“Life-threatening diseases go undetected in some cases. In others, patients are treated for conditions they do not have.” The continued debate on overtesting within the U.S. healthcare system was recently exposed by a new F.D.A investigation conducted by federal investigators, discussed in the article “F.D.A. Targets Inaccurate Medical Tests, Citing Dangers and Costs” by Robert Pear. In the article, Pear discusses the various findings of the newly released federal study, which concluded that “Patients have been demonstrably harmed or may have been harmed by tests that did not meet F.D.A. requirements.”
Studies Find Declines in Screening and Early Detection of Prostate Cancer
The article, “Studies Find Declines in Screening and Early Detection of Prostate Cancer,” by Denise Grady discusses the findings of two studies published in the AMA journal that suggest that prostate cancer screenings are happening less and less for men. The reason for the decline in screenings is that “there is less effort to find it” and by a “recommendation….made in 2012 by the United States Preventative Services Task Forces”. The Task Force’s reason for this decline in screening is that the “risks outweigh the benefits” and with more testing “there is unnecessary surgery and radiation” involved.
I believe that this article highlights the importance in identifying the conundrum that the healthcare system has in providing good care and services to people without providing too much or too little. Overutilization is a real problem in the healthcare system. There is a chance that testing can cause more harm than good. However, there is also a chance that we may not be doing enough in preventative care for chronic diseases. If zero men are being screened then there is likely a higher chance of prostate cancer cases being missed or not diagnosed.
The article suggests that less testing correlates with less cases of prostate cancer, but this statement is not verified. I doubt whether there is enough evidence or research to make this conclusion. There could be other reasons for less cases such as environmental factors.
Grady suggests that “better ways to screen [are] needed.” Screening can be both cost effective and preventative. If doctors can narrow down “high risk” patients they will be more successful in finding prostate cancer. Unnecessary screening can be avoided and necessary screening can be administered.
Ultimately, I think there is much need for an overhaul in the way we provide healthcare to patients. Problems with preventative testing does not just affect men, but it also affects women. Some women are required to have annual mammograms to screen for breast cancer or suspicious tumors. Does the radiation from this screening cause more cancer cases? When is preventative care too invasive and harmful? How can we tell? Further research needs to be conducted to determine the effect of this relationship.
In Groopman’s book How Doctors Think, he harps on an important concept that I though was similar to a main point in the ted talk. In his description of the case for the patient Anne Dodge, Groopman quotes the doctor who solved her case, Dr. Falchuk. Dr. Falchuk explains how even though he received a patient who has seen many other doctors, he started from scratch and let her talk freely. The doctor allowed her to begin from the start of her condition, even though it was something that had been going on for 15 years. Dr. Falchuk asked an open ended question, which influenced his patient to answer more openly, which in turn, helped lead to a correct diagnosis.
Does the way a doctor phrases a question (open ended/ closed ended) affect the response that the doctor gets from the patient? Do open ended questions take up too much of a doctors time? Do open ended questions lead to an over diagnosis of a patient?
In the article “How Long Is Too Long for Antibiotics in Acne?” the advantages and disadvantages of long-term antibiotic treatment for acne are discussed, and it was ultimately determined that most patients on this treatment are on it for too long before being switched to more effective treatment. Arielle R. Nagler, MD published her findings in The Journal of the American Academy of Dermatology, and her results show “that the average duration of antibiotic use was 11 months,” with “almost two-thirds (64.6%) of young adult patients were treated with antibiotics for their acne for 6 months or more” and “a third (33.6%) on antibiotics for a year or longer.” The remaining “15.3% of patients were taking antibiotics for 3 months or less.” The article goes to say that physicians should be able to determine sooner than that whether or not a certain treatment is working, and that they need to forgo ideas that certain antibiotics are universally “superior” to other, similar antibiotics. In addition, Nagler hopes to see more research on alternative treatments in the future.
The Boston Globe article, “A medical collision with a child in the middle” discusses a term that I have never heard before: “medical child abuse”. This is a new term that is used to describe a broad range of cases where health care providers believe that parents are harming their children by pushing for unnecessary tests and treatments for their children. This term along with the story told in the article about Justina and the Pellitiers, made me think about how this new allegation shifts the doctor-patient relationship. There is a certain amount of patient choice in the doctor patient relationship but in the case of most children, this patient choice is a decision for a child’s parents. By taking away parent’s custody of their children, are hospitals removing patient choice from this relationship? If an adult patient is pushing for certain treatments or tests, doctors can refuse but that is not as extreme as parent’s losing custody of their children. Without their parents, how does the doctor patient relationship change for children?
What’s the problem with medicalization? If people with anxiety are better able to live their lives with medication that they’re given once they’re diagnosed with SAD, then what’s so bad about it? Shouldn’t the greater fear be that there are people who aren’t getting treatment because their symptoms aren’t recognized?
At the very least, how can doctors and healthcare providers draw the line between medicalization and overdiagnosis or even misdiagnosis?
“New Screening Guidelines Won’t Assure Fewer Mammograms”
This New York Times highlights how healthcare providers will not necessarily follow the new screening guidelines suggested for breast cancer detection. Recent research has found that annual mammograms for women over the age of 40 are not as beneficial as previously thought. As a result, the American Cancer Society has updated its recommendation, stating that women should not begin annual mammogram screening until age 45 through age 55; then, they should receive screening every other year until they are at an age expected to have less than 10 years of life left. The ACS also recommends eliminating clinical breast exams entirely. These recommendations are based off of several studies, including one that showed a higher proportion of breast cancer diagnosis occurs when women are premenopausal. However, after menopause this proportion significantly decreases. This explains the ACS recommendation for annual screening to stop after age 55 and occur biannually. Harm also results from false positive findings, which can result in a second exam, another screening, or a biopsy. A cohort study conducted in 2005 concluded that performing a clinical breast exam as well as a mammogram resulted in the detection of 0.4 extra cancers as well as 20.7 false positive tests per 1,000 women. This depicts that the cost of performing these extra tests outweighs the benefit. Another study showed that using biennial screening instead of annual screening in women 50 to 69 might result in 57,000 fewer false positives over all for every 100,000 women over 10 years.
Although these studies prove that the ACS recommendations are valid, changing current screening procedures will be difficult for several reasons. Physicians have been conditioned to approach breast cancer prevention aggressively and to be invasive. Studies show that once this happens it is hard for them to reverse course. Moreover, physicians tend to believe that providing more care protects them from lawsuits and malpractice. Lastly, financial incentives also play a role in unnecessary screening.
This article relates to the concept of overtreatment that we discussed in class. The biopsy and screening not only cause unnecessary risks, but also unnecessary money to be spent on screening that is not benefiting the patient. Consequently, one of the reason the new screening guidelines will not assure fewer mammograms is that physicians are driven by financial incentive to provide more mammograms to their patients in order to generate higher income. In turn, unnecessary mammograms can be justified by stating that more care protects the patient by ensuring that harmful results do not go undetected. This is the fundamental justification for overtreatment; being extra cautious when it comes to preventative treatment outweighs the risks associated with the additional unnecessary treatment. Although a significant amount of studies have been performed proving the ACS recommendation for less frequent mammograms is logical, several factors are at play making physicians hesitant to follow these guidelines. These factors include the fear of being sued for malpractice due to insufficient care and the advancing of the medical field toward a profit-driven consumerist business.
Overtreatment in the United States has been an issue pushed to the forefront of health care debate in recent years. Overtreatment is defined as providing unnecessary health care, whether it be invasive procedures or prescribing medicine, to a patient by a doctor who more often than not is incentivized by money. A New York Times article written by Julie Creswell examines the issue of overtreatment in a small Indiana town.
I read a news article recently about a woman in a small town in Indiana who found out about her doctor being sued for performing unnecessary operations. This woman had been going to this cardiologist for more than 30 years. When she was 27 years old, she first came to this doctor regarding an abnormality in her heartbeat, and the doctor told her that an open heart surgery would be necessary to fix this problem. She did not question the procedure at the moment. However, a number of patients of this town have recently filed lawsuits against this doctor and two other physicians that work with him. In response to these lawsuits, it was discovered that these doctors received nearly $5 million in Medicare reimbursements, making them the most reimbursed cardiologists in Indiana.
This article reminded me about what we have been talking about in class about the “Overkill” idea and how the payment method in the US promotes that doctors prescribe more medications, more treatments, and more surgeries. I find this incident very worrying because of the lack of professionalism of such doctors in treating their patients. While some people might argue that patients should be aware of this trend and be knowledgeable about their health, so they can avoid this over diagnosis, I personally believe that this is a “Band-Aid” solution to the problem. While it is true that patients should be involved in their medical appointments and their treatments, it should not be the patient’s concern to investigate whether or not the treatment they are receiving is actually necessary, or just a way for doctors to earn more money. Patients are not supposed to have the academic and clinical experience that a doctor has; after all, this is why they come to the doctor to begin with. Rather, the system should be settled in a way that doctors are not rewarded for doing this.
One thing that I found surprising is how our healthcare system compares to other countries’. The U.S. spends the most money on healthcare than any other country but our life expectancy and infant mortality rate is worst than every other well developed nation. I use to think that the U.S. had one of the best medical research centers and that our healthcare was one of the best in the world. One of the reasons I used to think that was because the United States is one of the most powerful nations in the world so consequently I thought that the healthcare system would be the best. Someone would think that with all the money the U.S. spends on healthcare, it would be the best in the world. Continue reading “Process Reflection 1”