Take a look at kyphoplasty/vertebroplasty payments by CMS......another questionable benefit procedure that CMS pays thousands for.
1
A lot of the old stuff doctors need to unlearn frequently comes from studies done only in men or only in male animals. As a petite woman, I suspect I've been medicated based on these older studies. Who knows if my medications work as well in women or smaller adults. And even if my meds should be adjusted for size and biological sex, just getting this information out to doctors, let alone getting them to follow it is difficult.
As a pediatric critical care physician who teaches both fellow and residents in a large, busy unit, I often remind the trainees that sometimes it is best to "Don't just do something. Stand there." I also remind them that there are many historical instances in medicine when it seemed that the "correct therapy or treatment" turned out to be entirely wrong. As physicians we should use the best available medicine in real time, and we should be willing to adopt as the evidence changes.
2
This is an interesting article, but it overlooks another factor on why ‘practicing’ physicians may be loathe to give up procedures they use routinely. Perhaps this has to do with “fee for service” medicine as it is currently delivered in the US. Doctors charge patients based on the numbers of procedures they apply during patient care. The more procedures, the higher the bill. This is translated into ‘relative value units’ the more RVUs one can generate in a practice the higher the income. Am I missing something as to why physicians continue to do what they do? Not so different than buying a car...the more gadgets the salesmen can get you to buy, the higher the profit margin. So what else is new?
1
@Donald Anti kick back legislation (Stark Law) prevents physicians from benefiting financially from imaging and lab tests. For primary care physicians, there is little or no financial incentive for over-prescribing procedures or tests. In fact, because they have to follow up on all of those results (which is not reimbursed) there may be a disincentive. With tight glycemic control - the challenge is that we WANT there to be something like that to make a difference in these critically ill patients. For those of us in training when the initial reports suggested tight control mattered, it became a point of pride to tightly monitor our patients. This was a sign that you were a conscientious, knowledgeable doc. Unlearning can be very hard once you are out in the real world.
@DocShott Just an FYI.....The Stark law has many gaping loopholes. Like in-office ancillary imaging exemption.....
1
There is a book called "House of God" by Samuel Schemm. It is about medical training and the topics of which you speak. Read it. It will enlighten and inform your childish ruminations.....
1
No one who is not a physician should comment on medical practices because they cannot be aware of all of the factors that influence any medical decision. While this is true, to some extent, of any area of expertise, it is much moreso regarding medicine. Not even a physician can make a valid assessment of another physician's medical decision without knowing in detail the thought process behind that decision, especially if there is any variance from accepted standards. Even physicias like to believe that things are much simpler than they are, in reality. I'll go no further, because I cannot do justice to a subject here, that requires a book-length format to even have the possibility of being adequate - and it would be a boring book, difficult to get through.
2
@Alan The reality is that it is only patients who experience medical care consequences, patients are therefore *always* in a position to assess the care/medical practices of physicians. Research in this area clearly demonstrates that doctors routinely make mistakes in terms of decision-making, and these mistakes are often the outcome of faulty reasoning. Therefore your contention that "No one who is not a physician should comment on medical practices..." is simply nonsensical. The correct ethical stance is that there must be continuous oversight of doctors in order to prevent those who routinely harm or kill patients (accidentally or on purpose) from practicing. A medical license is not a license to harm or kill.
Today lay people are becoming far more informed and educated about medical care. Also, doctors are no longer assumed to be perfect god-like practitioners who always make the most appropriate decisions and always know more than the patient. Patients bodies are sources of knowledge that often enable them to determine when doctors make incorrect diagnoses. In fact, today's patient is far more likely to question diagnoses, and seek information and obtain another opinion. For example, my friend was diagnosed with having an ulcer, but he knew that wasn't a correct diagnosis as his symptoms were completely different from those of an ulcer. So he sought a second opinion, and was correctly diagnosed with having a Schatzki ring--clearly seen in a swallow study.
7
Dr. Carroll,
Have you ever been in private practice when you have had to deal with
1. patient satisfaction.
2. Insurance guidelines.
Sitting in the haloed academic world when you don't have to fight on the ground war it is easy to be practicing guidelines.
4
@Michael
It's not "Academic" to recognize a systemic problem. It's an essential step in solving it.
Your point about the institutional barriers to even learning about change is a good one. A massive problem right now is that in many large clinics, doctors can lose income by taking time off from seeing patients on the assembly line. It takes time to learn and implement something new.
The author should have made the strength of those barriers clearer, because he did come off as a bit smug in his knowledge, but his message is still worth having
2
In my practice (overseeing dozens of physicians-in-training), I don't think it's the "unlearning" process that's difficult per se. It's the "not doing anything" part that gives doctors trouble. Going in with a 'I-need-to-do-SOMETHING-to-help' mentality combined with a 'lawsuit more likely if you DON'T do SOMETHING' reality, can we blame physicians for trying to do more rather than less? The sad truth is, sometimes the doctor is treating his/her own anxieties by over-utilizing care on a patient.
5
@Scoot You make a valid point given the research that exists on the doctor-patient relationship. However, the Hippocratic oath that all physicians take requires that they be concerned first and foremost with "the best of my ability and judgment..." meaning they must practice based on ability to care rather than on pleasing patients.
I know that it is almost impossible for any physician to uphold that oath given that most doctors now practice under the regulations imposed by corporate employers. This is a primary aspect of practicing medicine today that has contributed to reducing physician autonomy and thereby prevents most physicians from being able to simply choose to employ what they know to be best practices.
In fact, given the current situation in terms of physician employment, having new physicians take the Hippocratic oath seems quite pointless.
1
@Scoot, hit the nail on the head. As a radiologist I find myself at the bottom of the hill where everything rolls. There are days on call where it seems 50% of imaging falls into the "have to do something" category. This is "THE PROBLEM" from where I sit. Not likely to improve when each year the new docs seem to want more and more tests. Scares me to death when we talk of bundled payments. Seems clear to me that volumes of tests will not change, only reimbursement. Good luck finding anyone good to read those exams for nothing. That's alright, all the new docs are arm chair radiologists anyway.
It's easy to understand the reasons why conditions are as they are described in this article. It's easy to understand why medical and dental care is so expensive, when it does not have to be. It's easy to understand those, when you understand, it's ALL ABOUT, the dollar.
I think the concerns about medical malpractice lawsuits have an affect on this practice as well as what insurance companies will cover. "Accepted standard of care" is one of the statements used in lawsuits.
2
My neice was a gifted student, and was accepted into medical school. She dropped out after about a month. Asked why, she said the students were so selfish they wouldn't even form study groups, because that might help the other, see? I asked a doctor I knew at church, and he confirmed that it was true at his school, and thought it to be true all over. Combining this with my own experiences, I believe that doctors truly have no concern for patient welfare, only for what adds to their bank account. Compounding this is that the AMA has discovered that if they don't cure you, they have an income stream for life.
1
@Knox
Perhaps your niece should consider medical school in another country. Every other developed nation has some type of universal healthcare for its people; overall costs are significantly lower versus the US (on a per capita and percent GDP basis) and outcomes, like overall life expectancy, are increasingly superior. I have little doubt that where the shared goal is to deliver quality healthcare (no doubt at salaries sufficient to attract bright people to the field) versus maximizing income (primarily for those at the top of the feeding chain), one will find more cooperation at all levels - including medical schools.
@Knox What you described is true. I saw that in dental school, which for the first two years of academics, was combined with the medical students. But types were in it all for themselves. There was no real camaraderie. It was a long four years of distrust, unethical behaviors and back-stabbing. The professors in dental school would even say you can make more money with your mouth than you can with your hands. So learning what you were supposed to learn, and become skilled at it, did not matter. It still does not matter after being licensed to practice. The back-stabbing and unethical behaviors are still present. It's ALL about the dollar.
@Knox
The reason this atmosphere is present in medical school is that it is pyramidal system and not everybody succeeds.
You are right doctor's are greedy and we don't really need them when dr. google is there. Right!
We aren't overusing induction of labor. In fact, we are almost certainly under-using it. Every year in the USA, there are roughly 2,000 fetal deaths after 39 weeks of pregnancy, and a blanket policy of encouraging 39-week inductions could probably save almost all of them. As recent research demonstrates, this can also reduce c-sections, reduce maternal complications and also reduce NICU admissions in term babies.
2
Read the book ending medical reversal. Also, why did the death rate in Israel go down when doctors went on strike? Maybe modern medicine does too much harm.
@kirk Death rates go down when doctors go on strike because they don't go on strike all the way. Urgent problems are still treated, while risky but necessary surgeries are postponed.
2
I agree that medicine needs to look at some “common” practices that have no medical benefit. Many are in the OB world. There are studies noting there’s no need to do cervical checks the last few weeks of pregnancy. Knowing if you’re 1 or 2 cm dilated tells you nothing if a woman is about to have a child, yet it’s still common practice (of course, as a a patient you can always reject this). Same goes for no eating or drinking during labor, with some docs giving the excuse of “what if you need an emergency c-section?” To justify this, yet drinking water during labor has proved beneficial as the uterus is a large muscle and hydration is helpful during one of the largest natural traumas a body goes through.
I’m not anti-doctor, I have lots of MDs in my family, yet I think there needs to be a level of authentic, personal care that seems to have gone out the window, especially with insurance companies and technology affecting this industry.
3
Regarding the persistent "myth" that tight glucose control improves outcome in ICU patients, please also consider:
1) Having 25% of your patients die despite your best efforts is nothing short of demoralizing. Any therapy that promises to improve this rate is welcome, especially if we think that with special attention we can limit the occurrence of hypoglycemia.
2) As shown by Kahneman and Tversky, stories that make good sense are more convincing and stick around longer even when disproven. Given the negative effects of high blood sugar in every other situation, it made "good sense" that tight glycemic control would be beneficial in this patient population, too.
3) Doctors are rather human.
4
I've lived my entire life with physicians—my midwestern general-surgeon father and subspecialist academician OB-gyn husband, plus my academician subspecialist OB daughter in a different part of the US. I expect anyone else in my observation post would have seen what I did: radical change in 3 generations of medical knowledge and practice.
My dad learned surgery from an older surgeon, scoffed at the academic articles in JAMA, still made house calls in the '50s, was treated like God, and probably felt secretly that’s who he was. I don’t think he spent much time with drug reps. He probably did harm an occasional patient, but God sometimes errs, and my dad's deep religious faith undoubtedly pushed him to find better ways to help his patients. My mom ran the household as he wished.
My husband kept up to date through constant study and re-evaluation of what he taught and did. He banned drug reps from his office and relied on medical literature for advice. He rejected the God identity, but expected to be treated with respect and deference by colleagues and patients alike. He knew when he was right—and when he didn’t know, he was comfortable acknowledging that. He had me to run our home.
My daughter, unlike her male precedents, is a fully engaged parent—as well as teacher, writer, researcher, and social activist! Her fully employed husband is also, of necessity, her "wife"; I leave the details of their hectic life to your imagination.
Best practices? Best way to learn? Change?
10
Some doctors may not agree with the conclusions of the study. If you are a diabetic in the ICU, you are likely sick with multiple co-morbid conditions that can kill you. A patient in the ICU, should be monitored continuously and should not die from a hypoglycemic event. There are continuous glucose monitors that can also be use to monitor an ICU patient. Just because there were more deaths in the tightly controlled group does not prove it had anything to do with tight glucose control. Therefore, doctors can use their own judgment on which ICU patients to tightly control or not rather than be told by a researcher who never saw the patient that every patient should be treated the same.
5
Reading these comments gives me greater insight into the physician burn out our country is experiencing.
I see semi informed patients all day who are often anxious, scared and frustrated by their pain and prospects of mortality. Commenters here seem to lack insight and understanding on many components of medical training and patient care. Most don’t even know how to be a responsible patient (informed, focused, direct and polite if you will) much less synthesize a nuanced and complex issue such as glycemic control in the ICU which is poorly represented in this article and misappropriated to serve the author’s overly simplistic exploration of a nuanced and fascinating reality of human learning and behavior. But don’t worry, I will care for you, suffer with you, learn for you, and treat you to the best of my humanly fallible abilities. I won’t tolerate bullies in my practice but as you cast aspersions on one of the noblest of professions (sorry an IT engineer doesn’t cut the mustard) I would ask you what is the alternative?
See, You don’t have a monopoly on sanctimony
13
@JC
Very well said. A compassionate but firm pushback to the anti-doctor current that is rising in this country.
2
@JC The thing is, you are defending your position, but seem to be denying the fact that insurance companies dictate what is or is not to be done for(to) patients. And the quality of medical students has gone down. It's all about the dollar to them, and the perceived respect and prestige of being called "doctor". Many of them never really learned, they were just good test-takers. So insurance companies own the medical "profession", along with pharmaceutical companies, that tell the doctors what the pill du jour will be.
@JC
Do you actually recognize that this article was not written by a lowly IT engineer but a fellow doctor and professor? Way to show off your snobbery and completely prove the author's point about stubbornly refusing to change your mind/practices despite considered criticism and better science because "you know better than all those non-doctors". I can see you responding exactly the same way if the author had mentioned the over-prescription of antibiotics: Knee-jerk defiance, taking it as a personal slight when it's more of a commentary on a systemic issue.
Nobody's calling you a bad doctor specifically, my friend, but that doesn't mean other doctors are like you. Relax and learn to take some constructive criticism of your wider profession or else, yeah, you sound like a dinosaur.
It really doesn't help any doctor's case when you respond like this, as if you're so above everyone else and are just constantly the victim of overzealous, uninformed patients, journalists, fellow doctors, and apparently, for some oddly specific reason, IT engineers. Add to that, passing the blame for a complex, multi-faceted problem onto patients themselves as if you're all just blind robots forced into doing the ignorant bidding of the masses, whilst ignoring the larger forces at play in the system. Nobody is bullying you. You have all the power.
The alternative is simple: Look at the science. Apply it. Don't just stomp your feet in petulance.
If the profession is so noble, act like it.
4
While I agree with the basic premise of this article, this article is entirely too superficial in its analysis of the issue. The eye catching title is incendiary and misleading
5
@Grave lee Unless you have actually been in the game, you can not know. The article just scratches the surface of what the problem is, that we all pay for- over treatments, unnecessary treatments, all in the pursuit of the dollar.
1
Years ago in school we were discussing an eye condition. All the students when asked how they would treat it opted for a new to the market “wonder drug .” The professor stopped and said;
“The new drug is fine, but we’ve been treating this condition successfully for years! “ Then he said, “ Just because something new and wonderful has come along it doesn’t mean that the old stuff has suddenly stopped working!!”
I think in some instances here, the reluctance to change may be due to the fact that “ the old stuff and the old way” has been working for that doctor for years and he/she is very comfortable and confident with it.
Again? This may explain some, but certainly not all of the reluctance to change. Especially when there is no overwhelming evidence that the new recommendations are substantially more effective or the old methods are actually ineffective!
4
This isn’t “unlearning” as much as it is being comfortable doing less. Most physicians I know, myself included, want to do something to make the patient better. Most of the cases in this article site examples where there really isn’t anything to do other than sit on your hands. This is very difficult. Working hard to achieve tight glycemic control makes you feel like you are helping that sick kid in the ICU. That is why it is readily adopted. Doing nothing, even though it may be the better option, is not satisfying. It took me a long time to stop giving steroids to spinal cord injuries. When I trained this was standard treatment. I subsequently was quite aware of the literature demonstrating this was not of any benefit, but it was extremely difficult to treat a patient with a devastating spinal cord injury and not do anything. This wasn’t because I wasn’t aware of the literature, it wasn’t because of any protocol, and it wasn’t for fear of litigation, but it was born from the same desire that sent me to medical school. I wanted to help the patient in anyway possible.
11
And what do we do when patients demand MRI for every ankle sprain,every sore and aching shoulder?
At least 20% of my patients come in with an unnecessary expensive imaging modality
At what point will patients bear some of the responsibility for the over testing that is done?
7
@beth dollinger it is a physician's duty to explain to these patients why these procedures or tests aren't appropriate. Granted, that's harder than just ordering a useless test - but that IS what good medicine requires. Your patients don't have your years of education and expertise - of course they ask for things that aren't right!
You can look at what they have and know that it is a simple sore shoulder from overuse, because you have seen lots of sore shoulders, and you know about them. Your patient just has two shoulders, and one of them hurts more than he or she ever thought was possible. They are scared, upset, and certain that something terrible is wrong. Of course they ask for fancy tests and imaging, and maybe inappropriate medicine or treatments.
4
@Janice
When I explain things to my patients, and they still complain to the hospital patient representative, I end up with:
1) A patient complaint that mandates I respond. Cumulative patient complaints, regardless of their merit, threaten my group's standing with the hospital and thus our jobs.
2) An automatic peer view complaint. I am again required to respond to these and getting too many flags, even non-sense flags, threatens my position within my group.
Keep in mind, I am in a good, supportive group and we have good terms with our hospital system(s). There are many others in my specialty who are at risk of getting fired without due process and without notice for this stuff.
I'm not talking about patients asking for tests and then understanding when I say they're not appropriate tests. I'm talking about patients and their families trying to live stream me to facebook (has happened multiple times) while yelling at me (happens almost daily) and threatening to call ambulances to take them to other hospitals(they're welcome to do this, and I won't get in their way).
1
@Janice
You can explain logic and medical science all you want but in this age of anti-intellectualism, patients will simply turn to complaining online or even to the doctor's employers (which they are encouraged to do by the way, with a multitude of surveys). Who do you think those paper pushers will favor?
And some of the outdated recommendations are still monitored by the electronic medical record to see if I'm a 'good doctor' and avoid lowering Medicare reimbursements. People over 60 can reasonably have a higher blood pressure, but I will be penalized if the vital signs show that. Today I removed 'diabetes' as a diagnosis, because the patient sees an endocrinologist. With the diagnosis, I will be penalized if I don't check her A1c, but she didn't need it done again. Why subject her to a blood draw and generate extra expense for no good reason other than to satisfy the computer?
10
What is needed is a discussion of the practice of "defensive medicine" - physicians and others doing procedures to reduce the perceived risk of being sued for failing to provide care that the patient, (or patient's family) thinks they need.
10
@Ronald Coleman
My impression is physicians are more concerned with getting some objective information to aid their decisions than avoiding lawsuits (although that is also a component). Experience shows that judgment and intuition is no match for objective findings, so avoiding ordering tests and going with your thoughts can be disastrous.
2
@Ronald Coleman
It's not a perceived risk. The literature actually shows that patients are less likely to sue doctors that order more tests.
2
I remember when it was advised to offer liquids to pre surgical patients, depending upon when they were headed to surgery. Regardless, I had to argue to give water to patients who weren't scheduled until the afternoon. The NPO after midnight may apply to an early morning surgery, but not later. I wouldn't be surprised if the stubbornness of not following better advise is still prevalent, and I've been out of nursing for over 11 years.
Would love to hear back on that.
12
I will agree that as a profession we often over prescribe, over order tests, and occasionally over treat. The vast majority of us do this not because we don't care or because we have some God complex but because we are often pressured into it by an out of control legal system, patient expectation/satisfaction ("he didn't even order an X-ray"), health care system demands ("doctor you didn't send this patient to physical therapy first") or other myriad factors.
Her are some ideas: Stop advertising medications and treatments direct to consumers, stop giving us ridiculous Press-Gainey scores and stars on Google, provide government funded studies instead of funding by pharma, big food, or other self-interested corporation. Look at the fact that hospital administrators outnumber physicians, that we spend more time documenting in electronic medical records than seeing patients, that we have to worry about bad reviews and being sued every day, that pharmaceutical companies are making record profits and so are insurers. I get it, physicians are an easy target. And yes, there are some bad actors out there, but the vast majority of us just want to take good care of our patients within the best our ability based on the knowledge and experience we have accumulated over the years. We are open to change when provided with good unbiased studies that show clear benefit to our patients in changing our practice. Those are few and far between.
41
@TW TW,well stated,good post.You nailed it!
1
@TW I largely agree with what you say, I am not a physician but have worked with them. However, I do feel there is a role for patient reviews of physicians, but they have to be viewed correctly. I looked up a friend of mine who had become a hand surgeon. The patient reviews of him said he was arrogant and condescending which was the behavior I had seen years ago, he was really a nice guy in many ways, but he came across that way to patients and people he worked with, the reviews were spot on. I went to see a podiatrist who was a jerk, he sold me a pair of orthotics for 500 dollars (which I found out he buys from a lab for 90 dollars), I had agreed to the price and made him state there were no extra charges for fitting etc. He just gave me the orthotics with no fitting, and tried to charged me additional for the plaster of paris, fitting, etc. I had to call and complain several times and his assistant said "he waived the fee". I gave him a very negative review and I think he he deserved it and people deserved to know my experience. So I think patient reviews can be valuable, but they can also be used wrongly. I taught in a university and feel the same way about teacher reviews, although most professors think they are worthless, sometimes they are unfair, but students taking a class are entitled to have some idea of others experiences with a professor as are patients with their doctors.
1
@TW Bingo! I’d give this 5 stars if I could.
2
As the poster Joe implied, one reason doctors do not change their practices is that the latest findings will be overturned by even newer findings later on. If this piece was written after the first tight glycemic control study, the doctors who did not change would have been wrong. Wait a while, and the doctors who did not change were right.
Current example: recommendations to test how well someone’s liver enzymes metabolise drugs. There were recommendations that everyone be tested. But, except in limited circumstances, it never seems to help.
5
A large problem today is that doctors pay far more attention to professional marketing by pharmaceutical companies than they should. Going to my endocrinologist office, his wall are plastered with advertising from the companies pushing insulin pumps and other pharmacological solutions to diabetic treatment.
Once when he saw my blood workup, he became suspect that I may be taking drugs from another doctor since my blood fats profile was too good, and my A1C levels are below 7. My blood pressure is normal for may age. He was already warning me at one point that blood pressure medicine may be in my future, even with these results. I have been achieving this with diet and exercise alone.
I chastised him by saying instead of marketing posters from the drug companies, he should be putting up pictures of fruits and vegetables instead. That is what he should be pushing on his patients.
But you have to understand, there is no money in wellness.
16
@Michael Panico
You are correct. I recall a number of intravenous cardiac drugs, in their time, being used on numerous heart failure patients, with all the research/literature in professional magazines promising a new era in cardiac care.
Only the new era showed, after several years of use, major, even deadly, side effects. But, my hospital scrapped those drugs immediately. I remember one nurse manager who smirked at me for not having read the "latest findings" in XYZ magazine, only I didn't embarrass her when the latest findings overturned the previous ones.
My beef with drug companies isn't in trying new remedies, however expensive they are to develop, but in the billions spent on ads, wooing doctors, etc. That is more than frivolous; it's dangerous.
6
@Michael Panico I liked everything you said except the last line. I talk to all my patients about healthy diet and how we could reduce or eliminate meds with lifestyle change. Most of the time their eyes glaze over and I feel like I’m delivering a lecture. The data is in. We know that diet, exercise, wearing seat belts, not smoking and being in nature are the best medicine. It takes a lot longer to talk about wellness and I guess you are right. There is no reimbursement (or gratitude) for that.
1
@Chieftb
As well asmaking the assumption that lecturing your patients is going to help them, you are assuming that your patients are *capable* of making those changes. Behavioral change is very difficult and we have little knowledge about even the basics of weight maintenance.
When the research scientists reverse themselves 180 degrees we have good reason to believe that they do not know what they are talking about.
9
@Mike Murray MD
From the The Care of the Patient - Francis W. Peabody, MD, JAMA, 1927 -Medical education, however, is less likely to suffer from such stagnation, for whenever the lay public stops criticizing the type of modern doctor, the medical profession itself may be counted on to stir up the stagnant pool and cleanse it of its sedimentary deposit.
Then there is the Clinical Research to Clinical Practice – Lost in Translation." NEJM ...The concern is essentially that doctors erroneously rely on what they have previously been taught and don’t change treatment philosophies as new information becomes available... there is great concern that doctors continue to rely on what they learned 20 years before and are uninformed about scientific findings...how excruciatingly slow the medical establishment is to adopt novel concepts. Even simple methods to improve medical quality are often met with fierce resistance.
what we are supposed to do...
The Principals of Medical Ethics adopted by the American Medical Association: “A physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients, colleagues, and the public." This has unfortunately been replaced with an apathetical goal to merely provide so-called adequate care.
Hasn’t this always been the case in each of our acknowledged professions. It’s why textbooks are so frequently changed and updated. If the best medicine is “new medicine” why are senior physicians so revered ? Any why do so many surgeons continue to practice well beyond their “best years”. Yale Med School reportedly has a “no tenure policy” just to avoid the limitations of “old medical knowledge”.
This example has nothing to do with old knowledge or old doctors. Joint Commission, Medicare, Leapfrog, and therefore administrators pushed the tight glycemic protocols on dubious physicians. Many of us questioned the data but now that hospitals and insurance companies are the ones practicing medicine, we as physicians have little input. Some may not keep up as much as we would like, and there are some bad doctors, but the glycemic control issue was not our fault.
6
Unlike some of the other commenters, I don't reflexively blame the doctors, although of course they do sign the prescriptions and order the procedures.
Instead, I go right to following the money. For example, what prescriptions were used to control blood sugar levels and how much was spent on them? How much advertising in the medical journals, how many drug rep visits and "free" samples? Etc.
What I'd like to see is a similar study for the biggest blockbuster drugs. Around 25 million Americans are on statins at a cost of $15-20 billion. And that's only the financial cost.
The cost in adverse effects (which the US has no effective means in place to track) may be vast. Doctors are not required to report the adverse effects of drugs, but even in my home town I personally know one death and five devastating nerve-muscle diseases.
Statins seem to be of benefit for secondary prevention (have had cardiovascular event), but for primary prevention the data is weak. But who tracks how many take for primary/secondary?
Studies haven't even been done for people over 75, and yet incredibly, about half of them are on statins now!
Doctors mostly follow the ACC/AHA guidelines of 2013, but how many know that their heart risk evaluator is both the most aggressive (largest number on statins) and also the least predictive?
Pharmaceutical and medical device industry run the show, and it's both costly and bad care. 1/4 of Americans over 45 on one class of drugs!
StatinVictims.com
13
One of the largest problems with our litigious medical care system is that medical mistakes are repeated over and over again, due to the fact that the hospital 'industry' does not want to be sued for acknowledging errors. So 1,000's die unnecessarily because of keeping messed up procedures and care behind the 'white curtain'. There is much silence in this area. Often what is written on death forms and the actual reasons of death are different and due to negligence, ignorance and/or arrogance
1
My take on this article is apparent visibility of consequential limitations of Western based medical practice.
Unless there is sea change in the outlook and take of holistic view of medical science, I don't see any solution to the problem under discussion .
"The implications of mechanical thinking go far beyond human health. An understanding of life that recognizes the interconnection of parts and whole would transform science, society, policy, and the environment" Jeremy Lent, in The Patterning Instinct: A Cultural History of Humanity’s Search for Meaning.
Western medical system ought to credit natural products and traditional medicines which are of great importance. Such forms of medicine as traditional Chinese medicine, Ayurveda, Kampo, traditional Korean medicine, and Unani have been practiced in some areas of the world and have blossomed into orderly-regulated systems of medicine.
"Only a tiny fraction of the existing plant species have been scientifically researched for bioactivities when the first pharmacologically-active compound morphine was isolated from opium, natural products and traditional medicines have already made fruitful contributions for modern medicine. When used to develop new drugs, natural products and traditional medicines have their incomparable advantages, such as abundant clinical experiences, their unique diversity of chemical structures and biological activities". Review: The Traditional Medicine and Modern Medicine from Natural Products
2
Keep your doctors younger. They are better informed and are not living in the past and are still flexible with new knowledge.
5
@DENOTE MORDANT
Another prejudiced remark in the belief that older people cannot change. Not true but it continues forever. But do take into consideration the extra experience older doctors have achieved. That is more than one way to consider this.
11
@DENOTE MORDANT
That's a tricky issue.
On the one hand, there is data showing that (at least for hospitalists), there is a slightly increased patient mortality rate when the hospitalist is over age 55.
On the other hand, there is much wisdom in experience.
Seems like little changes when it comes to human behavior: Francis Peabody commented to the Harvard community in 1927: "The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine—or... more bluntly, (doctors) are too "scientific" and do not know how to take care of patients".
Then as now, test results carry more weight than the patient's story - if you can't measure it, it doesn't exist! Rather than chasing test results, "to rule in or out" a recognized disorder, how about teaching the scientific method... to proceed in an orderly manner toward the establishment of a truth. "Practice is science touched with emotion".
This is hard to do when medical schools teach students to match diagnoses to treatments, like a child's word game or in a bingo hall; when saddled with nearly 300K of debt before your first job at 30 years of age; when the hospital or medical center, by carrot or stick, coaxes "providers", not practitioners, to see 25 patients a day; when insurance companies reimburses the documentation of a procedure rather than listening to the patients' journey.
Patients' have a "bill of rights", to be better consumers in our health care shops. But for patients and practitioners, there is only room for procedures and dispensing potions, not for relationship building, nor faith, nor scientific inquiry.
Why, if doctors are “God”, Can’t they unlearn the bad habits that they may have developed? Not bad habits just practices/procedures that have become more a less obsolete (but then again are bound to go back on the overused/obsolete list at the whim of a new “study”)
This seems to be the nature of the medical profession – always seeking new and better things while maintaining a good constant income for the people that “try“ to make this happen(And to be able to maintain and update on the latest and greatest would require constant reading of articles such as this but in even more arcane publications such as JAMA and New England blah blah blah. I still like to use this the “God” thing about doctors , As a mere ribbing or joke, As when I’ve been in the hospital they usually tell you oh “, you nearly we’re gonna die” but since the doctor intervened, you lived , Therefore it was by his touch that you Lived, therefore he is God (in my life experience I’ve only had male doctors, with the exception of a female chiropractor close parentheses
Learned that 8 years ago when I had inguinal hernia surgery with an 8" incision. Six weeks of quite painful recovery. Meanwhile a friend had the same done with the DaVinci system and he was better in 2 weeks with minimal pain.
3
@RA
Doing a hernia repair with a DaVinci robot is MUCH, MUCH more technically difficult and has a much longer and steeper learning curve than a conventional open Lichtenstein type repair. It takes much longer to become proficient performing a DaVinci robot assisted hernia repair than a conventional open repair.
Complications from hernia surgery, such a nerve injury, can cause chronic pain and permanent disability. Regardless of the method used, the most important thing is that the operation is done correctly the first time.
If all surgeons were forced to use surgical robots for hernias, the complication rates would be higher.
The patient is best served when the individual surgeon uses the method that they are most proficient at, which produces the most reliable results and the fewest complications in that surgeon’s hands.
The latest and greatest isn’t always the best.
5
@RA
The DaVinci system is not without its own issues, mainly related to training. The recommended length of training had to be reduced because doctors wouldn't be able to spend the unpaid time necessary to become proficient in using the robot. Real paying patients end up helping to train doctors. It might take more than 400 procedures for a cardiologist to become proficient. Be sure to find out how many procedures identical to yours a DaVinci-assisted doctor has performed. A documentary entitled "The Bleeding Edge" exposes the dangers of the robot without a highly trained operator. Be sure to do your research. As with most of the for-profit, bottom-line medical industry in the U.S., buyer beware and be highly informed.
@RA Recent study using Medicare data revealed patients having prostatectomy with Da Vinci surgery had dramatically great rates of urinary incontinence than with open prostatectomy. Like discussed by others a better outcome might be possible with the Robot if a person is highly experienced with Robotic surgery, but it requires more training.
An equally concerning issue is the blind faith / credibility that "concensus" statements developed by medical organizations regarding treatment recommendations get afforded in the first place. Tight glycemic control is just one of many examples over my ~25 year career that has later proven to be not only NOT beneficial but harmful to patients.
John Ioannidis , and others , have written extensively on the flaws of our current academic/research/publication paradigms that simply lead to false conclusions and oftentimes are influenced by overt conflicts of interest. More focus on better research ( with less conflict of interest) on the front side of this equation would mitigate the need to retract on recommendations that are the "standard of care" today and revealed to be harmful to to patients later.
6
As a physician, I see the practice of mindless medicine on a daily basis. Doctors get away with ignoring new standards more than other professionals. Imagine a lawyer ignoring new laws, a pilot not trained for a new airplane, a technician trained 20 years ago trying to fix something.
Inertia, laziness and profit incentives result in a perfect storm of wasted resources.
13
@Daniel B
"Inertia, laziness and profit incentives result in a perfect storm of wasted resources."
To which list I will add "physicians' arrogance".
9
@Daniel B
How many of those standards are really standards and not just new government hurdles or industry funded "research?"
The Surviving Sepsis Campaign is currently trying to push a "one hour bundle" through based on no new literature. Hospital and government administrators are already punishing us for not giving broad spectrum antibiotics and large volume fluid resuscitation to every patient who might have sepsis, now they want it faster and with even less time to consider the correct diagnosis. If they push it through, CMS will roll with it, and then it becomes the law of the land.
@Daniel B Of course I am sure you well know keeping up with current standards of practice and new guidelines takes a great deal of effort and in some areas quite confusing and subject to differing opinions, because different experts and committees have different opinions, and often they are very valid opinions.
It's hard for anyone to unlearn things. Part of the problem is that medical organizations change their minds or base recommendations on poor or no evidence or even simply mostly on "expert opinion" when all else fails. Keeping up with legitimate medical literature is getting more difficult, but at least the proliferation of through away journals has declined.
1
Doctor's HAVE to be required to do continuing education, even if it takes them away from their practices, for a time. It's hard for all of us to deal with change, but most of us do, even when we're old. Continuing education, and open minds, is how we do it.
4
We are all required to do continuing medical education (CME) already.
5
Dr. Spock gives a recipe for home-made oral rehydration solution: 1 quart of water, 2 tsp. sugar, 1/2 tsp. salt or (better) "light salt" (a mixture of sodium and potassium chlorides).
He doesn't tell you how to get a sick child to drink it. We found that if you squirt a large eyedropper (about 1 tsp) of the solution into a child's mouth, about half will be swallowed. Repeat until you have used about half a cup of solution. Repeat hourly until child is rehydrated. We managed a night of severe (hourly) diarrhoea this way, and the child was fine in the morning.
5
@Jonathan Katz
Use a 1:1 mixture of apple juice and water. Has been shown in the literature to work just as well as Pedialyte. It's also cheaper and doesn't taste like spit.
Ah, doctors are not thinkers. They do what they were taught. Putting themselves in a box with blinders. They loath change. I know this from experience. I was a nurse for over 50 years, working with them.
16
@heysus. I suspect you worked with a limited number.
1
@heysus This is a broad generalization, certainly true in some cases and not in others.
@heysus
Thank you for your 50 years of service, but as a physician right around the corner from you, I try to learn from patients, nurses, social workers, etc... as my parents taught me...‘If you are not a part of the solution, you are a part of the problem".
"It is hard for doctors to unlearn things" probably should be replaced by "It is hard for doctors to lose opportunities of profiting with sick people."
The letter "The High Costs of Unnecessary Care" of Aaron E. Carroll, MD, MS1 , shows it in part. When doctors have a health business, 70 % of them use their procedures, because they make money.
It is biblical "The root of all ills is the love of money"; and doctors are in an excellent place to satisfy that love.
8
@Dr. Ricardo Garres Valdez
the bible pointed out 7 unclean spirits: Lust, Gluttony
Greed (avarice), Laziness (sloth), Wrath, Envy, Pride
in 1927, Francis Peabody called out doctors using testing and tools to care for patients, when money was not a key motivator- arrogance/pride
in 1967, Time magazine article entitled, "the plight of the US patient", patients were now being called consumers, and doctors became providers; now rather than faith, the power of healing is in the potion, pill or procedure
lets try to tackle one of these unclean spirits: As seen in every other country but the US, tackle a major driver for doctors to seek the dark side: NYU just did, with free medical education, so that there is one less temptation
https://www.nytimes.com/2018/08/16/nyregion/nyu-free-tuition-medical-sch...
This kind of article really rubs me the wrong way. The Pedialyte vs anything else ... Is that for mildly ill American kiddies who need a sip of something or is it showing non inferiority for treatment of say enteric fever.
Yeah ankle x-rays are so useless until u miss the widened mortar space , as an anesthesiologist I've seen a bunch of them.
Why don't u get out of your ivory tower for a while but if u choose to speak to us from on high please provide all your references.
And tight vs less tight control.of blood sugar in ICU settings has been a surprising set of shifts and turns. Just like beta blockers for surgery. So what.
Both are a whole lot better than before insulin was introduced into medical care.
You aren't helping us.
11
@Mrf "So what." In the later study with better controls and participants in ICU for a broader range of ills, the mortality rate difference of 27.5 vs. 24.9 means lives saved. If 3000 were in the tight glucose control group, then 825 patients died rather than 747. That's 78 lives lost. And you say "so what".
Then there's patients who experienced hypoglycemia -- over 13 times as many in the tight glucose control group. And you say "so what".
Then there are what are likely additional costs associated with providing the tight glucose control. And you say "so what".
I'm not sure I'd want to have an anesthesiologist who says "so what". What did you say your name is?
10
Choosing Wisely app is not available in U.S.
2
Medical journals are conflicted about reporting serious and negative side-effects related to certain meds. As a result many physicians are in the dark as we prescribe. We may be misled to the point that we are not even made aware of deadly side-effects. (And sorry, the pharm reps are there for financial reasons, not to protect pts or physicians)
One deadly secret, which has been made public by a series of lawsuits, is Akathisia. The evidence surrounding a cover-up of this antidepressant side-effect should startle most providers. Medication-induced suicide is real and on the rise for all ages, not just children.
And it appears that physicians are thrown under the bus in these cases by the pharmacuetical defendants. Yet, another reason doctors should readily unlearn routine prescribing where new evidence is contradictory.
7
Let’s not solely blame the doctors. Regulators at the Centers for Medicare and Medicaid (CMS) and state health departments drive overutilization also.
For example, there is unanimous consensus in the Ophthalmology and medical communities derived from multiple studies demonstrating that pre-operative testing for minor surgeries such as cataract surgery, ophthalmic laser procedures, etc. does not improve quality of care. A recent estimate placed the cost of this testing at $ 500 million/year.
As a practicing ophthalmologist, my hands are tied.
12
The preoperative medical evaluation for cataract surgery is a terrible waste of resources driven not my cms but by hospital committees that ignore the guidelines in favor of defensive over testing. The risk of complications is about the same as a root canal and less than a colonoscopy but this antiquated practice continues. Very frustrating for all involved
3
Fully agree that we overuse many treatments that have questionable benefit. Good luck using that as a defense against a lawuit brought on my bloodsucking malpractice attorneys... funny they mention nothing about that in this article. The amount of money spent on 'defensive medicine' is the biggest problem. Where is your research on that NYT?
11
@d, They LOVE their CT scanners in ER and use them too liberally. Do not allow them to do this to your child over and over. Demand ultrasounds. Only use CT machines for severe crisis, not sore throats.
1
@james - of course, no one should be doing CTs for sore throats, or even ultrasounds. Actually, your child shouldn't even be in the ER for a sore throat. While you demand that physicians stop over testing, why don't you stop over using?!
@james
If there is concern for retropharyngeal abscess, the correct test in 2018 is a dose reduced CT scan. Xray is no longer the test of choice and ultrasound is not helpful. I have very rarely needed/ordered a soft tissue neck CT on a child.
Useless investigation are part of “Defensive Medicine.” You don’t want to deal with lawyers - order an ankle X-ray, you know it will be negative.
Better safe, than sued
5
@Hassan
The best defense to a potential malpractice claim is meeting the standard of care when treating a patient. "Standard of care" is a minimum standard, like a C or C-grade, not an A. If a health care provider falls below the "SOC', then in essence she/he came really close to flunking. I suggest that to maximize the odds of not being named in a lawsuit, instead of first ordering an ankle x-ray, the health care provider, whether doctor, nurse practitioner, or physician's assistant, obtain a proper history, perform a proper physical examination [yes, that means touching the patient AFTER listening] and THEN decide if you need an x-ray to confirm your differential diagnoses. That's the proper way to practice medicine. Unfortunately, instead of actually critically thinking, too many health care providers these days order unnecessary tests when all she/he had to do was follow the basics. Don't blame the attorneys when the finger should be first pointed back at the health care provider.
3
Hi Hassan, that’s you being wrong. The best way to avoid legal troubles is not to upset the patient. Standard of care and even outcomes have less to do with it. If the patient/relatives don’t get upset, who is even going to examine the quality of care?
1
A major driver of excessive cost is your government agency CMS (Centers for Medicaid and Medicare Services). Their sepsis campaign with publicly reported data drives hospital care and cost astronomically. Of course, they don't track or report the costs or outcomes of their measures. They wasted millions of dollars in this country on their pneumonia campaign and now they are doing an even bigger waste on sepsis. Now, if you come to a hospital for strep throat and have a fever you will likely get useless blood cultures, lactates and maybe even liver function tests. You will divert care from sicker patients because these useless test need to be completed quickly. You will likely also get excessive and expensive IV antibiotics. This is considered a "quality metric". Doctors who do not go along can lose their jobs. No one is looking out for the patient who goes bankrupt due to a sore throat.
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@Julie
there are also corporate emergency medicine groups that fire doctors who miss any "potential" cases of sepsis (i.e. the 20 year old with fever, mild tachycardia, and sore throat who should have been discharged very quickly)
1
There is a huge bias not just in physicians but in the public towards action. Just looking at the examples in the article, people want a special re-hydration recommendation, ask me to medicate their child, beg to be induced early, insist on x-rays. If I don't the next person who does is right and I messed up. He said I didn't need an x-ray but the ER did one.
Much of what I prescribe gives people something to do while it gets better on its own.
22
@Bob So true. Paternalism had many obvious problems and I'm glad we've moved away from it. Still, a more collaborative model leads to different opportunities for increased testing - how many times have I recommended holding off on the x-ray/labs/etc but the patient gets them done "just wants to make sure". I don't blame them but it's certainly something to consider in the calculus of increased cost.
4
The issue of glycemic control in the ICU that the author spends so much time on ma y have had some statistical differences in the results but the differences in clinical outcomes were very small.
Many imaging studies and lab tests are done because of the fear of malpractice suits.
But a much better example of a procedure that was shown to have no benefit was the scoping of a painful knee to remove debris. A study at the VA showed no long term benefits yet it is still done.
A single payer system with science based guidelines for physician reimbursement for procedures is the only certain way to decrease the overuse of procedures and imaging.
14
@Edward Blau the problem with single payer system is you are essentially stealing money from healthy people (taxes) to pay for care for sick people. You also have to consider the money pot is not limitless and sooner or later the single payer will have to ration services. A more rational,ethical solution is a return to the insurance plans of 50-60 years ago. Catastrophic coverage and pay as you go for office visits, routine care. This puts the patient in a position of taking responsibility for their own healthy or unhealthy lifestyle choices.
It's also important to note that unnecessary tests often do identify something unusual, which then requires additional testing, only to finally realize (after ruling absolutely everything out) that it was always nothing. Tests can be invasive and are not risk free, while the fear of an illness is emotionally devastating. If there aren't clinical signs of disease, then just leave it alone, please.
10
As a recently retired radiologist, this is true in spades. The volume of unnecessary imaging is truly staggering, especially from Emergency Departments but also from primary care physicians and specialists. This often involves ionizing radiation, therefore increasing the risk of radiation induced malignancy. I have less issue with ultrasound and MRI where the issue is merely financial.
Guidelines exist but are rarely utilized, in my experience.
17
Overutilization of health care resources has been a major problem in the US for over 40 years. The work of Jack Wennberg, MD (and ongoing through the Dartmouth Atlas - at dartmouthatlas.org) shows in study after study the degree to which variation in health care resources occurs.
A study from the 1970's showed kids in an area of Vermont had a 75% chance of having their tonsils removed while in other areas only a 20% chance.
Payment reform might be the answer but the devil is in the details.
6
How much of this happens because Nurses are ordering exams and stuff from rote rather than the order coming from a Physician after a history and exam? We all know it goes on and has for some time.
In lots of clinics and ERs, Nurses are given attitude that they legally do not have, such as ordering X-rays before a Physician has seen the patient. You are not going to get a Nurse to follow the Ottawa Rules deciding when a foot or ankle or both or neither should get an X-ray despite the fact that it is highly effective in reducing unnecessary x-rays. In more than a few places the Nurses are dropping orders for CT scans- which are very expensive and expose patients to a significant amount of ionizing radiation.
4
@David Gregory
Consider that ER protocol orders, signed by a physician, do give nurses the autonomy to order these studies. Also consider how slowly physicians address a waiting room of 50-100 people that triage is responsible for. Also consider that ER medicine in the "quick care" category (i.e. your ankle) is less based on nuance and more based on trying to reduce future liability and appease a demanding public. Never seen a nurse order a CT scan without a conversation with a provider, but obviously this varies on culture (see tonsil study).
6
@David Gregory, are you referring to nurse practitioners? They can order tests, review results and diagnose.
I don't know how this information can be more widely disseminated, because 1) it's the truth, and 2) there's a certain ignorance (as the article highlights) among physicians, particularly those who've already completed formal training (but not exclusive to that group), that the bulk of their "new" learning stops with their first "real" paycheck. I suppose a more legitimate application of continuing medical education (CME) requirements could go a long way, but status quos exist for a reason. Sometimes those reasons are bad.
7
If insurance companies didn't pay for these ineffective procedures, then more than likely they wouldn't be performed.
3
Bad idea. I don't want insurance companies inserting themselves when more than they already do in the process of deciding what treatment is ok and what is not. They operate in auto-reject mode already.
12
And as my former primary-care doctor used to say, "Insurance clerks are practicing medicine without a license when they tell me what I can and cannot do with my patients." This doctor is now in a boutique practice that doesn't accept insurance, thereby reducing the overhead (estimated at about a third of the total cost) of having insurance companies as part of the doctor-patient equation. This doctor is now available to wealthy clients.
After a 30+ year career in Emergency Medicine, I have seen this movie too many times. A study comes out on a new treatment or procedure. It purports to show a statistically significant improvement over the "old way" and becomes the standard of care. Over the next few years complications of the new way start to become reported, first as isolated incidents, then enough to note a causal relationship. The original study is then re-analyzed or included in a metaanalysis which finds it biased or not 'powerful' (statistically)enough to support its conclusions. (usually this is either because of the bias or the financial stake of the investors/researchers). Then it has to be unlearned. Over time many Docs develop a healthy skepticism about new info until it stands the real test of time. In many cases the new treatment is exponentially more expensive and offers minimal improvement. That does not mean that the old way doesn't work. It's usually not a life or death issue but occasionally it is.
32
Agreed! it is an epistemologic problem...when we are uncertain of the validity of the "knowledge" the status quo is not unreasonable
2
Our TVs are flooded with medicine commercials. The only purpose of them can be to convince the consumers to pressure their doctors to prescribe, at least consider these medications. We are creating mass hypochondria and offering "treatments" for conditions that may not even be noticed by the "patients" until the commercial convinces them they have it!
Controlling, even regulating medicine advertising to the public who are not the "deciders" on their use may curb this practice, bordering abuse.
27
New Zealand is the only other country that allows prescription drugs to be advertised, which is surprising. It seems a rational, common-sense country, but medical coverage is now both public and private. I avoid drug ads as much as possible, but when I can't, the long list of side effects that are speed read at the end make me even more determined to do everything I can to avoid taking any of these medications. I prefer to make positive lifestyle choices over pills and procedures to the extent possible.
Under our current system of market driven health care there's a very effective method for getting doctors to stop ineffective treatments. Since it is essentially impossible to receive any medical care without an insurance company being involved, if a treatment is ineffective, insurance companies should STOP PAYING FOR THEM. I guarantee doctors will stop performing them instantly.
But insurance companies do pay for them, despite a clear market disincentive to, which gives the lie to notion that the market delivers the most efficient and beneficial outcomes.
4
@Bob Jolly
I'm not sure you truly want someone who has not evaluated you to decide what treatments are appropriate. Not every illness fits into a category on a spreadsheet.
It's hard enough arguing with insurance for what should be routine things
7
actually if insurance won't pay then the patient has to, let's not reinforce a broken system!
6
What a terrible idea! Insurance companies want to reject every claim all the time. I don't want any insurance company deciding what treatment is appropriate.
3
Whenever patients are blamed for the actions of doctors whether it slow adoption of new guidelines or over prescription of drugs, I wonder why doctors go to medical school if they follow their patients every whim? Of course, blaming the patient is absurd. Patients, especially those in intensive care, have little or no say in their care. Wanting more care doesn’t mean they want more days rugs or tight control of glucose levels it simply means they want attention to their needs and profession monitoring of their concerns as well as a clean hospital and responsive nursing staff and doctors who listen.
11
@Justice Holmes
Consider changing the surveys that ask the patient many questions about their quality of care. These directly impact hospital reimbursement, thus the catering to the patient.
2
This argument is slightly misleading. The glucose goals were changed from "tight" (very low) to slightly less tight. They weren't reversed, to encourage loose blood glucose control, or hyperglycemia.
It's also worth noting that only a minority of patients ever reach "tight"glucose control, even now. Most remain at or above goal.
5
No surprise here.
I work in a small Pediatric group. We tried for a few years to have regular monthly meetings to review current care and changes in the way we take care of children. I remember presenting about a blood test that has been shown useless. After the talk, one doctor thanked me as she walked out, and said (literally), "Well, that may be the scientific evidence, but at {the last hospital I was at} they did that test all the time. They are very smart there, so I'm not going to stop ordering it." I think we stopped the monthly education meetings shortly thereafter.
At least she has moved on, and now we are a younger group that embraces being new and current.
20
Given recent data supporting better neonatal and maternal outcomes among women whose labor is induced at 39 weeks, it's misleading to associate labor induction with childhood developmental problems. Ironically it seems that in an article about unlearning things that we've learned, you're touting already outdated beliefs about spontaneous labor.
22
Thank you! Someone send this author the ARRIVE trial results, please. He lost me right there.
And if he was referring to the March of Dimes initiatives on delaying delivery, I’d like to point out all the subsequent ways in which they were shown to be misguided.
4
@DesertMD
Thanks for this comment, was just about to point this out as well. Given sometimes misguided trend toward natural childbirth and low intervention during labor these days misleading information like this in a major newspaper is unhelpful.
4
When Medicare insists on costly and risky procedures to “confirm” various ailments when patients are hospitalized then it’s nit only expensive it’s potentially harmful. These are radiation intensive and those studies requiring contrast intravenous dye can put kidney function at risk. The “proof” that these tests may provide is intended to limit hospital stay reimbursement but the cost burden is again shifted to the patient.
After 30 plus years as a hospital based RN I have lost hope that we can achieve effective efficient affordable and compassionate high quality healthcare.
Even those not on Medicare are affected by this as the commercial insurance industry usually follow suit when Medicare makes these changes for the elderly and disabled among us. Sad
10
Homans' sign is a classic case of this phenomenon. Dr. Homans 'found' & published a simple physical exam test to find out whether someone has a blood clot in the veins of their calf in 1941. Within a year he did more research & found it was 50% accurate. In other words absolutely useless. He quickly published a retraction article.
To this day people still talk about 'Homans' sign'....
18
@jeff wade md One of my pet peeves! I just did a textbook chapter review and it had Homan's sign in it. I told the authors that it was pretty much useless and to take it out.
2
Greed is the root cause of over prescriptions, over use, over diagnostic suggestions, over referrals and unnecessary surgical procedures. It’s rather unfortunate that certain hospitals and doctors simply don’t care for the health of patients. This defeats the very definition of a doctor and the oath taken by them.They are not doctors but criminals, who exploit the health of patients badly.
Medicine over use and unnecessary surgical procedures not only creates huge hole in the pockets of the patients but also makes them weaker and weaker and forces them to go round the hospitals repeatedly thereby squeezing their blood.
It’s too bad that a few hospitals and doctors have damaged the reputation of divine profession on whom the patients have immense faith.
4
The overuse certainly is costly to our healthcare system. But what isn't mentioned is that it's incredibly profitable for the doctors, hospitals, surgical centers, device manufacturers and pharmaceutical companies. So why would they "unlearn" them?!
Take procedures alone - Many are and have been overused for decades. Some, such as hysterectomy, with or without ovary/gonad removal (c*str*tion), has been proven over and over again to be incredibly damaging yet ~90% of them are unnecessary and have been for many decades. It's at least a $17B industry... much too profitable to "unlearn." GME requirements used to be 70 but were just increased to 85.
The uterus, ovaries and tubes work together as a unit and are essential a woman's whole life for anatomical (bladder, bowel, v*gin*) and skeletal (spine, hips, rib cage) integrity, sexual function and endocrine function. The ovaries of an intact woman produce hormones her whole life which protect her from early mortality and many chronic health problems (heart disease, stroke, dementia, memory and cognitive impairment, parkinsonism, osteoporosis, ocular deterioration, skin aging, lung cancer, mood disorders, sexual dysfunction).
6
Amen to this... I am a pediatric dentist that has spent the past 2 years trying to teach dentists about less invasive options for treating cavities, and some of the opposition has been remarkable, reminiscent of politics or religion. (look at the 2016 NYT article by Catherine Saint Louis, A Cavity Fighting Liquid Lets Kids Avoid Dentists Drills, about silver diamine fluoride)
"Willful ignorance" is my new favorite term, as described by Dr. Nicola Innes in her article, Don’t Know, Can’t Do, Won’t Change: Barriers to Moving Knowledge to Action in Managing the Carious Lesion; “The “don’t know” could be due to general ignorance (perhaps remedied with an appropriate educational intervention) or the more problematic willful ignorance, where the subject chooses not to learn more about a topic (perhaps because it challenges his or her current beliefs).”
Trying to tell some dentists that they don't have to drill every cavity is like trying to tell a kid there's no Santa.
17
Dr Ignacio Ponseti at the University of Iowa developed a non-surgical treatment for congenital clubfeet in 1963. It was rejected by the Orthopedic community for 3-4 decades. It is now the gold standard treatment around the world. He was ridiculed for his treatment until the internet and parents forced a paradigm shift at the turn of the century. He broke the iron triangle with his treatment that is 1) low cost 2) available around the world and 3) 95%+ successful.
See Joseph Bernstein MD - "Not the Last Word: Ponseti Broke the Triangle" Clinical Orthopedics and Related Research 17 July 2018
14
Another victory for evidence-based medicine. The only thing not going up in disease care is quality.
4
My daughter has a very pleasant experience in MI America as far as her delivery and medical treatment of my granddaughter is considered. Touchwood so far so good.
However I am of the opinion over use must certainly move over in the interest of patients.
How do you argue with a dismissive know-it-all MD—and why is it necessary to heavily research my own condition when that’s what we pay them for?
21
Patients argue with this know-it-all MD all the time when he tells them they are fine, but they insist, after heavily researching their "conditions" on Google, that they need MRIs, blood tests, specialist referrals, etc.
How do they do it? It's called "chutzpah."
4
Excessive treatment is built into the training of the modern day physician. Zeal to help quickly becomes transformed into zeal to conquer illness. Yet going for the glory often is done at the cost of sacrificing the patient and patient health. The problem is doctors don't have learn about any alternatives to medicines and surgery, in spite of the virtual explosion of non-medicinal and non-surgical options. As the field of options widens, doctors options seem narrower and narrower, even as their scope of authority changes little. A paradigm shift is required, which requires open-mindedness, incorporation of new models of diagnosis and treatment, and ultimately the relinquishing of final authority.by the medical profession This will almost certainly never happen.
4
In a fee-for-service System, follow the money.
Benefits or lack thereof, or even harm, is secondary to money.
Trust me, I’m a retired doctor and had the opportunity to watch this up close.
34
@Sam Kathir So I go to urgent care with chest pain and rapid heart beat, 70+ female. They call an ambulance. I decline and make cardiologist appointment. Cardiologist does another ECG, says atrial fibrillation at 154 bpm, go to hospital. Does TEE, shocks heart, orders anti-coagulant. So, was this necessary? How am I supposed to know? I have some doubts since there was an infectious disease involved that was undertreated and a published cause of heart problems. This was not mentioned by me because it would only cause trouble. Lyme disease is one of those things that apparently is never going to see changes in the paradigm. Doctors can see that treatment helps people, saves lives even, but they deny that it can persist. No amount of evidence of their own eyes is enough. The question is whether they are stuck in the past and incapable of change when a disease does not do what they thought it should. Or are the medical boards, insurance, government health agencies the real cause of doctors' reluctance to get involved. The latter is certainly doing a great deal of harm.
1
The “excess costs” in the health care system are being directed to physicians by physicians. There is absolutely no incentive for physicians to do fewer tests, surgeries, or imaging procedures in our current system.
The lag time between quality study results and putting those results into practice is due to pure laziness on the part of physicians. When I used to go to physician conferences, I realized that most were just summarizing recently published studies, and I learned nothing new. I was appalled by how my colleagues were thrilled with “new” ten year old information. They were too busy skiing in the Alps to bother reading medical journals.
Physicians, heal thyselves
11
A very apt cite can be made from Haider Javed Warraich's opinion piece in the Digital NY Times for Jan. 6, 2018 which states:
"A paper published last year by researchers at Harvard showed something very striking--patients being taken care of by younger doctors were less likely to die. Younger physicians are also less likely to order unnecessary tests in both men and women, to face disciplinary action from state medical boards or be cited for improper prescription of opioid pain- killers and other controlled substances. These findings are far from isolated: The majority of research shows a consistent, positive relationship between lack of experience and better quality of clinical care."
It would appear that a good bit of the demand for certain healthcare procedures is indeed physician-generated. Perhaps these antiquated medical procedures are principally the domain of older physicians.
[JJL 09/11/2018 1:50 pm Greenville NC]
14
@John Joseph Laffiteau MS in Econ
The study cited referred to 736,537 admissions and 18,854 hospitalist physicians in numerous hospital settings. There was no association in mortality rate and age in high volume physicians. E.G. physicians who do it a lot knew how to do it well, no matter where they are on the age spectrum of hospitalists. The over-all spread that showed younger physicians under 40 with a 10.8% mortality rate vs 11.1% and 12.1% for the two older groups included physicians in small volume hospitals (many small volume hospitals do not have busy older attendings and staffs of bright new interns/residents, get critically sick patients who will be shipped to teaching hospitals/advanced centers unless they die first).
7
The god complex answers to the greenbacks.
2
@D. Whit. wow. you are obviously not a primary care physician, board certified internist or family practice, taking roster call or answering phone queries from skilled nursing facilities 24/7 for zero compensation. many surgical specialties benefit financially from volume. the front-line people making diagnoses and hustling to the hospital at 3 am don't. that's why NO ONE IS GOING INTO PRIMARY CARE MEDICINE TODAY. Incursion of data miners and univ./hosp/ based administrative types guarantee that UnitedHealthcare in it's many iterations and guises will own medicine into the future.
14
This article omits the profit factor as one of the probable causes of over treatment. This omission is indicative of the unsophisticated blindness that has allowed the US’s long slide into virtual economic slavery to the healthcare industry.
13
My healthcare is too important to abdicate to drs. I question everything, learn what I can (important to avoid fake news, opinions & conspiracy nonsense), and get 2nd opinions.
It’s ashamed, but American healthcare is big business first & foremost. You’re on your own in America. Caveat emptor.
18
How about the physicians who continued doing radical mastectomies long after research conclusively demonstrated that it was no better than a lumpectomy and far more difficult and disfiguring for the patient?
17
@Lupi
Yes, that went on for years.
5
@Lupi
I think you’re unfamiliar with this. radical mastectomies haven’t been done routinely In decades. And there are many reasons why someone would choose mastectomy for treatment over lumpectomy. It’s “no better” only in the the narrow lens of mortality, but that ignores any number of endpoints (cosmetics, avoiding radiation, simplifying follow up, decreased risk of local recurrence, etc...)
5
I was a PhD basic research scientist at a medical school. Unless the MD is also a PhD researcher, their idea of keeping up with the literature is confined to reading JAMA and New Eng Journal of Medicine. Typically unaware information published in the state-of-the-art experimental journal, their information base will always be severely lagging.
10
@mably Probably the average Board Certified Internist seeing 25 patients with multiple complicated dx every day and taking call 4 nights a week, in between nursing home and house call coverage, wants to read about treatments that aren't gonna kill the patient - like a slew of over-hyped new diabetes drugs, or, back in the day, thalidomide. Somehow being responsible for keeping alive someone with whom the doc has had a long term relationship negates experimenting in the name of being considered current. Ever stop to think that many physicians are aware of the newest state of the art what the heck ever, they're just waiting to be sure 30% of the first long term treated patients don't experience some state of the art side-effect.
15
@winchestereast Can I get an amen!
Managed an Internal Medicine practice for 30 plus years, in a building of Board Cert Internists. Never saw MD's hesitate to monitor blood pressure at pretty much every visit, or put an at risk patient on anticoagulants, monitor pro-times, etc. in spite of the extra, uncompensated work of following labs and adjusting doses, probability that someone would fluctuate, resulting in a stat lab call to track down and adjust for over, under anti-coagulated states. Most physicians like taking in new information, are science geeks. Also like to see patients maintain well-ness, avoid risks. So, are these results particular to pediatricians? Surgeons? More common in practices where extenders (PA's, NP's, OD's) care for patients? Not to worry, Mr. Carroll. The Board Certified Internist and Family Practice MD is an endangered species. We'll have diagnosis by computer, treatment by NotADoctor, and the numbers will look good.
9
@winchestereast The term "extender" is insulting. But I guess that is why you used it.
It has been known for well over a decade that swabbing clean skin with a disinfectant before giving intradermal, subcutaneous, and intramuscular needle injections has no benefit. Yet, I can't think of an instance when I got an injection where a nurse, PA or doctor didn't swab the injection site, most often with alchohol. I often ask if the person knows swabbing has no benefit and have seldom encounter a practicioner who knew. This lack of knowlege extended to my own son an ER doc until I pointed out the studies. Much of what's done in medicine is done out of habit and custom. Some of these customs like swabbing injection sites are relatively harmless and possibly of psychological benefit to patients. Others, like wearing a white coats, which spread germs, are truly harmful no matter how reassuring seeng an MD in a white coat might make patients feel. Today, ER docs. PAs and nurses are usually "naked from the elbow down." But I often see doctors doing rounds in hospitals from other branches of medice wearing white coats even though those coats are pretty effecient at spreading germs from one patient to another.
18
@Miles
"swabbing clean skin with a disinfectant before giving intradermal, subcutaneous, and intramuscular needle injections has no benefit."
What?? Please post the "studies" that "prove" this.
Don't you think that it's a little odd that you "know" this when no one else does??
7
My grandfather, a 90 year old retired MD, tells me the same thing. No benefit in the alcohol swab and injection a few seconds later (apparently not enough time elapses between swab and injection to actually kill the bacteria on your skin).
Must be an “old school” thing younger practitioners are unaware of, or are taught to do with no scientific backing.
Do you think, Dr Carroll, that it should be admitted that practicing physicians do not study the medical literature and perhaps hold the same level of skepticism as I held as a practicing internist.
The vioxx issue was a case in point. I could never understand how my peers use that drug which increased cardiac adverse events, after I read about its pharmacodynamics and its negative effects on aspirin. And yet it took years to get if off the market and its cousin, Celebrex is still on the market. Neither would have had a chance if other MDs read the literature.
And the list goes on. Doctors are busy and they are also people with the same tendencies as the rest of the population. But that is not an excuse for ignorance.
15
John, I use Celebrex on my postop patients routinely. It would be nice to have Vioxx, if only for price competition— although tbh, ibuprofen seems to be just as good and safe in this setting. Have not seen any problems with standard dosing and short periods (you know, the first 3-5 days after laparoscopic surgery). This has allowed me (and my patients) to substantially reduce narcotic use, to the point that most of my patients rarely fill their narcotic prescription. COX2 inhibitors are a perfect example of the problem described in the story: massive over prescription for minor aches, particularly in older patients with arthritis who may need to use them long term (in the absence of long-term studies during the FDA approval process), followed by blow back when side effects proved more common and severe than the marketing guys suggested. We docs over-reacted in each case. Just like we over-reacted in using narcotics to avoid NSAIDs in general for pain control, afraid of causing bleeding and renal failure. Instead we helped create heroin addicts and increase the supply of narcotics in the street, maybe even increased crime rates.
8
@Carlos
As far as I can tell, short-term use of opioids is safer than other analgesics, especially if you are on meds that affect liver and kidney function. It’s moral panic as much as anything. And isn’t ipuprofen being considered for a black box warning?
I have had my share of disagreements with physicians, especially with those who do not l-i-s-t-e-n to me. Smug and arrogant know-it-all types, one in particular who refused to order an MRI, even though I was DX’d with CPMS [chronic progressive multiple sclerosis] 18 years earlier, had “new” symptoms, and was aware something was amiss. I had a health plan with one out-of-network referral per year, and after five years of dismissive physician behavior used that trump card, went to a stellar university MS doc who was able to order an MRI at the offending physician’s practice....and was DX’d with a brain tumor, meningioma, requiring 7.5 hours of surgery at the university hospital, not the practice that dismissed me out of hand. So yeah, luck of the draw with physicians. Patients need to be proactive, do their own “research” and bring “stacks of paper” with them to politely challenge boneheaded docs. There are a lot of them about.
32
Here's a test of will for readers. Ready? Vitamin D supplementation does nothing. Nothing? Nothing!
Are millions of you ready to give up those "bone saving" supplements? I bet not.
See? It's hard.
26
It's like chicken soup....It couldn't hurt.
2
@A Doctor
OK,
1. Advised by doctor to supplement after testing showed low levels. Are you saying ignore Dr when they advise vit D supplementation?
2. Are you saying that supplementation does not raise vit D levels in blood?
3.Or, are you saying that blood level tests of vit D are worthless because do not actually measure the levels and so should not be used as guidelines?
4. Or are you saying that guidelines for vit D levels are wrong?
Unless one understands the basis of your recommendation, why would they follow it?
13
@David Well, too much vitamin D does cause toxicity: it is a fat soluble vitamin. It can cause hypercalcemia, nausea, weakness, vomiting frequent urination. Not benign.
Require retraining at intervals in order to maintain license. Currently Docs don't have any time to stop and get new info much less smell the roses. ( I'm one of those annoying patients who bring stack of internet printouts to my doc.)
6
This is already a thing.
Doctors are required to do “continuing education” over 2-3 year cycles to maintain Board Certification (required by most hospitals for admitting privileges, if your doctor admits) and state licensing— which every licensed doc needs, obviously. Unfortunately the “education” often times focuses on rare diseases, rather than common things. Maintenance of Board Certification usually requires passing a test (the interval of the testing has been changing) which forces you to stay up to date. Patients probably do not pay much attention to whether their docs are BC’d— admittedly not something you care much about as you roll into the ER with your heart attack. But you should pay attention for routine visits. But as the anecdote the story starts with, sometimes being too well read and ahead of the pack leads to its own problems, because the latest study findings could be flawed/contradicted later.
2
@Dee Most specialties do require frequent time consuming expensive recertifications.
6
It is human nature to believe that what you have done and been informed is correct should remain your approach, after it has been shown to not be correct and you should not be doing.
In general it is human nature to think your performance exceed the mean - and even if new evidence suggests what you are doing is deadly, the evidence does not apply to you. Smoking, vaping, texting and driving, unprotected sex, illicit drugs are all done by persons sure that the rules and results on average do not apply to them - they wont get cancer, they wont crash, they wont get AIDS, the wont overdose.
7
Indeed this is a serious problem. Others have commented on "customer demand" and "I Googled it" as drivers for employing dated and ineffective treatments. However, I reject the idea that this problem is solved by automation or checklists. Each patient encounter is an "n of 1" experiment where the variables are virtually infinite and rarely completely knowable. There is risk in assuming that, because a large study (e.g. glycemic control or blood pressure control) has an outcome for a certain characteristic, that this intervention is applicable to all patients with only that characteristic. Even the meta-analysis buries critical individual characteristics. There is no substitute for longitudinal care by an educated and compassionate physician, in my view. This is not to denigrate other professionals, but in the end, we physicians are accountable.
24
Many of the comments here and elsewhere on the topic of overuse suggest that malpractice avoidance is a major driver. Conversely, doesn't the failure to use proven effective treatments also expose providers to malpractice? If, in fact, physicians are motivated to reduce malpractice risk - how do we explain the painfully slow adoption of proven effective treatments?
3
@JS Malpractice is based on the physician not meeting "standard of care"and new therapies often are not "standard of care" Thank you lawyers as they are the ones who decide these things, not docs.
8
@JS - IRS not about the avoidance of malpractice, it's about the avoidance of lawsuits. Patients often do not understand the subtleties and complexities of medical practice, but they certainly know if they're dissatisfied and it's the doctor's fault!
1
There are plenty more more mundane things that doctors order long after the guide lines have changed. I still hear people, almost bragging about going for their annual physical. This is one of the most useless wastes of time in medicine. At the physical, the doctor has to order blood work from which there are sure to be numbers outside the range of normal. After a bunch of expensive test, it turns out to be normal for that patient. Women do not need a pap test nor even a yearly pelvic exam but I still hear women getting reminders from their doctors to schedule them. Doctors prescribe antibiotics because the patient expects them. For a long time, dentists were prescribing them for all heart patients.
More immediately dangerous, are doctors in the ER who fail to perform the latest and best treatments for head injuries because that isn't what they learned in med school, twenty years before. What doctors need is real continuing education, not the convention, frequently beside a big tourist attraction, where there are a variety of lectures one can get credit for by just attending. These are life and death issues, doctors should have to show proficiency in the new methods, not rely on their ancient training.
41
@S.L.
Watch a young woman die of cervical cancer, then tell me women don't need pap smears. Women don't need them every year, unless something is abnormal, but they do still need them. The HPV vaccine may eventually change that, but right now we don't have enough information to stop recommending pap smears to women who've gotten the vaccine.
A yearly physical exam for healthy young adults probably isn't medically necessary. For a healthy young person who's not over weight, lab tests definitely aren't indicated. However, the visit does create a trusted relationship between the patient and doctor. If something does happen, the patient is more likely to go to the doctor for help early and the doctor will be better able to help them. Those visits do allow doctors to counsel young patients and intervene early when they notice harmful behaviors.
Once people hit middle age, a yearly exam really is important. There's a number of screening and prevention tools that are recommended for varying ages and populations. The best way to make sure you're up to date is to schedule a yearly exam.
8
Changing behavior that is profitable is difficult. High intensity actions–strict control of glucose, C sections, critical care, etc–are all paid more by 3rd party payers.
In my own experience using Pedialyte rather than an IV for mild dehydration led to decreased interest in my working ER at small hospitals. And using a nasal spray with xylitol, demonstrated to resolve and prevent sinus and ear infections as well as asthma–just by cleaning the nose–is ignored by a good many ENTs.
The solution we see is empowering patients to re-enter the marketplace by state (as well as individual and employer) support of health savings accounts. And they could be made much more appealing by allowing them to pay–pre tax– for housing and education, as well as being shared in the family and, to a lesser extent, the community–where charity should start.
5
Here’s my “two cents.” Many doctors are very resistant to their “well-educated” patients, i.e., patients who have actually researched their own health concerns, in order to have a more “fruitful” discussion. Apparently, doctors do not “cotton” to this practice. Two quick examples: a cardiologist who I consulted about my heart (I was experiencing fast, irregular heartbeats during boot-camp), then “frowned” at my questions. The second example was with a podiatrist who “scoffed” when I queried about why he asked his “over-fifty” patients about their “falls” but did not inquire the same of his “under-forty” population. I challenge the “notion” that older people “take a tumble” more often than younger people do. I fell many times in my teens, twenties and thirties: Platforms. Stilettos. Wedges. Clogs. But that data has been all but ignored by an “ageist society” that, once again, has put all of us “oldsters” into the “Help! I’ve fallen and I can’t get up!”category. Medical school is a “trade school” for smart people and, yet, physicians become “stuck in their ways” like all the rest of us. Perhaps, all practitioners need to take a step back, listen to their patients’ concerns, then do the research, themselves, with as much interest as they once had in training. Science is a self-correcting system. Let’s keep it that way.
14
@Billie Tanner
Physicians worry about falls in older patients because the consequences are much worse. Weaker bones and less brain mass means that falls become very dangerous. Also, older patients should be doing fewer things that cause falls, so more falls in them could indicate that something is wrong with them physically.
Young people usually fall down because they're doing all the things that you mentioned -- walking in heals, climbing on stuff, drinking alcohol, etc. It's probably not because of a neurological problem. And most of the time, young people can just dust themselves off from a fall that would cripple an elder. Screening young people for falls would not be helpful at all.
When do authors use "providers" vs "physicians" when discussing health care? As a physician for >20 years, my thoughts:
Physicians order medications and tests for patients when indicated, based on training and experience, with the individual patient's needs considered first.
However,
1) Orders are also placed via protocols due to triggers that are often decided via committee (or just decided); physicians sign these orders later.
Consider sepsis protocols - yes, these order systems result in patients getting intravenous fluids and labs based on triggers like elevated heart rate and fever. But this comes at a cost. Responding to alerts and triggers causes other patients to wait while we respond to all the false alerts [false alert in this case - eg person with high heart rate and elevated temperature due to URI and good immune system].
It enables justification of automation.
It enables hospital systems to hire fewer human beings.
Practicing medicine is a privilege and yes, an art. Automation should augment, not replace, the human touch.
More importantly:
2) Other providers order medications, labs, consults, studies, procedures on patients, etc. These physician assistants (PAs) and nurse practitioners (NPs) are often well-trained but many are not. Evidence shows they order more indiscriminantly, which can absolutely cause harm to patients. This needs to be at least noted in this article, if not covered completely, to truly explore this issue.
36
@Elizabeth Which evidence shows this?
1. Indeed research vacillates for a time, often. It is hard to trust til significant time goes by and studies reproduce etc. What makes the paper about silicone breast implants causing rheumatic disease may in fact never have been studied so, worried patient, come back in 5 yrs and turn off the TV. Physicians are cautious .First do no harm.The example of bs in the icu is a good one
2. The pressure from patients in quick visits is understated in this article Patients want tests Tests are not necessarily going to change outcomes."I want to know what is wrong" "we know what is wrong.I have listened and examined you" "I want the mRi" " why?"" I want to know what is wrong ." The work of A Verghese not withstanding,this is deeply ingrained in the culture-- so they go to the ER and.. get the test.
It takes a lot of time for over worked under paid PCps which there are fewer and fewer of to explain. When we do that well we can unlearn as you call it. It is not however unlearning It is learning something new actually, and if the research is going to reverse itself in 3 yrs because it was fraudulent or drug company sponsored with data withheld or not reproducilble etc then stop saying doctors have to unlearn This article panders to an anti doctor sentiment without understanding what we actually do,,and is simplified. Medicine is a slow business in a world that wants it all from a drive up window.
15
Much of what physicians do is driven by fear of liability. Many lay people think that a physician should exhaust every possible MRI, CT scan, blood test, every time, to always rule out every possible malady. Talking about healthcare reform without talking about tort reform is silly.
21
@Tamarine Hautmarche. Not just liability (i.e. malpractice suit, complaints.) There are surveys of patient satisfaction, and woe be to the physician who goes against what the patient wants, no matter how irrational. Physician salaries/advancement often depend on the result of such surveys.
13
Why, oh why are doctors till prescribing antibiotics when there is no evidence of a bacteria infection?
16
@David J. Krupp 1. It's not always possible to determine definitively whether there is an infection or not; and if so, if it's bacterial or not. 2. Patients - and parents of child patients - demand antibiotics. 3. Until recently, it was thought that although at times antibiotics aren't necessary, they're relatively harmless, and the risk/benefit ratio is good. Now we know that over-prescribing has led to worldwide bacterial resistance. Physicians have become more cautious. 4. Non-physicians (e.g. nurse practitioners) have been shown to prescribe more antibiotics than doctors.
18
@Primum Non Nocere
Antibiotic resistance in bacteria has been known to be a serious problem since at least the 1950's. Nobody listened. See "The Tangled Tree" by David Quammen.
1
@David J. Krupp
Most of the time they should not, but there are times where empiric antibiotics make sense. In some very ill patients you don't know if they've got a virus or a bacteria or fungus, so you may just start abx until you get cultures back a few days later. Why? Because if you wait until you've got evidence of a bacterial infection, the patient might not be salvegeable. Also, in some patients who have severe lung disease, I've seen doctors offer antibiotics if they get the flu. Pneumonia is one of the most dangerous complications of flu in patients with severe lung disease, so the doctors are hoping to prevent that with prophylactic antibiotics.
Also, sometimes antibiotics are appropriate for prevention of disease. Lyme disease is a good example: if you're in an endemic area and have a tick on you for >36 hours, you should probably get a round of doxycycline.
4
As a psychologist, I know that trying to unlearn or stop doing something that has become a habit is very difficult.
What is easier is to just ADD new information such as " I used to do it that way, but now I do it this way" or " I don't do that anymore because there is something better which is....."
Our minds are designed to acquire new information and fit it into a context that it already has. It doesn't do well in trying to subtract or stop doing something without the context of adding something new for good reasons.
It's all about the WAY you teach yourself to change that makes all the difference. It is usually not helpful to try to force yourself to stop because it's bad or because you'll be punished because that introduces complicated emotional reactions to the negative consequences such as anger, resentment, resistance, etc. and make it even more difficult to make the changes....
25
In other professions, if you perform obsolete or antiquated practice, you loose your license or loose your job. As a IT professional, I have to stay up to date to stay employed. If this is as large an issue as indicated in the article, then stop paying doctors and hospitals for performing treatments or protocols that do not work or are not recommended. As consumers of health services, we rely on the professionals to stay up to date. If they do not, then they should not get paid.
17
@Dennis Gerson Agreed, health pros should be paid for workable treatments and also for improving outcomes. By the way, it is loose (baggy) clothing and lose your license/job.
1
@Dennis Gerson
"... stop paying doctors and hospitals for performing treatments or protocols that do not work or are not recommended."
So when you come in after twisting your ankle, and I refuse to do an X-ray, you're going to be alright with that... right?
Yeah, right.
1
@Dennis Gerson
Is that why I have to keep dealing with ridiculous password requirements, even though there's no evidence that those requirements prevent hacks? In fact, they may increase the risk of hacking because people do silly things like email the password to themselves because it's so hard to remember. Yet ya'll 'IT professionals' seem to insist on it.
There has been an attempt to 'pay for performance' with physicians. Sometimes that's a good thing, but sometimes it's led to the exact problem this article is talking about.
Let's talk about blood pressure guidelines. Some studies came out showing that very tight control of blood pressure reduced stroke and cardiac death, so some major insurances started penalizing doctors who didn't keep very tight blood pressure control on their patients. However, family practice doctors quickly realized that there was a difference between a 60 year old and an 80 year old with clogged arteries. The 60 year old could benefit from the lower blood pressure, but the poor 80 year old needed a higher blood pressure to keep blood going through his clogged arteries and to his brain. So family doctors were then financially punished for keeping their older patients safe by allowing them to have higher blood pressures.
It turns out it's very difficult to tell what the 'best' treatment for any single person is. This is not IT, where the systems are well defined and understood.
2
Excellent analysis. Unfortunately clinicians have to worry about lawsuits and maybe that's the bottom line. Is there a medical journal study that looks at the effects of lawsuits on clinician behavior? Until clinicians are comfortable that they won't lose in court because they followed guidelines and did not do the unnecessary study, they will naturally err on the side of protecting themselves.
19
Patients need to be better informed so that they can question physicians during discussions of testing. Not that patients should think that they have the same expertise as a physician but they need to understand the pros and cons of what is being suggested. What does this test measure? What will be different if you know the test results? How will outcomes be impacted - for the better, for the worse, no impact?
Physicians can't do things to us without our permission. We need to be better participants in the process.
15
@Randy Harris. This is so true. One needs a physician who views you as a partner in your own care. And we each need to take responsibility, as best we can, to stay informed on our health and ailments.
I remember taking my 85 yo frail father to an appointment with his PCP. He had severe dementia, diabetes, and a history of strokes and severe heart disease. My mother, who thought that more treatment equals better treatment, asked his PCP whether she thought my father had “PAD” (peripheral artery disease) based on the TV ads she’d seen. The PCP said yes and offered to send him to a specialist. If I hadn’t been there to ask the obvious questions (what is the treatment; is he really a candidate for the treatment; how would the treatment benefit him; what are the potential harms) it would have been off to a useless, and potentially harmful encounter with a doctor who didn’t know him very well.
16
@Randy Harris
Only the well-educated, highly literate, and confident members of society can do this. The amount of medical illiteracy is staggering. Only 12% of the population is completely health literate, according to health.gov. You can do it, I can do it, but most people can’t understand medical information well enough to make their own decisions.
Yes. Doctors as a group are professionally (not necessarily politically) conservative. Many of us don't do well with change. It takes a long time for there to be widespread adoption of good things (aspirin for heart attacks) and a long time to get us to stop doing things (arthroscopic knee procedures) for which there is less/no evidence. But I think this article would be just as accurate if stated as "It's Hard for People to Unlearn Things." For example:
1. I always need antibiotics when I get a cough.
2. My child always needs antibiotics for ear infections
3. I need an annual checkup
or less medically:
1. My vote will never count
2. If I read it on the Internet, it must be true
3. Doing more is always better
We try to practice evidence based medicine, but keep in mind, we are held accountable to "community standards". Is there good evidence for pre-operatively evaluating healthy patients for cataract surgeries? No. But if I don't do it, my patient won't get her surgery. Sometimes you have to be practical.
58
@GeriMD
All of the "medical" unlearns mentioned by GeriMD will come about when patients pay for their own care out of their own pockets. Patient responsibility coupled with an income and/or wealth based maximum liability (say 5% give or take of yearly gross income for an average middle class family) and a universal tax based backup plan to defray catastrophic costs, would not only restore the patient doctor relationship, but would eliminate the huge bureaucratic and administrative drain that now consumes as much as a third of every healthcare dollar.
3
@Mike Z
You are assuming that patients can make heads or tails of medical information. Most of us don’t even know what lab tests measure. We consult professionals (MDs, attorneys, CPAs, etc) because we don’t have the training to make medical, legal, or financial decisions. They do.
Try telling this to malpractice lawyers. 80% of what a physician does in terms of testing is done to protect themselves from malpractice. If a patient comes in with ankle sprain, the physician will get an x-ray to protect him/ herself.
62
@Peter Absolutely. You get sued if you didn't do something. No one was ever sued or reported to the Medical Board for doing the x-ray, CT scan or
c-section, or prescribing an antibiotic.
1
And what about when physicians resist change in service of the bottom line? A recent blood test showed my vitamin D level to be 2,500. That's above the old 2,000 but below the recently contested current recommended level of 3,000. My doctor recommended a supplement. I disagreed. But, in a more dramatic example, my physician refused to give me a prescription for the Cologuard colon cancer test spouting all kinds of wrong data and information to back himself up. Why? The organization he works for has a significant investment in a colonoscopy unit. So, he was insisting I take a $3,000 procedure over a simple $600 test that's just as accurate. I finally won over a gastro professional in another location.
19
I've been a nurse for 36 years. I also have a PhD. Still, convincing a physician to do something different is VERY difficult. There are those rare ones who will consider another's input, but most believe in their rightful place as "captain of the ship" and discard advice from other health care professionals. This hierarchy harms people. It makes them disregard useful data from patients, nurses, family etc. The attitude of superiority is a threat to safety and the medical profession should be working hard to overcome it.
117
@Nurse PhD It is not necessarily superiority but the fact that the liability stops not with the employed other medical staff such as the nurse practitioner or PA, but the doc's malpractice. I was liable for everything my PA and NP did, to the tune of many more dollars than they were liable, even though they were practicing medicine. The malpractice system needs changing.
6
@Nurse PhD So totally agree. My health nosedived overnight while I was still in my 20s. Doctors who couldn't find the cause either told me to learn to live with the pain or offered me highly suspect medications which caused other ill effects.
Turns out I'm fluoride intolerant. Since scrupulously avoiding fluoride contaminated drink & food since 2014, my IBS, arthritis, chronic cough, and other ailments have all disappeared. No more kidney or liver pain, either. At least 15% of the population is like me.
We are misdiagnosed and miserable because doctors listen to marketing rather than patients.
5
@Nurse PhD
~attitude of superiority~
I call that Dotoritist.
I also wonder what the impact of malpractice suits and precedents is on this finding. I’ve been told by practicing medical friends that one can lose a malpractice case if one has not been following established practice, even if one was following a newer, better practice. If true, does that influence the extent to which doctors embrace new recommendations, even if only subliminally?
35
"This overuse doesn’t provide a benefit. It can lead to harms. It can also cost a lot of money. "
That pretty much sums up health care. It is an industry, why would it eliminate products that produce more revenue? Why would it choose a cheap solution over and expensive one? Witness the profusion of stents to treat angina.
In short, why would we expect people in the industry to come up with solutions to the high cost of health care? This is not a technical or intellectual problem. It is a conflict of interests where the power of the competing interests determines the outcome.
33
This is a well written piece.
I often say doctors/medical workers fall into three categories like all other professions except they can deal in life and death. One can argue the exact percentages.
1/3 can save your life or be real helpful.
1/3 tell you what you already know or can't help you.
1/3 can up sell you, rip you off, harm you or even kill you.
12
I used to tell the paediatric residents that I taught that getting physicians to change an aspect of the way they practiced (often learned in medical school or residency, a good while ago) was about "as easy as killing Godzilla." Looks like it hasn't changed.
27
I think that a significant part of doctors' inability to "unlearn things" is twofold. First, they don't want to stop performing the procedures they have become good at such as complex spine surgeries to correct things like spondylolisthesis and spinal stenosis. Second, there is money, big money to be made in doing lots of procedures.
Doctors, especially the specialists should have to undergo more frequent upgrades to their skill sets and their mind sets. Just imagine how much the practice of medicine changes in say ten, twenty or thirty years.
17
@Emergence Doctor's in the USA already need recertification and CME to keep their jobs so this is not the problem.
2
Physicians indeed have a hard time unlearning in the face of new evidence. We also have a hard time learning in the face of new evidence. These are both subsets of a much broader issue: We are not taught to think systematically.
There's a reason airline mechanics and pilots use checklists to analyze problems and to be sure their planes are "healthy". Guess what? Doctors almost never use checklists; we're just supposed to be wise and experienced enough to intuit what to do. This works a lot of the time, but, when it doesn't, lives may be harmed or lost.
It's especially likely not to work when there is new research supporting a change in approach; the doctor may not remember, or even be aware of, the needed revision. (An apt example: Dr. Carroll, the author of this Times essay, uses induction of deliveries rather than waiting for natural labor as an example of an outdated and ill-advised practice. Well, it used to be until about a month ago, when it was found that labor induction at 39 weeks reduces the need for C-sections. Google "induced labor 39 weeks" for details.)
What to do? This would require a wholesale revision of medical education, making it, well, more mechanical, and reducing the prestige of the omniscient physician. It might at least help to remember a favorite line from my med school graduation: "Half of what we've taught you is wrong. Unfortunately we don't know which half."
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@BGZ123 you should read The Checklist Manifesto. Written by a doctor the studied introducing checklists into hospitals. A real eye opener regardless of your field.
https://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000
1
Brilliant! We need check lists in each medical specialty. At the same time we need to revisit checking pain levels, those frowny-smily faces, as if they were vital signs. Originally developed to trigger an assessment of pain, pain numbers merely get the patient to focus more on their pain and getting pills, while encouraging medical professionals to prescribe ever more pain medications. We are training patients to take pills when they hurt rather than move around, drink water, stop eating meat or use distraction to manage their pain. No wonder we have an opioid epidemic in this country. Sumter Carmichael MD
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@BGZ123
See "The Checklist Manifesto" by Dr. Atul Gawande.
And don't have too much confidence in medical studies to prove (or disprove) anything. See "John Ioannidis argues that problem base, context placement, information gain, pragmatism, patient centeredness, value for money, feasibility, and transparency define useful clinical research. He suggests most clinical research is not useful and reform is overdue. (https://www.ncbi.nlm.nih.gov/pubmed/27328301)
Also "Lies, Damn Lies, and Medical Science in the Atlantic (https://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-an...
2
Dr. Carroll includes antidepressants in his list of thing "we" prescribe to many of to children.
However, unlike the other things on the list which are clearly inappropriate, the use of antidepressants is much more complex.
There are many children and adults, too, who could benefit from antidepressants but will never receive a proper evaluation for depression much less treatment.
And, yes, there are children who are inappropriately prescribed antidepressants but the "we" is pediatricians and family practitioners who prescribe these despite having little training in the treatment of depression or other mental illnesses. The people who should be treating them, i.e., child psychiatrists, are not prescribing too many antidepressants.
We do have a severe shortage of child psychiatrists but to become onet, one must perform one of the longest postgraduate training program of 5 years which is longer than most surgery training program only to enter one of the lowest paying specialties.
15
Yeah, no. The shortest surgical training programs (residency) ARE 5 yrs. But be careful what you call a surgeon. Dermatologists and gastroenterologists are not. Many other specialists who do invasive procedures, like cardiologists and radiologists also will train for about 5 yrs, although that generally includes an added fellowship past residency.
One of the reasons why child psychiatrists are in short supply is that they are paid extremely poor wages, and a psychologist, social worker or advanced practice nurse can see the patients (if not prescribe meds appropriately) at a cheaper hourly rate.
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@Steve
Disagree with you.
Antideppressants are over-prescribed and according to labeling, many treated patients complain that they are ineffective.
Many reknowned psychiatrists report that these meds can “manufacture more depression”, among other things.
Dr. Healy, Dr. Breggin and many others have huge concerns with suicide for pts on these psychotropic drugs. These are pts who had no underlying issues, but were prescribed for off-label use. The culprit: Akathesia and Emotional Blunting
1
I think there are other issues as well. Although I am not a physician, I know enough physicians to suspect they may not learn enough about medical research while in med school to gain a full appreciation for it. I also wonder if there is reluctance to accept research that takes them in the opposite direction from where they had previously been advised to go. Do physicians suspect that in the future, new research will then have them reverse direction again? I have also noticed that medical research sometimes emphasizes the straight empirical methodology but spends relatively little time explaining the science. Maybe the research results suggest a particular direction, but there is no scientific rationale for that direction. Just generating a statistic is not enough, the researcher also has to be able to explain why it came out that way.
13
The ABCDEs of technology adoption and errors https://www.linkedin.com/pulse/20141205113121-955834-the-abcdes-of-techn...
1
Another article we need to see that will also be supported by research: It’s Hard for Teachers to Unlearn Things. That’s Costly for All of Us.
8
I think one of the challenges arises for most physicians because of the way they learn.
About a quarter of my engineering class went on to med school and as engineers they learned how the various systems work while many of their pre-med counterparts simply memorized the material - when you memorize things - it is hard to unlearn - when you thinks systematically, you simply change a principle of operation .
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@SteveRR I find this assertion preposterous. Physicians don't learn merely by rote. Ask any doctor what their education consisted of. Of course they learn the underlying principles of "how the various systems work" in the first two years of medical school, which itself is preceded by undergrad courses including biology, inorganic, organic and bio-chemistry, physics, and calculus. They also have to demonstrate an ability to analyze information that's presented to them, and to write cogently about it. Then after these 6 years, they have the last two years of medical school plus 4 +/- years of residency, in order to put that academic information together with practice under senior clinician supervision on real-world cases, understanding deeply how those systems work. So, 12 years of understanding systems.
10
@SteveRR I should have said "12 years of understanding systems" before doctors even get out into the world to practice.
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@Primum Non Nocere
There is a marked difference between learning how a system works that one expects never to fundamentally change, vs. learning how a system works that is extremely mutable. Engineers are more familiar with the latter, and are more amenable to out of range system behaviour. Regardless, keep in mind that the range of each group overlaps to a large degree.
Another reason we physicians have a hard time letting go of certain interventions or over use of diagnostic studies is the constant threat and fear of law suits. An act of omission is much more likely to be prosecuted than an act of commission.....so rare to be blamed for doing too much. Evidence based medicine is the gold standard, but until the public and the courts are on board, these sorts of issues will persist.
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@Deborah Ottenheimer
Doctors trot out "fear of lawsuits" as the major reason they over order tests, over prescribe antibiotics, etc. Have they really consistently tried explaining why they won't do - recommend against something
- because it is not in the patient's best interest? I once had a Dr. look somewhat shocked because as he was handing me an Rx after just telling me a throat infection I had wasn't bacterial - I asked him why he was giving me antibiotics. How many of those are out there? ( how many patients dies from NOT taking an antibiotic they don't need?)
There ARE studies out there that suggest even where there may be grounds for a medical mistake - when doctors and hospitals are honest and upfront and apologetic about the mistake, patients are more accepting. It's when they feel tricked and kept in the dark (the traditional method of covering medical mistakes), that they resort to legal redress.
If doctors are professionals they have a responsibility to say no, and explain why.
4
"If doctors are professionals they have a responsibility to say no, and explain why."
If doctors say No, they get dinged on patient satisfaction surveys, which are mandated by the new Medicare rules and whose results affect compensation.
If doctors spend as much time as they would like to in explaining why, they will get behind on the treadmill they run every day, incurring the wrath of later-scheduled patients (see above), and of their corporate supervisors, who will fire them as "unproductive."
@Deborah Ottenheimer
Correct. And it's hard to convince parents of a sick child that half strength apple juice is as good as Pedialyte.