Below, a guest-post by Dr. George Lundberg, Editor-at-Large of MedPageToday; Editor in Chief of Collabrx; President and Board Chair of the Lundberg Institute. (Full disclosure: I am a member of the Lundberg Institute’s Board)
What Lundberg says is not meant to be news. Today, physicians tend to agree that many of the tests that patients undergo are unnecessary. Three years ago, one hospitalist shared a story on HealthBeat, describing how he warned his residents about over-testing. His hospital may not have been happy about his disclosure: tests boost revenues.
But in some cases, we have solid medical evidence showing that for certain patients, these tests do more harm than good– though vested interests may try to bury that evidence. (See Dr. Hoffman’s post below.)
Yet doctors continue to order the tests– why?
George Lundberg brings a unique perspective to this problem. Drawing on his wealth of experience, both as a practitioner and as a teacher, he puts it in a historical context. For 40 years, he has asked physicians why they perform so many tests. The frankness of their responses is matched only by Lundberg’s own candor as he diagnoses the excesses in our medical system .
How to Avoid Avoidable Care
Why do physicians order laboratory tests? The traditional reasons are: diagnosis 37%, monitoring 33%, screening 32%, previous abnormal result 12%, prognosis 7%, education 2%, and medicolegal 1%.
In order to confirm these data, I began to ask the same question of many groups of clinical and laboratory workers over three continents in the 1970s, ‘80s and ‘90s during Socratic teaching sessions on how to use the clinical laboratory correctly. And I began to get very different answers.
I was told that physicians order laboratory tests to: confirm a clinical opinion; establish a baseline; complete a database; curiosity; insecurity; public relations; documentation; peer pressure; patient pressure; pressure from recent literature; question of accuracy of prior result; unavailability of prior result; personal education; research; personal reassurance; a need to show to an attending physician; hospital policy; state legal requirement; concern for liability; CYA’ personal or hospital profits, fraud and kickbacks; hunting or fishing expeditions; frustration at nothing better to do (don’t know what’s wrong with this patient, better get some lab tests); to buy time (maybe by the time the lab tests come back I will have some better ideas what is wrong with this patient); simple availability; and ease of doing.
When I was editor-in chief of JAMA I introduced a new series called “Toward Optimal Laboratory Use” by observing that: “The huge variety and volume of available laboratory tests confronts the physician with a major dilemma: What tests should be ordered on what patients? When, how, how often, at what cost, grouped or individually, and in what sequence? What is the interpretation of the results and what steps should be taken? . . . Standards have not been established, but are urgently needed.
I wrote those words in 1975.
Today, these questions remain largely unanswered. Outcomes credited to performing or not performing screening or diagnostic tests still are largely unknown although millions of such tests are performed on Americans each year.
In 1989, shortly after he became the Secretary of Health and Human Services, I asked Dr Louis Sullivan how much medical care was unnecessary. He said that he thought that between 30 and 40% of medical care was inappropriate or unnecessary. Many people cite similar numbers in 2012.
Looking at the reasons lab tests (and imaging is likely similar) are ordered, it is easy to see how a person who is “not sick” transitions through the “worried well” into a lifelong “patient.” Better not to do un-indicated fishing expeditions to begin with.
It is not that nobody cares about this. There has been a recent deluge of at least 15 American books on the topic of overtreatment or unnecessary care:
2000; Severed Trust: Why American Medicine Hasn’t Been Fixed. Basic Books. Lundberg, GD;
2002; Overkill: How Our Nation’s Abuse of Antibiotics and Other Germ Killers is Hurting Your Health and What You Can Do About it. Rodale. Thompson KM;
2003; Epidemic of Care: A Call for Safer, Better, and More Accountable Health Care. Jossey-Bass. Halvorson GC and Isham GJ;
2005; Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises. AMACOM. Deyo RA and Patrick DL;
2005: The Health Care Mess: How We Got into It and what it will take to Get Out. Harvard University Press. Richmond JB and Fein R;
2006: The Trust Crisis in Healthcare: Causes, Consequences, and Cures”. Oxford. Shore DA;
2006: Money Driven Medicine: the Real Reason Health Care Costs so Much”. Harper Collins. Mahar M;
2006: Money Driven Medicine: Tests and Treatments that don’t Work Cundiff DK;
2007: Overtreated: Why too Much Medicine is making us Sicker and Poorer. Bloomsbury USA. Brownlee S;
2008: Too Much Medicine: A Doctor’s Prescription for Better and More Affordable Health Care Paragon House. Gottfried D;
2008: Hippocrates Shadow: What Doctors Don’t Know, Don’t Tell You, and How Truth Can Repair the Patient-Doctor Breach Scribner. Newman DH;
2008: Do Not Resuscitate: Why the Health Insurance Industry is Dying and How We Must Replace it. Common Courage Press. Geyman J;
2011: Rethinking Aging: Growing Old and Living Well in an Overtreated Society. UNC Press. Hadler NM
2011: Overdiagnosed: Making People Sick in the Pursuit of Health Beacon. Welch HG, Schwartz LM, Woloshin S.
2011: How We Do Harm: A Doctor Breaks Ranks About Being Sick in America St Martin’s Press. Brawley OW.
Alas, Shakespeare foretold the effects of all this concern while writing MacBeth in approximately 1605: “it is a tale told by an idiot, full of sound and fury. Signifying nothing.”
Nobel Peace Prize recipient Bernard Lown MD, when recently asked if he was an optimist or a pessimist replied that he was both: a pessimist about the past because it cannot be changed; and an optimist about the future because it can be changed.
Physicians Hold the Key
In 2012, one almost must take an optimistic view on avoiding avoidable care, because as a country and as a profession, we simply must do a better job of acting out our professionalism. Physicians hold the key. “Doctors orders” dictate as much as 75% of all medical costs. Physicians can fix the problem if they begin to exert their will power.
Virtually every time I address this topic in lectures, some physician comes up to me afterwards and tells me that he wants to do the right thing but that authorities, such as hospitals, tell him not to because they need the revenue.
Around the world, medical care is generally about health. In modern America, medical care is mostly about money and it is about jobs.
Still this may change, because it must. We are heading for a wall.
Could it be that there is now a movement sizable enough to make real change in this hemorrhage of money on unnecessary care? To “bend the cost curve”? To ascend to a “tipping point”? I don’t know, but there are at least glimmers of hope. The “Choosing Wisely” movement that sprang up inside organized medicine got off the ground in 2012.And around 150 medical leaders assembled in Cambridge MA on April 24-26, 2012 to try.
The conference called “Avoiding Avoidable Care” was organized by Vikas Saini MD and Shannon Brownlee under the auspices of the Bernard Lown Foundation, with support from many other organizations, such as the Institute of Medicine and the Robert Wood Johnson Foundation. If you are interested in this topic, and you certainly ought to be, it is worth your time to click here to study what has been done and to follow the movement as it evolves.
It is easy to feel discouraged. But I believe that we must not be disheartened. We simply must fix this problem.