By Dr. Allen Frances
Two years ago, I wrote that the first "PREVENTING OVERDIAGNOSIS" conference was easily the most important meeting I had ever attended. http://m.huffpost.
Last week's third "PREVENTING OVERDIAGNOSIS" conference, held at the National Institutes of Health in Washington, DC was even better. The conference was sponsored by the National Cancer Institute in collaboration with Oxford University, the British Medical Journal, Consumer Reports, and Bond and Dartmouth Universities. Hundreds of presentations covered the causes, consequences, and cures of overdiagnosis from every conceivable angle and laid out an agenda for future action. The international audience of 350 was as bright a group as I have ever encountered in almost 50 years of attending medical meetings.
The topic is the highest priority public heath problem we face in the US and increasingly around the world. Medical mistakes are the third leading cause of death in the US- and are often occasioned by excessive testing and treatment delivered in an uncoordinated way by doctors who know lab tests, but don't know their patients.
Clearly, too much medicine can be very bad for your health. And it is also a disaster for the health of our economy. The US spends $3 trillion a year on heath care- more than the GDP's of all but four countries in the world. Because one third of this enormous investment is sheer waste, it is no surprise that we get lousy outcomes compared to countries that spend much less, but spend much more wisely.
The biggest culprit in overtreatment is over testing. We have developed sophisticated technology that discovers incidental 'diseases' that would have little or no impact on our lives and then treats them with disproportionately blunderbuss interventions that often cause more harm than good. Rates of breast, prostate, and thyroid cancer increased dramatically not because people are sicker, but because disease definition has been broadened to inflate diagnosis. Much of what is now called 'cancer' is not really cancer at all, or so slow growing that it is not really health or life threatening.
Aggressive treatments that are delivered for non-aggressive 'diseases' cause more problems than they solve. Our current excess of therapeutic zeal follows a long historical tradition of well intended, but overly exuberant, doctors harming their patients with really terrible treatments. Not so long ago, doctors routinely bled their patients, gave them emetics and cathartics, and poisoned them with heavy metals. Future observers of our current practice will find some of what we are doing now equally wrong headed and harmful.
Diagnostic inflation has also resulted in overtreatment of diabetes, hypertension, osteoporosis, attention deficit disorder, most problems that lead to orthopedic surgery, and lots more of what constitutes everyday medical practice.
Overtreatment is driven by many powerful and interacting forces and will be difficult to tame.
Most destructive has been the commercialization of medicine as a big business- healing art transformed into profitable cash cow. Perverse financial incentives encourage disease mongering, false advertising, over testing, quick diagnosis, and unnecessarily aggressive treatment.
Often the best medical decision is to cautiously watch and wait, but this is discouraged by reimbursement mechanisms that favor quickly jumping in with potentially harmful, very expensive, and often unnecessary treatments. The powerful medical-industrial complex will exert all its considerable financial and political might to protect its profits, even if this means compromising patient welfare and eating up the economy. The obvious solution here is to substitute capitation for crazy fee-for-service incentives that reward the health system for doing more.
Too much medicine has also been driven by a medical research enterprise that systematically rewards scientists, journals, and the media for hyping often-false positive findings. Negative findings that would encourage the public to have a healthy skepticism about exaggerated claims are buried.
The result: patients accept, and even clamor for, testing and treatment that is more likely to harm than help. People fear the risks of illness too much and fear risks of treatment far too little. A great deal of conference time was thus productively devoted to the communication tools necessary to help right this imbalance. Patients must become informed consumers to balance the benefits of treatment with its risks and protect themselves from a system pushing them to always want more than may be good for them.
Regulators of medical excess no longer regulate. Seven years ago, the Food and Drug Administration, approved only one third of drug applications. This year, it has approved 96%. And drug companies are increasingly winning the right to mislead both the public and physicians, with false advertising and pushing off-label prescription.
Quality Assurance programs also play an unwitting role. Historically, QA has focused on identifying the things that should have been done during the course of treatment, but were left out. As a result, nine tenths of QA measures tap errors of omission, only one-tenth errors of commission. Unless this imbalance is redressed, QA will continue to drive doctors to do too much, even in situations where less would be more.
Unless applied cautiously, 'Personalized' or 'Precision' medicine may make things worse, becoming the next slick advertising gimmick to justify the use of treatments that have failed to prove their effectiveness in large groups. A more precise medicine would offer much less, not more, treatment.
The battle to tame medical excess is classic David vs. Goliath. But, fortunately, David has some potentially effective pebbles and might sometimes does come from being in the right. Thirty years ago, Big Tobacco seemed as impregnable as the medical-industrial complex, but it was toppled by its obvious outrageousness, dedicated opposition, public and media awakening, and lawsuits. The same combination, along with the inevitable need for cost containment, will eventually tame the medical beast- the question is how long will this take and how much harm will be done to patients and the economy before we get back to patient-driven, rather than profit driven medicine.
The conference wasn't perfect. There was a preaching to the choir feeling. Future conferences should invite debate with leaders from the forces promoting overtreatment- e.g. the insurance industry, Pharma, hospital associations, physician specialty groups, and consumer advocacy. Government and employers wind up footing the lion's share of medical costs and need to hear how much of their expenditure is not only wasteful financially, but also bad for the people they are trying to help.
The conference was attended by about a dozen science writers interested in the topic, but it did not itself become the big media story it can and should be. More intense public relations could lead to numerous stories alerting the public about which specific tests and treatments are most overdone and most risky.
And there could have been more discussion about how best to unite the various groups fighting against medical excess and hype. 'Choosing Wisely'; the Lown Foundation's 'RightCare' initiatitive; the HeathNews Review; the British Medical Journal; Consumer's Reports; and the many researchers and educators engaged in the field are all individually wonderful, but might collectively be more effective if their efforts were better coordinated.
Bottom line: Medical marvels are oversold and overbought. Doctors need to be more humble and safety-conscious. We can't overstep our knowlege base without putting our patients at risk. Patients and doctors need to accept the uncertainty and limits of medicine. False certainty leads to terrible decisions.
We must not ignore the most important ethic in medicine laid out 2500 years ago by Hippocrates: First Do No Harm.
