Medicine, alongside achievements in sanitation and public health, remains one of the major achievements of modern society. The reduction (or eradication) of many infectious diseases from the developed world, breakthroughs in anesthesiology and surgery, and advances in the care of chronic diseases (including HIV) are just a few of the multitudes of achievements.
But these accomplishments have also arguably led society to view medicine as having few limits. There is a movement today to introduce some skepticism into the presumption that all medicine is good and that more is better. I’m not referring to those who lie far outside the normal spectrum, such as the anti-vaccine advocates, but rather people within the health care system recognizing its important limits.
Introducing “low-value care”
The recent work by Carter and colleagues published in Medical Care is part of this movement. Their work reveals just how much medical care is still being practiced today despite evidence showing its ineffectiveness, inappropriateness, or potential harm. Professionals in the field now refer to these medical services–which include things like receiving an MRI after a fainting spell–as “low-value care.”
The authors explored 16 “low-value” services delivered nationally to adults age 50 and older. Despite seeing a general decline in 15 of the 16 services over a 5-year period (the 16th service increased), they found that some of the services were still fairly commonly practiced. For example, that MRI after fainting (called syncope), was performed in roughly 35-45% of cases, depending on the insurance plan.
Moreover, they found that despite the declines, health care inflation led insurers to spend more each year on these 16 services, and more than $415 million in 2014 alone. In other words, delivering low value care is still common and increasingly expensive.
Referring to some medical services as “low-value care” risks being too polite
The Choosing Wisely campaign, developed by the American Board of Internal Medicine Foundation in partnership with Consumer Reports, lists more than 500 medical services that deserve greater scrutiny. This list includes things like routine PSA tests, which can help to detect risk for prostate cancer. But without other risk factors, such tests are often misleading and lead to unnecessary biopsies and even surgeries that carry serious risks. Risks such as incontinence aren’t quite captured by the term “low value.”
That we are still mistreating nearly half of all viral respiratory infections with antibiotics is even less fitting of being called “low-value care.” Such treatment is certainly of low value because antibiotics don’t kill viruses. But, when we also acknowledge that doing so contributes to the growth of antibiotic resistant infections that now cause 23,000 deaths each year, applying the term “low value care” seems inaccurate, if not impotent.
Carter and colleagues, in the current study, have rightly avoided inflammatory headlines while including potentially life-threatening care among their 16 low-value services. A procedure like cervical spinal fusion involving the use of bone growth protein is arguably one of these. The authors note there is consensus on the low value of use of this protein, and that the Food and Drug Administration (FDA) issued multiple warnings of severe complications associated with its use. The authors find its use in roughly 7-9% of cases.
A modern movement with roots in the study of iatrogenesis
Much of this work has its roots in the work of one of the most influential (and controversial) historical critics of the medical system. Ivan Illich, a cultural philosopher and antagonist of many western institutions, wrote the popular book “Medical Nemesis” [PDF] in 1975. This book brought the word iatrogenesis, harms created within and by the medical care system, into common use.
Illich challenged what he came to see as self-aggrandizing behavior within the medical system, arguing that it (and eventually the public) came to believe that all medicine was good and that more medicine was better. Many aspects of human life (from birth to death), he said, were also being subsumed by the medical system; a “medicalization” of life that he argued would eventually render populations as patients for life.
He poignantly wrote:
“Society has transferred to physicians the exclusive right to determine what constitutes sickness, who is or might become sick, and what shall be done to such people.” (Medical Nemesis, p. 6)
It is within this context, he argues, that the medical system essentially ran away with itself, in great part with the permission and support of the public.
As we continue to investigate “low-value care” history offers some warnings
History offers plenty of reasons why such skepticism is both healthy and needed. With centuries of hindsight, we can reflect on (and now laugh off) the obvious dangers of venesection (i.e., bloodletting). Easy enough, except the last vestiges of its practice were surprisingly found in a popular medical textbook [PDF] published as late at 1942. We can also now be aghast at the use of mercury ointments, pills, and injections to treat syphilis and other skin conditions, though these were still in practice as late as the 1950s [PDF].
Harder to write-off was the widespread use of lobotomies in the early 1950s in treating schizophrenia, but also for “tension, apprehension, anxiety, depression, insomnia…” among other issues. While short-lived, lobotomies were performed on an estimated 50,000 people (mostly women) in the U.S. and thousands more abroad.
Also, hard to write-off was the off-label prescribing in the 1960s of the sedative Thalidomide for preventing morning sickness in pregnant women. This practice resulted in thousands of children worldwide being born with birth defects. Tellingly, the skepticism of an FDA inspector limited such prescribing to pregnant women in the U.S.
With an eye to the future
Today, it is still hard for the average patient to question the authority of physicians, and even harder to know what services are appropriate or not. My own most recent physical included an electrocardiogram (ECG) and a PSA test despite my not having any risk factors or symptoms. Choosing Wisely advises against both of these tests because of their inability to accurately detect problems, and because of the high potential for false positives that may lead to further unnecessary invasive (and potentially harmful) testing.
Did I discuss this with my physician or ask why it was necessary? No. But I should have.
The current study reminds us that it is worth thinking skeptically and with an eye to the future. In 50 years, are we going to have the same hindsight about some of the medical services included in the current study? Will we also find ridiculous the blatant overuse of antibiotics or over-reliance on cesarean sections? And are we going to have the same regrets about the widespread use of opiate pain-killers?