Quality

A BBC report from earlier this weeks makes it very clear: overuse of elective medical procedures is not just an American problem, or even just a developed-world problem. The report tells the story of women in a number of rural villages in India, where hundreds of women have been convinced, cajoled, and frightened into having hysterectomies they almost certainly didn't need.

The story suggests that the procedures are probably being done to make money for unscrupulous local doctors. The docs work in India's private medical system, but the public insurance program for the poor allows patients to see private physicians when they can't acces the public healthcare system. According to the story, the doctors often tell patients they have cancer and need an immediate hysterectomy--sometimes without even performing a biopsy, and without offering other, less invasive forms of cancer treatment. Unnecessary operations make money for the physician, but they're a huge financial burden for patients--and although the article didn't mention it, unnecessary treatments also expose patientsto needless risk of serious complications and death.

The Indian government is starting to react to the apparent epidemic of overuse. But in addition to fixing perverse financial incentives, it's important to consider the role informed and empowered patients can play in ensuring unnecessary treatments don't happen. The article notes that women find it hard to refuse a surgery that the doctor says they need right away. One young woman said she wasn't even able to discuss the surgery with her husband first. Fixing that rushed and insensitive process is crucial. Patients in rural India have just as much right to make their own decisions as patients in rural Indiana--and fortunately, there are effective tools to help them make those decisions. Even if the public medical system can't yet reach all parts of rural India, it might be possible for the government to make sure shared decision making and decision aids are available--that could save money, and help patients avoid unnecessary treatment.

UPDATE: Dr. Mohammad Zakaria Pezeshki, Associate Professor in the Department of Community Medicine at Tabriz Medical School in Tabriz, Iran, saw this post & responded with some good thoughts of his own. He points out that it's crucial to have decision aids in patient-accessible languages, and that opportunities to inform and engage patients are not limited to shared decision making. Check out the post and the rest of his blog, Earth Citizens' Health!

As California’s oldest governor, Jerry Brown has gone out of his way to demonstrate his vigorous good health, jogging around the Capitol and even challenging reporters to pull-up contests—which he won. Now that he’s been diagnosed with prostate cancer and begun radiation therapy, some news outlets seem to be experiencing a bit of schadenfreude, gleefully calling the 74-year-old governor’s diagnosis a “blow to his healthy image.”

This op-ed is co-authored by Jeff Borkan, Chair of the Department of Family Medicine at Brown University School of Medicine.

The media attention and Congressional investigation into the tragic epidemic of spinal meningitis in people who had injections for back pain has focused on unsanitary conditions at the compounding pharmacy that produced the medications. At last count 620 cases and 39 deaths have been confirmed in 19 states because the steroids used in the injections were contaminated with a common fungus. Yet remarkably little has been said about the underlying cause of this tragic outbreak -- the widespread overuse of an unproven procedure (epidural steroid injections) that put the contaminated steroids into the spinal cords of patients in the first place.

The procedure involves inserting a needle into the spinal canal, one of the most vulnerable parts of the human body, and then injecting steroids, which are supposed to reduce inflammation and allow the back to heal. Each year, more than 9 million Americans are treated with spinal steroid injections, and one study found that the number of Medicare recipients undergoing this procedure increased by 159 percent between 2000 and 2010.

How did steroid injections come to be performed so often? Patients assume that most medical treatments are supported by years of careful studies. They think any invasive procedure that might put them at risk of harm is performed only by trained and certified physicians with rigorous clinical oversight.

In the case of spinal steroid injections, nothing could be further from the truth. There is no widely accepted guideline for the use of epidural steroids, and the U.S. Food and Drug Administration has never specifically approved steroids for that use. There is scant medical evidence to show that the use of epidural steroids is any more effective at relieving back pain than routine, conservative care or even sham (fake) injections. There are many possible side effects of this procedure, and while the most serious complications are rare, they can be disabling or life threatening. Yet this unproven, risky treatment is routinely offered on an outpatient basis by physicians who have widely varying levels of training and expertise. While most of those physicians undoubtedly believe they are acting in their patient’s best interest, there is no escaping the fact that they are paid nicely for a procedure that takes only a few minutes to perform.

There's no doubt that regulators should go after the makers of unsafe medications. Slipshod manufacturing practices can't be tolerated when people's lives are at stake. At the same time, we need to rethink our willingness to pay for procedures and tests that have known risks and unknown benefits. Epidural steroid injections are just one of myriad examples of such treatments, and taken together, the overuse and misuse of medical procedures is costing us dearly, both in terms of wasted dollars and wasted lives. It’s time to build a health care system that serves patients rather than profits, and the first step is recognizing tragedies like the spinal meningitis outbreak for what they are, cases of overuse.

Australia's Medicare system took a big step toward cheaper and more effective healthcare recently by ordering a systematic compilation of procedures that are harmful, not supported by evidence, overused for a large number of patients, or of low value for some other reason. The list is based on recommendations from the British National Health Service's National Institute for Health and Clinical Excellence (NICE), evidence assessments from the Cochrane Collaboration, and other sources. The list is full of old favorites for people who pay attention to overtreatment--procedures like vertebroplasty, elective angioplasty for stable angina, PSA testing, and some arthroscopic knee surgeries. But it also includes a wide variety of specific surgical techniques and other, more technical examples of ineffective practices that we non-clinicians don't hear about or talk about as much.

It's hardly a complete list of all the ways patients get overtreated. The study didn't include pharmaceuticals, and lots of overtreatment is more the result of being in an overly-intense treatment environment (like a hospital or an ICU than the result of a specific decision to do a specific procedure. But it's certainly useful to see a good long list of ways that we can eliminate waste in the medical system--hopefully other systems outside Australia will take note, and groups like Choosing Wisely will take a look at the list, draw from it, and add their own examples!

The paper describing how the list was created is here; the full list is in an appendix to that paper, here.

Each fall, medical students in their fourth and final year select a medical specialty and apply to residency programs. Residency, which lasts anywhere from three to eight years, is run by teaching hospitals. It's when newly minted MDs learn the hands-on, practical skills of doctoring -- how to make diagnoses, perform surgeries, order and interpret tests, etc. They also learn how to deal with patients and families, and work with other caregivers.

We've just closed out a month where everything from the White House to professional football players' cleats turned pink to raise awareness of breast cancer. Every year during October, there's a constant focus on raising money for breast cancer research, and on reminding women to get screened. The mantra is always, "Early detection saves lives."

As we've written before, it's an article of faith for many patient advocates and medical organizations that cancer screening is an unadulterated good. But a new study in the Lancet on breast cancer screening provides yet more evidence that while mammography can save lives, screening also causes serious harms. They find that for every woman whose life is saved, three other women will be overdiagnosed and face unnecessary treatment. That doesn't even count the harm caused by false positives on screening mammograms, which lead to unnecessary stress as well as biopsies and other tests. It's worth noting that the population in the Lancet study includes women over 50, in line with the US Preventive Services Task Force's recommendations. Expanding screening to women under 50 means that fewer of the women screened will have harmful cancers, so the harm of overdiagnosis is more likely to outweigh benefits from catching cancer early.

To go along with the Lancet study, the New England Journal of Medicine has a new Perspective piece by Drs. Steve Woloshin, Lisa Schwartz, William Black, and Barnett Kramer. They make a forceful argument against one-sided pro-screening campaigns that present the benefits of screening, while ignoring the harms. The piece is linked to a great slide show with some of the most egregious pro-screening advertizements.

For most patients in the real world, getting good medical care involves complicated decisions. It’s not as simple as what often gets shown on TV, where a patient goes in, the doctor figures out what’s wrong, and then he performs some lifesaving surgery. Most of modern medicine, especially for the elderly, is a lot messier — usually there’s not “right” answer, no perfect treatment. And a patient needs to be an active participant in making choices in treatment.

Hosted this week by Dr. Jaan Sidorov at the Disease Management Care Blog, it's "A Brainy Health Wonk Review on Health Reform, the Affordable Care Act and Lots More!" Go check it out.

Health Wonk Review will be back on September 13th, hosted by Louise Norris of the Colorado Health Insurance Insider Blog.

Boston Globe health reporter Chelsea Conaboy has a brief profile of Dr. Bernard Lown in the most recent edition of the Boston Globe Magazine. It covers some of the most important moments in a truly remarkable life, including our conference this April on Avoiding Avoidable Care. Check out the piece here.

If you haven't seen it yet, you can also read more by and about Dr. Lown at his blog.

Last year Dr. Ken Murray, a pediatrician at USC, published an article called "How Doctors Die." In it he describes how physicians, many of whom witness end of life care and death as a regular part of their practice, often choose to die differently than their patients. He gives the example of a friend of his, an orthopedist who found out he had a very lethal form of pancreatic cancer. Instead of enduring surgery, chemotherapy, radiation and long hospital stays, he instead chose to close his practice and spend his last months at home, surrounded by his friends and family. Dr. Murray goes on to talk about "death with dignity" and how many physicians choose to avoid the extreme end of life measures that they regularly provide to their patients.

Though the article was beautifully written and thought provoking, it wasn't very academic. He spoke from personal experience, and included no references. Some readers asked for data to back up his observations, so last week Dr. Murray posted a follow-up article with a more critical examination of the evidence. That article, "Doctors Really Do Die Differently," entertained a variety of studies with topics ranging from living wills to CPR effectiveness. Both are good and worth a read.

The topic of end of life care is eerily applicable in my life right now. On Saturday morning I got a call from my Mom telling me that my great-grandmother passed away. She was 101 years old (almost 102!) and her health had been in decline for decades now. A couple of nights ago she fell and broke her hip. The paramedics came, options were discussed, and it was decided that taking her to the hospital and trying to perform surgery wouldn't do much good--she was on the way out. They provided morphine to be administered through the night, to keep her as comfortable as possible. My wonderful mother sat with her through the night and held her hand as she passed away in the morning. (You can read my tribute to Grandma Ada here).

As I sat down to start writing this post I thought about the hard decisions that were made that night. I thought about Dr. Murray's comments about “death with dignity.” Grandma Ada did have a living will, but it wasn’t accessible at the time. She had made it clear, however, that did not want her hip replaced (again) if she broke it and that she did not want to die in the hospital. Had she been rushed to the emergency room and aggressively treated it would have just been prolonging the inevitable, not to mention putting her through a lot of unnecessary pain and discomfort. It was her time to go, and I’m glad that it was at home, surrounded by family, and in peace.

The topic of end of life care is one that has been receiving quite a bit of attention from some big names. Time Magazine’s Joe Klein recently did a cover story about his experience being, as he described it, his parents’ “death panel.” The story, called “How to Die,” is both a memoir of his parents and an indictment of our fragmented, “fee-for-service” healthcare system (the article requires Time membership; the video summary is free). Newsweek also had a cover story broaching the subject. Written around the time of the claims that the ACA included "death panels," Evan Thomas’s "The Case for Killing Granny" told the story of his grandmother’s experience of having to insist that she wanted to be placed in hospice rather than stay in the ICU. Both stories highlight different weaknesses in our current approach to end of life care and suggest ways that we can improve.

As a future physician, I am proud to become part of a profession that has such a high regard for life. Physicians are rightfully on the offensive to keep death at bay. However, if we always equate life as a “win” and death as a “loss,” without regard to quality of life, then in the grand scheme of things medicine is a zero-sum game—in the end, we always lose. If, however, our determination--our almost righteous zeal--to protect life is accompanied by a reverence for the inevitable experience of death, then helping to ease a patient’s departure from this life, according to her preferences, can be seen as one of medicine’s sweetest triumphs.

As Evan Thomas put it,

“Our medical system does everything it can to encourage hope. And American health care has been near miraculous…But death can be delayed only so long, and sometimes the wait is grim and degrading. The hospice ideal recognized that for many people, quiet and dignity—and loving care and good painkillers—are really what's called for.”

This week I started my second year of medical school. I already consider my summer here at the New America Foundation an invaluable part of my medical education, and I am sad to leave. My great-Grandmother’s passing has coincidentally provided me with the perfect opportunity to craft a farewell post about one of the topics that I have become passionate about this summer—shared decision making. Throughout all of a patient’s life, she should have an active role in her care. Though this applies at all stages of life, it is especially applicable at the end of life. What makes these end-of-life decisions different from those made earlier in one’s life is that they must be made in advance.

As a final request at the close of my internship, I ask that you have a discussion with your loved ones about end of life care. Talk about what you want to happen and (perhaps more importantly) what you don’t want to happen. Consider drafting a living will or advanced directive, and making sure that someone always knows where it is.  It was fortunate that Grandma Ada’s wishes were honored without having to pull out the legal paperwork, but that is often not the case. Evidence has shown that those take the time to create a living will are far more likely to receive the care that they want when they can no longer speak for themselves. That goes for people who want every intervention possible, as well.

Ultimately, honoring wishes about end of life care isn’t about costs; it’s about your will being made known about one of the most important moments in your life. Then, and only then, can healthcare professionals do what they are called to do: enable you to live your life, as you want to live it, with minimal pain and suffering.