The Naked Doctor is an ongoing project at Croakey that aims to encourage discussion and awareness of the opportunities to do more for health by doing less.
In this latest edition, Dr Justin Coleman suggests that an equitable health system does not mean trying to give everyone the very best, if that means “the most tests, the most expense, the most treatments”.
“Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient,” he says.
Perhaps one area where more intervention is needed is in tackling overdiagnosis and overtreatment – Dr Coleman suggests that if the ‘medical market’ is left unchecked, the balance naturally tips towards overtreatment.
He concludes with a powerful call to action:
“As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.”
The article below is based upon his plenary address to the Qld RACGP Annual Clinical Update in Brisbane last month.
It is dedicated to the late Professor Gavin Mooney, whose philosophy was that we must “judiciously apply what we know works, rather than enthusiastically embrace what we wish would work”.
The ethical imperative to tackle overdiagnosis and overtreatment
Justin Coleman writes:
Two years ago my good friend Gavin Mooney gave me a signed copy of his latest—and, as it turned out—last book, Evidence-Based Medicine in its Place.
Professor of Health Economics at Curtin University, Gavin was an irascible Scot, and his book detailed his work with another great Scotsman, Archie Cochrane, who of course pioneered the science of Evidence-Based Medicine.
According to Mooney, after their first meeting, Cochrane informed him that he had revised his opinion of economists.
On the basis of the evidence of an afternoon with Mooney, he now placed them second bottom, with sociologists at the bottom. This merely confirmed for Mooney that there was much on which they agreed.
Mooney told me the story, repeated in his book, of how Archie Cochrane first gained notoriety as a very junior staff member at the massive Department of Health in London.
The young Archie presented slides from an RCT on outcomes after heart attacks following rehabilitation, either while remaining a hospital inpatient or after early discharge home.
London’s ‘Who’s Who’ of learned physicians nodded sagely as Archie showed the crucial slides where the hospital outcomes—represented in red—outdid the blue columns of home-based outcomes across nearly every parameter. A couple of supportive comments, no questions.
Then the young epidemiologist pretended to look flustered. ‘I’m terribly sorry. I seem to have mixed up the red and the blue!’
He had deliberately switched the labels. All the better outcomes were in fact in the home-based, early discharge group.
Needless to say, chaos ensued as suddenly a hundred disgruntled audience members grilled him on every possible dubious aspect of the study design!
Best practice or common practice?
Until that time, there had been no reason for a London physician to doubt that an intensive, expensive, high-tech hospital stay would improve health outcomes.
It made perfect sense, and a whole bunch of highly intelligent, caring physicians had spent their careers ensuring that such a system existed. Where it wasn’t affordable, public and charity funds were sought to ensure more people could get longer hospital stays.
This was best-practice care, in the same way that bed rest for back pain, monthly breast self-examinations, and antibiotics for sore throats have been understood by clever and well-meaning people to be fairly obvious best care. More about Archie—and Gavin—later.
In the brilliant Mitchell and Webb parody of a Homeopathic Emergency Department, Webb attempts to save a trauma victim’s life by drawing on his palm in pen to extend his life line. He justifies it by asking ‘Have you got a better idea?’
Luckily, the answer is ‘yes’.
There are some things that do work better than a pen mark, or a homeopathic vial of water, even a vial where the water molecules somehow retain the memory of a herb they once knew, while conveniently forgetting they were once flushed down a toilet.
And there are some things that do work better than our mainstream medical interventions, even when tens of thousands of medical practitioners believe they are doing the right thing.
This has always been true, and will ever be so. Our mistakes from the past remind us that we are making mistakes right now. Full credit to all those anonymous doctors and researchers who unwrapped these anomalies.
The art of discovering nothing
History rightly lauds those who discovered ‘something’; Alexander Fleming and penicillin.
But I also dips me lid to those who discovered ‘nothing’. Bloodletting doesn’t work. Arsenic doesn’t work. Keeping kids with polio in hospital back straighteners for six months of their lives doesn’t work.
In many cases, our patients would be better off if we chose not to act.
There’s a minimum standard in the medical profession—not the gold standard, but let’s call it the bronze.
The bronze standard is that the patient is no worse off as a result of seeing us. The bronze standard is probably achieved by enthusiasts who light ear candles and discover people’s chakras. Let’s at least stop doing things which fall below the bronze standard.
We must balance the important and exciting work of discovering new stuff with the un-sexy hard-slog science of analysing those times where we have over-reached and over-enthused.
The best of our medical predecessors started this process and we must continue it; this is why we are a science and not merely a tradition.
Two hundred years ago, the French physician Phillipe Pinel cared enough about the damage his colleagues were doing to his psychiatric patients to observe:
“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.”
It took a young epidemiologist Archie Cochrane to highlight the flaws in obstetric practice that should ideally have already been obvious to the world’s leading obstetricians and their institutions.
And these were not minor flaws. Obstetrics units in one part of the world were teaching methods which had already been shown in another part of the world to kill women and babies, and vice versa.
Cochrane didn’t do the research himself; his genius was to inspire others—in this case, Iain Chalmers— to collect, collate and analyse all the available evidence and, importantly, reject the shoddy stuff: the anecdote and the meaningless trial, so that obstetricians and their departments could make informed decisions as to how to get the best outcomes.
Archie never delivered a baby nor managed a single maternal complication, but his legacy would probably have saved more lives than any doctor watching his slide presentation in London.
Somewhere on the spectrum
Let’s look at chronic diseases, and use diabetes as an example.
Insulin’s invention in 1922 was a miracle, which converted the inevitable rapid death sentence of Type 1 diabetes into a chronic disease. Chronic in the best sense of the word, because insulin bought you time; years, decades.
That simple chemical justifiably sits at the high table in the pantheon of superb medical interventions.
But diabetes, like most chronic diseases, has nominal cut-off points which define its existence and degree. Diseases stretch themselves out along a spectrum, blissfully unaware of how we choose to dissect them.
Medical tests and interventions that work brilliantly at the sharp end of the spectrum do not work nearly so well when we slide towards the middle and enter the grey zone.
Any gains to be had here in the land of the long grey cloud are far foggier than anything out at the extreme edge.
Benefits diminish; every diagnostic test becomes less accurate; false positives increase exponentially; patient numbers increase—and with them, costs, pain and inconvenience; health gains are smaller in this less-sick population; and suddenly being diagnosed with a chronic disease such as diabetes or pre-diabetes doesn’t look so good any more.
Instead of being grateful to Chronos, the Greek god of time who grants you each extra year of life, suddenly the old bugger expects you to jab your finger three times a day, jab your stomach three times a day, and to roll a boulder up Sisyphus’s mountain just to have your liver pecked out by Prometheus’s eagle.
There comes a point where ignoring your diabetes educator becomes…to continue the theme…tantalising!
If the ‘medical market’ is left unchecked, the balance naturally tips towards overtreatment.
The paradigm promoted by industry, the media and some doctors, particularly the sub-sub-specialists, is that the only important news is a new invention, new drug, robotic surgery, more MRIs.
Is the best doctor always the one at the cutting edge? Is the best endocrinologist for my grandmother the one who has just spent a year in America learning the finer points of subcutaneous insulin infusion pumps?
There exists a cut-off point on every disease spectrum, inevitably ignored by drug companies and often enough by doctors, where medications simply don’t help. At that point, they do nothing. Beyond that point, they actively harm. This is true almost by definition for every medical or surgical intervention.
There is pressure from multiple sources—patient, doctor, pharma, specialist, psychologist, media, disease-awareness campaigns, patient advocacy groups—to nudge this point towards the midline of the spectrum.
This is true for diabetes, but also for depression, ADHD, lipid levels, cardiac stents, and deficiencies of a host of replaceable substances including testosterone, oestrogen, and various vitamins, the trendiest of which is Vitamin D.
If we don’t test early and often for all these problems, we are ignoring our duty of care and if we don’t treat when the test result comes back in red, we are downright obstructive and possibly liable.
Andropause: the new epidemic
Take testosterone. In the past five years we have witnessed a concerted wave of discussion around the andropause. Feature articles have called it the hidden epidemic, hinting at reverse sexism whereby women get their daily oestrogen but our men’s hormones have rights too!
Disease-awareness campaigns, subtle in Australia compared to countries that allow direct-to-patient advertising, ask males if they ever experience tiredness, weakness or low libido. The suggested remedy is to get your levels checked by your friendly local GP. It’s not advertising: it’s just caring.
This tumescent rise in publicity tied in beautifully with the advent of ‘men’s clinics’, whose doctors were the only clinicians with enough spare time to keep up with all the clever new ways of getting the testosterone into your body; oral, patches, gels, suppositories, inhalants; no orifice was left unsullied in the competition to supply Vitamin T.
PBS expenditure on testosterone has increased 450 % since 2006. Patients at the pointy end of the spectrum—men with testicular cancer and orchidectomies—have been swamped by the enormous market of men who are…wait for it…ageing. A bit like what’s happening to the percentage of cancer-sufferers in the opioid market.
Last year, the departing boss of the US Medicare system, Dr Donald Berwick, estimated that 20-30 per cent of US health spending is ‘waste’—as in; it yields no benefit to patients. That one quarter of the US health budget wasted could power the entire GDP of most countries on the planet.
Berwick listed five reasons for this catastrophic waste, and the first of them was ‘overtreament’. We are not talking a minor problem here.
Why do we overtest and overtreat?
Let’s look at some causes of overtesting and overtreating. Why do we do it?
Some of it is simply because the evidence doesn’t exist yet.
There was no shame in a medical graduate treating headaches with bloodletting a century ago; no-one knew any better. According to the prevailing understanding of the human body, it made sense and it no doubt appeared to work in some people.
But lack of evidence is not the only reason for our actions.
I like the list prepared by Australian surgeon Dr Skeptic (clearly his parents were prescient when naming him) of the reasons why we act even when evidence tells us ‘Don’t just do something, stand there!’
Defensive medicine: If you miss one rarity and thereby harm one person, this is more likely to end you up in court than causing far more harm by routinely overtreating everyone.
It takes an epidemiologist to tell you about the latter, whereas a lawyer will be quite happy to keep you posted about the former.
The language of inaction vs. action: Overinvestigation and overtreatment are very difficult concepts to convey to patients.
If we tell the patient ‘I really don’t know precisely why you have low back pain; would you like me to run a few tests?’ then the answer will be ‘yes’.
Our choice of language suggests that after doing the tests, we will know why they have low back pain. But whether doctor, physiotherapist or chiropractor, ye may ask the gods of radiology but shall not receive an answer.
If we give a glucometer to a person with pre-diabetes, or with diabetes that doesn’t require insulin, we will indeed get an answer as to precisely what their blood sugar is at any given moment, but this knowledge will not actually improve health outcomes.
The answer does not help the patient, therefore we are asking the wrong question.
This flawed logic of Test = Answer = Cure is used by iridologists and scientologists. And doctors.
Influence of recent experience: obstetricians who attend a birth with complications are significantly more likely to recommend a Caesarean section in their next 50 cases, before they settle back into a more sensible, case-by-case evidence-based approach.
The lottery mindset: Few people have a good understanding of risk.
My chances of winning the first division prize in tattslotto this Saturday are the same whether or not I buy a tattslotto ticket. The same. Not absolutely, mathematically, precisely the same, but the same in any meaningful, ordinary sense of the word.
People don’t understand tiny chances. I have more chance of being dead next Saturday than being both alive and collecting my winnings.
Studies consistently show that both doctors and patients, just like gamblers and stockbrokers, overestimate gains and underestimate losses.
People will jump at a whole body CT scan to ‘rule out’ a tiny risk of cancer, and ignore the fact that the radiation from each such scan increases their lifetime cancer risk by about 1%.
The prevailing wisdom: Medical students come out of university knowing thousands of new words and knowing about thousands of new interventions. The consultants taught us all the pharmaceutical and surgical interventions in their own specialised area of expertise.
But it’s not really anyone’s job to teach you about how to avoid patient referrals into the system; how to stop the cascade before it starts.
A recent Australian study showed that half of all IV cannulas inserted in ED are never used. Why does every junior ED doctor put the IVs in? Because everyone else has always put them in.
When ‘more’ is harmful
If a junior doctor is trained in breast surgery outpatients and has met women whose cancer was detected by screening mammogram, it takes some active un-training not to assume that therefore all women are better off having a mammogram.
When I was a student, my consultant orthopod took the time to kindly explain the intricacies of spinal fusion and of arthroscopic debridement for osteoarthritic knees, and I think he probably mentioned that ‘some patients don’t seem to gain as much as others’.
However, this is a starkly different prevailing wisdom from the reviews that have shown that neither spinal fusions nor arthroscopies for osteoarthritic knees differ much from placebo. In the US alone, 650 000 such arthroscopies were performed each per year in the late 1990s.
Ironically, sometimes the richer you are, with more access to the private system and doctors who will cut corners for you, the more intervention you get and the more harm is done.
The extreme of this is the Hollywood celebrity with their own physician on call, who would feel like a fool telling his client that for their thousand-dollar callout fee they get absolutely nothing except ‘watch and wait’.
When Michael Jackson went to his umpteenth plastic surgeon, she didn’t say ‘no’. When he complained he was getting anxious and couldn’t sleep and needed something more than light sleeping tablets, I bet Dr Conrad Murray now wishes he had opted for conservative management.
Making the system work
I believe it is our ethical responsibility to avoid overtreatment at an individual level, and also to support system-wide changes in the way we spend money on health.
I am no slave to evidence-based medicine; not one of those sceptical EBM types who eat gruel for breakfast and secretly believe deep down that nothing works. Although, on a bad day this pessimism reaches its ultimate fruition—absolutely nothing I do works!
EBM is a necessary but not sufficient condition for practising good medicine.
When my friend Prof Gavin Mooney gave me his book, he explained why he’d called it EBM ‘in its place’.
He did not want to promote a system of slavish adherence to a deontology. As a leftie health economist—a rare breed indeed—his primary concern was always one of health equity. Not health equality, which is clearly unattainable, but equity, where we strive for equal access to equal care for equal need.
An equitable health system does not mean trying to give everyone the very best, if by that you mean the most; the most tests, the most expense, the most treatments. Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient.
Gavin was killed in tragic circumstances last Christmas, and I dedicate this article to his memory.
His philosophy was that, sometimes, less is more. We must pare things back, strip away excesses and judiciously apply what we know works, rather than enthusiastically embrace what we wish would work.
As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.
• Dr Justin Coleman is a GP at Inala Centre of Excellence in Aboriginal and Torres Strait Islander Health. He is senior lecturer at Griffith University and University of Queensland, and President of the Australasian Medical Writers Association (AMWA). Twitter: @drjustincoleman. Web: http://drjustincoleman.com/
On related themes, the program for The Preventing Overdiagnosis conference, which will take place in the US in September, has been announced.
The conference is hosted by The Dartmouth Institute for Health Policy & Clinical Practice, in partnership with the BMJ, the leading New-York based consumer organisation Consumer Reports, and Bond University.
Speakers include Lisa Schwartz and Steven Woloshin, co-authors of Overdiagnosed: Making People Sick in the Pursuit of Health; and Otis Brawley, author of How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.