In The Blogs

Overtreated

| Wed Jul. 8, 2009 11:04 AM PDT

David Leonhardt's column today suggests that maybe I'm not quite as out of touch as I thought I was about the realities of healthcare for most people. His piece is about slow-growing, early-stage prostate cancers, and to make a long story short, it turns out there are lots of different treatments for it but pretty much zero evidence about which one works best. However, the price tags range from about $2,000 for doing nothing ("watchful waiting") to $50,000 for the latest whiz bang proton radiation therapy.

But here's the tidbit that caught my eye:

A fascinating series of pilot programs, including for prostate cancer, has shown that when patients have clinical information about treatments, they often choose a less invasive one. Some come to see that the risks and side effects of more invasive care are not worth the small — or nonexistent — benefits. “We want the thing that makes us better,” says Dr. Peter B. Bach, a pulmonary specialist at Memorial Sloan-Kettering Cancer Center, “not the thing that is niftier.”

When I read about healthcare, pretty much the only thing I hear is that everyone wants infinite amounts of it. And they always want the latest and greatest stuff.

Not me. My motto is, "That healthcare is best that cares the least." Or something like that. Basically, I prefer to get the minimum reasonable amount of healthcare possible, and I have a strong preference for the simplest, oldest, best-known treatments. I'm not exactly a fanatic about this, but generally speaking I think that most new treatments turn out not to be nearly as effective as we think, and the more time you spend around hospitals the better your chances of catastrophe.

Does that make me an outlier? It seems like it. But maybe the difference is just information: I read an awful lot about this stuff, and it's convinced me that there are dangers to overtreatment just as there are dangers to undertreatment. Leonhardt's "fascinating series of pilot programs" suggests that with better information, more people might agree.

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Kevin Drum is a political blogger for Mother Jones. For more of his stories, click here.

Comments

Personally, I don't think

Submitted by Royko on Wed Jul. 8, 2009 11:24 AM PDT.

Personally, I don't think the risk of seeing lots of frivolous heath care usage under universal coverage are as high as opponents of universal coverage make it out to be. Healthy people are not going to go to the doctor just because they can -- it's no fun going to the doctor! And most sick people just want to be well, so they'll do pretty much what their doctor says. There will be a few who demand overtreatment, as there are now, but it's a manageable problem.

I will say that I am surprised of the number of people who have told me to go to the doctor/ER for flu and fevers. I've had them often enough to know that they just need to run their course. Maybe I'm taking a risk, but I can't see running to the doctor every time I get a run of the mill flu. Perhaps better public education can help this (antibiotics don't work on colds or flus!) but public education programs usually have limited results at best. Maybe a reasonable co-pay would help limit this kind of behavior. (And offset the cost.)

Completely agree. But what

Submitted by House Whisperer on Wed Jul. 8, 2009 11:29 AM PDT.

Completely agree. But what am I to do with a concerned chest pain patient with a 3% chance of a pulmonary embolism? Until society is comfortable with a certain miss rate, I will scan her chest. Almost every time. It is not easy to determine which tests, a priori, are unnecessary. It is not even truly possible to determine a person's risk tolerance, which may change after the fact when a bad outcome occurs.

(Disclaimer: I do make an effort to inform patients that all tests have limited sensitivity and specificity and risks, and that "better safe than sorry" does not always apply. Occasionally, an astute patient will decline a certain test, and things usually turn out okay.)

Please explain

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 2:27 PM PDT.

Why wouldn't you do a chest scan in such a case? 3% chance of pulmonary embolism sounds pretty bad to me. How much does a scan cost? Does such a scan have risks associated? Yes, there's a chance of a false positive, but would the risks and costs of further diagnostics really outweigh the potential benefits?

I have a lot of

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 11:36 AM PDT.

I have a lot of cardiologists and surgeons eager to operate and all poo-poohing the notion of let's monitor and see what happens....

Hard to know who is right. Suspect it's not me.

What percentage of money

Submitted by B on Wed Jul. 8, 2009 12:20 PM PDT.

What percentage of money gets burned up in tests and what percentage gets burned up in treatment?

I suspect cholesterol tests, PSA tests, prostate exams, breast exams, ultrasounds, echo-cardiograms, annual physicals are the cheap items. If they aren't we really need to address this on the front end through efficiency and expansion of medical training.

What to do when you have a slow growing (or potential) tumor, a heart murmur, or minor trouble with birthing is where decisions come into play.

I feel for the doctors dealing with hypochondriacs but I would hope there's a way to deal with that without impacting the healthcare of the general populace.

A Decade Ago...

Submitted by bike365 on Wed Jul. 8, 2009 12:35 PM PDT.

I had a standard abdominal hernia repair. The surgeon preferred the new method of installing reinforcing mesh, which sure seemed better on paper: less invasive, problem solved forever, faster recovery. The practice seems to have fallen out of favor...and left me with recurring pain that might require further surgery. The thing is, the price for new or old method was the same and the same surgeon would have done either. But I think marketing by mesh makers and the less-invasive tool makers tipped the scale in their favor in the absence of a strong competing interest. I'm thinking more and more like Kevin, that the new fangled isn't necessarily an improvement. And on same painful days I think the makers of Vicodin are involved in a conspiracy.

cultural expectations

Submitted by elisabeth on Wed Jul. 8, 2009 12:40 PM PDT.

I have recently been diagnosed with a recurrance/metastases of an old cancer. The treatment options are many and varied, the information is, for at least some treatments, not based on very much evidence -- especially with newer therapies, there just isn't a lot of information yet. So, evidence-based medicine isn't so easy to adopt.

At the same time, there's a real cultural narrative that tells you the patient that you're supposed to do everything possible, that you should demand every possible treatment and that if you don't you are some how giving in/giving up. I think the narrative about prostrate cancer may be being re-written, but for many other cancers that story seems to be go for what every treatment there is.

And, the differences between/among doctors are many and varied. My long-time oncologist went on maternity leaves just after she'd developed my treatment plan. While she was gone, the covering oncologist suggested we a) lengthen the time between infusions of one drug -- saving some money over time, adding convenience, and maybe reducing side effects. b) do two different screening tests that my "real" oncologist doesn't think are really useful. So, both of them might think the other was suggesting a kind of "overtreatment" ...

Finally, we have an appointment at the Mayo Clinic for a 2nd opinion -- supported by both doctors here -- and again, I'm not sure whether or not that counts as "overtreatment."

elisabeth

Submitted by Art Eclectic on Wed Jul. 8, 2009 5:47 PM PDT.

elisabeth - look into Beta Glucan as something to consider along with your current therapy:

http://beta13dglucan.org/

Wikipedia article is good too, but a tough read unless you have an MD.

Less can be more

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 12:58 PM PDT.

Many years ago, I went to a doctor to try to figure out why one of my parotid glands had swollen up like a balloon. The doctor I went to said it was in all likelihood a parotid tumor, and my best course of action was to have it surgically removed immediately. He also explained that the surgery was quite delicate and had a small chance of resulting in either partial or complete facial paralysis on the side where they operated. I asked for alternatives, and he said that a fine needle biopsy of the gland might indicate whether it was a malignant tumor and help evaluate the urgency of surgery. A much less invasive, and lower risk procedure, which I went with instead of opting for immediate surgery. As it happened, it came back negative for any malignancy and I opted to pass on the surgery completely. Several years later, I got diagnosed with Sjogren's Syndrome, and the doctor who diagnosed me explained that the parotid gland problem was a fairly common one for many Sjogren's patients, and was not the result of a tumor at all.

So, put me down on your side. Given a choice, I definitely went with the less invasive, less costly procedure, and that ultimately turned out to be very much the right decision. If I'd gone with surgery, I would have lost a gland, and risked facial paralysis, for no reason at all, and been out a much more sizable chunk of change. Given good information, there are many occasions where I would elect for a lower cost/less invasive procedure over a maximalist one.

I knew two women who were

Submitted by tpx on Wed Jul. 8, 2009 1:06 PM PDT.

I knew two women who were diagnosed with breast cancer around the same time. One was a young adult and one was middle aged. The middle aged woman had witnessed both her mother's and grandmother's death by breast cancer despite receiving the latest medical treatments, and she had decided not to have mastectomies nor chemo therapy. The young woman chose to have the double mastectomies and the chemo. I saw her after her chemo and she was not recognizable. Both women died around the same time, except one suffered much more and had quite a bit more in medical expenses. Had the young adult lived, her medical expenses and suffering no doubt would have been worth it to her.

Atul Gwande wrote a piece

Submitted by Ed D. (not verified) on Wed Jul. 8, 2009 1:24 PM PDT.

Atul Gwande wrote a piece for the New Yorker which touched on this topic of treatments. The main theme was about autopsy. But running through the conclusions was the statement that all the new fangled technology starting about 1980 has not significantly affected the accuracy of diagnosis. Seems the old 'differential diagnosis,' a process of elimination done through interview by the doc works as well or better than all the new drop through, check list, automated flow chart methods.

Had it work on a friend. He had a week of severe headaches and the doc couldn't figure it out. MRI didn't help the effort. So he called his father who was a retired teaching doc. The father diagnosed it over the phone in ten minutes using the differential method. Hmmm.

Unfortunately, I've known

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 2:23 PM PDT.

Unfortunately, I've known plenty of people who have used information not as a way of talking themselves out of something, but to demand more expensive treatment, when it simply wasn't necessary. It happens from the most mundane (insisting on antibiotics for an ear infection) to the most extreme (experimental surgery for someone who clearly has less than a year to live no matter what.)

I'm very pessimissitc about this topic, but I think that health care in the US is currently buffeted against two American maxims 1) that "better safe than sorry" and 2) "you get what you pay for." That neither of them has anything to do with the reality of health care and everything to do with the problem of funding gets lost in the conversation.

Of course, as a physician, I

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 3:04 PM PDT.

Of course, as a physician, I see the people who want medical care, but my experience has been that there are a lot of people who want extensive testing. I've only met one person who wanted repeated colonoscopies, but I see a lot of people who want blood and imaging tests every single day in my primary care practice. When I was young and idealistic, I used to explain the advantages and disadvantages of PSA testing (prostate cancer screening). After about 4 years of doing that, I finally had a patient decide that he did not want to have a PSA test. Everybody else says, "I would want to know, if I have cancer."

There was someone who has posted a couple of times on various blogs recently bemoaning the fact that his sister-in-law had a cough for some months before she was diagnosed with lung cancer from which she quickly died. I was recently dropped from a malpractice suit by someone (a heavy smoker) who did not get an over-the-top lung cancer work up and who then went on to develop lung cancer ... four years later. The other docs settled with her because they had not done the "standard of care" (aka CYA) work up in 2003. The problem with both of these cases, as tragic as they were, is that there is no effective treatment for lung cancer. There are no screening tests and there are no treatments that have been shown to prolong life. Diagnosing either of these women earlier would have resulted in longer survival time from diagnosis only.

How expensive is a PSA test

Submitted by B on Thu Jul. 9, 2009 12:04 PM PDT.

How expensive is a PSA test and what are the disadvantages? I frequently see false positives written up as disadvantages of non-invasive cancer screening. I think that's a little condescending to public understanding of health science.

It's possible it was an informed decision, but I suspect the fellow who refused a PSA test might also wait a few months to tell you he had trouble urinating through an inflamed prostate, had a mole the size of a grapefruit, or shooting pains down his left arm.

There are treatable diseases, including some lung cancers. Educating the public as to the nature of early symptoms (including simple medical screening) and simple preventative measures should be an important aspect of healthcare. If all that does is raise flags for you concerning hypochondriacs and lawsuits, I'd hope you're not the average physician.

watchful waiting

Submitted by MarkH on Wed Jul. 8, 2009 3:51 PM PDT.

Kevin Drum wrote:

the price tags range from about $2,000 for doing nothing

Don'tcha think this is one of the best indicators the system is over-priced? Now, if you're suggesting the 'watching' requires tests or picture-taking, then maybe it should cost something. But, for literally "doing nothing" I think we should be able to get a second opinion on that price.

Where's the competition for "doing nothing"?

RE: why not just scan anyone with a 3% risk of PE?

Submitted by House Whisperer on Wed Jul. 8, 2009 4:31 PM PDT.

(from 2nd post):
radiation exposure, cost, time, risk of contrast allergy, IV infiltration leading to extremity problems, scanner busy when the trauma patient comes in, etc. It's a good question you asked, and the answer many docs give is, "just scan 'em all." That is not really a good approach. I should also mention this central question of risk in diagnostic testing has parallels for each complaint and differential diagnosis (not just chest pain we're talking about).

I should also mention that

Submitted by House Whisperer on Wed Jul. 8, 2009 4:33 PM PDT.

I should also mention that most people don't have the analytical skill seen in readers of this blog. So you might think, just discuss the risks and benefits and let the patient decide, and sometimes this works, but not often.

Kevin, My hus has a very

Submitted by Anonymous (not verified) on Wed Jul. 8, 2009 4:58 PM PDT.

Kevin,

My hus has a very rare cancer. It's so rare that there are not enough patients to get studies with any validity. So people try all sorts of things and hope it will work. One of the options he had was to go in and remove as many organs in his abdomen that might get the disease: stomach, gall bladder, colon...you name it, if it's possible to live without it, they take it, and 30% die from the surgery. But the kicker is that there is no way of knowing if this extreme surgery really DOES produce better results. Yet people opt for this surgery. We talked about it, but the awful quality of life that you get afterword, plus the lack of any meaningful statistics made it pretty much a no-brainer. But of course, when it's your life it's really hard not to DO everything you can.

One other anecdote. My Dad was a doctor. He practiced medicine for over 50 years. He came down with diabetes in his 70's and died last year at age 84. He was in a nursing home for the last two years of his life and the only medicine he would take besides his insulin was aspirin. He'd seen enough to know that so many of the meds that are prescribed to the elderly cause side-effects, then you have to take something else to counter that, that he just said, no meds, no extraordinary measure. He lived a good life and went from relatively healthy to dying about 2 months.

I'm not saying these stories apply to everyone, just that we are under so much pressure to DO, when often doing doesn't help, or makes things worse.

JoyousMN

elisabeth, It is good to go

Submitted by Trippp on Wed Jul. 8, 2009 8:49 PM PDT.

elisabeth,

It is good to go to Mayo. You'll get the best advice possible, and if you need the experts they will see you the same day. The Drs are on salary and the clinic is non-profit, so patient care is their one and only priority.

I'm not a shill, I've just been spoiled by them for over 40 years. Enjoy the marble and art work - it was donated by grateful patients over the years.

Tripp

The issue is not just "less" care

Submitted by Anonymous (not verified) on Thu Jul. 9, 2009 8:38 AM PDT.

Kevin selects an important quote from the article, but far more important was the article's emphasis on what constitutes "effective" care. Part of the dilemma is that most of the time no one really knows and that the model for reimbursement disinclines many from finding out or wanting to know. We saw in the stimulus bill how hostile many medical interests are to doing the studies to find out which procedures and approaches are most effective. I think I would have little problem with choosing the more invasive and more costly treatment if you could prove to me that it's the way to cure what's wrong with me -- at least I'd be more likely to choose this than a cheaper treatment that is demonstrably less effective (although if I were very old and otherwise very sickly, I might opt to manage my condition rather than 'cure' it). But the issue with prostate cancer in the article is that no one knows which treatment works.

Why all the opposition to finding out?

Easier Said Than Done

Submitted by Brian Hildebrandt (not verified) on Sat Jul. 18, 2009 11:57 AM PDT.

I think it's not a one size fits all approach. Some therapies have a lot of research and statistics behind them, other's not so much. A blanket approach isn't always the best.

If the therapy doesn't prolong life but decreases it's quality then it's a no brainer... but we don't always have full information.

I find it sad however when people are mortgaging their homes to follow treatments that may not be warranted. I guess in the end it all comes down to; be an informed patient and treat at your own risk.

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