By some estimates, unnecessary medical treatment constitutes one-third of medical spending in the United States. Some doctors are finally acknowledging publicly (in The New York Times) that “Overuse is one of the most serious crises in American medicine.” The crisis is not only of misspending of resources, overuse of medical treatments is causing treatment-induced harm, including preventable deaths.
An important development is that some medical specialties are addressing the crisis by recommending less tests and less unnecessary treatment.
The American Board of Internal Medicine Foundation (ABIM Foundation) is leading an initiative, called Choosing Wisely, which has garnered 9 professional medical specialty partners with 8 others preparing to follow. These partners include:
- American Academy of Allergy, Asthma & Immunology
- American Academy of Family Physicians
- American College of Cardiology
- American College of Physicians
- American College of Radiology
- American Gastroenterological Association
- American Society of Clinical Oncology
- American Society of Nephrology
- American Society of Nuclear Cardiology
These specialty societies represent 374,000 physicians. Each society has developed a list of "Five Things Physicians and Patients Should Question" which you can access from the choosingwisely .org website
Additionally, eight new specialty societies have joined the campaign and will be releasing lists in fall 2012:
- American Academy of Hospice and Palliative Medicine
- American Academy of Otolaryngology–Head and Neck Surgery
- American College of Rheumatology
- American Geriatrics Society
- American Society for Clinical Pathology
- American Society of Echocardiography
- Society of Hospital Medicine
- Society of Nuclear Medicine
Conspicuously absent from the list of specialty societies that are acknowledging an over-use of tests and treatments, are ALL the neuropsychiatric associations, such as:
the American Psychiatric Association, the American College of Neuropsychopharmacologists, the American Academy of Neurology, the American Neurological Association–indeed the very specialties that have been in the cross-hairs of controversy precisely because of their overuse–if not abusive prescribing practices. Psychiatry has generated unprecedented profits for pharmaceutical companies and for psychiatry’s societies.
Unfortunately, the exponential increase in the use of expensive drugs–in particular, the new, neuroleptics (antipsychotics), antidepressants, and so-called mood stabilizers–has severely undermined the health of those who ingested them–without demonstrable clinical value. What’s more, since psychiatrists and neurologists have been widely prescribing these drugs singly and in untested drug cocktails, the number of people–including toddlers–who are being "diagnosed"–on the basis of arbitrary check lists, then prescribed toxic psychotropic drugs–has exponentially increased, rather than decreased.
THE NEW YORK TIMES
April 4, 2012
Doctor Panels Recommend Fewer Tests for Patients
By RONI CARYN RABIN
In a move likely to alter treatment standards in hospitals and doctors’ offices nationwide, a group of nine medical specialty boards plans to recommend on Wednesday that doctors perform 45 common tests and procedures less often, and to urge patients to question these services if they are offered. Eight other specialty boards are preparing to follow suit with additional lists of procedures their members should perform far less often.
The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.
“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative. “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”
Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters. But their change of heart also reflects recent changes in the health care marketplace.
Insurers and other payers are seeking to shift more of their financial pain to providers like hospitals and physician practices, and efforts are being made to reduce financial incentives for doctors to run more tests.
The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine Foundation and in partnership with Consumer Reports.
The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.
The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.
Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.
Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.
“Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. “With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.”
Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, disagreed, saying the United States can pay for all Americans’ health care needs as long as care is appropriate: “In fact, rationing is not necessary if you just don’t do the things that don’t help.”
Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.
Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation.
Still, many specialists and patient advocates expressed caution, warning that the directives could be misinterpreted and applied too broadly at the expense of patients.
“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder. “This kind of one-size-fits-all approach can be a real detriment to good care.”
Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.
“I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.”
Many commended the specialty groups for their bold action, saying the initiative could alienate their own members, since doing fewer diagnostic tests and procedures can cut into a physician’s income under fee-for-service payment schemes that pay for each patient encounter separately.
“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”
This article has been revised to reflect the following correction:
Correction: April 4, 2012
An earlier version of this article misidentified, at one point, the organization whose member groups recommend that doctors curb the use of 45 common medical tests that may be unnecessary. It is the American Board of Internal Medicine Foundation, an organization that promotes physician professionalism — not the American Board of Internal Medicine, the specialty board with which it is affiliated.