“Tens of thousands of Americans undergo unnecessary surgeries that maim, and even kill, patients”. That’s the subtitle on USA Today’s A1 article from Friday, June 21, entitled “Under the knife ‘for nothing‘.” And the article doesn’t even address the unnecessary tests that lead to those surgeries, which harm even more patients (unnecessary testing often “discovers” normal or benign findings, leading to unnecessary intervention, causing unintended outcomes in some patients, not to mention needless anxiety and time away from work or family). Such is our addiction to MORE in the American healthcare industry, amped up on a compensation system (fee-for-service, FFS) that financially rewards doctors, hospitals, pharmaceutical and device companies for pushing the snake oil. Let’s move some smack … Baby needs a new pair of shoes (or a longer car).
This is not new news. Many institutions and individuals have published research asserting and confirming America’s addiction to medical and surgical overtreatment (defined here as any ordered test or performed treatment that had a poor chance of helping the patient and that physicians practicing without conflicts of interest (FFS) would not have ordered or performed). USA Today is merely the latest media source to (finally!) report on the overtreatment phenomenon in the US (Time, Newsweek, The New Yorker, The New York Times, Consumer Reports, Wall Street Journal are others). I’ve even written about it …
The USA Today article goes on to list eight (8) common surgical procedures often done without true medical necessity. Articles within the last month have also called out tests that appear to have little to no benefit in typical circumstances: annual bimanual pelvic exam and PAP smear (New York Times online 29April2013); annual PSA testing for many men (cancer.gov and consumerreports.org ); excessive x-ray testing in many forms (medicalnewstoday.com ).
I’ve discussed in previous posts what drives doctors (consciously or unconsciously) to order unnecessary testing and treatments (FFS and/or absence of EBM in their practice). But sometimes it’s not the doctor who’s pushing the snake oil, rather the patient seeking it. Why? What characteristic of the human condition or American culture drives patients to seek care unlikely to be helpful, particularly when that care can harm?
I believe two forces are at play:
(1) Most Americans have a poor understanding of probability; the possibility the treatment might help overshadows the probability it won’t, not to mention the possibility it might harm. A more sensible approach would be to insist upon research evidence of benefit before risking harm. Or adhering to the approved and licensed uses for the treatments, rather than doctors and patients inventing such uses on a hunch. For more information, see my prior post, “Our Problem with Science“, or “The Ongoing Debate for EBM: fighting for the scientific soul of our profession“.
(2) We wish to buy hope from our doctor, rather than solely receive cognitive or surgical expertise, and who can blame us? Hope is a defining characteristic of the Human Condition. It’s why we buy lottery tickets by the millions each month. In some clinical circumstances, however, physicians must help patients shift their mindset from “more healthcare means more hope” to “precise healthcare means best outcome”. Hope is not a plan. By the way, many heart failure patients live longer and better once enrolled in Palliative Care rather than Intensive Care.
What’s to be done about the supply and demand for snake oil? One big step forward is the Choosing Wisely campaign sponsored by one of the nation’s most respected professional societies, in which we help patients choose care that is evidence-based, not duplicative, truly necessary and unlikely to harm. Tell me what else we docs can do to help our patients stop seeking snake oil … leave a comment.