Are Today's Hospital Patients 'Overtreated'?
IRA FLATOW, host:
You're listening to TALK OF THE NATION: SCIENCE FRIDAY. I'm Ira Flatow.
Up next, when medicine can become too much of a good thing. Is your health care killing you? In her new book, my next guest argues that our health care system delivers a lot of care that we really don't need. It does not improve the health of patients. A lot of it is based on, not on sound science. In some cases, it might actually leave patients worse off than they started.
So in a system where some people are getting no health care, other people are getting too much. How can we find the balance? Joining me now to talk more about it is my guest, Shannon Brownlee, medical writer and a Schwartz Senior Fellow at the New America Foundation. Her new book is called "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer."
Welcome to SCIENCE FRIDAY, Shannon.
Ms. SHANNON BROWNLEE (Medical Writer; Schwartz Senior Fellow, New America Foundation): My pleasure to be here, Ira.
FLATOW: What made you decide to write something like this?
Ms. BROWNLEE: Well, I've been writing about medicine for more than 20 years, I hate to admit that. That tells me I'm older than 25. And the more I wrote stories about sort of how medicine was going to save us from this death in the other disease, the more I started realizing that a lot of what I was writing about didn't have very good evidence behind it. And one story in particular sort of struck me. It was the story of a very painful and ultimately useless treatment called high-dose chemotherapy for breast cancer.
And in writing this story, when I - or reporting this story when I was at US News & World Report, I started realizing there was lot of medicine that didn't have - didn't have valid science behind it, and that just stunned me.
So I got interested in sort of how this medicine really works and how do we decide what we pay for, and how the doctors decide what they're going to do.
FLATOW: Mm-hmm. So you - are you saying that a lot of medicine is just ideas handed down from generation to generation without scientific backing?
Ms. BROWNLEE: Yes.
FLATOW: That it actually works.
Ms. BROWNLEE: Yes, that's exactly what I'm saying. And it seems kind of stunning - it's the 20th century. We've had these incredible gains in life expectancy and we have all these amazing, high-tech kinds of tools that we see physicians being able to use, and many of them are quite miraculous and real breakthroughs.
But an enormous amount of medicine is not based in science. In fact, the Institute of Medicine estimates that maybe half of what physicians do has valid evidence to back it up. And another expert named David Eddy, in medical evidence, says he thinks it's about 15 percent.
FLATOW: Wow. 1-800-989-8255, talking with Shannon Brownlee about medicine. She's the author of "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer." And a lot of these things that you'd - are common, every day surgeries that people are getting.
Ms. BROWNLEE: Surgeries, tests screening tests for cancer, all kind of things. Imaging - there's all sorts of - all walks of medicine have their well-demonstrated bits and they're not-so-well demonstrated bits.
FLATOW: Mm-hmm. You mentioned knee surgery, spinal fusion surgery, tonsillectomy, radical mastectomy, all over prescribed, many cases not needed.
Ms. BROWNLEE: Well, here's the thing. Probably not needed, but we don't really know. This is the problem. We don't really know if, for example, back surgery is really any better than physical therapy, less invasive back surgery -another kind of back surgery called disceptomy - whether a person who's had this particular back surgery has actually been helped by the back surgery, if their pain went away or if their pain was going to go away by itself.
This is the problem is that we don't really know. We do know in the case of back surgery, lots of people have worst pain after their surgeries. So there's often uncertainty in medicine.
And we kind of go in assuming that physicians have more information and more data at hand than they often do.
FLATOW: Mm-hmm. And you point out that a lot of the problems that we're seeing today comes from specialization, where specialized doctors don't actually communicate with one another.
Ms. BROWNLEE: Yes, this is - there are these two economists at Harvard, Chandra and Baker, who have written a very interesting series of papers about this problem, and they call it the coordination costs.
Medicine has become increasingly specialized, the knowledge has been - become increasingly specialized, and more and more and more physicians are going into the specialties, in part, because they're paid a whole lot better than your primary care physician is.
But the problem is is that when you have many, many physicians involved in your care - if you're hospitalized or if you have a chronic disease or in multiple chronic diseases, and many specialists are involved in your care - there's nobody there coordinating your care, and it turns out that coordination is really important. It's like playing football without a quarterback and everybody is running their own play.
FLATOW: Yeah, so you sort of need your own ombudsperson.
Ms. BROWNLEE: You do, but the problem is unless - even if your ombudsperson is a physician, they are not necessarily going to be able to coordinate what those physicians do when you're in the hospital. There's a - I quote, a really wonderful doctor named Don Burwick who runs - he's trying to reduce the rates of error in hospitals, and he has an institute, the Institute for Health Care Improvement.
And he writes about his own wife's experience in several very prestigious hospitals in Boston and talks about his intense frustration at the fact that one doctor would say one thing and then something else would happen to his wife that countered - contradicted with this, you know, what one doctor said. And he couldn't - he himself could not get them all to talk to each other and really coordinate the care she was getting.
FLATOW: But the doctors are acting in good faith. They think they're doing the right thing.
Ms. BROWNLEE: Yes, they are. And they're acting within their own narrow slice of medicine. This is part of the problem. Instead, every specialist, every super specialist knows one little bit of your body at a time. The pulmonologist is concerned with your lungs. The orthopedist is concerned with your bones. The nephrologist is concerned with your kidneys, and they're not able necessarily to think about you as a whole person.
FLATOW: Mm-hmm. 1-800-989-8255, talking with Shannon Brownlee, author of "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer." Terrific stuff in this book, Shannon. One area that you looked closely at, which I think that concerns all of us is medical imaging, all these CAT scans and MRIs that are being ordered. A lot of them not medically necessary.
Ms. BROWNLEE: Yes, and it's very hard to persuade physicians or patients that seeing isn't always the same as believing. It's a very hard case to make, but it's one of the things - one of the indications that we may be imaging too much is that we aren't necessarily getting better at diagnosis and treatment in areas where we do a lot of imaging, and where imaging rates have gone up and up and up and the image have gotten better and better and better.
Yet, the incorrect diagnosis rate is staying exactly the same, and one example of that is appendicitis. You can now image somebody's belly with CT scan and look for these particular signs that say the person has appendicitis.
But what happens is that the CT image is wrong part of the time. And so when physicians start to believe that images are more important than their own sort of diagnostic abilities, their own ability to measure - that means to know that the patient has a high temperature and that they have this very specific tenderness in the lower right quadrant of the belly that they can feel with their fingers; they feel this thing called guarding, where the muscles involuntarily tighten up as you get closer and closer to where the appendix is.
So these are all classic signs of appendicitis. So, you know, the doctor in the E.R. comes along. He does all these signs and he's pretty sure you've got appendicitis. And he says to himself, just to make sure, I'll give you a CT scan. So he does the CT scan and the CT scan says, no, you don't have appendicitis, and so the physician says, well heck, I don't know what you have.
So, you get a bunch of other stuff - ultrasounds that don't show anything. And the doctor sends you home, and two days later you come back with a burst appendix. And this is a true story. And an E.R. doctor told me that story while we were standing in line, waiting for an airplane.
FLATOW: Yet, you watch television and you see a show like "House," where they came up with every single kind of tests and, you know, imaging that is possible. I want to imagine people come away saying, how come I'm not getting that…
Ms. BROWNLEE: Yeah, it's right…
FLATOW: …when I go to a hospital.
Ms. BROWNLEE: Yeah, that's right.
FLATOW: I mean, and they expect that kind of service.
Ms. BROWNLEE: That's right. And we've come to believe that more is better and more high-tech is even better than just plain more, and the end - and that the shows really contribute to that perception. But an image is a static picture of your body and your body is this dynamic thing that's changing all the time.
And images can lie. Malcolm Gladwell at the New Yorker does this beautiful essay about mammography, and he starts with a story of these very fancy cameras that bombers were using during the First Gulf War to find the scud-launching sites in Iraq.
And they would look at these little cameras and they'd see what was clearly a scud launcher and they'd bomb the daylights out of it and they were absolutely certain that they had hit all of these scud launchers. But when the military sent people in on the ground to see if they'd actually hit any, they hadn't. Seeing isn't that what the Iraqis were doing is they were running these things around. They were doing decoys that weren't the real scud launchers, and then they'd run the real scud launcher out and shoot the scud off.
FLATOW: Mm-hmm. So, seeing is not believing all the time.
Ms. BROWNLEE: Yeah.
FLATOW: I remember when we were kids, we - you may not be old enough to remember the fluoroscopes you got in the shoe stores to look at your feet and things like that.
Ms. BROWNLEE: I don't remember that.
FLATOW: They were cool.
Ms. BROWNLEE: But that's because I grew up where we didn't have to wear shoes.
(Soundbite of laughter)
Ms. BROWNLEE: I grew up in Honolulu.
(Soundbite of laughter)
FLATOW: That may be true, but then, we're exposing ourselves to all this unnecessary radiation.
Ms. BROWNLEE: Yes.
FLATOW: Are kids getting these CAT scans and other x-rays and being exposed then to unnecessary amounts of radiation unknowingly?
Ms. BROWNLEE: There are some people who are worrying about this right now, that there is this sort of sleeping epidemic that we haven't seen yet, but as the number of CT scans goes up - and CT scans are basically a whole lot of little x-rays - you get a pretty good dose. You think of a CT scan for scanning your chest when you're having a cardiac procedure is the equivalent of at least a couple of thousand chest x-rays. It's a lot of radiation.
FLATOW: A couple of thousand chest…
Ms. BROWNLEE: A couple of thousand.
Ms. BROWNLEE: Now, if I'm off by a zero, don't blame me. If there's a caller out there who knows the right answer, please call and tell us.
Ms. BROWNLEE: But it's a lot of radiation.
FLATOW: Even if that's a couple of hundred.
Ms. BROWNLEE: Even if it's a couple of hundred.
Ms. BROWNLEE: There are people who are now concerned that especially for children whose bodies are especially susceptible to radiation and they're small. A CT scanner on a kid is a whole lot more radiation per body size than the same CT scan on an adult. And there are really concerns that by giving children repeated CT scans for a bump on the head, for a little, you know, a little worry about appendicitis or whatever it is that isn't necessarily contributing to a better diagnosis, a better treatment, may down the line be contributing to increased rates of cancer.
FLATOW: Hmm. And you talk about, in your book, about some doctors who are bucking the trend who say, well, maybe we're doing too many CT scans.
Ms. BROWNLEE: Yes.
FLATOW: And they don't get treated very well.
Ms. BROWNLEE: Well, I have this wonderful doctor at the University of New Jersey Medical School who's the head of the radiology department, and he is one of the iconoclasts who's been saying we need to reduce the number of scans we're doing. We really need to rethink how we're going about this, and he teaches his residents that. He's kind of one-man band there, and his whole department feels this way, but he's a rarity.
FLATOW: He sort of looked like as a maverick.
Ms. BROWNLEE: Yes, he is looked on as a maverick.
FLATOW: Talking about overtreating this hour in TALK OF THE NATION: SCIENCE FRIDAY from NPR News, talking with Shannon Brownlee, author of "Overtreated: Why Too Much Medicine Is Making Us Sicker And Poorer." And we never even got to this part yet about the economics of this whole thing. I mean…
Ms. BROWNLEE: It's enormous.
FLATOW: And that's part of the reason why we're having all these tests.
Ms. BROWNLEE: Yes.
FLATOW: Because they make money on these tests.
Ms. BROWNLEE: That's right. I mean, the problem is that we have a payment system that pays hospitals and physicians to do more not to do better. It pays for quantity not quality. And it is a peculiar system we have. There's a similar system in Canada, but they have budget caps and so they don't spend quite as much as we do. But the most of the other developed countries in Western Europe have systems where physicians are paid salaries for the most part and then they pay hospitals in different ways. But our system is really this very deep piggy bank for the medical industrial complex.
And physicians - and I'm not saying your physician is standing there, sort of rubbing his hands together saying, ha, ha, ha, you know, what can I do to give you another procedure so I can make more money. I don't think most physicians are that way. They aren't any greedier than the rest of us, but the system encourages more in every way, and that's part of the problem.
FLATOW: Mm-hmm. And…
Ms. BROWNLEE: The - sorry, go ahead.
FLATOW: No, I'm sorry. I'm trying to figure out because we're all stuck with a health care system that we know is broken. In your research on the book and your conclusions, what's a consumer to do? How do you, you know, not get overprescribed and not pay too much and find the right way to get, you know, medicine?
Ms. BROWNLEE: Number one, you can start choosing which hospital you go to if you have a choice. Now, part of the problem is is that hospitals in regions tend to overtreat. They tend to have lots and lots of specialists in them, like the region around Los Angeles has its - all of the hospitals there tend to be more likely to give people unnecessary care than, say, hospitals in Seattle in that region.
But if you do have a choice, one of the things you can do is go to a place called dartmouthatlas.com, www.dartmouthatlas.com - same word as the college, Dartmouth College - and look there for a hospital in your area. And they talk about - on the atlas, they talk about how much care and how many specialists there are at particular hospitals.
The problem is is that in trying to decide who's delivering really good quality, we don't really have very good measures. So if you go to something like US News & World Report, what you're going to see is basically a popularity contest, because much of the data that U.S. News uses is really reputation data among other physicians. That's how they sort of decide the Johns Hopkins is really terrific and Beth Israel up in Boston and UCLA in Los Angeles. But if you're concerned about getting too much care, you go to the dartmouthatlas.com.
But other thing we can do as patients is there are many things, many procedures that we should be making choices about whether we want them or not and sharing the decision with our physicians. And this is kind of a new idea, where you, the patient, really need to get a lot of information.
Sometimes, you can get it from the Web. Sometimes, your physician has ways of giving you information in a way that you can really understand so that you can understand the risks and the benefits on either side of getting a procedure, not getting a procedure.
FLATOW: Mm-hmm. And then, you have to make the judgment on your own.
Ms. BROWNLEE: You have to decide what you value and that should - and your own personal values should come into the decision especially when there's a great deal of uncertainty. So an example where the person's values comes in very strongly would be if you decide - whether you decide to get a mastectomy or a lumpectomy with radiation for early stage breast cancer. It turns out they're equally effective. You have equal likelihood of never having a recurrence. But you have to be the one who decides what you value the most.
FLATOW: All right. Shannon, we've run out of time. But I want to thank you for taking time to enlighten us about this and give us some good advice. Shannon Brownlee is a medical writer and a Schwartz senior fellow at the New America Foundation, author of "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer."
Stay with us, we'll be right back. I'm Ira Flatow. This is TALK OF THE NATION: SCIENCE FRIDAY from NPR News.
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FLATOW: This hour we're talking with Shannon Brownlee. We're going to bring her back for a little bit longer. We have some more time. I thought she had to go. She is medical writer, Schwartz senior fellow at the New America Foundation. And her new book is called "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer." Sorry, Shannon.
Ms. BROWNLEE: That's okay.
FLATOW: Let's take a couple of phone calls if we can. Let's go to Beth(ph) in Dayton, Ohio. Hi, Beth.
BETH (Caller): Hi.
FLATOW: Hi, there.
BETH: Shannon Brownlee's comment about the appendix really hit home with me because I had the exact opposite experience with my husband. Sometimes, the doctor's feeling isn't enough because not all diseases present the way you expect them to. His appendicitis didn't present with the guarding in that specific area. He just presented with excruciating pain from his groin up to his chest, and they sent him home with gastroenteritis. And his appendix burst because of that. And it wasn't until he had the CAT scan that they saw what it was. So - and he wound up being in the hospital for two weeks for something that would have taken two days if they would have done the CAT scan in the first place. So sometimes they're…
Ms. BROWNLEE: That's a thank you - oh, sorry. Thank you for that example because it's a really beautiful example of sort of how to use a CAT scan judiciously. You think the person might have appendicitis, but you aren't getting one of the clinical signs that would really tip you off, and so then you do the CT scan to help you make the decision, help you make the diagnosis and you go, aha. Now the hard part is is that even then it might not have shown up on the CT scan. That's the thing is it doesn't always show up.
FLATOW: Mm-hmm. So you're saying…
Ms. BROWNLEE: So - sorry, go ahead.
FLATOW: No, I'm sorry. Thanks, Beth, for calling. So you're saying that first, you practice good old-fashioned hands-on medicine…
Ms. BROWNLEE: Yeah…
FLATOW: …and then rely on the test a little bit later.
Ms. BROWNLEE: Yeah, exactly. Use the test as one of the tools in your armamentarium, but don't - but what happens is physicians tend to rely on the visual. They rely on the imaging because they think the imaging tells the truth all the time. But in fact, the image tells the truth most of the time, but doesn't always just like clinical signs don't always tell the truth.
FLATOW: Let's go to Ben(ph) in Palo Alto. Hi, Ben.
BEN (Caller): Hi, there. And thanks for having me. I'm actually a surgeon. And I was listening to this and thinking, you know - two comments. One is that oftentimes, it's not we who are pushing the extra testing. I was just sitting with a patient yesterday who was pushing me to get an MRI that I really don't need and wasn't going to be satisfied until I ordered the MRI no matter what I said, even though it's not really going to change the course of treatment. So it's oftentimes, the patients and the physicians - the medical machine-pushing things.
The second comment is you brought up a beautiful example of mastectomy versus lumpectomy and radiation, which is something I deal with all the time. And I'm not sure which side you're following on this basic invasive or less expensive approach. But for instance, if patients were choosing lumpectomy and radiation because they think that's going to be less expensive and less dealings, in fact, in the long-term, radiation therapy makes breast reconstruction more expensive and more complicated. And sometimes, the result of that radiation therapy and lumpectomy can be pretty severe. They may not be in terms of numbers any different, but having taken care of these patients for 15 years, I can tell you that there is no simple solution there. So I just wanted to make those two comments.
FLATOW: Thanks for calling, Ben.
Ms. BROWNLEE: Those are both really wonderful comments. Thank you very much. It's absolutely true that we as patients have come to sort of believe that we need more and that we're not getting treated right unless we're getting every test in the book, when in fact that's often not what you really want to have. The other comment about mastectomy and lumpectomy really hammers on the point that patients need to be fully informed about what all of the risks are on each side and all of the benefits are on each side and then they need to make that decision.
FLATOW: All right. Now, Shannon, now, I have to say goodbye.
(Soundbite of laughter)
Ms. BROWNLEE: For real?
FLATOW: But we'll get the name of your book in again and drive up through Amazon reading terrifically for this afternoon.
(Soundbite of laughter)
FLATOW: Thanks for taking time to be with us, okay.
Ms. BROWNLEE: My pleasure. Thanks, Ira.
FLATOW: You're welcome. Shannon Brownlee is a medical writer and author of "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer."
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