Why do we think more care is better for us?

The U.S. spends nearly $3 trillion a year on health care, significantly more than any other nation.

In fact, America’s annual health care spending is greater than the total gross domestic product (GDP) of every other country except China, Germany and Japan.

Yet our measurable health outcomes — from infant mortality to life expectancy — aren’t any better than nations spending much less.

I’ve written about this paradox before, pointing to a few factors that drive up health care costs. They include the perverse financial incentives of health care’s fee-for-service payment model, the unjustifiably higher costs of devices and drugs in the U.S. and our systematic investment in specialists over primary care physicians.

But these are just a few of the reasons.

In the coming weeks, I will write about four common myths that contribute in powerful ways to our high health care costs and lagging clinical outcomes. Each represents a major opportunity to improve quality, personalize medical care and make health care more affordable.

Let’s kick things off with myth #1: More visits, tests and procedures lead to better health.

It seems logical that doing more would lead to better clinical outcomes. Sometimes that’s true. But more often than not, that assumption is far from factual.

Here are three common clinical practices that reveal the surprising truth behind this myth:

1. Annual physical exams. Beginning in the 1940s, the annual comprehensive physical examination was created as a “routine check-up” for patients with no visible symptoms or specific complaints.

These once-a-year exams have been standard medical practice ever since. In these face-to-face visits, the doctor asks about the patient’s health history, checks vital signs, listens to the heart and lungs, and examines the head and body.

The intent is to help physicians identify medical problems early and treat them immediately. Many swear by them. In fact, these routine check-ups are among the most common reasons adults see a physician. They account for nearly $8 billion in annual health care spending alone.

But, in practice, the doctor almost never finds anything wrong when there are no symptoms present.

As a result, many professional groups and researchers have concluded the annual physical exam adds little or no value. What’s more, experts have uncovered a number of serious drawbacks to such yearly visits. Studies show they can lead to false positive results, triggering a series of unnecessary tests. Or worse, they can give patients false assurance that everything’s OK, leading them to ignore new symptoms later on.

While a physical exam for a symptomless patient may be a waste of time and money, there’s a great deal of value in periodic laboratory testing — for blood lipids and glucose, for example – based on a person’s age and sex.

And for patients with a specific health problem such as diabetes, ongoing in-person and lab evaluations are essential. However, for patients without a specific medical condition, physicians could order the recommended screening studies electronically and discuss each patient’s results by phone without an in-person visit.

Why don’t they? Most insurance carriers refuse to pay the doctor for this service unless it is part of an office visit.

The result or more office visits and thus more health care spending: zero measured improvements in patient health.

2. Prostate cancer screenings. Physicians conduct the prostate-specific antigen (PSA) screening to detect prostate cancer early and allow for early treatment. It is commonly assumed that early detection saves lives.

But two large clinical trials show no overall benefit from mass screening for prostate cancer. And the United States Preventive Services Task Force recommends against PSA-based screening, finding that for every 1,000 men screened, at most 1 man avoids prostate cancer.

Certainly, the thought of saving one human life is reason enough to give such an exam, right? Not so fast. Of that same 1,000-man sample, up to 120 men walk away with e a false-positive test result – wrongly indicating the presence of cancer.

A positive PSA test is typically followed by a biopsy to confirm the presence of cancer with a major risk of a complication.

And even when the set of tests rightly identifies a patient with cancer, rarely does the cancer lead to health problems.

Unfortunately, in most cases, doctors can’t differentiate between cancer that will become harmful and cancer that won’t. So, when tests suggest the presence of prostate cancer, most men pursue treatment.

The most common treatment options are surgery, radiation therapy, hormone therapy and chemotherapy. Each option exposes men to possible surgical complications, along with erectile dysfunction and incontinence.

All of this might be worth it if the outcome was an increased cure rate. But that has never been shown. Instead, the impact on survival and life expectancy remains unchanged based on the largest research studies.

Once again, more is not better.

3. Surgery for patients with back pain. There are numerous treatment options for back pain: medication, physical therapy and surgery.

Surgery is by far the most risky and costly option. And, strangely, it’s a lot more popular in some parts of the world than others.

The rate of back surgery in the U.S. is five times higher than in the UK. And certain counties in the state of Washington boast 15 times more back surgeries than in neighboring counties.

This raises the obvious question: Are higher rates of back surgery tied to higher incidences of back pain or other medical problems?

There’s no evidence to indicate there is. So then, perhaps these locations with higher rates of back surgery are able to achieve superior clinical outcomes? Wrong again.

Studies have shown little difference in long-term outcomes for patients who undergo back surgery compared to those who select non-surgical treatment.

There are a few situations where surgery is essential and beneficial, such as when there is nerve compression. But for an overwhelming number of patients with low-back pain, non-surgical treatments prove just as effective.

How can we explain the higher incidence of patients undergoing a complex and often ineffective procedure? Welcome, once again, to America’s perverse fee-for-service payment model.

In America, health care providers are rewarded for the quantity of patient visits, tests and procedures. Achieving the exact same result without surgery pays dramatically less than performing a risky intervention.

Surgeons and hospitals make much more money from surgical intervention than from conservative treatment. Clearly, they act accordingly.

Why do we think more care is better for us?

In a word: culture. That applies to both American culture and the culture of medicine.

We want to believe that doctors have all of the answers. We want to believe physicians can cure almost anything. And we want to believe that a routine check-up, prostate exam or back surgery adds value.

We love anecdotes about a surprise diagnosis leading to a life-saving treatment — or about a patient who was miraculously cured by a procedure. But we often leave out stories about patients who experienced only temporary relief or, worse, suffered serious complications.

Of course, doctors should never withhold necessary and effective care. There are many problems for which invasive procedures lead to the best outcomes and we need to encourage their use. But we should examine the scientific evidence first and not make decisions based on fairytale anecdotes or the potential for higher reimbursements.

In the United States, there are so many health problems that suffer from lack of attention. High blood pressure, for instance, is a leading cause of death and disability in the U.S., but physicians only achieve control of their patient’s elevated blood pressure levels half of the time.

If we want to improve the health of our nation, we need to reduce the cost of medical treatment and stop wasting money on care that adds no value.

Until we reward doctors and hospitals for the quality of care — rather than the quantity of care — we’ll continue to lead the world in spending. But, at the same time, we’ll never lead in superior clinical outcomes. And until we bust the myth that more is better, little is likely to change.

Robert Pearl is a physician and CEO, The Permanente Medical Group. This article originally appeared on Forbes.com

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  • Kristy Sokoloski

    Excellent article. I was especially glad that you covered in such depth the issue of annual physicals. With that in mind my question is this: have the found the same to be true of annual well women visits? I made the decision last year to cut out that aspect and this year will be the last time I let my PCP do an annual physical exam. I had mentioned to a friend that I have not found them to be beneficial and one reason is one thing you stated here: that the problems are not always found during these visits. That is the case for me: the problems are found when I start to notice that there is something going on that shouldn’t be going on.

    • elizabeth52

      I think you’ve made a wise decision, Kristy. I’m Australian (age 56) and have never had a well-woman exam, routine pelvic and breast exams are not recommended here. (I’ve never seen a set of stirrups and hope to keep it that way!)
      The former is not a screening test for ovarian cancer, is of poor clinical value and carries risk, even unnecessary surgery. The CBE: no evidence of benefit, but it leads to excess biopsies. For all of this examining and testing US women have poorer health outcomes. 1 in 3 will have a hysterectomy by age 60, that’s a high number, and many US women lose healthy ovaries, at more than twice the rate of UK and Australian women. (See articles by your Dr Carolyn Westhoff, Ob-Gyn)

      The annual well-woman exam is, in my opinion, a commercial product, and IMO, has nothing to do with decent healthcare. It’s FAR more likely to harm you.
      Pap testing – horribly overused leading to high over-treatment and excess biopsy rates.
      Finland has the lowest rates of this always-rare cancer, since the 1960s they’ve offered 7 pap tests, 5 yearly from 30 to 60. The evidence has moved and the new Dutch program will scrap population pap testing and will offer instead 5 HPV primary tests (or HPV self testing – already in use) at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV+ will be offered a 5 yearly pap test. (until they clear the virus)

      Mammograms, controversial. The Nordic Cochrane Institute, an independent, not-for-profit, medical research group, has produced an excellent summary of the evidence. It seems the risks of screening exceed any benefit, women should carefully review the evidence before agreeing to screen.

      Personally, I see most screening tests and exams a great threat to our health and well-being. (and could even take our life) Any doctor who does not respect our right to choose and make an informed decision is one to be avoided. Millions (billions in the States) is made from medical excess, it will be hard to turn that around. I think change starts with individuals rejecting excess and non-evidence based exams and tests. It’s great there is more discussion about this serious problem.

      Also, something needs to be done to stop those doctors who coerce women into unnecessary exams and tests simply to secure a script for the Pill. This is a shocking abuse of rights and would amount to medical misconduct here, and possibly more, coercion negates all consent.

      • Kristy Sokoloski

        It was not an easy decision to make although I had considered that two years before I cut out the well woman visit. And then last year I decided that this year would be the last time I had an annual physical. At the time in my life I used to do it but not because anyone told me I ought to. I just felt I should and then when I started having female issues then I started doing annual well woman exams as far as moreso to keep an eye on the problems I had although I had been getting them since I was 18 (this was when the guideline was 18 or sexually active whichever came first).

        As for mammograms I didn’t do it for 3 years because the kind of mammogram I needed for what they considered an abnormal finding I couldn’t afford. Turned out that what they saw was density of my breasts. Well, duh, I am a young woman. Yes, I am 42 but I am still young so of course a young woman’s breasts are going to be dense. Well, when I had a mammogram done it was normal which I knew it was and would be.

        In relation to pap smears, my one in 2012 came up with an abnormality that the doctor wanted to do an endometrial biopsy and an ultrasound and I was like I don’t think so. I told my doctor I couldn’t afford those tests, plus because of the way my body has become thanks to all the surgeries I have had (some of them for female issues) my body is such that even that biopsy even though it’s minimally invasive supposedly my body would treat it as major surgery. So I am trying to limit what surgeries I have to just my feet because of an experience that I had thanks to one of my other problems where my feet were tied in to that problem and it had to be corrected or my quality of life would not be good. I have mild CP so have issues with my feet that need to be stayed on top of. The reason is because of the way they had affected my quality of life at one time. So it was all the more reason that I make sure that the pap result was not a fluke so I went to another doctor that I use as a back up for second opinions to see if I could get her to do another pap and send it to a different lab but she was of the opinion that I should have had those tests and when she said, “if one is not going to follow up in the first place then why have the test (meaning the pap smear) to begin with” well, that made it very easy for me to make that decision to cut out the well woman visit. And then when I went to consult another gyn recently about seeing if there were newer treatments for one of my female problems that is acting up again he wanted to harp on the previous pap smear and would not answer my question about the other treatments until we had the conversation about the abnormal pap. The reason he knew about the abnormal pap is because of the way that a number of doctors in this area have become: where they have gone under or formed their own corporations. And he went on to tell me that the second pap that my own gyn did back in Feb of 2013 when it showed normal could have been a false negative. Yep, maybe it could have been a false negative, but I am of the opinion that the first pap smear result was a false positive. My own gyn does not know that I am not going back this summer to see her unless I have a problem with something and I might but I will not be having my well woman visit. And of course when I went to her back in March (a long story why that happened in the same week that I saw the other gyn I just told you about) she wanted to try to say about having me undergo an ultrasound to find out why I was bleeding. Well, the reason I was bleeding for 3 weeks was because I had a cervical infection going on. Once I got put on antibiotics for the infection and it cleared up I was fine.

        We’ll see what my Primary Care Physician thinks when I tell him that this year’s physical will be the last annual one he’s done. I had gone for a period back in the early 2000s where I didn’t have a physical done by a Primary Care Physician for 7 years so I have done it before.

        And as for what you said about too many hysterectomies being done for nonmalignant problems I agree. I have had a few people suggest to me about getting a hysterectomy done so that I won’t have to deal with painful periods anymore and also thinking that it would cure one of my female problems (endometriosis) which it won’t cure. I am sorry, I do not agree with having a hysterectomy just because someone can’t stand the pain of their periods. And I have discovered there are other ways to deal with the pain of endometriosis without needing to go that extreme. But that’s just me.

        And the one friend as well as some others that I told this after I told them they were like what one of the posters said that the staff at the Pediatrician did, act shocked by what was said. Oh well, let them be shocked.

      • Karen Ronk

        Amen, Sister!

  • NewMexicoRam

    The problem is that people think they are buying a service when they pay for health insurance coverage, rather than joining a risk pool. Unfortunately, the insurance companies don’t help matters when they make their huge profits, which just accentuates the belief that “they owe us.”

  • elizabeth52

    Interesting when the annual exam was suggested all those years ago, the UK did a ten year study and found there was no benefit so the exam was never introduced. The US had already started performing the exam. There is no doubt in my mind these exams lead to more excess….procedures, investigations and even, surgery.
    It’s important to follow the evidence and do randomized controlled trials before introducing a screening test or exam and the research should always be conducted by an independent group. (and reviewed at regular intervals)

  • Eric Strong

    Completely agree with the article. I also wonder whether the lack of necessity of the annual physical exam for a patient with no significant chronic problems and no complaints also extends to the pediatric population. We were once having trouble scheduling a well child visit, and I suggested maybe we would just skip this one, and was given horrified looks by the staff. But the more I think about it, the more it seems like the well child visit is primarily to give vaccinations and assess growth curves, neither of which requires a pediatrician.

    • Kristy Sokoloski

      I would love to know how an annual physical benefits those that have chronic health problems then maybe I might change my mind about them and well woman visits. So far, no one has been able to give me a clear answer on that one.

      • buzzkillerjsmith

        Chronic health problems should be managed with directed examination and diagnostic testing. Most pts get what they need in terms of screening on the fly during visits for indication At least my pts do.

        • Kristy Sokoloski

          So, basically, the answer is that annual physicals and wellness visits are not beneficial to those who have chronic health problems. Is that a correct understanding? I want to make sure I fully understand so that I can further explain not only to my gyn why I won’t be getting paps anymore and also mammograms (although my PCP ordered my last one which was last summer) and to my PCP himself why I won’t be having an annual physical anymore after I let him do this one. I am sure that neither one of them will be thrilled but oh well. As for directed examination and diagnostic testing that tends to come more from the specialists I see for my various problems, but even at those visits I don’t always get diagnostic testing. Which nothing wrong with that if everything’s stable but if I know something is going on that’s not right like has been the case with my arthritis and it getting worse that’s been a bigger fight. And believe me I do not like to get tests or surgery done if I can help it, but sometimes I know they are necessary to further guide treatment for my various conditions when called or as I say if something gets worse like the case with my arthritis. Thanks again.

          • buzzkillerjsmith

            No, No. I’m sorry I was not clear. Certain screening tests and, particularly, immunizations, certainly ARE beneficial, even to those with chronic diseases.

            I meant that a full physical with routine blood work and so on should usually not be done since most folks are already getting what they should have for their particular disorders. I also meant that appropriate screening tests are usually ordered when the pt comes in for followup on these disorders, on the fly so to speak.

            Folks with chronic diseases should definitely see their docs at appropriate intervals and have physical exam and diagnostic studies done that are appropriate for given disease(s).

            As far as paps and mammos are concerned, it really depends on your individual situation.

            I’m not here to give medical advice to individual pts but will only comment in a general way.

          • rbthe4th2

            If someone is dumb enough to *truly* act or follow on “medical advice” on the internet, they get what they deserve. I’d like *general* advice, or some specific advice but never would I expect it to substitute for a paid doctors’ check up.

          • Kristy Sokoloski

            And as I told him just now I wasn’t expecting any kind of medical advice. My decision was already made, I just needed to understand further what he was saying.

          • rbthe4th2

            That comment wasn’t directed at you Kristy.

          • Kristy Sokoloski

            No, I wasn’t expecting specific medical advice. I just wanted to make sure I understood what you were trying to say. My decision had already been made, I just wanted to make sure I understood where you were coming from. Thank you.

    • buzzkillerjsmith

      Routine physical examinations for adults have not been shown decrease suffering or prolong life. The USPFTS gives the standard guidelines for what should be done and when. Easily found on the web.

  • buzzkillerjsmith

    Full Disclosure: I hate Kaiser with a passion.

    Why does Kaiser think that less care is good for us?

    In a word: money.

    Pearl has an ax to grind. Less care = bigger bonuses for Kaiserdocs. I should know. I used to be one. Partnership (tenure), the whole 9 yards. They couldn’t believe it when I quit. No one quits after the first 3 years.

    Give the devil his due. We must allow that Pearl is right in these particular cases.

    But when it comes to this guy and others of his ilk, be skeptical. They will cherry-pick and have a bias towards doing less when the evidence is equivocal. The same goes for the guv’ment these days, but you know that.

    Kaiser has opened a lobbying center in DC called the Center for Total Health, “an interactive learning destination.” How Orwellian is that?

    • John C. Key MD

      You are correct on this. Glad you had the guts to say it. Recommendations of the USPSTF need to be viewed in the same light for similar reasons. That being said, the worthlessness of the “annual physical” is clear.

  • Patient Kit

    “Fairytale anecdote” checking in here. I can’t speak for the population on this. I speak only of my own personal experience. My early stage ovarian cancer was found during my annual well-woman visit. During my pelvic exam, my GYN felt something on my ovary. She ordered a vaginal ultrasound to get a better look. That imaging showed a “suspicious” looking cyst. She ordered a CA125 test. My numbers were elevated. I had zero symptoms. No abdominal discomfort. No symptoms at all. I’m in my fifties and post-menopausal, so my age was a factor in why my doc investigated my ovarian cyst further.

    Long story short, I ended up in surgery in the hands of a GYN oncologist. And the tumor that was inside the cyst did turn out to be cancer. It was staged at 1A. I guess I will never know whether I could have just lived a long time with that cancer inside of me, undetected. But I also, thankfully, didn’t have the experience of waiting until I was experiencing symptoms, finding my cancer at a late stage and going through far more complicated surgery and treatments.

    Maybe my case isn’t science. Maybe it is pure luck. Or an angel on my shoulder. Or a miracle. All I know for sure is that my early stage ovarian cancer was found during my annual well-woman visit.

    Now I see my GYN ONC for a checkup to monitor for cancer recurrence every 3 months. That’s a pelvic exam 4 times a year, plus blood tests and sometimes imaging. I’m one year post-surgery now. In another year, if all is well, we’ll go to monitoring checkups every 6 months instead of every 3 months for 3 more years until I reach 5 years since my cancer dx/surgery. Then back to annual.

    Apparently, I never needed the initial well-woman visit. I wonder whether science says I don’t really need all this follow-up surveillance.

    Science is great. Science can do some amazing things. The same can be said of technology. But science can’t do or explain everything. Science isn’t everything. Whatever strange cocktail of science and mysterious forces bought me to where I am today — alive & kicking & healthy — I’m very grateful to be here. Maybe my well-woman visit was only a passageway for those mysterious forces to take. But I give my docs a lot of the credit for how healthy I am today. I give myself some credit to. And I give that angel on my shoulder credit. Real good teamwork that started with a well-woman visit.

    • Kristy Sokoloski

      Patient Kit,
      You were very fortunate that yours was caught during a well woman visit. For those like myself the problems are not found during these type of exams, same with the annual physical also known as the “well adult” visit so henceforth they are often not beneficial. And for me, they are not to my benefit. If I have a problem going on it’s going to be found at other times that I go to the doctor and not one of these “well” visits.

  • samiam

    @southerndoc1, what you say may very well be true. However, screening involving pap tests/pelvic exams are a different type of screening given they involve penetration of a woman’s vagina. To group these types of exams in with other types of screening is another part of the issue, namely; there is no acknowledgment that many women find the exams extremely problematic. When exams involve penetration of a woman’s vagina you would assume more care would be taken to obtain informed consent. Perhaps it’s time to call a spade a spade.

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