Another Way to Do Harm
Editor’s Note
In PSQH, we usually focus on preventing patient harm that results from errors—medication overdoses, wrong-site surgery, MRI accidents, failure to rescue, etc.—that trace back to systemic problems in healthcare institutions. Those problems include poor communication, environments full of distraction and stress, inadequate training, power hierarchies, to name a few. Recently, I’ve seen strong reporting about patient harm that results from a different kind of systemic problem—the overuse and inappropriate application of treatments—with disturbing evidence that economic gain is sometimes a driver.
This is controversial and important material. Below are some of the reports I have read and heard recently, with links to the original stories and sources. Interested readers may use the comment feature following this article to discuss these issues.
• On The Washington Post’s “Wonkblog,” Sarah Kiff reported from Avoiding Avoidable Care, a two-day conference organized by the Lown Cardiovascular Research Foundation and the New America Foundation and co-hosted by the Institute of Medicine. In the context of national healthcare reform, the conference addressed the following questions:
- How much care in the United States is avoidable?
- Can we quantify its consequences, in terms of financial impact and harms?
- What factors drive over-utilization and inappropriate medical services, how can we curb it, and do physicians have an ethical duty to do so?
On the conference’s homepage, there is a series of essays addressing specific questions about reimbursement, ethics, and culture. Kiff’s article, “What tonsillectomies tell us about the future of health care,” focuses on the current epidemic of tonsillectomy in the United States despite a lack of evidence that it’s needed or effective. Readers of PSQH may be reminded of Tanya Lord’s article in the March/April issue, “Noah’s Story.”
• At the annual conference of the Association of Health Care Journalists (AHCJ) I attended in April, there was much discussion about the marketing and overuse of screening exams. Gary Schwitzer has been covering this topic on HealthNewsReview.org, where he and a panel of reviewers score media outlets on their coverage of current health stories. Among their review criteria are the questions:
- Does the story adequately quantify the benefits of the treatment/test/product/procedure?
- Does the story adequately explain/quantify the harms of the intervention?
During his presentation at AHCJ, Schwitzer discussed recent debates about medical screening, and recommended the work of Steven Woloshin, MD, and others at the Dartmouth Institute for Health Policy & Clinical Practice, who have published recently in The New York Times and contributed to an article, “Do Physicians Understand Cancer Screening Statistics? A National Survey of Primary Care Physicians in the United States,” in the Annals of Internal Medicine.
• How We Do Harm: A Doctor Breaks Ranks About Being Sick in America is the title of Dr. Otis Brawley’s new book about the “overtreatment of the rich, undertreatment of the poor” and the “financial conflicts of interest that determine the care that physicians provide.” Brawley practices oncology at Atlanta’s Grady Memorial Hospital, one of the largest public hospitals in the United States, and is chief medical officer of the American Cancer Society. Brawley spoke to the AHCJ conference mentioned above; his talk and book (co-written with journalist Paul Goldberg) are full of stories of patients and friends he has seen harmed by what he calls “subtle corruption”: inappropriate incentives, inadequate knowledge, unsubstantiated beliefs (often on the part of patients and consumers), and disparities in care that mirror racial, economic, and social divides in our country. A video of Brawley’s (60 minute) talk to the AHCJ is available here. For a briefer sample of Brawley’s message, click here for his analysis of problems with screening for prostate cancer.