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Medicine Science

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.'"
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Doctors Are Creating Too Many Patients

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  • Title (Score:5, Insightful)

    by turkeyfish ( 950384 ) on Saturday May 07, 2011 @10:40AM (#36056214)

    Perhaps the title of the article should read lawyers and doctors create too many patients.

  • Symptomatic (Score:5, Insightful)

    by nuggz ( 69912 ) on Saturday May 07, 2011 @10:43AM (#36056226) Homepage

    So we should wait till everyone is symptomatic?
    Many conditions can be treated more effectively and cheaply if they're detected early.

    Some conditions dont' even become symptomatic until significant damage is done.

    The question really is how to balance the best treatment with the financial constraints.

  • by rsilvergun ( 571051 ) on Saturday May 07, 2011 @10:47AM (#36056246)
    Study after study shows people with access to more health care live longer. I'll point out John McCain and Earvin "Magic" Johnson as too people that'd be dead w/o the extensive and highly personalized healthcare they receive. This sounds like another conservative shill trying to convince the poor they don't need to see doctors like their rich people do, but than again the author could be another one of those Homeopath loons/Charlestons...
  • Kind of agree... (Score:5, Insightful)

    by Anonymous Coward on Saturday May 07, 2011 @10:48AM (#36056250)

    As I understand the current situation:

    1) If they don't do the tests and catch a problem, the doctor and hospital will be sued.

    1a) The results of a trial may put licenses at risk, depending upon the State Board's agressiveness.

    2) If they due the tests either tax subsidized insurance or a Medicare type program will pay for the tests and treatment.

    Conclusion: How could the situation any different.......

  • by Moryath ( 553296 ) on Saturday May 07, 2011 @10:50AM (#36056266)

    You were demonstrably sick.

    Here's what generally happens in the US of ADD. Someone comes in to the doctor's office overtired. They have a cold because they overworked themselves and shot their immune system to hell through fatigue.

    The doctor then proceeds to order up bloodwork, EKG, MRI... a thousand useless tests. Even worse is the "full body scan" crap advertised on Right Wing Wacko Radio lately. Spend thousands of dollars getting scanned, followed by thousands of dollars fixing the 3-4 "abnormalities" it finds in every human that are of no danger to your life whatsoever.

    Y'know what would have worked equally well? Send them home with a doctor's note, have them get some fucking rest, and while we are at it, reinstitute actual worker protections so that they weren't burning the candle at 5 ends at their job taking home 50+ hours of work home each week on top of the 60 they already spend in the office including "working through lunch" out of fear that thanks to the the Retardicans fucking up the economy they're going to get downsized or replaced or their job sent to India.

  • Absolutely (Score:3, Insightful)

    by sunilhari ( 606555 ) on Saturday May 07, 2011 @10:57AM (#36056310)
    Doctors have a much lower threshold for diagnosis of "sick people" because if they miss anything, they can get sued for malpractice (founded lawsuit or not). Even if the lawsuit is completely without merit, most lawyers will settle instead of clearing the doctor with a full trial due to cost. So when the threat of lawsuit is over a doc's head, good medicine goes out the window and lawsuit-preventing medicine goes into full effect.

    I realize not every doctor is actually good, and that they can make egregious errors and need to be corrected. Enact tort reform, cap damages, and actually encourage preventative medicine instead of paying lip service to it and you'll get lower costs and better yield for the non-sick 999.

    I don't expect a doctor to start caring about the other 999 until that 1 possibly sick person can't sue him and take everything he owns.

  • by EdwinFreed ( 1084059 ) on Saturday May 07, 2011 @10:58AM (#36056316)
    TFA makes a lot of assertions about unnecessary treatment and increased costs with no associated benefits, but doesn't present or link to a single piece of actual peer-reviewed data. In the specific case of changing the cutoff of blood glucose levels from 140 to 130, the appropriate question to ask is whether or not treating the many side effects of diabetes sooner saves more than it costs.
  • Seems every personality trait (inability to pay attention to boring teachers; enjoying math more than people; shyness; risk-taking extroverts; etc) are being labeled with some mental condition that shrinks like to charge a lot for.

  • by DevConcepts ( 1194347 ) on Saturday May 07, 2011 @11:17AM (#36056410)

    DAMMIT!!! I want my mod points!!! +5

  • by Richard_at_work ( 517087 ) <{richardprice} {at} {}> on Saturday May 07, 2011 @11:29AM (#36056462)

    in the UK for the NHS, and her position on this has always been that patients want you to diagnose them with something, and if you do not then they will re-present either to another doctor at your practice very quickly, or at the local accident and emergency room. And last month she was provided with the best example of this ever...

    Ever since I met her, she has complained to me (in a friendly way) that people present to the A&E (she was working A&E minors at the time) with conditions that 30 years ago would have been treated at home, but because the home remedy and care experience isn't being passed down these days, current generations of parents do not know how to care for minor conditions any more and are quick to panic.

    One example of this is D&V (diarrhea and vomiting - generally any tummy bug that causes you to crap loads and throw up loads) - patients, or the parents of young patients, will regularly show up to A&E with D&V and expect the doctors to do something. If they were to be admitted, it would remove a bed from use for other more serious reasons, and the only thing they would get would be intravenous saline, and thats not even guaranteed. Seriously, would you rather be crapping and throwing up at home in privacy, or in a hospital in public? Do it at home folks.

    Anyhow, on with the example - in this case, she was working as a GP at a practice and a mother presented her 3 year old child with D&V, my wife kindly explained that everything was fine, the kid was not in undue distress, they don't tend to worry that the kids not eating or drinking for at least 5 days, and it was just a case of waiting it out. After a lengthy consultation, the mother and child left.

    Four hours later, my wife switched to do a locum shift at the local A&E department - and who was her second patient...? The mother and child. The child hadn't presented any more serious symptoms and had not declined in condition, the mother just wanted someone to do something. So my wife, who had suffered the embarresment of calling the patient in and realising why they were here (the parents faces went bright red when they realised who the doctor was that was calling them apparently), had the job of telling them exactly the same thing again.

    To put their minds at ease, she called her senior in who explained the same thing. And then just to top it off, had a paediatrics doctor come down to again reassure them that the only things they could do was to allow the D&V to run its course. After a six hour period in A&E, the parents and child left with no treatment, no medication and essentially nothing gained.

    And then my wife finds out, a day later, that the parents had driven the twenty miles to the next major hospitals A&E department and done the same thing there - to be told the same thing and sent home in exactly the same manner.

    No names and no identifiable information because I don't know any - my wife is very good at venting but retaining the pertinent private details so even I can't identify the patients.

    Long story short, the patients are more of an issue these days than the medical carers - patients thing the doctor is there to treat them and damn them if they don't.

    Plus, of course, its easier to overtreat for a minor condition than it is to defend the non-treatment in court for the one case in a million that goes from "minor, non-worrying condition" to "death or loss of limb". One of the things my wife is frightened about is the one in a million case where a reoccuring headache is actually the brain tumour that everyone suspects - but she cannot refer all thirty patients a week who come in with that complaint to the specialist simply because the money isn't there.

  • Really? (Score:4, Insightful)

    by MaWeiTao ( 908546 ) on Saturday May 07, 2011 @11:32AM (#36056470)

    I find it rather interesting that this claim is being made when I've found it to be quite the opposite to my experiences overseas, especially in Asia.

    In the US, someone gets the cold or even the flu and they just deal it. There's a massive selection of over-the-counter drugs to help deal with so many basic illnesses.

    In Taiwan, as an example, feel a bit off and people start insisting you visit the doctor. And why wouldn't they when, thanks to their social healthcare system, it only costs a few dollars for a visit? So people go in constantly for things like simply colds and then get prescribed a ton of medication that aggressively deals with all the symptoms. Of course, the flip side is that their equivalent to our pharmacies are lacking in any real medication.

    So doctors end up being overburdened and are underpaid when practicing for the state. Visit those clinics and the routine consists of describing your symptoms, the doctor makes a few assumptions about what you've got and prescribes something for it. I've had visits where they don't even bother measuring heart rate. The expectation is that if you've got something serious it will be apparent when your condition doesn't improve or even worsens. Many doctors open private practices where they can charge whatever they want. It's more expensive but for people willing to spend the money they can get the care they want right from the start.

    And it isn't something unique to Taiwan, I've observed similar things in Japan and some parts of Europe. Who the hell isn't going to take advantage of something if it's cheap? In my experience the US is the opposite. Unless you're well-off or have a low co-pay you're going to put a visit off until you really need it.

    On the other hand, I have found American doctors to be excessively cautious. But then, I've always attributed that to a fear of lawsuits. They don't want to risk overlooking something that a patient will then come back and blame them for. As always, this is a complicated issue which isn't being properly addressed.

  • by DrgnDancer ( 137700 ) on Saturday May 07, 2011 @11:32AM (#36056472) Homepage

    The second broken arm was $10,000 more than the first, but the first "treatment" resulted in your arm breaking in exactly the same way a second time. Don't get me wrong, there are a ton of factors involved in the location and severity of a bone break, and it may well have been inevitable that your arm would break the same way when you injured yourself in a similar manner; *but* it's also arguable that the less elaborate and complete first treatment resulted in the bone healing weaker and more likely to rebreak.

    Regardless of whether the first break contributed to the second, it's also not inconsiderable that getting such a similar injury in nearly the same place caused the doctors to have to take much more care in the second treatment. Having two healed breaks, practically on top of each other, is almost certain to weaken the bone; the addition of some titanium plated for support of such a weakened bone might have been prudent caution.

    You also mention therapy, which is certainly a not inconsiderable expense but can significantly increase the pace of recovery. It may not make you any stronger or healthier in the end, but the "end" might be 8 weeks instead of 12.

    I'm not a doctor of course, and I don't know the details of your case, but in my mind your having had two such similar breaks is an excellent argument for the second being more expensive. Now the urologist thing does seem a bit suspect, but again, it's hard to say. Is your son experiencing some sort of symptoms that such an operation might alleviate?

  • Re:Symptomatic (Score:4, Insightful)

    by MoonBuggy ( 611105 ) on Saturday May 07, 2011 @11:40AM (#36056512) Journal

    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.

    Using your discretion necessitates taking responsibility for the diagnosis. The eight people you saved from unnecessary and potentially damaging medication will be better off, as will the ninth who you gave a valid prescription to, but the family of tenth guy who died without being medicated might sue.

    If you just followed the guidelines, you might end up unnecessarily medicating six of those ten, and one or more of them may still die, but if it goes to court you just need to compare the numbers on the patient records to those on the guidelines and that's that - you have proof that you "did the best you could".

    The whole issue is based on the fear of litigation. That's been said before. The thing I haven't seen any analysis on, though, is whether that fear is founded. We all have some anecdote about an unjust lawsuit that we read about in the news, but I haven't seen any real figures on whether it's the actual risk of litigation that's prohibiting doctors from taking (necessary) risks, or whether it's the unfounded fear of litigation that almost certainly won't actually happen. An interesting Ph.D thesis for someone, perhaps...

  • Re:Title (Score:4, Insightful)

    by h4rr4r ( 612664 ) on Saturday May 07, 2011 @12:19PM (#36056756)

    Sounds great, for 18 years I went undiagnosed with a serious medical conditions. The impact to my health is now permanent, the perception many people have of my due to my ADD like symptoms in the past still has not changed 10 years later. 1 blood test found the problem. If I paid for it in cash it would have cost less than $200. Yet for 18 years I heard I was tired, or had too much stress, or was just depressed. No shit I was depressed, that was because of the medical problem. It fucking causes depression.

    The minute we do what you are talking about my story will be very common. I would say 90% of doctors I have met could be better replaced with google and the ability for patients to order their own blood tests. They never follow up, they only order test as a last case and do nothing more than suggest the latest drug the pharma rep-whore just showed them. If that drug fails, they just try another. An expert-system on a PC would be better than them.

  • Re:Symptomatic (Score:4, Insightful)

    by Dunbal ( 464142 ) * on Saturday May 07, 2011 @12:37PM (#36056878)

    A few points: First and lucky for me, I live and practice in a country with very little medical litigation - even for clear cases of medical malpractice (of the "oops we amputated the wrong leg" variety).

    Secondly, that is what informed consent is all about. There is absolutely nothing unethical about giving the patient information and letting him make the decision. There's nothing wrong with saying "look, honestly your results are a little abnormal but since you aren't sick I think we should just observe you for a while, re-test you in a few months, and take it from there". Of course you're not going to do this if you suspect something serious, like a lurking cancer. This is where you want to be aggressive - IF the patient agrees (but you have to tell him why). But for the thousands of less serious conditions - why not be more relaxed? Exactly how many patients do you think actually comply with all those pills and strict dietary recommendations anyway? The medical literature says not too many.

    Informed consent for some people is getting the patients to sign a form. For me it's taking the time to explain, in detail, what I suspect, why I suspect it, and what the consequences are with and without treatment. And really you can't win a law suit against that. But it should never be about the legal aspect anyway. "Defensive medicine" is not good medicine.

  • by h4rr4r ( 612664 ) on Saturday May 07, 2011 @01:00PM (#36057048)

    What happens when you legislate that the "guberment" will back loans of people who clearly will not pay them back (aka subprime loans)?
    The housing market collapses.

    That was not the driving factor, most sub-prime loans were not government backed. They were far to large to qualify for that.

    What happens when you legislate that you cannot tap your own natural resources because of environmental concerns?
    Someone else taps those resources and charges you outrageous prices. $4+ per gallon gas and rising.

    Do you think US based oil companies would charge you less out of patriotism? Oil and gas prices are set by international markets for these products.

    What happens when you fail to secure the borders?
    You get an overwhelming flood of non-taxpaying welfare recipients who destroy your healthcare system, overload your criminal justice system, and undermine your educational system.

    Most illegals are young men, between the ages of 18-35. They work here then go back home. They are not a burden but a resource of cheap labor. Also the USA-Mexico Border cannot be secured. It is too large and no fence is going to keep out anyone with a fence.

    Either you are sadly misinformed or tragically stupid.

  • by stewbacca ( 1033764 ) on Saturday May 07, 2011 @01:19PM (#36057198)

    How would you like to work in an industry where you are told here is what you get paid by the government?

    Doesn't seem to be a problem in England, Germany, Belgium, France, Norway, etc. etc. etc.

    Capitalism is great an all, but some things (like the health of citizens) are more important than profit.

  • by cetialphav ( 246516 ) on Saturday May 07, 2011 @03:58PM (#36058202)

    The reason you get this kind of treatment from the Vet is because you are shelling money out of your own wallet for the cat. You have the option of doing nothing and letting nature take its course. Doctors who are doing voluntary procedures (e.g. Lasik, breast enhancement, etc) will give you the same treatment. When I got Lasik, my doctor gave me a fixed price that covered everything and it was all well explained.

    The problem with the current medical system is that the money flows through intermediaries and not directly from the patient to the doctor. There are doctors who are trying to change this ( []), but they are the minority. Insurance should really protect against big financial burdens, not for the treatment of a cold. By having all the money flow through insurance companies, we just add inefficiencies into the system.

  • Re:WOOOOOOOOSH (Score:3, Insightful)

    by WorBlux ( 1751716 ) on Saturday May 07, 2011 @04:19PM (#36058320)

    Empathy is irrelevant here. The article is about new techniques being abused to get people to pursue treatment where it is not needed or where it may even be harmful, not that new techniques should not be used, or that new techniques are perfect. Pointing out that someone is offtopic or missing the point is not and excercise of cruelty. No matter when in this post this person with the chinese mystery illness was he would have been considered sick. This is not the case with the original topic And original topic which was not misdiagnoses, but a specific type of misdiagnoses. Diagnosing something as a problem when it is not actually a problem.

    Cut of the PC crap where you can't do anything that might offend anyone who is less privileged or worse off than you are. You are doing sick people everywhere a disservice by acting as if they are so fragile that they can't handle some public criticism . While doctors individually are generally well-meaning that doesn't mean there aren't systematic factor about the health care industry that lead lead to something other than wellness. A treatment may or may not be given, and the patient may or may not require it. For instance a doctor afraid of malpractice may diagnose where there is actually not a problem, because it's much harder for spot an error where treatment was given but not necessary than to spot the error where treatment was necessary but not given. Also if people go to the doctor and don't get anything other than a clean bill of health they feel a bit jipped. You go to a doctor when you are wanting treatment, and doctors though well-meaning by humouring this may doing more damage with the treatment than a minor abnormality could.

    Yes, the whoosh post was flippant and a bit of a better-than-though game. However moralising is almost always the same sort of one-one-upmanship. "Look at how caring I am, you uncaring fool." You're message would be better received if you just let the facts frame the main point instead of the judgement.

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