The Doctor’s Conundrum: When Does Help Turn Into Harm?

In the late 19th century, Dr. William Halsted, a pioneer of modern surgical techniques, performed ultra-radical mastectomies for women with breast cancer. The procedure, soon named after him, involved the surgeon removing not only the breast itself but also surrounding musculature and the associated lymphatic system.

Halsted believed, and taught generations of medical students, that the more radical the procedure, the higher the likelihood of survival. And so this approach remained the standard of care for decades – despite his never proving that this mutilating procedure lowered mortality.

Today we know he was wrong.

Much of the aggressive and invasive health care we provide in the United States today, compared to time-tested, more conservative approaches, adds little value. And when independent scientific comparisons are done, the more complex approach often results not only in higher costs, but also in complications and adverse effects – all without significant benefit to the patient.

Recent reviews of clinical outcomes have shown that many medical problems that we might have treated in the past with aggressive surgery would have avoided threatening patient health if managed instead by watchful waiting, with routine follow-up. But despite that information doctors continue to routinely recommend intervention, even in the absence of evidence suggesting a better outcome.

Both physicians and patients frequently assume that “new” equals “improved,” possibly from reading about the newest brand of medication or operative treatment.

We should celebrate the 21st Century medical treatments that lead to remarkable outcomes. But we also need to question these aggressive treatments that add little value, and can lead to harm.

As an example, a JAMA study concluded that up to 22.5 percent of pacemakers are inserted unnecessarily. And long-term follow-up of many commonly performed surgeries demonstrate minimal impact.

An oft-cited example is low back pain. Thousands of Americans undergo disc removal or spinal fusion each year, despite limited evidence that either surgical procedure is more effective than non-operative therapy in providing long-term pain relief or improved function.

And for patients with the typical wear-and-tear osteoarthritis of the knee, physical therapy proves as successful as the commonly performed arthroscopic surgery.

Why do the recommendations by physicians to patients so often contradict the best science?

Overtreatment Explained

The reasons for this preference to intervene are easy to identify. A medical culture attempting to maintain the status quo. A reimbursement system based on fee for service that creates perverse incentives. Direct-to-consumer advertising for the latest, most expensive drugs and invasive procedures. And physicians lacking the time to explain why a procedure or drug is unlikely to make a difference and can lead to even more problems.

When patients hear words like cancer or heart attack, they immediately want everything to be done that can be. This makes sense. The psychology literature indicates our tendency to be optimistic about success and deny the likelihood of a complication occurring. As such, most of the time doing more is the default decision. Unfortunately, rather than leading to a better outcome, frequently little or no benefit is realized at dramatically higher costs.

Even when physicians try to explain the alternatives clearly, they encounter a real challenge. One procedure may have a slightly better chance of cure, but a much higher risk of complications and major long-term side effects. Helping individuals understand these percentages and weigh the impact on their lives is difficult.

Many physicians, perhaps by nature or training have a hard time accepting that many of the treatments they perform have limited benefits. It is hard to tell a patient that little more can be done that will make a difference in outcome. For the physician, this can feel like failure. And this psychological reluctance is amplified by a fee-for-service system of reimbursement that encourages physicians to do more.

Economists would predict that when doctors are paid more for doing more, and performing more complex procedures, rather than recommending simpler, more conservative approaches, they will do it. For example when a patient has prostate cancer with a very low risk of spread, watchful waiting is often the best course. But urologists who are paid much more to perform a major surgery still prefer to recommend the operative procedure despite significant risks of impotence and urinary incontinence. Similarly, the cardiologist who is paid dramatically more for performing a procedure on the heart rather than prescribing a low- cost medication is likely to do so.

The upshot? Physicians across all specialties are taught in medical training that more is almost invariably better than less, and once they open an office and are given hospital privileges, this imperative is reinforced again and again — even when they are unaware it is happening.

How Much Does An Ounce Of Prevention Really Weigh?

Prevention is often the best medicine, but even preventive screening can be taken too far.

Consider the annual physical. For healthy individuals, free of symptoms, the medical literature is clear that this visit adds little or no value. When the Cochrane Collaboration Systematic Review looked at the benefits of this visit, it concluded that patients who underwent an annual physical proved no less likely to die, be hospitalized, suffer a disability or miss work.

Naturally, people should undergo recommended preventive screening based on their age, family history and any chronic illnesses they may experience. Done appropriately, screenings reduce the chances of dying from colon, cervical and breast cancer, and minimize the chances of a heart attack or stroke.

But screening more frequently than national guidelines recommend is ineffective, a waste of time and resources. So why does this ineffective ritual of the annual physical exam continue? Psychological studies reveal that a powerful anecdote can be much more influential than data. Doctors and patients remember the one patient in a thousand for whom a routine examination found something unexpected. Meantime, they overlook the 999 for whom it made no difference and led to unnecessary tests and procedures.

Increasingly, too, national experts are questioning whether tests such as the one for prostate cancer, the PSA, are advisable. The literature reports that more than 1,000 men free of symptoms would need to be screened to save a single life – and that to find that one individual, dozens of men would need to undergo painful biopsies, complete with attendant risk of infection, nerve damage and other complications.

How We Harm The Dying

Perhaps the most extreme example where physician practice adds minimal value, often at great expense, is end-of-life care.

My elderly uncle suffered from heart failure and had a series of small strokes. From any realistic perspective, he was going to die in a matter of days. Yet when his kidneys started to fail, the consulting nephrologist ordered renal dialysis in an attempt to “reverse the abnormality.” But all the other physicians involved recognized that subjecting him to this procedure three times a week was unlikely to extend his life. Two weeks after treatments began, while hooked up to the machine, my uncle died. All the dialysis accomplished was to make his last days more uncomfortable.

By no means is this story rare. Any time I talk to audiences about futile end-of-life care, people tell me similar stories about their loved ones – about treatment that had almost no chance of making a difference, and often led to complications. But what’s most surprising is that this aggressive end-of-life care often has the opposite outcome than expected – it shortens the patient’s life.

The American Society of Clinical Oncology (ASCO) points out that “chemotherapy given in the last month of life has “little or no benefit to patients.” Yet based on data from the Dartmouth Atlas, 6 percent of cancer patients receive chemotherapy in the last two weeks of their lives. And for lung cancer patients, that percentage can be as high as 29 percent, a study in the Journal of Clinical Oncology found.

Indeed, for patients with a specific type of lung cancer, palliative care – not additional “curative” chemotherapy – significantly improved quality of life and mood, the New England Journal of Medicine concluded in a study. This is something we might have predicted. But surprisingly these same patients who received palliative care, rather than aggressive treatment, actually survived longer.

And this type of futile care is not what patients want. A study from the California Health Care Foundation reported that although 70 percent of Americans want to die at home, only about 30 percent do.

The problem is cultural, not educational. Doctors understand that chemotherapy has major, often painful side effects, and offers limited benefits in certain situations. But what they need more than additional knowledge is courage and time. They need to be able to admit when more chemotherapy is unlikely to make a difference, and to invest the time it takes to make certain the patient feels supported. Doing that may be difficult, especially since it’s less time-consuming to prescribe another round of treatment. But this approach, which requires the physician to focus on a way to manage pain, reduce anxiety and set realistic expectations, also increases the time that dying patients get to spend at the end-of-life with family and friends.

What Should We Do?

Given the cultural biases and inherent financial incentives, the issue of unnecessary care will be hard to solve. But these four steps offer promise:

1. Empower patient decision-making. New tools, including interactive videos, can help patients objectively evaluate the pros and cons of procedures and treatments. Shared decision-making using standardized aids, including printed information, videos and podcasts, is a concept that begun in the mid-1990s. These aids have been shown to increase knowledge, lower anxiety, sharpen perceptions of risks and benefits, and lead to fewer tests and elective surgeries.

2. Shift to value-based pay practices. Paying for the value of care, rather than for the volume of services, would eliminate the perverse incentives in the current fee-for- service reimbursement system. A major step in that direction was the announcement from the U.S. Department of Health and Human Services to shift 50 percent of Medicare reimbursements to reward higher quality and pay based on clinical outcomes by 2018. And this shift will be accelerated by aspects of the Affordable Care Act, Accountable Care Organizations, patient-centered medical homes and bundled payments.

3. Determine when new approaches are really better. To help accomplish this, every medical journal should require authors to compare new procedures, devices and drugs to current, often lower-cost alternatives. In a similar vein, the FDA should revise its charter to enable it to require that existing therapies be compared to new drugs and devices prior to approval. Such side-by-side comparisons would be extremely helpful not only to the health system as a whole, but to provide a direct benefit to the growing number of patients exposed to increasingly large insurance deductibles, where sounder choices could potentially save them thousands of dollars each year out of pocket.

Sloan Kettering Institute in New York City recently developed and published a new tool to better inform the decisions of oncologists and their patients – a cost effectiveness index for chemotherapy agents they prescribe. Applying this framework to all of medical care could be very powerful. If a new procedure or drug were only 5% more effective, patients and physicians might well question why manufacturers charge 100% or 200% more.

4. Reform medical malpractice. Changes to litigation for medical malpractice would lessen the burden of unnecessary care associated with defensive medicine. What motivates many doctors to do too much for patients, including much they would never choose to do for themselves, is fear of missing an extremely unlikely problem and being sued. Making malpractice litigation and awards more rational would be better for the health care system in general and patients in particular.

In the end, only when doctors and patients alike recognize that more is not always better, and how excessive care can create additional problems, will we consistently avoid treatments of borderline value. The more-is-better philosophy, and the new-equals-improved formulation, makes sense in theory, but seldom in practice.

Dr. Halsted’s ultra-radical mastectomy for women with breast cancer seemed to make sense to him and his colleagues more than 100 years. We now no longer perform that procedure, but we still cling to that belief. To do right by patients, we must start to recognize how often less is actually more.

Dr. Robert Pearl is the CEO of The Permanente Medical Group, a certified plastic and reconstructive surgeon, and Stanford University professor. Follow him on Twitter: @RobertPearlMD.

Photo by Bart Heird/ CC BY-NC 2.0