All the latest news on excessive testing and treatment – the Naked Doctor strikes again
AnÂ important campaign has just been launched in the US, with the backing of nine medical societies and several consumer groups, to encourage doctors and patients to identify tests and treatments that may not be necessary.
As part of the ABIM Foundationâs Choosing Wisely campaign, this websiteÂ lists tests and procedures identified by medical societies as commonly used but not always necessary. The nominations come from societies representing immunologists, family physicians, cardiologists, gastroenterologists, clinical oncologists, nephrologists, radiologists and others.
According to the ABIM statement, the lists cover matters such as whether brain imaging scans like a CT or MRI scan are necessary after fainting (probably not), and whether patients need stress imaging tests for annual checkups (not if you are an otherwise healthy adult without cardiac symptoms).
You can read more about the campaign in this JAMA article from Christine Cassel, president and CEO of the ABIM Foundation.
But others are not convinced the campaign will change physician or patient behaviour and see it as more of a political measure.
Meanwhile, this NYT report on the campaign mentions that a major conference will be held in Boston this month, âAvoiding Avoidable Care,â which is being billed as âthe first major medical conference to focus on the perils of unnecessary and unhelpful medical careâ.
All of which suggests that Croakey columnistÂ Dr Justin Coleman has excellent timing in presenting his second instalment of the Naked Doctor column (which made its debut here earlier this year), which he introduces below by describing some of the feedback he’s had so far.
The column seeks 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.
Justin Coleman writes:
When the Naked Doctor bared all in January, the world stood up to watch.
Health gurus and fellow sceptics from all over the planet sent wolf-whistles of encouragement, while others posted a raspberryâor Bronx cheer, depending on country of origin. Stripping back some of the excesses of medicine is clearly a debate whose time has come.
The Australian Institute for Patient and Family Centred Care plugs away at patient-centred medical care. The Slow Medicine movement is a bit like the Slow Food one, except even healthier. The folk at Healthy SkepticismÂ beat Naked Doctor to a title which pretty neatly sums up the aim of the whole shebang. And the American College of Physiciansâadmittedly, not a recent Naked Doctor discoveryâis climbing on board, big time, with a push to save $200 billion a year on excessive testing.
Interestingly, some commentators suggested that Naked Doctor is exposing himself to his clothed colleagues while ignoring the excesses of the alternative medicine industry. As to the former charge, there is nothing indecent about subverting a medical practice when new evidence suggests it is unhelpful to our patients. Thatâs what good doctors get paid to do, by a health system which can ill afford the alternative.
As for ignoring complementary and alternative medicine (CAM), the charge sticks. The lack of evidence for diagnosis and treatment is a pandemic of overwhelming proportions in CAM. Naked Doctor chose to limit entry into the strip show, where the audience at least knows the rules. He doesnât envy those on the stage next door, attempting to peel back the layers to reveal the ghost within. He watches with interest the ongoing debate about whether those charged with that very taskâCAM academicsâwarrant their university tenure.
Naked Doctor thanks his many emailers and tweeters for suggestions for this updated list (which is archived here and also reproduced below).
Enjoy the show.
Naked Doctor: the list
Start at home with our very own Melissa Sweet who introducedÂ the over-intervention themeÂ to Crikey readers. A systematic approach is needed to balance the all-powerful âgive us moreâ lobby.
Speaking of which, Melissa does give us more; in her non-Croakey spare time, she sums up our âless is moreâ theme atÂ Inside Story.
Recent Croakey stories include Simon ChapmanÂ refutingÂ the claim of the UK quit smoking campaign that ânot manyâ smokers quit by going cold turkey, and Olga Anikeeva tries toÂ stem the tideÂ of antibiotic resistance.
Adelaide psychiatrist Jon Jureidini offersÂ a fine explanationÂ of âunexplanationsâ in psychiatry. Jon moonlights as spokesman forÂ Healthy Skepticism,Â a small group with a big mandate to counter misleading drug promotion.
Brisbane GP Andrew GunnâsÂ unravellingÂ of the numbers needed to treat and to harm (NNT, NNH) is worth reading for the opening quote alone:Â âIt is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.âÂ Philippe Pinel 1745-1826. Oops, a spoiler! Read it instead for the Galen quote, which is even better.
Sharon Beglee at The Daily Beast pensÂ a neat appraisalÂ of situations where saying âNoâ to a test or procedure can potentially save your life. Some thoughtful doctors are voting âNoâ when it comes to their own healthâand Sharon names names.
In 2010,Â Archives of Internal MedicineÂ started a columnÂ âLess is More: How Less Health Care Can Result in Better Healthâ. Section editor Deborah Grady maintainsÂ the impressive article list.Â Naked Doctorrecommends a pleasurable browse through the less-is-more garden, plucking full-texts at whim.Â A commentary on the overuse of stents in stable coronary artery diseaseÂ describesÂ what went wrong in previous meta-analyses, which included acute-MI patients. Nothing wrong with the number crunching; the results just didnât apply to most of the stent population. Overuse of health servicesÂ is understudied; why has it taken decades to reduce antibiotics for viral infections, despite the education campaigns themselves almost going viral?
Josh Freeman, physician educator, Kansas US, writesÂ a lovely blogÂ mixing medicine with social justice. A number of articles discuss the inequities of spending money on treatments that donât work.Â He worries aboutÂ sounding nihilisticÂ when identifying useless screening tests (know the feeling!) or whenÂ criticising doctorsÂ who donât keep up with significant shifts in evidence. But thatâs part of what we clinicians get paid for.
Shannon BrownleeÂ discussesÂ a study by cardiologists Grace Lin and Rita Redberg, who designed three theoretical cases where evidence suggests non-intervention was the correct treatment. TheyÂ foundÂ that their cardiologist colleagues would almost always recommend surgical intervention. Surprise! Maybe author Upton Sinclair had it right when he said:Â It is difficult to get a man to understand something when his salary depends upon his not understanding it.Â Talking of which, it is a concern when the BMJÂ notesÂ that, of the chairs and panel members producing North Americaâs screening and treating guidelines for hyperlipidaemia and diabetes, half have financial conflicts of interest.
Always worth a mouse click is Dr Richard LehmanâsÂ journal reviewÂ which consistently espouses the same themes asÂ Naked DoctorÂ but does it on a weekly basis and is wittier. Only click on him if you promise to return.Â The American health system is saturated with the influence of the pharmaceutical and medical devices industry: huge payments are made directly to individuals or institutions to influence purchasing decisions. In the UK, we call this corruption, but only for the time being.
We previously invited Dr Gary Schwitzer (HealthNewsReview.org) to come out of the closet and declare himself a Naked Doctor. Gary prefers to leave his hat on, but sent us a large series of articles onÂ disease-mongeringÂ and onÂ overtreatment.Â He recently highlighted 10 imbalanced TV news stories around health screening from the respected US ABC.
Chris Del MarâsÂ BMJ editorialÂ 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 donât, doctors expect that their patients expect intervention. Confused? Paul Little explains the conceptÂ here.
Pharmed OutÂ is a Georgetown University project educating healthcare professionals about pharmaceutical marketing practices. Check out the video links on the home page. Â A former drug repÂ âfesses up:Â Statistics are like prisonersâtorture them enough and theyâll tell you what you want to hear!Â Grab aÂ âNo Drug Repsâ certificateÂ 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,Â lists âovertreatmentâÂ 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.
Has all this scepticism left you feeling naked? If so many treatments donât seem to make much difference, what is left? Itâs not our brief to list the many interventions that do work, but we do like Dr Mike EvanâsÂ entertaining videoÂ which demonstrates how physical activity can be more effective than pharmaceuticals. The same observation prompted âexercise prescriptionsâ, championed by the folk atÂ Exercise is Medicine,Â as an alternative clothing option for naked doctors.
Revealing what lies behind the screening
We live in testing times. The National Cancer Institute providesÂ a wordy but interesting overviewÂ of the hazards of cancer screening.
H. Gilbert Welch, author of âOverdiagnosedâ (see books, below) is a natural wordsmith, craftingÂ a fine articleÂ for the NYT: If you feel O.K., maybe you are O.K. Â The truth is, the fastest way to getâŚdiseaseâŚis to be screened for it.
Two former âtrack favouritesâ for cancer screeningâmammogramsÂ andÂ PSA testsÂ âseem 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 TodayÂ is a hardworking site which covers medical news for clinicians and is prepared to call bad behaviour when spotted.Â Its scope is broad, so use the search function to find topics such as theÂ risks of mammographyÂ Â or the increased likelihood ofÂ an ADHD diagnosisÂ in kids who start school early. For those who can cope with long lists, readÂ â22 things amiss in medicine todayâ, by the formidable editor-at-large Dr George Lundberg, whose time at the helm of JAMA wore down his inclination to pull punches.
Patients referred for MRIs by physicians who owned their own MRI machine wereÂ almost twice as likelyÂ to have no pathology on review by an independent radiologist. Nothing beats the moolah as an incentive for ordering a test. Do private hospitals alsoÂ see dollar signsÂ when over treating patients with dementia?
Books that bare all
British epidemiologist Goldacre bases the book on his weekly âBad ScienceâÂ columnÂ in the Guardian, where he givesÂ bad medicineÂ a lot of column inches. In the chapter âPill solves complex social problemâ, he even makes the big call, âBefore 1935 doctors were basically useless.â Older Naked Doctor readers excepted, of course.
How We Do Harm: A Doctor Breaks Ranks About Being Sick in America
Otis Brawley and Paul Goldberg
Dr Brawley, Chief Medical Officer with The American Cancer Society, closes ranks with everyone else in this blog as we all break ranks with those forces promoting âthe overtreatment of the rich, the under treatment of the poor [and] the financial conflicts of interest that determine the care that physicians provide.â
The Treatment Trap: how the overuse of medical care is wrecking your health and what you can do to prevent it
Rosemary Gibson and Janardan Prasad Singh
For a taste of what lies behind the logorrhoeic title, Gibson blogsÂ here.Â Her 16 yearsâ messing about in the politics of health quality and safety gives her a keen insight into the US health system
Overtreated: Why too much medicine is making us sicker and poorerÂ
Shannon Brownlee, 2007, US
Find out about Roemerâs Law âA built hospital bed is a filled hospital bed.âÂ Discover the âLimits of Seeingâ, where high tech scans make us as transparent as jellyfish, but just as often cloud the diagnosis. And read the last chapter âLess is Moreâ, which would have made a great title for this Croakey page, if onlyÂ Naked DoctorÂ had thought of it first.
Testing Treatments: Better research for better healthcareÂ
Imogen Evans, Hazel Thornton, Iain Chalmers, Paul Glasziou
With the addition of Queenslandâs Paul Glasziou, this second edition discusses how to ensure research into medical treatments best meets the needs of patients. The chapterÂ Earlier is not necessarily betterÂ covers aÂ Naked DoctorÂ 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 takeÂ Naked DoctorâsÂ word for it, when you can read theÂ BMJ book reviewÂ 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
Shemâs classic 1978 novel has the narrator as an intern admitting his hospitalâs most important benefactor and secretly ordering no investigations or treatment. The patientâs 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. AnotherÂ Naked DoctorÂ favourite is his tenth law; If you donât take a temperature, you canât find a fever. Indeed!
Disclaimer:Â Reading House of God as an intern wasÂ Naked DoctorâsÂ 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. Please leave your comments and suggestions below.