by Kenneth W. Krause.
Kenneth W. Krause is a contributing editor and “Science Watch” columnist for the Skeptical Inquirer. Formerly a contributing editor and books columnist for the Humanist, Kenneth contributes regularly to Skeptic as well. He may be contacted at firstname.lastname@example.org.
Why can’t most of us meet with and interview our primary care doctors before hiring them? Even during treatment, why are we reluctant to ask questions probing our physicians’ competence, rationality, or general intelligence? And why do they really wear those gleaming white coats and frequently insist we address them by the lofty title of “doctor”?
Such simple inquiries might lead average patients to suspect that so-called “medical science” and American healthcare in particular prospers best in a self-serving culture of secrecy, arrogance, and denial. But average patients, certain experts say, don’t know the half of it.
Evidence suggests, for example, that one in four American patients is harmed by medical mistake—the fifth leading cause of death in the U.S. Doctors operate on the wrong person or body part as often as forty times per week, and, according to a recent survey of leading medical professionals, approximately twenty-five percent of all medications and medical procedures are unnecessary.
In 2008, the non-profit Washington D.C.-based National Quality Forum released a list of overused tests and treatments. Featured on the roll were antibiotics, x-rays, cardiac CT scans, heart bypass surgeries, back surgeries, knee and hip replacements, prostatectomies, angioplasties, and hysterectomies.
Indeed, little-known research shows that one-third of American heart bypass patients never required surgery. Every year, 300,000 women—many of whom die prematurely from cardiovascular disease and osteoporosis-related conditions—have healthy ovaries removed for no reason. Tens of thousands of children receive unneeded ear tube implantations annually, and a similar number of adults submit to back surgeries unsupported by evidence of success.
Medical overuse is a money-hungry green monster, say healthcare experts Rosemary Gibson and Janardan Singh. It not only “thrives on the fact that too little scientific evidence exists to justify a great deal of today’s medical practices,” it also “wants to prevent good science from informing policymakers and the public about what really works” (Gibson and Singh 2010).
The U.S. consumes more medical products and services than any other country on the planet. In 2010, America spent sixteen percent of its gross domestic product on healthcare, and, according to the Congressional Budget Office, that share will swell to a whopping twenty-five percent by 2025.
Pulling no punches, Gibson and Singh argue that “volume, volume, volume” is the primary aim of today’s “highly-caffeinated” healthcare industry. Hospitals, clinics, and physicians, they say, will gleefully “sell anything,” including “tests, treatments, and procedures that are inappropriate, unaffordable, and promise more than they can deliver.”
Patients, on the other hand, tend to present as easy marks, checking their common sense and consumer skepticism at the lobby doors. For whatever reasons—fear, hope, misplaced trust, the reckless and emotion-stoking popular media, or a deplorably enabling and inapt insurance scheme—American patients are clearly convinced: more is always better.
The most common and expensive overuse occurs daily—office visits, intra-facility referrals, lab tests, and x-rays, most routinely. Expensive for patients, that is, but quite lucrative for healthcare providers.
In 2004, the National Institutes of Health featured x-rays on its list of known carcinogens, capable of triggering breast, lung, and thyroid cancers and leukemia. Of course the benefits of x-rays—relatively benign, single-snapshot exposure techniques—generally outweigh the risks for patients in need.
Computed tomography scans are another subject. Consisting of hundreds of x-ray beams generating high-definition, three-dimensional images, CT scans have become exceedingly popular. Three million were performed in 1980. Today, Americans expose themselves to sixty million every year.
But that’s how the use of new and beneficial technology trends, right? Not so fast. According to a 2007 New England Journal of Medicine study, one-third of adults, and one million children annually, are unnecessarily exposed to CT scan radiation (Brenner and Hall 2007). A 2004 study in Radiology discovered as well that one in 1,200 45-year-olds who undergo a single full-body CT scan will die from radiation-induced cancer later in life, as will one in fifty who receive annual scans for thirty years (Brenner and Elliston 2004).
After leading the International Atomic Energy Agency team to Chernobyl following the nuclear power catastrophe in 1986, Dr. Fred Mattler began studying the effects of medical imaging techniques in the U.S. In 2008, his Radiology report revealed that these all-too common tests constitute our primary source of exposure to ultra-hazardous ionizing radiation (Mettler, Huda, et al. 2008).
Healthcare professionals and administrators are quick to remind us that patients frequently ask for superfluous treatment. Nevertheless, hospitals and the popular media often share cozy economic relationships in which the former control content and the latter forsake journalistic integrity. Indeed, in my hometown of La Crosse, Wisconsin, a local television “news” station has effectively reduced itself to a mere advertiser of area medical services.
Even so, most culpable are those managing the dysfunctional culture of healthcare. In 2000, one study found that most elective angioplasty patients could not recall being informed of even one risk factor, including stroke, heart attack, and death (Holmboe, Fiellin, et al. 2000). How might misinformation affect outcomes? Difficult to say, but a 2011 JAMA paper found that, of the 200,000 heart angioplasties performed in the U.S. every year, thirty-eight percent result from “uncertain” and another twelve percent from “inappropriate” indications (Chan, Patel, et al. 2011).
In 2010, a similar study revealed that doctors were more likely to discuss only potential benefits, and that a scant twenty percent of prospective back surgery patients, and thirty percent of knee- and hip-replacement patients, were ever advised of potential complications (Zikmund-Fisher, Couper 2010). Yet many back surgeons, for example, maintain that degenerative disc disease—the most commonly cited indication for spinal fusion surgery—can be treated just as effectively with physical therapy and medication.
According to Marty Makary, Johns Hopkins surgeon and associate professor of health policy, “every subspecialty of medicine has its own particular tropism toward overtreatment” (Makary 2012). One problem, he explains, is the common yet frequently undisclosed “eat-what-you-kill” model of physician compensation, where doctors are paid like salesmen—in part, through lucrative commissions.
In the U.S., radiation is regularly prescribed for treatment of pancreas cancer. Curiously, however, such cancers respond to chemotherapy only about twenty-five percent of the time and, even then, patients live an average of only one (very unpleasant) month longer.
The patient decides, of course. But can decisions be characterized as “informed” when neither hospitals nor their physicians disclose highly relevant facts? First, in contrast to most situations involving prescription drugs, hospitals hold relative monopolies on the sales of chemotherapy and, as such, can charge whatever markups they deem feasible. Second, ignoring potential conflicts of interest, prescribing doctors earn bonuses based on their sales of chemo.
Professional associations like the AMA require physicians to disclose commercial affiliations to medical journals when publishing and to audiences when speaking. The government also compels reporting of funds received from drug and device companies. Patients, on the other hand, are frequently left in the dark during their most desperate moments.
But hospital opacity certainly doesn’t end there. Potential customers would doubtless prefer to know how many times a particular procedure is performed each year by a given facility’s staff. Indeed, a 2003 New England Journal of Medicine study revealed quite clearly that volume matters (Birkmeyer, Stukel, et al. 2003). For example, in hospitals where surgeons performed more than four pancreas operations annually, the death rate was 4.6 percent. By contrast, where they operated fewer than two times, mortality rose to 14.7 percent.
Even so, American hospitals tend not to divulge such information. Administrators might argue, for instance, that doing so would harm new doctors. Apprenticeships, however, are very common and successful in other parts of the world. State-of-the-art patient simulators would also help train inexperienced physicians. But such programs are expensive and might threaten hospitals’ bottom lines—not to mention administrators’ and older physicians’ salaries.
Instead, according to Makary, hospitals “pump endless amounts of money into advertising campaigns.” They disingenuously market themselves as “comprehensive cancer centers,” for example, in an effort to boost their “essentially bogus” rankings in popular magazines and to lure new customers who have little else upon which to base their decisions.
So what happens to consumers who become patients in sub-standard facilities or departments—will they ever be referred to better hospitals? Unlikely, says Makary. “Over time,” he recalls, “I learned that sub-optimal care—even when better care was known to be just a referral away—was ubiquitous.”
Our system of physician accountability is no better. Makary, in fact, likens it to that of the Roman Catholic Church, which infamously chose to reassign, rather than remove, child-molesting priests. In 2011, Public Citizen revealed that wayward doctors are seldom reported to state medical boards. Of the 10,672 physicians with disciplinary actions pending between 1990 and 2009, including 220 who had lost medical privileges on an emergency basis, more than half went unreported.
But part of the problem is that medical standards are not nationalized. Unlike aging pilots, for example, who are removed by the FAA as they lose their vision, reflexes, or good judgment, physicians are often allowed to work until they die. Worse yet, compared to others of similar educational background and socioeconomic status, doctors suffer from elevated rates of serious substance abuse and psychiatric disease.
Useful records do exist. The U.S. Department of Health and Human Services, for instance, maintains the National Practitioner Data Bank listing all doctors who have been disciplined, suspended, or have lost or settled malpractice suits. But the general public has no access. Only state medical boards and human resource departments can retrieve the physicians’ names.
Overtreatment and medical mistakes affect us all. We pay for them in higher medical bills (and, as taxpayers, higher Medicare costs) and in higher insurance premiums and deductibles. Yet, in the current culture of medical secrecy, arrogance, and denial, hospitals and physicians have little or no incentive to compete based on medical outcomes, efficacy, and patient safety.
Changes are underway. Massachusetts and Minnesota require hospitals to reveal the number of specific procedures they perform each year. New York facilities report mortality rates for heart bypass surgery, and several more hospitals now use safety-attitude questionnaires to encourage openness, communication, and teamwork.
But much more needs to be done. First, we must radically expand, standardize, and perhaps even nationalize the cache of data available or, better yet, automatically volunteered to all patients. Public health was revolutionized by evidence-based medicine. The administration of healthcare is no less critical and should follow the same model.
Second, we need to reconsider the ways in which many physicians are compensated. Doctors should not be encouraged to act as salespeople for their hospitals or, worse yet, for equipment manufacturers and drug companies. Everyone should agree that perverse incentives and conflicts of interest ought to be eliminated.
Finally, consumers must aggressively represent their own interests. Each patient who regards him- or herself as something less than a customer, or his or her doctor as something more than a human being providing a competitive service, makes it that much harder for the next patient who does not.
We must carry our skepticism unflinchingly—past the lobby doors and into the examination room. Doctor-patient relationships must derive from mutual candor, integrity, and humility. Only then can meaningful healthcare reform begin.
Birkmeyer, J.D., Stukel, T.A., et al. 2003. Surgeon volume and operative mortality in the United States. N. Eng. J. Med. 349(22): 2117-2127.
Brenner, D.J. and Elliston, C.D. 2004. Estimated radiation risks potentially associated with full-body CT screening. Radiology 232: 735-738.
Brenner, D.J. and Hall, E.J. 2007. Computed tomography—an increasing source of radiation exposure. N. Eng. J. Med. 357(22): 2277-2284.
Chan, P.S., Patel, M.R., et al. 2011. Appropriateness of percutaneous coronary intervention. JAMA 306(1): 53-61.
Rosemary Gibson and Janardan Prasad Singh. 2010. The Treatment Trap: How the Overuse of Medical Care Is Wrecking Your Health and What You Can Do To Prevent It. Chicago: Ivan R. Dee.
Holmboe, E., Fiellin, D. et al. 2000. Perceptions of benefit and risk of patients undergoing first-time elective percutaneous coronary revascularization. Journal of General Internal Medicine 15(9): 632-637.
Marty Makary. 2012. Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care. New York: Bloomsbury Press.
Mettler, F.A., Huda, W. et al. 2008. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 248: 254-263.
Zikmund-Fisher, B.J., Couper, M., et al. 2010. Deficits and variations in patients’ experience with making 9 common medical decisions: the decisions survey. Med. Decis. Making 30: 85S-95S.