A new Croakey project: Naked Doctor, profiling overdiagnosis and overtreatment
Up to $3 billion of public money is wasted each year under Medicare, according to estimates by Dr Tony Webber, who headed the Professional Services Review for more than six years.
His article in today’s Medical Journal of Australia – which has drawn widespread media coverage – argues that poor policy (such as the Medicare Safety Net, “one of the most poorly thought-through pieces of health legislation”) and the practices of a “minority of unscrupulous and greedy practitioners” are responsible for this waste.
General practice management plans (GPMPs) and team care arrangements (TCAs) “have created opportunities for a bonanza for some practices”, he says. Obstetricians and ophthalmologists receive particular mention. Webber also questions the repeated use of procedures and investigations by some gastroenterologists and cardiologists in patients “whose clinical condition appears not to warrant them”.
Webber says maladministration does not only occur with the MBS and the PBS. “On several occasions I came across significant cost-shifting between the states and the federal government. Medicare was being used to subsidise state health budgets. Private radiology and pathology services were used for public inpatients, Medicare benefits were used to fund staff specialist study tours and to buy essential equipment. This is against the provisions in the Council of Australian Governments National Health Care Agreement. When this was pointed out to officers in the DoHA, I was told not to say anything.”
Webber says that while most health professionals are motivated and ethical, colleagues feel let down by a system that often does not deliver a timely or cost-effective service with proper controls. “Many doctors I have spoken to are disillusioned by the inappropriate claiming and practice they are aware of,” he says.
Meanwhile, with impeccable timing, Brisbane GP and writer Dr Justin Coleman today launches a new project at Croakey, the Naked Doctor, which aims to encourage discussion and awareness of the opportunities to do more for health by doing less. It is a compilation of articles, books and other works that highlight overdiagnosis and overtreatment.
Coleman is a GP who works in Aboriginal and Torres Strait Islander health in Brisbane. He holds a Masters in Public Health, and is President of the Australasian Medical Writers Association. You can also find him on Twitter.
Naked Doctor is a work in progress. Comments and suggestions are welcomed.
Below are two items: an introduction to the project; and Naked Doctor’s first entries (some articles are from subscriber-only journals; if you are unable to access an article, please leave your details on the bottom of this post or email Croakey asking for a copy).
Introducing the Naked Doctor: When is ‘no action’ the best action?
Justin Coleman writes:
The modern doctor seems to have an intervention for every occasion. He or she wears a magician’s coat of surprises, each more incredible than the last. Hidden pockets contain pills, scalpels and lasers, with sophisticated medical tests providing the performance instructions.
At its finest, the medical method is impeccable; type I diabetes was a rapid death sentence prior to insulin and accurate blood sugar tests. Sometimes, though, the heavy clothing creates it own problems. Tests point to the wrong diagnosis, treatments cause harm and the promised magic fails.
Some failures are a consequence of bad luck and random variation. But the closer we study these problem areas—applying the scientific method—the more we find predictable patterns emerging. Many tests and interventions fail because they should never have been used in the first place.
The Naked Doctor probes the places in medicine that would be better stripped bare. Places where the correct option is to do nothing. The ‘doctor’s bag’ accompanying a home visit before the second world war contained no medication which would be considered of any use today, and quite a few dangerous poisons. The physician would have been of more use turning up empty handed—or, given the lack of latex gloves and infection control, perhaps not turning up at all. The modern example of cancer screening via whole-body CT scanning offers as much protection as the emperor’s new clothes, and the guileless emperor would be better off naked.
Naked Doctor’s old anatomy professor Norm Eisenberg used to claim ‘only half of the stuff we teach you in this medical course is true. The problem is, we don’t know which half!’
Luckily, various health professionals and journalists around the globe dedicate themselves to steadily peeling back the covers. Naked Doctor exposes their disrobing of over investigation and overtreatment. We invite you to watch, and to contribute.
Naked Doctor: the list
Start at home with our very own Melissa Sweet who introduced the over-intervention theme to Crikey readers. A systematic approach is needed to balance the all-powerful “give us more” lobby.
Speaking of which, Melissa does give us more; in her non-Croakey spare time, she sums up our ‘less is more’ theme at Inside Story.
Sharon Beglee at The Daily Beast pens a neat appraisal of situations where saying ‘No’ to a test or procedure can potentially save your life. Some thoughtful doctors are voting ‘No’ when it comes to their own health—and Sharon names names.
Sharon also dispels four health care myths in the Scientific American, although it’s doubtful much dynamite is required to explode myth 4: The US has the best health care system in the world.
In 2010, Archives of Internal Medicine started a column ‘Less is More: How Less Health Care Can Result in Better Health’. Section editor Deborah Grady maintains the impressive article list. Naked Doctor recommends a pleasurable browse through the less-is-more garden, plucking full-texts at whim. Discover that doctors themselves think their patients get too much care, and find out the interventions voted ‘top 5’ for superfluities to avoid in general practice and paediatrics.
Josh Freeman, physician educator, Kansas US, writes a lovely blog mixing medicine with social justice. A number of articles discuss the inequities of spending money on treatments that don’t work. He scrutinises the money spent on MRIs and suggests patient advocacy organisations don’t necessarily have the population’s interests at heart.
Shannon Brownlee discusses a study by cardiologists Grace Lin and Rita Redberg, who designed three theoretical cases where evidence suggests non-intervention was the correct treatment. They found that their cardiologist colleagues would almost always recommend surgical intervention. Surprise! Maybe author Upton Sinclair had it right when he said: It is difficult to get a man to understand something when his salary depends upon his not understanding it.
Blogger Dr Jay Parkinson wonders if Lindsay Lohan and Steve Jobs received the worst health care in America…by which he means the most health care. The more famous you are, the more care you get and therefore the more can go wrong. A certain M. Jackson springs to mind. Jay deplores the relative lack of interest in preventative health.
Former BMJ editor Richard Smith teaches ten lessons about the world delivering the wrong care to the wrong places. When North America has 250 times Africa’s number of health workers per percentage of global disease burden, then modern clinical medicine is as out of control as the banks and is unaffordable globally.
He points out the Victorians eventually couldn’t live with the difference between rich and poor, and we got income tax with substantial transfers of wealth within countries. We now need such transfers between countries. Less over here, more over there; them’s fightin’ words, Dr Smith!
Croakey readers will be familiar with Dr Gary Schwitzer’s HealthNewsReview.org which is often relevant to our theme; could Gary himself be a closet Naked Doctor? One blog here covers disease-mongering, the ancient alchemic art of creating something out of nothing.
Chris Del Mar’s BMJ editorial provides a cogent argument for avoiding antibiotic prescription for colds, sore throats and ear infections. Unfortunately, patients expect doctors to intervene, and even when they don’t, doctors expect that their patients expect intervention. Confused? Paul Little explains the concept here.
Pharmed Out is a Georgetown University project educating healthcare professionals about pharmaceutical marketing practices. Grab a ‘No Drug Reps’ certificate for your waiting room or play Drug Ad Bingo in your spare time.
Departing boss of the US Medicare and Medicaid system, Dr Donald Berwick, lists ‘overtreatment’ as the first of five reasons for the very high 20-30 percent of US health spending he calls waste that yields no benefit to patients.
In a world where dental undertreatment is the norm, dentists are not immune from the temptation to overtreat when the patient can afford it. Many experts think it doesn’t make sense to operate in the early stages of decay…yet a majority of practitioners are inclined to do so. Just say Aaaaargh!
Revealing what lies behind the screening
We live in testing times. The National Cancer Institute provides a wordy but interesting overview of the hazards of cancer screening.
Two former ‘track favourites’ for cancer screening—mammograms and PSA tests —seem to be running off the pace in 2012, although both still have plenty of backing. The controversy provides insight into the pros and cons of screening tests.
Med Page Today is a hardworking site which covers medical news for clinicians and is prepared to call bad behaviour when spotted. In Arithmetic stings when well people seek medical care, Dr George Lundberg gives a simple maths lesson, demonstrating the large number of false positives generated by even an accurate test for a rare condition. The increase of well people seeking medical care lowers the prevalence of all diseases and increases the rates of false diagnoses.
Patients referred for MRIs by physicians who owned their own MRI machine were almost twice as likely to have no pathology on review by an independent radiologist. Nothing beats the moolah as an incentive for ordering a test. Do private hospitals also see dollar signs when over treating patients with dementia?
Books that bare all
Overtreated: Why too much medicine is making us sicker and poorer
Shannon Brownlee, 2007, US
Find out about Roemer’s Law ‘A built hospital bed is a filled hospital bed.’ Discover the ‘Limits of Seeing’, where high tech scans make us as transparent as jellyfish, but just as often cloud the diagnosis. And read the last chapter ‘Less is More’, which would have made a great title for this Croakey page, if only Naked Doctor had thought of it first.
Testing Treatments: Better research for better healthcare
Imogen Evans, Hazel Thornton, Iain Chalmers, Paul Glasziou
With the addition of Queensland’s Paul Glasziou, this second edition discusses how to ensure research into medical treatments best meets the needs of patients. The chapter Earlier is not necessarily better covers a Naked Doctor pet theme of the benefits and harms of screening tests.
Overdiagnosed: Making people sick in the pursuit of health
H. Gilbert Welch, Lisa Schwartz and Steve Woloshin
As a society consumed by technological advances and scientific breakthroughs, we have narrowed the definition of normal and increasingly are turning more and more people into patients. Well worth a read: but why take Naked Doctor’s word for it, when you can read the BMJ book review by Croakey regular and fellow sceptic Ray Moynihan.
Ten questions you must ask your doctor
Ray Moynihan and Melissa Sweet
Ray and Melissa would make their mothers proud and their GP nervous. Their approach to keeping the bastards honest is patient-driven quality control at its best. I just hope they book longer consultations. There is little doubt that a dose of healthy scepticism is just what the doctor ordered. Indeed, the Naked Doctor orders scepticism twice daily, taken with a glass of water and a grain of salt.
House of God
Shem’s classic 1978 novel has the narrator as an intern admitting his hospital’s most important benefactor and secretly ordering no investigations or treatment. The patient’s rapid improvement underlines the thirteenth and final law taught to the intern by his wise mentor, the Fat Man: The delivery of good medical care is to do as much nothing as possible. Another Naked Doctor favourite is his tenth law; If you don’t take a temperature, you can’t find a fever. Indeed!
Disclaimer: Reading House of God as an intern was Naked Doctor’s original inspiration for a career-long interest in avoiding overtreatment. He does still own a thermometer and uses it discretionally.
Naked Doctor welcomes suggestions for inclusion on this list, but is responsible for the final decision about which entries are included.