The New Health Dialogue

We've just closed out a month where everything from the White House to professional football players' cleats turned pink to raise awareness of breast cancer. Every year during October, there's a constant focus on raising money for breast cancer research, and on reminding women to get screened. The mantra is always, "Early detection saves lives."

As we've written before, it's an article of faith for many patient advocates and medical organizations that cancer screening is an unadulterated good. But a new study in the Lancet on breast cancer screening provides yet more evidence that while mammography can save lives, screening also causes serious harms. They find that for every woman whose life is saved, three other women will be overdiagnosed and face unnecessary treatment. That doesn't even count the harm caused by false positives on screening mammograms, which lead to unnecessary stress as well as biopsies and other tests. It's worth noting that the population in the Lancet study includes women over 50, in line with the US Preventive Services Task Force's recommendations. Expanding screening to women under 50 means that fewer of the women screened will have harmful cancers, so the harm of overdiagnosis is more likely to outweigh benefits from catching cancer early.

To go along with the Lancet study, the New England Journal of Medicine has a new Perspective piece by Drs. Steve Woloshin, Lisa Schwartz, William Black, and Barnett Kramer. They make a forceful argument against one-sided pro-screening campaigns that present the benefits of screening, while ignoring the harms. The piece is linked to a great slide show with some of the most egregious pro-screening advertizements.

Overtreatment has hit the popular press in a big way over the last couple of weeks. We haven't been able to highlight every article as it's come out, so here they are all in one place. Take some time this afternoon & catch up!

"The Cost of Assuming Doctors Know Best" - In The Atlantic, Shannon Brownlee & I outline the shared decision making program implemented at Group Health Cooperative in Washington State, and argue that it should be a strong signal to hospitals across the country to start their own SDM programs.

"Unnecessary care: are doctors in denial and is profit driven healthcare to blame?" - Jeanne Lenzer discusses the Avoiding Avoidable Care conference, previews our efforts to eliminate overtreatment, and poses the inevitable question: what has to change about payment structures for medicine to put the patient first?

"Is the USA’s problem ours too?" - Margaret McCartney assesses the risk of overtreatment in a truly government-run healthcare system, and finds that the UK faces many of the same challenges that the American healthcare system does, including rampant overuse & poor reaction to evidence.

"Patient power needs to be built on strong intellectual foundations" - Former NHS head Nigel Crisp argues that "the balance of power in health systems needs to be shifted so that people are enabled to live the life that they want rather than having to fit in with professional and commercial views."

Video: The harms of overtreatment - The video supplement to Jeanne Lenzer's article includes interviews with Shannon Brownlee, Dr. Vikas Saini of the Lown Institute, and the story of Michael Skolnik and the harms of overtreatment.

"The Epidemic of Excess Medical Treatment" - Dr. Marty Makary, Johns Hopkins surgeon and author of Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care, describes the numerous reversals of medical advice to come out in recent years and the massive scale of overtreatment in the US.

Dr. Marty Makary on the Diane Rehm Show - Dr. Makary is the sole guest for a full hour of excellent discussion on one of public radio's best interview programs.

"Psychiatrist Contends the Field Is ‘Committing Professional Suicide'" - Maia Szalavitz describes tje problems with the relationship between psychiatry and the pharmaceutical industry--a relationship that's getting so close and so corrupting that one psychiatrist says his fellows are “committing professional suicide.”

"How Hospitals Can Stop Killing So Many Patients" - On her Forbes column, Kare Anderson lays out some things that patients can do to avoid being harmed by the inefficiencies and patterns of overuse in American hospitals.

Health Wonk Review, October Surprise Edition - Finally, this week's Health Wonk Review has a whole slew of other posts worth reading. Check it out!

We don't often weigh in on electoral politcs here on New Health Dialogue, but the introduction of Paul Ryan into the race as Mitt Romney's running mate has distinctly shifted the focus of the debate onto Medicare, at least for the moment, and the editor of Delve Into '12, the New America campaign blog, asked for our thoughts.

You should definitely check out the full post (here) and the rest of their campaign commentary, but if you're short on time, here's an excerpt from the end of our post:

[...T]he Ryan budget slashes government healthcare spending, but it does relatively little to reduce total health spending. (In fact, if Ryan’s plan was implemented, it could reduce Medicare’s bargaining power and actually increase total spending.) While the ACA includes specific programs aimed at reducing waste (for instance by giving doctors incentives to reduce spending on ineffective treatments, funding research on which treatments actually benefit patients, and making it easier for cheaper generic drugs to get approved), the Ryan plan’s main savings mechanism is competition among private insurers. In theory, giving people a choice of insurer should reduce healthcare spending –people will choose plans that offer  better value, forcing inefficient plans out of the market. But competition among private insurers has failed to control spending in the private insurance market for decades, so some skepticism of its ability to rein in spending on the elderly is warranted. If that doesn’t actually work and total medical spending doesn’t go down, the Ryan budget saves money by shifting spending from the federal government to individuals.

Ultimately, the Ryan budget's laser-like focus on reducing the federal deficit has led to a glaring oversight in the proposal’s healthcare component. Policy should be focused on reducing total healthcare spending, including private insurance premiums and out-of-pocket payments, not just on reducing what the federal government spends. Healthcare spending has become a drag on the economy, accounting for up to two percentage points of unemployment—and that drag isn’t dependent on whether it’s funded by the government or the private sector. That’s the much more important challenge, and the Ryan budget ignores it completely.

Enjoy the weekend!

Last year Dr. Ken Murray, a pediatrician at USC, published an article called "How Doctors Die." In it he describes how physicians, many of whom witness end of life care and death as a regular part of their practice, often choose to die differently than their patients. He gives the example of a friend of his, an orthopedist who found out he had a very lethal form of pancreatic cancer. Instead of enduring surgery, chemotherapy, radiation and long hospital stays, he instead chose to close his practice and spend his last months at home, surrounded by his friends and family. Dr. Murray goes on to talk about "death with dignity" and how many physicians choose to avoid the extreme end of life measures that they regularly provide to their patients.

Though the article was beautifully written and thought provoking, it wasn't very academic. He spoke from personal experience, and included no references. Some readers asked for data to back up his observations, so last week Dr. Murray posted a follow-up article with a more critical examination of the evidence. That article, "Doctors Really Do Die Differently," entertained a variety of studies with topics ranging from living wills to CPR effectiveness. Both are good and worth a read.

The topic of end of life care is eerily applicable in my life right now. On Saturday morning I got a call from my Mom telling me that my great-grandmother passed away. She was 101 years old (almost 102!) and her health had been in decline for decades now. A couple of nights ago she fell and broke her hip. The paramedics came, options were discussed, and it was decided that taking her to the hospital and trying to perform surgery wouldn't do much good--she was on the way out. They provided morphine to be administered through the night, to keep her as comfortable as possible. My wonderful mother sat with her through the night and held her hand as she passed away in the morning. (You can read my tribute to Grandma Ada here).

As I sat down to start writing this post I thought about the hard decisions that were made that night. I thought about Dr. Murray's comments about “death with dignity.” Grandma Ada did have a living will, but it wasn’t accessible at the time. She had made it clear, however, that did not want her hip replaced (again) if she broke it and that she did not want to die in the hospital. Had she been rushed to the emergency room and aggressively treated it would have just been prolonging the inevitable, not to mention putting her through a lot of unnecessary pain and discomfort. It was her time to go, and I’m glad that it was at home, surrounded by family, and in peace.

The topic of end of life care is one that has been receiving quite a bit of attention from some big names. Time Magazine’s Joe Klein recently did a cover story about his experience being, as he described it, his parents’ “death panel.” The story, called “How to Die,” is both a memoir of his parents and an indictment of our fragmented, “fee-for-service” healthcare system (the article requires Time membership; the video summary is free). Newsweek also had a cover story broaching the subject. Written around the time of the claims that the ACA included "death panels," Evan Thomas’s "The Case for Killing Granny" told the story of his grandmother’s experience of having to insist that she wanted to be placed in hospice rather than stay in the ICU. Both stories highlight different weaknesses in our current approach to end of life care and suggest ways that we can improve.

As a future physician, I am proud to become part of a profession that has such a high regard for life. Physicians are rightfully on the offensive to keep death at bay. However, if we always equate life as a “win” and death as a “loss,” without regard to quality of life, then in the grand scheme of things medicine is a zero-sum game—in the end, we always lose. If, however, our determination--our almost righteous zeal--to protect life is accompanied by a reverence for the inevitable experience of death, then helping to ease a patient’s departure from this life, according to her preferences, can be seen as one of medicine’s sweetest triumphs.

As Evan Thomas put it,

“Our medical system does everything it can to encourage hope. And American health care has been near miraculous…But death can be delayed only so long, and sometimes the wait is grim and degrading. The hospice ideal recognized that for many people, quiet and dignity—and loving care and good painkillers—are really what's called for.”

This week I started my second year of medical school. I already consider my summer here at the New America Foundation an invaluable part of my medical education, and I am sad to leave. My great-Grandmother’s passing has coincidentally provided me with the perfect opportunity to craft a farewell post about one of the topics that I have become passionate about this summer—shared decision making. Throughout all of a patient’s life, she should have an active role in her care. Though this applies at all stages of life, it is especially applicable at the end of life. What makes these end-of-life decisions different from those made earlier in one’s life is that they must be made in advance.

As a final request at the close of my internship, I ask that you have a discussion with your loved ones about end of life care. Talk about what you want to happen and (perhaps more importantly) what you don’t want to happen. Consider drafting a living will or advanced directive, and making sure that someone always knows where it is.  It was fortunate that Grandma Ada’s wishes were honored without having to pull out the legal paperwork, but that is often not the case. Evidence has shown that those take the time to create a living will are far more likely to receive the care that they want when they can no longer speak for themselves. That goes for people who want every intervention possible, as well.

Ultimately, honoring wishes about end of life care isn’t about costs; it’s about your will being made known about one of the most important moments in your life. Then, and only then, can healthcare professionals do what they are called to do: enable you to live your life, as you want to live it, with minimal pain and suffering.