Friday, May 22, 2015

qotd: Atul Gawande and the overutilization narrative

The New Yorker
May 11, 2015
An avalanche of unnecessary medical care is harming patients physically
and financially. What can we do about it?
By Atul Gawande

Could pointless medical care really be that widespread? Six years ago, I
wrote an article for this magazine, titled "The Cost Conundrum," which
explored the problem of unnecessary care in McAllen, Texas, a community
with some of the highest per-capita costs for Medicare in the nation.
But was McAllen an anomaly or did it represent an emerging norm? In
2010, the Institute of Medicine issued a report stating that waste
accounted for thirty per cent of health-care spending, or some seven
hundred and fifty billion dollars a year, which was more than our
nation's entire budget for K-12 education. The report found that higher
prices, administrative expenses, and fraud accounted for almost half of
this waste. Bigger than any of those, however, was the amount spent on
unnecessary health-care services. Now a far more detailed study
confirmed that such waste was pervasive.

I decided to do a crude check. I am a general surgeon with a specialty
in tumors of the thyroid and other endocrine organs. In my clinic that
afternoon, I saw eight new patients with records complete enough that I
could review their past medical history in detail. One saw me about a
hernia, one about a fatty lump growing in her arm, one about a
hormone-secreting mass in her chest, and five about thyroid cancer. To
my surprise, it appeared that seven of those eight had received
unnecessary care.

Virtually every family in the country, the research indicates, has been
subject to overtesting and overtreatment in one form or another.

Another powerful force toward unnecessary care…: the phenomenon of
overtesting, which is a by-product of all the new technologies we have
for peering into the human body.

Overtesting has also created a new, unanticipated problem:
overdiagnosis. This isn't misdiagnosis—the erroneous diagnosis of a
disease. This is the correct diagnosis of a disease that is never going
to bother you in your lifetime.

My last patient in clinic that day, Mrs. E., a woman in her fifties, had
been found to have a thyroid lump. A surgeon removed it, and a biopsy
was done. The lump was benign. But, under the microscope, the
pathologist found a pinpoint "microcarcinoma" next to it, just five
millimetres in size. Anything with the term "carcinoma" in it is bound
to be alarming—"carcinoma" means cancer, however "micro" it might be. So
when the surgeon told Mrs. E. that a cancer had been found in her
thyroid, which was not exactly wrong, she believed he'd saved her life,
which was not exactly right. More than a third of the population turns
out to have these tiny cancers in their thyroid, but fewer than one in a
hundred thousand people die from thyroid cancer a year. Only the rare
microcarcinoma develops the capacity to behave like a dangerous,
invasive cancer. (Indeed, some experts argue that we should stop calling
them "cancers" at all.) That's why expert guidelines recommend no
further treatment when microcarcinomas are found.

Nonetheless, it's difficult to do nothing. The patient's surgeon ordered
a series of ultrasounds, every few months, to monitor the remainder of
her thyroid. When the imaging revealed another five-millimetre nodule,
he recommended removing the rest of her thyroid, out of an abundance of
caution. The patient was seeing me only because the surgeon had to
cancel her operation, owing to his own medical issues. She simply wanted
me to fill in for the job—but it was a job, I advised her, that didn't
need doing in the first place. The surgery posed a greater risk of
causing harm than any microcarcinoma we might find, I explained. There
was a risk of vocal-cord paralysis and life-threatening bleeding.
Removing the thyroid would require that she take a daily
hormone-replacement pill for the rest of her life. We were better off
just checking her nodules in a year and acting only if there was
significant enlargement.

H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on
overdiagnosis, and in his excellent new book, "Less Medicine, More
Health," he explains the phenomenon this way: we've assumed, he says,
that cancers are all like rabbits that you want to catch before they
escape the barnyard pen. But some are more like birds—the most
aggressive cancers have already taken flight before you can discover
them, which is why some people still die from cancer, despite early
detection. And lots are more like turtles. They aren't going anywhere.
Removing them won't make any difference.

We've learned these lessons the hard way. Over the past two decades,
we've tripled the number of thyroid cancers we detect and remove in the
United States, but we haven't reduced the death rate at all. In South
Korea, widespread ultrasound screening has led to a fifteen-fold
increase in detection of small thyroid cancers. Thyroid cancer is now
the No. 1 cancer diagnosed and treated in that country. But, as Welch
points out, the death rate hasn't dropped one iota there, either.
(Meanwhile, the number of people with permanent complications from
thyroid surgery has skyrocketed.) It's all over-diagnosis. We're just
catching turtles.

What if I recommend not operating on a tiny tumor, saying that it is
just a turtle, and it turns out to be a rabbit that bounds out of control?

Mrs. E., my patient with a five-millimetre thyroid nodule that I
recommended leaving alone, feared doing too little. So one morning I
took her to the operating room, opened her neck, and, in the course of
an hour, removed her thyroid gland from its delicate nest of arteries
and veins and critical nerves. Given that the surgery posed a greater
likelihood of harm than of benefit, some people would argue that I
shouldn't have done it. I took her thyroid out because the idea of
tracking a cancer over time filled her with dread, as it does many
people. A decade from now, that may change. The idea that we are
overdiagnosing and overtreating many diseases, including cancer, will
surely become less contentious. That will make it easier to calm
people's worries. But the worries cannot be dismissed. Right now, even
doctors are still coming to terms with the evidence.

Two hours after the surgery, Mrs. E.'s nurse called me urgently to see
her in the recovery room. Her neck was swelling rapidly; she was
bleeding. We rushed her back to the operating room and reopened her neck
before accumulating blood cut off her airway. A small pumping artery had
opened up in a thin band of muscle I'd cauterized. I tied the vessel
off, washed the blood away, and took her back to the recovery room.

I saw her in my office a few weeks later, and was relieved to see she'd
suffered no permanent harm. The black and blue of her neck was fading.
Her voice was normal. And she hadn't needed the pain medication I'd
prescribed. I arranged for a blood test to check the level of her
thyroid hormone, which she now had to take by pill for the rest of her
life. Then I showed her the pathology report. She did have a thyroid
cancer, a microcarcinoma about the size of this "O," with no signs of
unusual invasion or spread. I wished we had a better word for this than
"cancer"—because what she had was not a danger to her life, and would
almost certainly never have bothered her if it had not been caught on a


Comment by Don McCanne

Yesterday's Quote of the Day discussed the harm done by our health care
reform agenda that overemphasizes attacking overutilization while
neglecting more compelling goals of reform. Atul Gawande has been one of
the more credible and outspoken voices in raising the alarm on
overutilization, especially with his widely referenced 2009 New Yorker
article on the excessive use of health care services in McAllen, Texas.
But where does Dr. Gawande stand when he is faced with health care
utilization questions regarding his own patients?

In his current New Yorker article, "Overkill," he describes the
overtesting and overdiagnosis of thyroid carcinoma, which, in turn,
results in overtreatment - all manifestations of overutilization of
health care. For his own patient with a very small thyroid nodule, he
recommended leaving it alone - a recommendation that is well supported
in the medical literature.

Yet, apparently because the patient wanted something done, he elected to
remove her thyroid gland. She did turn out to have a microcarcinoma, but
he reports that it "was not a danger to her life, and would almost
certainly never have bothered her." She manifested two common problems
of overutilization: 1) a post-operative complication (hemorrhage
requiring a second operation), and 2) significant costs that were
unnecessary but added to the very high costs of health care paid by all
of us through taxes or insurance premiums.

Thus Dr. Gawande is himself an overutilizer while preaching the evils of
overutilization. Our current policy priorities are to combat
overutilization. What should be done in Dr. Gawande's case? Should he
and the hospital be denied payment for the thyroidectomy? Should he be
assigned low quality scores that will reduce future payments for his
health care services? Should he be disciplined by the appropriate
medical staff committee? Was his violation serious enough to report him
to the state medical licensing board for consideration of disciplinary

No to all of these. He is a highly respected, ethical surgeon who
certainly tries to do the right thing. He did make a clinical decision
that could be challenged, especially in today's environment where
overutilization is the primary target in health care reform.

Most cases of supposed overutilization as reported in many studies, such
as those from Dartmouth, represent similar judgmental decisions in which
opinion as to the optimal way to proceed would vary amongst the best of
authorities, and Dr. Gawande's judgement in this case falls within the
realm of acceptable medical practices (she did have cancer!).

We do not have and likely never will have processes through which we can
identify, with certainty, medical care that should be aborted in advance
because it clearly would constitute overutilization. Complex clinical
settings defy clarity in health care utilization. (There are exceptions
in which clear guidelines can be established, and those guidelines
certainly should be enforced.)

As mentioned yesterday, designing health policy based on overutilization
has been detrimental because it results in concepts such as
patient-driven health care, especially high deductibles, that have
impaired patient access to beneficial medical care and have exposed
patients to financial hardship. It also has generated concepts such as
accountable care organizations that, to this date, have not accomplished
much more than to increase the profound administrative waste that
permeates the U.S. system.

Our efforts should not be directed to trying to ferret out reputable
physicians such as Dr. Gawande, accuse them of overutilization, and
chase them out of the profession. That could be all of us, and who then
would be left to care for patients? (This is not to say that we
shouldn't rein in blatant abusers.)

Instead we should turn our attention to policies that would would make
health care truly universal, comprehensive, equitable, accessible, and
priced appropriately, while increasing efficiencies through policies
that would actually be effective in recovering waste - the prime example
being the replacement of our expensive, fragmented system of financing
care with an efficient single payer national health program.

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