Should academic physicians have the final word on acceptable practice?

The New York Times recently published an opinion editorial entitled “Squandering Medicare’s Money“in which Dr. Rita Redberg, professor of cardiology at UCSF, proposes that much of Medicare’s financial deficit could be reduced if the government did not spend “a fortune each year on procedures that have no proven benefit.”

To support her contention, Redberg cites several studies which indicate that many routinely performed tests and treatments do not improve patient outcomes in any measurable way, and are therefore unnecessary. Examples given are screening colonoscopies for patients over 75, PAP smears for women over 65, coronary stents for people with stable angina, and so forth.  At an estimated cost of $150 billion, these procedures seem like obvious candidates for the deficit-reduction chopping block.

That a significant portion of the medical care dispensed across the country today is “wasteful,” few will argue. But some caveats should be considered before embracing Redberg’s formidable recommendation.

To begin with, Redberg seems to overstate the conclusion of the clinical studies she cites.  For example, her mention that “women in their 40s do not benefit from routine mammography” implies that mammography is never valuable in this age group which is not factual.  The studies in question did find a benefit for routine mammography, albeit of too small a magnitude to be recommended as a public health measure.  Redberg also overlooks the difference between population medicine and individual medicine.  A study may predict that a particular procedure has little value when applied to a group.  In the case of a specific person, that determination can only be made after the fact.

But Redberg goes beyond dismissing specific tests as unnecessary.  She also rejects entire practices offhand, such as screening for prostate cancer after a given age.  Her outlook oddly implies there is no such thing as medical progress.  Yet it should be apparent that what is deficient today may not be so next year, the year after, or ten years from now.  A clinical study can only reflect the given situation at the time it is conducted.  Technology (drugs, tests, procedures) and epidemiology (disease patterns, co-morbidities, co-factors) change constantly. Screening for prostate cancer in older men may be of doubtful value at present, but biopsy techniques and treatment choices could certainly improve in the future.  Life expectancy also increases yearly, making some treatment choices for the elderly more beneficial now than they were ten or 20 years ago.  That clinical studies are obsolete the moment they are published is an acknowledged aphorism in medical circles, and what is “proven” today is frequently over-ruled tomorrow.  But when we decree no more unnecessary procedures, we decide necessarily such procedures will never be of use.

Most problematic is Redberg’s notion that the academic community should be granted the final word on what should or should not be acceptable practice.  Many substantial advances in Medicine were initially at odds with academic wisdom.  And at times, academic wisdom has shown itself to be downright harmful.  It was not long ago that academics, citing the “best available evidence,” urged hundreds of thousands of post-menopausal women to take hormone pills to reduce their risk of heart disease, only to discover a few years later that such treatment significantly increased the rate of cancer, stroke and venous embolism—and did nothing to lower the risk of heart disease.

When Medicare was introduced in the early 1960′s, the architects of the program abstained from selecting what would be or would not be covered.  This decision was medically correct but economically foolish.  It was medically correct because only personal knowledge of the patient can hope to best identify his needs, and only up-to-date knowledge of a rapidly evolving medical field can hope to best address them.  It was economically foolish because it placed no limit on what doctors and patients could spend to satisfy those needs.

Unbridled spending can only cloud the judgment of both doctors and patients, so that much medicine nowadays is undoubtedly unnecessary and wasteful.  But if it is easy to decry too many PAP smears, too many mammograms, and too many stents, deciding which PAP smear, which mammogram, and which stent to cut out is a different story.  Appeal to the authority of decision rules, guidelines, and task force recommendations is likely to further distort our judgment of what is medically valuable.  Such rationing schemes are ill-suited remedies for a serious case of economic miscalculation.

Michel Accad is a physician who blogs at Alert and Oriented.

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  • http://www.drdarrellwhite.com drdarrellwhite

    In some areas academic medicine is in a constant state of playing “catch-up” with the advances being made outside the walls of the Ivory Tower. I am an ophthalmologist, and this is particularly true in my world.

    The intraocular lens (IOL) is perhaps one of the most significant advances in all of medical history when we think of the impact it has had on the enjoyment of life in the elderly. When it was introduced in the 1970′s it was panned by academe. So, too, phacoemulsification, whose earliest proponents were on the receiving end of what can only be described as despicable character assassination at the hands of academic ophthalmologists.

    Now we have injectable agents that treat neovascular membranes in macular degeneration, and the community retinal specialists have discovered that there is an available medicine that can be safely and effectively used at 1/200 the cost (no typo…1/200), only to have academics line up behind the approved, branded, pharma-supported option.

    There is an inherent reality check applied when you actually take care of patients. When taking care of patients is pretty much all you do. The reality check is magnified when you listen to your patients, listen to the effect your treatment has on their lives and not just their tiny little piece of your specialty. (It’s a different topic, but there is also a reality check applied when it is YOU who is responsible for making payroll). Academic physicians, however well-meaning, and however less arrogant than Dr. Redberg, face an inherent insulation from these forces. This insulation is manifest in statements like Dr. Redberg, whose only exposure to the medical world at large comes from a journal rather than an office filled with patients, rather than a world filled with colleagues who take care of patients.

    Left to the academics we would still live in a world filled with an ever growing population of elderly individuals walking around post-op intracapsular cataract surgery, without IOL’s, wearing aphakic glasses as they emerge from cars driven by someone else.

  • Marc Gorayeb, MD

    Interesting post, identifying a vexing problem; but the author didn’t propose a solution to the evidence-based-medicine/individual-medicine dichotomy. Let’s face it. The issue is important only because physicians and patients are spending other peoples’ money to do these screening tests. You can’t have it both ways: you can’t have essentially free services without some form of rationing based on population statistics. We all know the solution to that problem, but for some reason we’re afraid to discuss it.

    • Primary Care Internist

      yes RATIONING, there i said it. I am not afraid of that word. But even better I think would be patient/family involvement in decisions. We are rapidly moving toward the (erroneous in my opinion) collective mindset that patients/families are nearly as equiped to decide what treatments they should and shouldn’t have as their doctor. So with that sharing should come sharing of cost exposure too. If families had to kick in, say, 1% of the cost of sending granny to the hospital & ICU for her fourth bout of pneumonia in a year, or for hemodialysis, or for “palliative” chemotherapy for her stage 4 lung or breast cancer etc., i think we’d see medicare costs reduce dramatically and suddenly. This is particularly true in NYC where many elderly residents are “dually-eligible” ie. are covered entirely by the taxpayer through medicare & medicaid. So in that case it’s easy to say “do everything” to doctors when granny gets sick.

      There is a perfect storm of (1) patients’ lack of financial exposure to their decisions; (2) lawyer’s single-patient view (rather than what makes sense for populations and societal costs); and (3) doctors’ complete lack of incentives to control costs – on the contrary, the ICU doc who has a unit full of 90yo demented terminally-ill patients on ventilators knows he/she will be paid by medicare, whereas taking care of the 45yo drug-overdose patient on medicaid is charity care.

      As far as Redberg, i am generally not a fan of academic types who repeatedly show their ignorance of actual medical practice issues. But in this case I think she’s mostly “on the money”.

  • http://www.hayesinc.com Michael Pennessi

    A solution is available that addresses the need for evidence-based-medicine. Unbiased evidenced based research is is a necessary activity to bring together physician/patient needs, define best practices based upon clinical, and yes, financial outcomes. There are very few firms that provide this service on a global basis; Hayes, Inc. meets this need.

  • Sharon Bass

    Life expectancy has gone down in the US. What does that imply about “medical progress? Screening tests can only help those not determined to kill themselves with obesity, smoking and a sedentary lifestyle.

  • BobBapaso

    “…acceptable practice?” Acceptable to who?

    The answer will always be different depending on who you ask. Patients are often happy with quackery.

    Evidence is always inadequate. No problem is totally studied and no study is totally unbiased.

    A consensus of everyone’s idea of best practice would now be possible with computer technology, but even that would not be best in every case. That is why we have medical licenses. Licenses to use judgement.

    We need more respect for the medical license. And, of course, continued efforts to improve the quality of the licensees.

  • doctor1991

    It is wrong and arrogant to state that these procedures have no value. The question is how much value, and whether they are worth the expense. I recently made a cancer diagnosis by doing a pap in an 80 year old. (After explaining to her there were differing opinions on its utility and asking if she wished to not do it) While her surgery was difficult, it probably extended her life significantly, as she is now cured. It is legitimate to balance this helpful instance against others. But it is not right to say in the absolute that something is useless or without value.
    @SB- life expectancy in the US is increasing, not decreasing, despite all the bad habits mentioned.

  • merelan1

    As a medical advocate I have had to fight insurance companies that will not pay for that drug, or for the administration of that drug that drdarrelllwhite mentions. Because of this situation, intravitreologists are forced to use the more expensive drug just to get paid. Medicare requires a major overhaul in general, but what about the common practice that allows doctor’s to, “un-bundle” procedures that are costing Medicare more money? Ultra-sound procedures when a suspicious lump is found during routine mammography is one example. If the patient has health insurance the ultra-sound is included in the price of the mammagram, but when the patient is on Medicare the ultra-sound is charged seperately from the mammogram.

    There is also the issue that Medicare will not pay for “well-checks.” this would also greatly reduce the spending that is out of control. There are hospitals that will not read radiology results if they know that prior procedures of the same area were shot. This is clearly a case of CYA against a potential lawsuit. While comparison films are helpful, the flat out refusal to read at all unless the prior films are produced is borderline criminal. I am tired of having to fight hospitals that have these rules in place.
    Doctors who’s experience is nothing more than academic, in my opinion, should not be making broad statements as to what is necessary and what is not.
    There are millions of patients that are afflicted with a “surgically induced” spinal disease that leaves patients suffering. Do these doctors even tell their patients in advance that these so-called, “safe” procedures have potential life-changing side effects, including excruciating pain and even life in a wheelchair? The answer is no. Medical research is a necessity and it’s implementation and incorporation into practice is needed more than ever

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