Atul Gawande is at it again – bringing to our attention what’s wrong with our medical system, with his revelational writings.
This endocrine surgeon come writer (author of Being Mortal) in an article, ‘Overkill,’ in the May 11th New Yorker, brings to our attention how much unnecessary care the US healthcare system provides. Costing $750 billion a year - “more than our nation’s entire budget for K-12 education”. But also costing in unnecessary pain and suffering with invasive tests and the crowding out necessary care.
Doctors recommend care of little value “because it enhances our income, because it’s our habit, or because we genuinely but incorrectly believe in it” says Gawande.
Do You Need That Test?
There is an epidemic of overtesting (total tests in a year are fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests he notes) – which are very often nothing more than a “fishing expedition.” But because no one is perfectly normal “you tend to find a lot of fish” leading to overdiagnosis.
Overdiagnosis is not wrong diagnosis, explains Gawande, but diagnosis of something that is never going to bother the patient in their life time.
We are usually talking cancers. But cancers that are indolent – or “turtles” as he calls them. Which the patient my die with, but not of.
“A recent review concludes that, depending on the organ involved, anywhere from fifteen to seventy-five per cent of cancers found are indolent tumors—turtles—that have stopped growing or are growing too slowly to be life-threatening.”
No body dares to just leave it be (or wants to as there is money to be made from “doing” – and no reward for avoiding unnecessary interventions). In his particular field of thyroid cancer he notes, “we’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all.”
Aided by Avarice
He lays much of this unnecessary care at the door of avarice. He compares two towns in Texas with almost identical demographics but one had twice the per capita Medicare costs of the other, because there was a “profit maximizing medical culture”– where doctors not only enhanced their immediate earnings by doing more, but many owned steaks in the home health agencies, surgery and imaging centers and local for-profit hospitals.
He quotes one cardiac surgeon as describing medicine as having become “a pig trough” noting “we took a wrong turn when doctors stopped being doctors and became businessmen.”
I would add that this tendency has been accelerated by “corporate-ization” where practices are bought up by large hospital groups, or other companies, whose overwhelming interest is the bottom line.
Features in the Affordable Care Act attempt to correct the financial gain of doing more, by allowing any group of physicians with five thousand or more Medicare patients to contract directly with the government as an “accountable-care organization,” and to receive up to sixty per cent of any savings they produce.
In summing up, Gawande’s conclusion is that the medical system is unnecessarily performing tests, to reveal problems that aren’t quite problems, which it then fixes, unnecessarily, at great expense and no little risk - of immediate harm or by “crowding out” necessary care.
It’s a great article. I urge you to read the whole thing.