Doctors Are Creating Too Many Patients 566
Hugh Pickens writes "H. Gilbert Welch writes in the LA Times that the threshold for diagnosis has fallen too low, with physicians making diagnoses in individuals who wouldn't have been considered sick in the past, raising healthcare costs for everyone. Part of the explanation is technological: diagnostic tests able to detect biochemical and anatomic abnormalities that were undetectable in the past. 'But part of the explanation is behavioral: We look harder for things to be wrong. We test more often, we are more likely to test people who have no symptoms, and we have changed the rules about what degree of abnormality constitutes disease (a fasting blood sugar of 130 was not considered to be diabetes before 1997; now it is).' Welch says the problem is that low thresholds have a way of leading to treatments that are worse than the disease. 'We are trained to focus on the few we might be able to help, even if it's only 1 out of 100 (the benefit of lowering cholesterol in those with normal cholesterol but elevated C-reactive protein) or 1 out of 1,000 (the benefit of breast and prostate cancer screening),' writes Welch. 'But it's time for everyone to start caring about what happens to the other 999.'"
Prescription Correlates + to # of Prescribers (Score:5, Interesting)
This is very worrisome, glad to see it being discussed. According to the USA Bureau of Labor Statistics, health care employment accounts for (by far) most of the growth in jobs in the USA http://www.bls.gov/oco/cg/cgs035.htm [bls.gov]. What happens when a new sport surgeon opens an office in your county? What happens when a urologist opens an office in a town of 10,000 residents? The free market says that when people take employment providing a "service" which they themselves are empowered to prescribe, that prescription rates increase proportionately to the wages.
I realized this when I broke my arm in almost precisely the same place, in almost exactly the same way. The first time it was a reset, an X-ray, and a cast. The second time, a new Osteopath building had been opened in town, with two new very smart and very nice doctors. Good people. Outcome was surgery, metal plates, screws, therapy, etc. My insurance paid for both treatments, but I got to see the bills. The second broken arm was over $10,000 more expensive than the first time. And when I read about the dangers of putting people under anesthesia, I really wonder how the risk was weighed against the benefit of making payments on the new doctor's office. I'm not grossly cynical about the health industry, but whenever a field of the economy becomes too respected (think Catholic Church), people begin to assume the best, and that's a recipe for problems.
By the way, there is a new Urologist in my town of 10,000, with a lovely office. He just told my wife that both our sons need teen circumcision, under anethesia. What is really worrisome is that the USA's aging population makes for an almost infinite number of diagnostic tests, etc., for these people to fill. If the government paid for car repairs, we'd have lots of mechanics and lots of repairs.
Re:Symptomatic (Score:5, Interesting)
And also to treat the patient and not a set of lab results. This happens all too often in my country.
For example my father in law, who has never been symptomatic, was being treated for gout because he had a uric acid score slightly greater than 7. Since I am also a physician I ordered a few tests to rule out other conditions that could result a slightly abnormal uric acid result, took him off the allopurinol and told him to eat all the red meat he wants. He is still not symptomatic, has no kidney trouble, and will be dead in 10 years from his prostate cancer anyway.
Why label him as a "gout" sufferer and even worse, treat him for it, if he doesn't actually manifest the disease? Doctors must remember that the way we determine what "normal" values are is by fitting large samples to a bell curve, chopping off the ends at 1 or 2 standard deviations, and calling the middle "normal". There are perfectly healthy people on either end of the curve, however. We need to use our clinical skills to figure out who needs treatment and who doesn't, otherwise you might as well not have doctors at all and leave medicine to some giant, complex algorithm.
From a doctor (Score:5, Interesting)
I'm an ER doctor. I can't create patients as they come to me with symptoms. I will say that people come to me with minimal symptoms such as cough and fever and then demand blood work, X-rays, and antibiotics, even though the majority of the time their symptoms are caused by a virus and will get better all on their own. Somehow, our society has become so weak that every cough, scraped knee, or hangnail requires a visit to the hospital. And somehow we think that physicians can't diagnose anything without a thousand dollars worth of painful tests. Whenever I try to explain to someone, "You have a cold. You're going to be fine," that's not a good enough explanation. I've even had a few people demanding admission to the hospital---which, if you didn't have a life-threatening disease before, you can certainly pick one up during a hospital stay. This problem is societal in nature and has been made worse with television shows such as House and ER where lay think that every problem requires specialists and lots and lots of tests. Don't blame me; I'm just a cog in the wheel.
'Do no harm' (Score:5, Interesting)
It might not be common knowledge that blood test 'normal ranges' (i.e. the range in which the quantity measured is said to be normal) were determined by taking thousands of healthy volunteers and performing the test - but creating the range based on the middle 95% of normal values. Therefore, even before we started testing people, we deemed 1 in 20 healthy people to be 'abnormal'.
Counting on my fingers, we do a minimum of 22 blood tests on patients admitted to our hospital. Statistically, even if you are well (though that is unlikely given you presented to the hospital, and were assessed and deemed unwell enough to be admitted) at least 1 of these blood results should be abnormal. And I haven't even started on your ECG, radiograph, blood pressure, pulse, oxygen saturations, respiratory rate, temperature etc etc etc. And if just one CT scan were performed, that looks at so many metrics, that several are bound to be abnormal to some degree (so called 'benign incidentalomas').
Part of being a good physician is knowing what abnormal results are significant, and what are red herrings. Ignoring a result is a difficult thing to do in medicine (the article has some good reasons why) and takes a good knowledge of the context, as well as plenty of experience, to be confidently able to say 'that is a red-herring'.
I disagree with the writer suggesting that thresholds should simply be raised. This is a stupid and dangerous way of dealing with this problem! The problem isn't how _far_ above threshold the value is, but whether it is or it isn't. Raising the threshold does not eliminate false-positive results, but will undoubtedly result in false-negative results. Tests in medicine are assessed to measure their 'positive predictive value' (see wikipedia), which, simply put, is about choosing a threshold that will find a balance between limiting false-positives, and limiting false-negatives. Instead of blanket raising of thresholds, doctors should be basing their decisions on the _evidence base_ - i.e. research done looking at how patients with these values fare with and without treatment. Only then will we know whether what we are doing is helpful or not.
The writer is writing in a public journal, and I think it is dangerous of him to suggest that some people don't really need treatment for diabetes - a condition that is hard enough to demonstrate to patients the dangerous long-term consequences. I wonder how many people reading this article have decided 'I don't really have diabetes - this person says so! And I thought I felt well, too!' and chucked their meds out the window. And yet, there is very strong research and evidence that shows that people diagnosed with diabetes (whatever their blood sugar) do much better if their blood pressure and glucose levels are kept below certain levels. And by 'doing much better' I mean, have less heart attacks, less strokes, go blind less, have less kidney failure, have less neuropathy and die less. All these things are real-world problems which damage peoples health. We are not just treating a number! (but we only know this from the evidence).
The other side to this argument is social. Here in the U.K. we are proud of having a largely non-private system. With all the cost and time pressures on the NHS, it means that we don't investigate or treat unless we feel it would benefit the patient. If an NHS doctor in the U.K. says you have a health problem, it's something you should probably listen up to, because he is not paid to do that. Of course some would argue that the flip-side is that patients may not get investigated or treated enough, which may be balanced somewhat by the law courts. I'm not saying it's good that doctors say 'well because this person has come in with a,b and c, and even though I don't think it is 'x', we can't justify in a law court not doing investigation 'y', but it does provide a counter balance.
Doctors should try to good, be very careful not to do harm, and base their decisions on rational arguments backed up by evidence.
(the article's suggestion of simply raising the thresholds is idiotic)
Re:Kind of agree... (Score:5, Interesting)
This.
It's more common in some areas of medicine than in others. But I know that in psychiatry if they don't make a diagnosis then the insurance company definitely won't pay. Whereas if they do suddenly the patient gets crap treatment and most of their medical complaints blamed on mental illness.
What's worse is that the area of psychiatry is hardly one where diagnoses are clearly separable from other options, and doctors usually get the difference between insomnia and depression wrong leading to patients being prescribed antidepressants when bed rest would do more good. Antidepressants usually interfere with sleep leading to often times even worse sleep.
Re:Kind of agree... (Score:5, Interesting)
Then there would be even more malpractice. Tons of that already. How about this simple in between step, one used in many fields, if your solution does not fix the problem you do not get paid.
If I take my car to the mechanic and he can't fix it, I don't pay him. If I buy a ladder to paint the roof and it does not work or breaks the first time I get my money back. Doctors are about the only field who expect to be paid even when they are totally useless. Then they have the gall to tell me I need a yearly checkup.