The Quest to Question Questionable Care
(July 14, 2015)
Eighty percent of what we call the "diseases of civilization" could be prevented if we applied just what we already know about diet and exercise. Medical error is the third leading cause of death in the United States. Those two facts are no longer seriously questioned, and partly because they are such revolutionary concepts for most people they are my favorite newsletter subjects. (They are also my favorite conversational topics, unfortunately for my friends, who seem to be fewer as of late.)
But no matter how virtuously healthy our mode of living, things will go wrong with us from time to time. When that happens we often must risk a trip to the doctor.
Sadly, though, when you finally take the plunge and consult a member of that hallowed guild, your responsibility for yourself has not ended. There is more than one pothole in the American road to health, potholes that produce the highest medical costs with some of the poorest results in the so-called advanced part of the world, and we want to avoid breaking an axle on that trip if at all possible.
One of the things to look out for is what sometimes seems like the siren call of unnecessary medical testing. I use that phrase because it often happens that if you’re spooked enough about a problem to submit it for evaluation to a medical doctor, you may be tempted to push (or to allow your doctor to push) to have it "checked out as thoroughly as possible”. By which I meaning having every imaginable scan, image and analysis done, not to mention having your blood tested until you're halfway to anemia, "just to be sure”. I promise you that this approach is almost always a very, very bad idea.
Few people go to their doctors today for a physical exam if they are healthy and have nothing going on that needs regular monitoring, and that is as it should be. Even WebMD will unbend enough to tell you that an annual physical exam “is not always necessary”. The healthy living advice you might ordinarily get at such a visit is usually provided at the other times you see your doctor, and routine examination procedures generally don’t turn up anything important on someone without any complaints.
So when we do go to our doctor with a problem we haven’t been able to handle on our own or anywhere else, we are a little worried and thus sometimes happier if the doctor exhaustively investigates every conceivable cause before proposing a diagnosis and treatment. Is an unneeded test or procedure really that big a deal? And isn’t it better “just to know”? In answer to the first question, yes, it is a big deal; in answer to the second, no it isn't -- it doesn't work that way.
It doesn't work that way because medical tests are very far from perfect. Each one tends to produce a certain percentage of false negatives (failing to show a problem that is actually present) and false positives (seeming to show something that is not actually there), and when you get a false positive it takes more money, guns and lawyers -- ah, I mean money, blood and stress (the guns and lawyers are for after that) -- to check it out.
Mammograms in particular tend to have an unsettling number of false positives, and they now are recommended as a routine test far less frequently than they once were. That is because umpteen women were getting cut on and irradiated, not to mention scared out of their wits, for lumps that were either small enough to resolve on their own, benign, or not really there at all. PSA tests are also done much less frequently than they were at one time, and for similar reasons.
If you don’t have an actual reason to run a test, an issue that turns up in such a case has a very high likelihood of being nothing at all. But that mirage will still cost you all kinds of money and stress and may involve invasive and health-threatening procedures – all for, at best, no benefit at all.
The admonition to think of horses and not of zebras if you hear hoofbeats is a bit of folk wisdom which was originated by a medical doctor for use in diagnosis, for just this reason. If it is midwinter, half your workplace is out sick and you come down with a fever, muscle aches and fatigue, you do not have to be tested for the plague. (Not until you break out in huge black swellings, anyway.) I can guarantee you that if everyone who had the flu last year had also been tested for the plague, a big bunch of them would have turned up positive, just because if you run any test enough times you're going to get a certain number of hits.
Waste in the American medical system is a huge subject which I can’t begin to thoroughly explore here in this humble little newsletter, but it has been estimated that about a third of what we spend in the medical biz is unnecessary. “Unnecessary” here meaning that the only improvement in health occurred in someone else’s bank account. A third of what is now a $3 trillion per year industry? Wow, we’re talking about real money, both on a national and on an individual level.
Here is a rough breakdown of that figure into the different categories and amounts for 2012, just for giggles and to maybe give you something else to think about the next time you are trying to figure out when you might actually be able to retire:
Unnecessary services $ 210 billion
Excess administrative costs $190 billion
Inefficiently delivered services $ 130 billion
Too-high prices $ 105 billion
Fraud $ 75 billion
Missed prevention opportunities $ 55 billion
This list is an eye-opener and each line of it could have books written about it. But let's just stick with the first item, "unnecessary services”, and remember again that medical error is the third leading cause of death. Again as a rough estimate, about $1.8 trillion was spent in the U.S. in 2012 on actual medical services, and over 400,000 of those receiving them died due to medical error. $210 billion is about a eighth-ninth. How many unnecessarily dead people is that? And those are just the ones who died from errors, not the ones in the "unnecessary operation was successful but the patient died" category.
I'm guessing that well over 40,000 people in 2012 died, then, from mistakes in procedures that they didn't even need. That doesn't even take into account the serious injury rate (which is about ten times the death rate). Granted, I’m making a lot of assumptions here to arrive at a number. But you see my point, I’m sure, even if you want to quibble a bit with the numbers.
Doesn’t that much unnecessary death and suffering totally frost you? It does me. It would be bad enough to die of a medical procedure. To die of one that was not needed is the worst kind of --- what would you call it? Waste? Misery? Bad joke? My paternal grandfather died from a medical error while in the hospital for what was almost certainly a non-existent heart attack, and it changed the entire trajectory of my family history. How many families has that happened to?
I don't want to sound too much like Dr. McCoy here. But medical testing and procedures are in general dangerous enough for ERRORS in medical care to be the third leading cause of the death in the U.S. So take care of yourself, do what you need to do and only what you need to do to stay healthy. And live long and prosper.
--dr. diane holmes
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