tip off

All the latest news on excessive testing and treatment – the Naked Doctor strikes again

An 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 Foundation’s Choosing Wisely campaign, this website 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.

The campaign has been welcomed by some doctors, including the surgeon and writer Atul Gawande.

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, “Avoiding Avoidable Care,” which is being billed as “the first major medical conference to focus on the perils of unnecessary and unhelpful medical care”.

All of which suggests that Croakey columnist 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.

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Introducing the second instalment of Naked Doctor

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 raspberry—or Bronx cheer, depending on country of origin. Stripping back some of the excesses of medicine is clearly a debate whose time has come.

Naked Doctor found friends in the expected places—HealthNewsReview.org, and the BMJ’s Richard Lehman —but also discovered some small, dedicated organisations with overlapping aims.

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 Skepticism beat Naked Doctor to a title which pretty neatly sums up the aim of the whole shebang. And the American College of Physicians—admittedly, not a recent Naked Doctor discovery—is 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. That’s 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 doesn’t 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 task—CAM academics—warrant 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.

• You can follow Justin Coleman on Twitter. 

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Naked Doctor: the list

Over-intervention unveiled

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.

Recent Croakey stories include Simon Chapman refuting the claim of the UK quit smoking campaign that ‘not many’ smokers quit by going cold turkey, and Olga Anikeeva tries to stem the tide of antibiotic resistance.

Adelaide psychiatrist Jon Jureidini offers a fine explanation of ‘unexplanations’ in psychiatry. Jon moonlights as spokesman for Healthy Skepticism, a small group with a big mandate to counter misleading drug promotion.

Brisbane GP Andrew Gunn’s unravelling of the numbers needed to treat and to harm (NNT, NNH) is worth reading for the opening quote alone: “It 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.” Philippe Pinel 1745-1826. Oops, a spoiler! Read it instead for the Galen quote, which is even better.

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.

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 Doctorrecommends a pleasurable browse through the less-is-more garden, plucking full-texts at whim. A commentary on the overuse of stents in stable coronary artery disease describes what went wrong in previous meta-analyses, which included acute-MI patients. Nothing wrong with the number crunching; the results just didn’t apply to most of the stent population. Overuse of health services 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, 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 worries about sounding nihilistic when identifying useless screening tests (know the feeling!) or when criticising doctors who don’t keep up with significant shifts in evidence. But that’s part of what we clinicians get paid for.

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. Talking of which, it is a concern when the BMJ notes that, of the chairs and panel members producing North America’s screening and treating guidelines for hyperlipidaemia and diabetes, half have financial conflicts of interest.

Always worth a mouse click is Dr Richard Lehman’s journal review which consistently espouses the same themes as Naked Doctor but does it on a weekly basis and is wittier. Only click on him if you promise to return. 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 on disease-mongering and on overtreatment. He recently highlighted 10 imbalanced TV news stories around health screening from the respected US ABC.

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. Check out the video links on the home page.  A former drug rep ‘fesses up: Statistics are like prisoners—torture them enough and they’ll tell you what you want to hear! 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.

Has all this scepticism left you feeling naked? If so many treatments don’t seem to make much difference, what is left? It’s not our brief to list the many interventions that do work, but we do like Dr Mike Evan’s entertaining video which demonstrates how physical activity can be more effective than pharmaceuticals. The same observation prompted ‘exercise prescriptions’, championed by the folk at Exercise is Medicine, as an alternative clothing option for naked doctors.

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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.

H. Gilbert Welch, author of ‘Overdiagnosed’ (see books, below) is a natural wordsmith, crafting a fine article for the NYT: If you feel O.K., maybe you are O.K.  The truth is, the fastest way to get…disease…is to be screened for it.

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. Its scope is broad, so use the search function to find topics such as the risks of mammography  or the increased likelihood of an ADHD diagnosis in kids who start school early. For those who can cope with long lists, read ’22 things amiss in medicine today’, 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 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?

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Books that bare all

Bad Science
Ben Goldacre
British epidemiologist Goldacre bases the book on his weekly ‘Bad Science’ column in the Guardian, where he gives bad medicine a lot of column inches. In the chapter ‘Pill solves complex social problem’, he even makes the big call, ‘Before 1935 doctors were basically useless.’ 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 ‘the overtreatment of the rich, the under treatment of the poor [and] the financial conflicts of interest that determine the care that physicians provide.’

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 blogs here. Her 16 years’ 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 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
Samuel Shem
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.

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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.

 

 

 

 

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