One Doctor's Quest to Cut Unneeded Treatments

medical care

We all know about medical malpractice. That is when a physician does something necessary but does it inexcusably poorly. I call that Type I Medical Malpractice.

Type II Medical Malpractice is when a physician or surgeon does the unnecessary, even if it's done well. Type II Medical Malpractice is a scourge in America.

When we think of modern medical miracles, all of us focus on dramatic events: hands are sewn back on, victims of horrific accidents and terrible infections live to work and smile again... the stuff of television programs.

Then there are all the medical miracles that we've come to take for granted: blocked heart vessels are opened or bypassed, breasts are removed for cancer and reconstructed, knees are repaired through tiny punctures... and all else that most want done to them if needed.

Science has learned how to ask whether any modern medical miracle really works. Would we have done as well, even better, without the miracle? Science has learned to do this with experiments that compare patients treated with the new "bell and whistle" compared to those treated the older way. For pharmaceuticals, such experiments are required before the drug is licensed. For procedures and devices, science relies on studies after-the-fact.

The result is that many such studies are available, covering nearly all the medical miracles we have come to take for granted. Many scientists commit vast amounts of time and effort to collecting these studies, assessing their quality, and teasing out whether there is evidence for a miracle. We're talking about thousands of scientists around the world involved in this effort.

Many are participating in the Cochrane Collaboration based at Oxford University in England and supported by monies from various governments. There are other groups including the United States Preventive Services Task Force and a group based in Canada but affiliated with the American College of Physicians. Society is swimming in documents asking whether science could or could not discern any evidence for a positive effect for over 5,000 modern medical and surgical miracles.

Some Health Care Costs May Outweigh Medical Benefits

We're in for a shock if we ask if there is either no evidence for benefit, or when there's evidence for benefit, is the benefit is too trivial to care about. Here's a partial listing of tests and procedures that, in my opinion, we must re-examine:

1) Oral hypoglycemic drugs for Type 2 Diabetes do not spare one from heart attacks, strokes, kidney failure, skin ulcers or anything else you might care about, including death before your time.

2) If you think coronary artery bypass surgery or angioplasty with or without stents can save your life or improve your angina, think again.

3) No one should submit to a screening test unless: the test is accurate, the disease is important and we can do something about the disease. Screening mammography, PSA, HbA1c and cholesterol all fail by at least one criteria.

4) The argument that arthroscopic surgery for your knee will do something good for you in the short or long term is an example of the power of belief over science.

5) Anyone who thinks that any form of surgery can benefit isolated low back pain has been fooled.

6) Any well woman who thinks treating a low bone mineral density will result in anything meaningful for them has been sold another old wives' tale. Since this is so, bone mineral density screening of well women is foolish.

And that's just for starters. The menu of Type II Medical Malpractice is long, high-priced, counter-intuitive, and incontrovertible.

It is outrageous that we Americans are asked to share the cost of providing this for each other. Refusing to do so is the rallying cry for rational health care reform, and it's long overdue.

The "stimulus bill" is spending over $2 billion for "comparative effectiveness trials." That's reinventing the wheel and postponing the reckoning.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America," and "The Last Well Person."

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