In a commentary last weekend in the New York Times, Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and author of the book “Overdiagnosed,” calls for the U.S. government to allocate a greater percentage of its research dollars — an amount equal to 1 percent of the country’s health-care expenditures — evaluating what are now considered standard practices in medicine.
Why? Because, says Welch, many standard practices — such as hormone replacement therapy for middle-aged women and P.S.A. prostate-cancer screening for older men — are later shown, in randomized clinical trials, to be ineffective or, worse, harmful to health.
The truth is that for a large part of medical practice, we don’t know what works. But we pay for it anyway. Our annual per capita health care expenditure is now over $8,000. Many countries pay half that — and enjoy similar, often better, outcomes. Isn’t it time to learn which practices, in fact, improve our health, and which ones don’t?
To find out, we need more medical research. But not just any kind of medical research. Medical research is dominated by research on the new: new tests, new treatments, new disorders and new fads. But above all, it’s about new markets.
We don’t need to find more things to spend money on; we need to figure out what’s being done now that is not working. That’s why we have to start directing more money toward evaluating standard practices — all the tests and treatments that doctors are already providing.
There are many places to start. Mammograms are increasingly finding a microscopic abnormality called D.C.I.S., or ductal carcinoma in situ. Currently we treat it as if it were invasive breast cancer, with surgery, radiation and chemotherapy. Some doctors think this is necessary, others don’t. The question is relevant to more than 60,000 women each year. Don’t you think we should know the answer?
Or how about this one: How should we screen for colon cancer? The standard approach, fecal occult blood testing, is simple and cheap. But more and more Americans are opting for colonoscopy — over four million per year in Medicare alone. It’s neither simple nor cheap. In terms of the technology and personnel involved, it’s more like going to the operating room. (I know, I’ve had one.) Which is better? We don’t know.
You can read Welch’s entire commentary on the New York Times’ website.