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You may not need that medical device: the growing problem of unnecessary health care

Much of the health care provided today adds little value. For example, one in 4 heart pacemakers are inserted unnecessarily.

Dr. Robert Pearl: “Much of the aggressive and invasive health care we provide in the United States today, compared to time-tested, more conservative approaches, adds little value.”

Forbes published a pointed commentary recently on the topic of unnecessary health care, one of the most serious problems facing our current healthcare system.

This issue is one that all of us need to be aware of each time we interact with our doctors and the healthcare system — if we want our medical care to help rather than harm.

“Much of the aggressive and invasive health care we provide in the United States today, compared to time-tested, more conservative approaches, adds little value,” writes Dr. Robert Pearl, a plastic and reconstructive surgeon and CEO of the Permanent Medical Group. “And when independent scientific comparisons are done, the more complex approach often results not only in higher costs, but also in complications and adverse effects — all without significant benefit to the patient.”

“Recent reviews of clinical outcomes have shown that many medical problems that we might have treated in the past with aggressive surgery would have avoided threatening patient health if managed instead by watchful waiting with routine follow-up,” he adds. “But despite that information doctors continue to routinely recommended intervention, even in the absence of evidence suggesting a better outcome.”

Adding little value

As Pearl stresses, “new” is not always a synonym for “improved” in medicine.

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“We should celebrate the 21st century medical treatments that lead to remarkable outcomes,” he says. “But we also need to question these aggressive treatments that add little value, and can lead to harm.”

As examples, Pearl points to many commonly performed surgeries. One major study, he notes, found that almost one in four heart pacemakers are inserted unnecessarily, and other research has shown that thousands of Americans undergo disc removal, spinal fusion and arthroscopic knee surgery when non-surgical therapies would have been more effective — and less dangerous. [After publication, it was brought to my attention that the study cited by Pearl about pacemakers focused on certain pacemaker-like devices, cardioverter-defibrilators.]

Many factors 

“The reasons for this preference to intervene are easy to identify,” Pearl says. “A medical culture attempting to maintain the status quo. A reimbursement system based on fee for service that creates perverse incentives. Direct-to-consumer advertising for the latest, most expensive drugs and invasive procedures. And physicians lacking the time to explain why a procedure or drug is unlikely to make a difference and can lead to even more problems.”

But we patients are part of the problem, too. “When patients hear words like cancer or heart attack, they immediately want everything to be done that can be,” Pearl writes. “Most of the time doing more is the default decision. Unfortunately, rather than leading to a better outcome, frequently little or no benefit is realized at dramatically higher costs.”

Prevention is “often the best medicine,” says Pearl, but even that is now overdone.

“Done appropriately, [preventive] screenings reduce the chances of dying from colon, cervical and breast cancer, and minimize the chances of a heart attack or stroke,” he writes. “But screening more frequently than national guidelines recommend is ineffective, a waste of time and resources.”

It can also lead to overtreatment, which is not without risk of harm.


So what can we do? Pearl offers four recommendations:

1. Empower patient decision-making. New tools, including interactive videos, can help patients objectively evaluate the pros and cons of procedures and treatments. …These aids have been shown to increase knowledge, lower anxiety, sharpen perceptions of risk and benefits, and lead to fewer tests elective surgeries.

2. Shift to value-based pay practices. Paying for the value of care, rather than the volume of services, would eliminate the perverse incentives in the current fee-for-service reimbursement system.

3. Determine when new approaches are really better. To help accomplish this, every medical journal should require authors to compare new procedures, devices and drugs to current, often lower-cost alternatives. In a similar vein, the FDA should revise its charter to enable it to require that existing therapies be compared to new drugs and devices prior to approval.

4. Reform medical malpractice. Changes to litigation for medical malpractice would lessen the burden of unnecessary care associated with defensive medicine.

“Only when doctors and patients alike recognize that more is not always better, and how excessive care can create additional problems will we consistently avoid treatments of borderline value,” Pearl concludes. “The more-is-better philosophy, and the new-equals-improved formulation, makes sense in theory, but seldom in practice.” 

You can read the full commentary online at the Forbes website.