In a long and provocative article in the New Yorker, Dr. Atul Gawande focuses on the current “avalanche of unnecessary medical care [that] is harming patients physically and financially” in the United States.
“Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm,” he writes.
Gawande, who is a surgeon and public health researcher as well as a best-selling writer (“Being Mortal”), opens the article with the troubling finding of a 2014 study, which reported that in a single year 25 to 42 percent of Medicare patients received at least one health care service that had little or no medical value.As Gawande also points out, the Institute of Medicine has reported that unnecessary medical care accounts for 30 percent of health care spending in the U.S., or $750 billion each year — “more than our nation’s entire budget for K-12 education.”
“It has been hard for patients and doctors to recognize that tests and scans can be harmful,” Gawande writes. “Why not take a look and see if anything is abnormal?”
But there are often very good reasons to not have those tests.
“The United States is a country of 300 million people who annually undergo about 15 million nuclear medicine scans, a hundred million CT and MRI scans, and almost 10 billion laboratory tests,” says Gawande. “Often, these are fishing expeditions, and since no one is perfectly normal, you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little nodule that can’t be complete explained, a lab result that is a bit off, a heart tracing that doesn’t look quite right.”
Some of those diagnostic tests, like CT scans, can be harmful in themselves. But the tests also lead, says Gawande, to another major problem: overdiagnosis — “the correct diagnosis of a disease that is never going to bother you in your lifetime.”
A misinformed fear of ‘turtles’
Gawande doesn’t only cite statistics in making his argument against pointless medical care. He also provides several personal examples of people who received unnecessary — and potentially — harmful health care services, including his own mother (who underwent unnecessary tests after a fainting episode that had been caused by dehydration) and a patient who insisted on having him remove her entire thyroid gland after a “microcarcinoma” was found next to a benign lump that had been surgically removed.
Gawande had advised the woman not to have the gland removed, but to simply have it monitored.
“More than a third of the population turns out to have these tiny cancers in their thyroid, but fewer than one in a hundred thousand people die from thyroid cancer a year,” he explains. “Only the rare microcarcinoma develops the capacity to behave like a dangerous, invasive cancer. (Indeed, some experts argue that we should stop calling them ‘cancers’ at all.) That’s why expert guidelines recommend no further treatment when microcarcinomas are found.”
The woman’s microcarcinoma was what Dr. H. Gilbert Welch, an expert on overdiagnosis and overtreatment (“Less Medicine, More Health”) and a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, refers to as a “turtle” — “indolent, non-lethal” cancers that “aren’t going anywhere.”
Research suggests that, depending on the body organ involved, anywhere from 15 to 75 percent of cancers are these “turtles,” reports Gawande.
“We now have a vast and costly healthcare industry devoted to finding and responding to turtles,” he says. “Our ever more sensitive technologies turn up more and more abnormalities — cancers, clogged arteries, damaged-looking knees and backs — that aren’t actually causing problems and never will. And then we doctors try to fix them, even though the result is often more harm than good.”
One town’s dramatic turnaround
Gawande’s article is more than a recitation of the harm and waste associated with many current medical practices. The article also describes how businesses and communities — aided by features in the 2010 Affordable Care Act have — have devised programs that are reducing unnecessary healthcare services while increasing necessary ones.
“It isn’t enough to eliminate unnecessary care,” writes Gawande. “It has to be replaced with necessary care.”
One of those communities is McAllen, Texas, a small town that Gawande featured in a 2009 New Yorker article. At that time, the town had some of the highest per-capita costs for Medicare in the country. Five years later, those costs have dropped dramatically — almost $3,000 per Medicare patient per year — while the care of those patients has improved.
In the wake of Gawande’s 2009 article, McAllen’s medical community experienced “bad publicity, a few prosecutions [for various types of medical fraud and kickback schemes], and some stiffened regulatory requirements,” writes Gawande. But those actions, he notes, don’t completely explain how that community eventually turned around its approach to caring for Medicare patients.
More important, he says, was a new emphasis on “viewing the primary-care doctor as a kind of contractor for patients, reining in pointless testing, procedures, and emergency-room visits, coordinating treatment, and helping to find specialists who practice thoughtfully and effectively.”
Replacing anxiety with reason
Gawande describes this approach — and why it seems to be working — in the New Yorker article. You can go there for the details.
But Gawande also acknowledges that for this type of approach to work, patients — not just the medical community — will need to understand and embrace it, too.
“Waste is not just consuming a third of healthcare spending; it’s costing people’s lives,” he writes. “As long as a more thoughtful, more measured style of medicine keeps improving outcomes, change should be easy to cheer for. Still when it’s your turn to sit across from a doctor, in the white glare of a clinic, with your back aching, or your head throbbing, or a scan showing some small possible abnormality, what are you going to fear more — the prospect of doing too little or of doing too much?”
That patient anxiety often trumps all reason — as it did in the case of Gawande’s patient who was determined to have her thyroid gland removed, even after being advised that it was unnecessary and posed some serious health risks.
“I couldn’t help reflect on how that anxiety had been created,” writes Gawande. “The medical system had done what it so often does: performed tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk. Meanwhile, we avoid taking adequate care of the biggest problems that people face — problems like diabetes, high blood pressure, or any number of less technologically intensive conditions. An entire health-care system has been devoted to this game. Yet we’re finally seeing evidence that the system can change — even in the most expensive places for health care in the country.”
Gawande’s article appears in the May 11 issue of the New Yorker.
Correction: An earlier version of this story misstated the date of the New Yorker article.