It is nearing midnight on a Saturday. It has been a marathon week. Just as your friendly Omaha doctor drifts off to sleep, his cellphone buzzes.
The patient — that would be you — is sick, seriously sick, but it's not life-threatening, the voice on the other end of the line tells the doctor.
Doc has a decision to make: He can treat you on an outpatient basis, or he can admit you to the hospital.
If he goes the outpatient route, he will need to make a flurry of phone calls to set up blood tests, lab work and care. He will not be paid a dime for this middle-of-the-night work he does in his pajamas.
If he admits you to the hospital, it's one phone call. He will go back to bed, sleep, wake up, pull on his white coat and see you in the morning — and he will be paid handsomely for doing so.
Of course, it will also cost you and the entire health care system more money.
Also, it probably won't make you any healthier.
“Think about how strange that is,” says Dr. Thomas Tape, a veteran doctor who is chief of the University of Nebraska Medical Center's division of general internal medicine. He's also the chairman of the board of governors for the country's second-largest physicians group.
“Our entire health care system in this country pushes people to go into hospitals, not keep them out.”
Tape is an Omaha voice in a rising chorus of American doctors demanding that the medical establishment and average patients alike rethink the way we hand out tests, scans and procedures like they are lollipops in a jar on the doctor's office counter.
The status quo has become shockingly, unsustainably costly, Tape thinks. And in many cases, it's not making us better.
We waste some $210 billion every year on overtreatment, according to the Institute of Medicine, a highly regarded and nonpartisan group that serves as the health arm of the National Academy of Sciences. That's right: Unnecessary tests, duplicate lab work and unneeded procedures annually cost us roughly the gross domestic product of Ireland.
And much of that waste — unnecessary scans, for example — can lead patients down a rabbit's hole of more testing and more physical and psychological pain, Tape thinks.
Overtreatment happens so often that a coalition of medical groups — groups that together represent millions of doctors — has started a public campaign called “Choosing Wisely.”
Last week, it released a list of 90 medical “don'ts” — basically, a greatest-hits compilation of tests, scans and studies that doctors should stop ordering so often.
There was plenty of competition, says Tape, who is board of governors chairman of the American College of Physicians, whose membership is 132,000 internists. Its task force pinpointed three dozen medical treatments that are overused and/or have dubious benefits, and then picked five to include in the overall “Choosing Wisely” list.
“We could have chosen any of the 36” to be in the Top 5, he says. “They all deserve to be highlighted.”
Here's Tape's favorite example: the CT or MRI scan for lower back pain.
Doctors have long ordered these costly scans for patients who come in complaining of a balky back.
The scan, in turn, sometimes shows what Tape calls “an abnormality” in the back.
An abnormality can lead to more tests. In one extreme example, a Harvard Medical School lecturer documented a case in which a 50-year-old man received an MRI after a week's worth of lower back pain, and then got a CT scan, an ultrasound and two more MRIs.
Here's the problem: Studies show absolutely no correlation between nonspecific lower back pain and what shows up on an MRI.
In one such study, doctors were handed MRIs of people who had back pain and of people who didn't. They couldn't tell the difference.
An MRI “does not improve patient outcomes” when it comes to lower back pain, according to the American College of Physicians. All it does is increase both cost and fear.
Tape says the vast majority of mild back pain sufferers would be better off with the relatively simple and relatively cheap combination of anti-inflammatory medicine and a little physical therapy. That's what the 50-year-old man in the Harvard case eventually got. His back pain improved, and all it cost him were thousands of dollars and weeks of anxiety.
The campaign against overtreatment faces several hurdles, each bigger than the last.
|FROM THE NOTEBOOK|
Columnists Michael Kelly, Erin Grace and Matthew Hansen write about people, places and events around Omaha in their new blog, From the Notebook.
Patients themselves often clamor for testing, coming to doctors armed with a self-diagnosis courtesy of WebMD and a notion that technology is a magic bullet toward a cure.
Doctors have a financial incentive to overtest — the fee-based payment system.
“You only get paid for doing things,” Tape says. “You don't get paid for doing nothing.”
Tape isn't the most popular doctor around the hospital when he mentions this financial incentive.
But more and more members of the medical community are starting to agree that the tallest hurdle yet is an American mindset that thinks when it comes to health care, more is always better.
We saw it during the health care reform debate, Tape says, when what could have been a conversation about overtreatment and end-of-life care quickly devolved into a yelling match about “rationing” and “death panels.” We have long seen it in a health care system that gives stunningly good care to people with diabetes or heart disease but does a poor job of preventing those serious, costly diseases from developing in the first place.
Why put in one stent for a blocked artery when you can also stent two other partially blocked arteries? Why skip that test for prostate cancer when you are a healthy 52-year-old male?
Because data show the extra stents don't help and often increase the complications postsurgery, Tape says.
And because that prostate test has a high false-negative rate and results in healthy people's getting a battery of other tests, he says. It likely hurts more people than it helps.
It won't be easy to eliminate overtreatment. There is currently no real way to get good data about how many tests Dr. Johnson orders as compared to Dr. Smith, Tape says. Doctors quite understandably guard their independence. And everyone, again quite understandably, is worried about creating any sort of new system that promotes undertreatment.
But with the “Choosing Wisely” campaign, Tape sees the start of something. More publicity. More education. A better chance that a doctor won't order a back MRI unless he needs to look at one while preparing for a planned back surgery.
“Let's lead by example and let our decisions be guided by what's best for patients, what helps them,” Tape says. “Let's try to cut out everything that doesn't.”
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