessary operations, which carry the risk of complications like infections and bleeding. The more medications patients are prescribed, the more likely they are to accidentally overdose or suffer an allergic reaction. Even routine operations like gallbladder removals require anesthesia, which can increase the risk of heart attack and stroke."

(Sanjay Gupta, "More Treatment, More Mistakes" The New York Times, July 31 2012)
* Virginia Moyer, a professor of pediatrics at Baylor College of Medicine and chair of the U.S. Preventive Services Task Force, points out that mammography use is responsible for about 20 percent of the cases of overdiagnosis of breast cancer. In fact, the Task Force came under fire a few years ago for recommending fewer women receive routine mammograms—even though the recommendation was based on evidence about providing the best care to women.
* Brain scans can reveal things that appear worrisome but aren’t. For example, doctors might mistake a twist in a blood vessel for an aneurysm. Those findings can trigger follow-up tests, and prompt referrals to specialists for expensive consultations. And CT scans of the head can deliver a radiation dose that’s the equivalent of 15 to 300 chest X-rays.
* People with sinusitis—congestion combined with nasal discharge and facial pain—are often prescribed antibiotics. In fact, 15 to 21 percent of all antibiotic prescriptions for adults are to treat sinusitis. But most people don’t need the drugs. That’s because the problem almost always stems from a viral infection, not a bacterial one—and antibiotics don’t work against viruses.
About one in four people who take antibiotics report side effects, such as a rash, dizziness, and stomach problems. In rare cases, the drugs can cause anaphylactic shock. Overuse of antibiotics also encourages the growth of bacteria that can’t be controlled easily with drugs. That makes you more vulnerable to antibiotic-resistant infections and undermines the usefulness of antibiotics for everyone.

* The activity most frequently performed without need was a complete blood cell count at a routine physical exam. In 56 percent of routine physicals, doctors inappropriately ordered such tests, accounting for $32.7 million in unnecessary costs.

Doc, Why Are You Treating Me This Way?
* "Bigger Is Better" and "The TV Told Me So"
One reason is that patients, motivated perhaps by an ingrained belief that more care is always better care -- not to mention ads from drug companies -- ask for it. And all too often doctors comply, in part because it’s faster and easier than explaining why a test or drug might not be a good idea.
* Old Habits Are So Hard to Break

Another reason doctors are less likely to own up to: It’s hard to kick bad habits. But researchers say that doctors often embrace evidence that reinforces their practice style while ignoring evidence that conflicts with it. For example, results from a trial published in 2007 found that angioplasty—an invasive procedure— worked no better than drugs plus lifestyle changes for people with stable heart disease. But several years later a study found that most doctors still chose angioplasty without giving those simpler, less expensive steps a shot first.
* Show Me the Money
Of course, doctors have financial motivations. Under the present system, hospitals and doctors earn more money by doing costly interventions than by keeping people healthy. So, doctors often order tests and recommend drugs or procedures when they shouldn't -- sometimes even when they know they shouldn’t. For example, research suggests that those who invest in imaging equipment order more CT scans and MRI tests than doctors who haven’t made the investment.
* The "Substandard" Is Standard
61 percent of 1,548 physicians responding to a survey by Jackson Healthcare in 2012 said defensive medicine has become the new "standard of care."
(Molly Gamble, "Top 10 Reasons Physicians Practice Defensive Medicine,"
Becker's Hospital Review, December 5 2012)
* The Bullies "Made Me Do It"
24 percent of 1,548 physicians responding to a survey by Jackson Healthcare in 2012 said the problem was peer pressure. Other physicians of my specialty are doing it, and I'm afraid I'll look "deficient" by comparison if I do not.
(Molly Gamble, "Top 10 Reasons Physicians Practice Defensive Medicine,"
Becker's Hospital Review, December 5 2012)
Patients Lost In the Wasteland
And, all that unneeded, expensive care can be hazardous to your health, but it can be devastating to your pocketbook as well. 
The problem has become so serious that such groups as the American College of Physicians, the ABIM Foundation, the National Physicians Alliance, and a coalition of medical societies in a project called Choosing Wisely began to examine the need to reduce unnecessary interventions that waste money and can actually do more harm than good. They recently found...
"A report by the Institute of Medicine estimated that $750 billion -- about 30 percent of all health spending in 2009 -- was wasted on unnecessary services and other issues, such as excessive administrative costs and fraud."

"An additional 90 medical services were added to the 40 items initially listed by the campaign in April 2012.

"According to a 2012 American College of Physicians (ACP) policy paper in the Annals of Internal Medicine, up to $765 billion, which accounts for around 30 percent of U.S. healthcare costs, are identified in the paper as the result of mostly inappropriate or unnecessary tests, treatments and other services.
"The routine use of 130 different medical screenings, tests and treatments are often unnecessary and should be scaled back."
 (Sherry Baker, "Americans Waste $765 billion on Unnecessary Medical Tests,"
 Natural News, October 30 2012)

Tara Haelle recently reported on defensive medicine in Scientific American. She spoke with James Froehlich, the director of vascular medicine at the University of Michigan Medical School, and Rich Sagall, a family medicine physician in Gloucester, Massachusetts.
According to Froehlich...
“The assumption has been throughout history that the more you know about human normal function and disease, the better equipped you are to treat disease and restore health.
“There are two problems with that. One is the assumption that the goal of medicine is to make people normal again. The other fallacy is that attempts to do so will lead to better outcomes.
“It’s been frequently commented that you can make a more informed decision about a car than about a surgeon. The point is that we all have a better idea of whether the brakes need to be changed than if we need a CT scan. This campaign is meant to empower a dialogue so there’s a better discussion about tests and procedures.”
The often debilitating anxiety that medical screenings can cause are also harmful.
Sagell said..
Researchers are finding that trying to make patients “normal” again or even finding out if a patient has something “abnormal” can lead to harm without changing the course of a disease or a patient’s outcome. Aside from excess radiation or treatment side effects, the often debilitating anxiety that screenings can cause are also harmful, says Sagall.

 “One question every patient should ask before submitting to any test is, ‘How will the results of this test influence the treatment plan?’” Sagall says. “Oftentimes it turns out it won’t.”
That dialogue is most successful, though, when consumers understand before they get sick that screening and treatment can cause harm.

(Tara Haelle, "Putting Tests to the Test: Many Medical Procedures Prove Unnecessary—and Risky," Scientific American, March 5 2013)

Real reform is unlikely to happen unless doctors' groups, supported by patients' groups interested in better medical care, band together with a common voice. Until then, the next time your doctor wants to order a test, a procedure, a treatment, or a new drug, you should ask why. Odds are that it will be the right decision, but just by asking you may be able to steer clear of actions that have great  downsides.

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