Reducing medical overtreatment will require large-scale political mobilization

Despite all the reports about overdiagnosis and overtreatment in the United States (and estimates are that almost a third of all medical interventions in this country are unnecessary), many doctors want to take a more reasoned and less wasteful approach to medicine.

But those “lone ranger” doctors are up against a powerful medical industrial complex that “just keeps on delivering treatments patients don’t need,” as journalist Shannon Brownlee (“Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer”), now senior vice president of the Lown Institute, explains in a recent article for the website KevinMD.

Brownlee describes the experiences of a young doctor who, after attending a Lown Institute conference during medical school on how to avoid overtreatment, “vowed to avoid hurting his own patients with useless treatments during his residency” at a Boston hospital. (Brownlee doesn’t name the hospital, and gives the young doctor a pseudonym, “Gene,” to protect his privacy.)

But, as the young doctor explained to Brownlee in an email, he quickly ran up against formidable obstacles. Writes Brownlee:

For example, he and a patient decided together that she does not need or want a mammogram, a perfectly reasonable decision given the evidence on mammography. When he told his preceptor of the decision, Gene was instructed to order the mammogram anyway.

Why? Because the hospital’s risk management company recommends it. “The risk management company doesn’t care about this woman’s anxiety about constant testing,” Gene wrote, or about the emerging evidence on mammograms. It just cares about protecting the hospital from a potential lawsuit.

Another of Gene’s patients, a diabetic, is doing badly on an oral diabetes medication plus insulin. When Gene suggested to his preceptor that the patient go off insulin except when he has symptoms, a recommendation that’s backed up with sound scientific evidence, his plan was treated as “absolute heresy.”

Gene, not surprisingly, is feeling a bit demoralized. He wrote, “What is particularly painful is to believe in my heart that a mammogram for this woman would be harmful, and insulin in this man is harming him, and to write the order anyway.”

Brownlee says she’s heard from many other doctors — as well as nurses, physician’s assistants and other health-care providers — with similar frustrations.

“Factors like greed, lack of time, overinvestment in hospital technology and infrastructure, and underinvestment in community-based care” are driving overtreatment, she writes. “Then there’s marketing by Pharma, laziness, fear of lawsuits, misguided patients, lack of evidence, and lack of knowledge of the evidence.”

As Brownlee stresses, a few “well meaning individuals trying to buck an aspect of modern medicine that is woven into its very fabric” are not going to be able to institute the huge changes that are needed to rein in the problem of overtreatment.

What we need is political mobilization — and on the same kind of scale, she argues, as that which ended both the Vietnam War and Jim Crow segregation and discrimination.

“Overtreatment is so hard to weed out because American health care is organized not as a common good rooted in social need, but rather as a commodity,” she writes. “The overtreatment (and undertreatment, for that matter), the safety problems and costs are symptoms of a deeper malaise that cannot be healed with piecemeal technical solutions. The estimated $1 trillion wasted in our current system diverts resources that could be spent on preventing chronic disease, building healthy communities, and addressing the deep injustice of health disparities.”

“A better health care system, health justice, and health itself cannot emerge from existing strategies for improvement,” she adds. “Transformation is what’s needed, not just reform, and the first step is gathering people who are prepared to imagine a better system.”

You can read Brownlee’s article on the KevinMD website.