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Last month, I wrote about the innovative treatment that cured my mother-in-law of her C. diff. infection (you can read about our “elegantly icky solution”). We were singularly thrilled when she recovered, happily overlooking the fact that her problem was caused by my own overdiagnosis of infection and overtreatment with a broad spectrum antibiotic. Of course, I’m not the only one guilty of overtreatment. According to a recent feature in the British Medical Journal, “Evidence is mounting that medicine is harming healthy people through ever earlier detection and ever wider definition of disease.” My laconic hillbilly grandfather had another way of saying the same thing: “Ifn’ it ain’t broke, don’t go fixin’ it.”

The BMJ article is provocative, challenging 20 years of overblown promises delivered by the preventative health community, and medicine as a whole. It seems we’re finally starting to see things a bit more like my grandfather, namely that more medicine isn’t always better medicine. Take mammography. Without a doubt, mammography has saved many lives, but the “Mammography saves lives” campaign created the unrealistic notion that the more mammograms, the healthier the society. Researchers tried to dial back expectations when studies showed that women aged 40-50 who underwent mammography were 10 times more likely to have a complication related to the findings of the test than they were to find real disease. A similar problem emerged with the public relations campaign for getting PSA tested on every male. Did every elevated PSA mean a cancer that needed treatment?

Let’s start by clarifying that while over-diagnosis and over-treatment are related, they are two different problems. First, the diagnosis dilemma: Physicians want to know the diagnosis whether they will or will not treat the problem, leading us to do a lot of testing without considering what we or the patient will do with the results. Sometimes we physicians seek a diagnosis to scratch an itch – satisfy our inner Sherlock – without paying proper attention to the long-term impact on the patient.

The problem of overdiagnosis gets compounded when it meets our patient’s unrealistic expectations. Once a “problem” has been identified, patients assume that doctors can and must “fix” it. How ill-informed are our patients? It’s not much of a stretch to say that people today think that everyone will live into their 90’s painless, scarless, and disease free...and then die quietly in their sleep. They believe that doctors can find any problem before it starts, fix it, and the patients can then go about their lives a few short days later.

I don’t mean to be a Grinch about this, but sometimes we need to give our patients a little dose of reality. Not every problem can or should merit intervention. We need to tone down the over-marketing of medical breakthroughs.

But telling patients what we can’t do – that some problems just take their course no matter the intervention – goes against the grain of why we went into medicine. Years ago, if someone were to ask me why I went into emergency medicine, I would confidently respond, “to save lives.” When my children were small and an ambulance passed the school playground, they would tell their school mates that someone had died and they were being taken to the hospital so their daddy could bring them back to life. OK, so maybe I overplayed my hand at home a little. And I had stories of cracking chests and re-starting hearts that would gather a crowd at any party. Don’t tell me that you haven’t done the same. The point is that we want to save lives. Medicine has gotten an unrealistic reputation for being able to fix everything, and we go right along with it. That motivation is right and good, it just isn’t reality. Some of those cracked chests were brain dead when we got them. Some of those back pains were going to get better or worse regardless of whether they got referred for surgery or not. I’m not negative on the benefits of medicine. It’s just that physicians play a role in helping re-align patient expectations.

As if patients and doctors weren’t doing enough to inflate medical expectations, enter the drug and medical device industries. Companies promise endless sexual pleasure, skin that won’t wrinkle, and bones and joints that won’t wear out. Patients are bombarded with TV ads suggesting that any problem, real or imagined, can be fixed with the right pill. “Talk to your doctor,” they all advise. But the not so subtle message is “Convince your doctor” that you need this product. The problem is that minor or questionable improvements in outcomes have been associated with major cost increases and problematic side effect profiles.

Insurance companies have played their part in encouraging overdiagnosis by instituting a billing system that requires a “diagnosis” for every complaint. Treatment for non-specific complaints of no significance are reimbursed less than are specific diagnoses, whether or not they’re treated. Moreover, since insurance company profits are based on scale, it is not in their business interest to lower the overall expenditure on health care. The result is that we hear insurance companies talking out of both sides of their mouths: “Yes, we want to lower how much we spend on certain tests and procedures, but no, we don’t want to lower the overall amount that is spent on health care in general.”

Of course, let’s not forget the contribution of lawyers to the overdiagnosis and overtreatment of disease. Lawyers, and the irrationality of the medical tort system, have poured gasoline onto an already white hot fire of patient expectations. Now, every cancer must be diagnosed, and no cancer is diagnosed soon enough. Any untoward outcome is assumed to have been the result of some practitioner not acting soon enough, not thinking clearly enough, or not being up on the most recent advances in medicine. Making matters worse, many of our own medical experts take the stand to support these unrealistic expectation. The result is reflexive testing, presumptive surgeries, pharmacopia, excessive cost, and increases in unintended and untoward consequences.

So what are we to do? I see three choices. First, we can wait for someone to regulate more cost-effective, outcome-centered care. To be sure, someone will do it if we don’t. Under the current healthcare law, the government will attempt to direct clinicians to more cost-effective medicine through various commissions, boards, and leaner organizations. But they will not protect us from the legal fallout of the unintended and unforeseen consequences of the actions that produces. The second choice is to get involved at the policy level, through political activism, lobbying, or research to shape the system as a whole. The third choice, which is open to all of us, lies in how we practice day to day. We can dedicate ourselves to do what needs to be done. Fix the broken. Learn best practices to do what is needed without causing more harm than good or spending more than is necessary. Coupled with that we need to communicate realistic expectations to our patients. A wise friend of mine said, “We must all become masterful educators, distilling complex data to a sound bite that patients will understand so that they can participate meaningfully in these discussions.” Being honest with patients about what they need and what they don’t, what medicine can fix and what it can’t, is tremendously empowering. For some time, we have listened to the overblown promises of preventive medicine and excessive care. We need to get back to our roots.

Mark Plaster, MD is Founder and Executive Editor of Emergency Physicians Monthly

1992–2012 - Mark Plaster celebrates 20 years of chronicling night shifts in this column. Tell us about your most memorable night shift in the comments below

 

 

Comments   

# Long Time E.D. Doc 2012-11-12 08:53
This little synopsis should be required reading on July 1 for each and every medical student and resident. Let them read it every year as their training starts as a reminder. Reading this would be way more helpful in the larger scheme of things than one more highly technical article on the diagnosis and treatment of a rare disease. (with apologies to the "academics" out there...)
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# Do nothingS. Carrier MD FACEP 2012-11-14 07:05
This follows directly to one of the most useful things I learned as a resident (from a Critical Care rotation, no less)
"Sometimes the hardest thing to do in Medicine is TO DO NOTHING"....
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# Freda Lozanoff 2012-11-14 08:52
We all know the problems with unnecessary tests and meds, but we can't change the patient's mindset especailly those that frequent the ER No amount of legislation or regs will change this. They have nothing to lose. But we do. If my patient is not satisfied , I will lose my job or be sanctioned.
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# Retiring ED/PA-CJerry Webb 2012-11-14 11:15
As an addage to an above comment, and after 32 years as solo-practition in a rural Maine ED..."The hardest thing to do in medicine, is to tell a patient/family why you won't be doing anything"... i.e., inappropriate closure of a "raspberry" contusion of their kid's forehead (when Mother Nature will do a better job).

About satisfaction reports/complai nts (P-G or Atavar)... our ED Director stated "Good, sound medicine trumps inappropriate patient expectations", in response to Admins threat of negative salary negotiations and patient complaints.
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# Megan Ranney, MD MPH FACEP 2012-11-14 15:30
Mark, great article as always. I would however distinguish between "screening tests" (like mammograms & PSAs, which have questionable value in most populations) and true "preventive care," which DOES improve health and decrease health care expenditure. (E.g., smoking cessation, good diet, stress management, avoiding alcohol/substan ce abuse.... low-cost social & behavioral changes to avoid disease in the first place.)

That said, I completely agree that we need to keep the patient's needs & long-term outcomes at the forefront. And you're right, over-diagnosing and over-treating often hurts the system as well as the patient! Here's hoping that we *do* change the discourse on this. Thanks for taking a stand on this!
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# Role for Evidence Based Diagnostics & EM Participation in "Overdiagnostic s" ConferenceChris Carpenter 2012-11-15 09:30
Mark -- nice essay. This is what we were talking about at ACEP (http://tinyurl.com/bs2vjj7) as well as the topic of an upcoming conference at Dartmouth in September 2013 (see http://www.preventingoverdiagnosis.net/ and http://pmid.us/22645185). I agree with Freda Lozanoff that it is difficult (sometimes impossible) to adjust patient's expectations towards reality. However, I think that it is our challenge to try. What is the alternative -- watching the most advanced healthcare system in the history of mankind sink under the weight of unfunded mandates, unrealistic expectations, and a ceaselessly profiteering malpractice milieu? Not a great option from my perspective.

The challenge is in how to deliver the message to our patients. Although I admit my bias, I propose the following:

1) Educate ourselves on which diagnostic tests do (and more importantly do not) achieve our objectives to alleviate suffering. The only resource of which I am aware that begins to provide these quantitative diagnostic accuracy and cost-effectiven ess discussions for EM is http://tinyurl.com/ajs6zuu.

2) Actively participate in the Dartmouth Overdiagnosis conference by either attending the event or letting your collective perspectives be heard in the months leading up to this conference. Perhaps an EPM column each month until the conference could explore areas of waste or minimal utility in diagnostic testing in a pro/con type debate so that all voices are heard?

3) Design more effective mechanisms to communicate with our heterogeneous patient populations so that eventually "shared decision making" in difficult diagnostic testing situations is truly a mutual stream of communication.

4) Begin designing and using electronic medical records to be more than expensive typewriters by bringing the evidence to the bedside in a manner in which it can be used. Publishing books and paper in print is passé and newer systems are coming (see http://pmid.us/21843213).

Kudos to Mark Plaster for bringing these perspectives to the forefront!
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