The Medicalization of America

I am bewildered by the angry speakers at the health care town-hall meetings. They defend both the current system of medical care and their freedom to choose. Freedom to choose? You can send an overnight letter by FedEx, but that hardly means we have a free market in mail service. Similarly, the medical industry is far, far removed from a free-market. A complex web of subsidies and licensing has resulted in a distorted health care market. People cling to it because it is what they know. A free market in health care would no more resemble our current system than the modern supermarket industry in the United State resembles food distribution in the former Soviet Union.

Lost in the heated debate is an examination of assumptions. Those who promote a position, by speaking in sound bites, are often unaware of the assumptions that underlie their position.

Naïve patients, patients who eschew responsibility, and arrogant and/or inexperienced doctors agree on a big lie: Medicine is an objective science. Present the same patient to ten doctors and all but the incompetent will agree on the diagnostic tests to run and the treatment protocol to follow.  None of this is remotely true.

I observe another, related hidden assumption held by many: At any time, there is an objective, fixed amount of disease and poor health. Thus if more diagnosis and treatment is applied, disease and poor health will decline. This assumption is false. It is no more true than believing additional food is the solution to poor nutritional habits.

You have probably never heard of Jack Wennberg. In her brilliant book Overtreated, Shannon Brownlee writes that Jack Wennberg “is one of the heroes of modern medicine.”  After reading Wennberg’s story it would be hard to disagree with Brownlee’s assessment.

Dr. Wennberg has been a professor at Dartmouth Medical School for over thirty years. As a young physician, Wennberg bought into the assumption that the most serious problem in health care was that there was not enough of it. Joining the University of Vermont in 1967, Wennberg began to compile statistics that would cause him to question his basic assumption. In some towns in Vermont, only 7% of children under sixteen had had their tonsils removed; in other towns, 70% had had their tonsils removed. Wennberg found similar variations for many treatments, including hysterectomies and appendectomies. As he shared his findings, physicians dismissed them. His critics explained that where surgery rates were higher, patients needed the surgery; where surgery rates were lower patients, patients were not getting needed treatment. In other words, Wennberg’s statistics were explained away with a “there is not enough medical care in some areas of Vermont” narrative.

Wennberg, along with statistician Alan Gittelsohn, dug deeper. According to Brownlee, they found the population of Vermont was “remarkably homogeneous in their health, their socioeconomic status, their level of education, and how well-insured they were. Practically everybody was white; nearly everybody had a personal physician, whom they visited on average about as often from one region to the next.” There was one explanation for significantly higher rates of surgery in some towns: The anomaly was not “driven by patients but rather by doctors.”

Wennberg’s conclusion was not welcome among doctors, especially those who maintained the delusion that a medical diagnosis was an objective, scientific fact. Eventually, Wennberg was run out of his position at the University of Vermont. In 1979 he joined the faculty at Dartmouth. The same pattern he found in Vermont, and later in Maine, he found all over the country. He found it for virtually every medical procedure: CT scans, cardiac catheterizations, back surgeries, knee replacements, etc. In 1993, Dr. Wennberg became the founding editor of The Dartmouth Atlas Project (DAP) to study “health care markets in the United States, measuring variations in health care resources and their utilization.”

In a June 2009 essay in The New Yorker, Dr. Atul Gawande summarized some of Dartmouth’s eye opening findings:

Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse… Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.

In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.

That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do. For instance, in 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.

To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.

Unfortunately, some, including President Obama, draw incorrect conclusions. If some areas of the country spend too much, they reason, experts can prevent the waste; and the saving can be applied elsewhere in the health care system. They believe that government, acting as a smart third party, can provide coordination so that high cost and/or excessive treatment options are rejected. This is an impossible dream! In the next part in a series on health care, we will explore why. More government involvement in health care means more medicalization of America, not less.

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8 Responses to The Medicalization of America

  1. Tesh says:

    I think your final sentence explains the town hall protesters, or at least some of them. The current system is broken, but the proposed solution would be worse. Given a choice between bad and worse, people cling to bad.

    That said, it’s a false choice. Proper reform is possible and long past due, but few are talking seriously about it. The push from the White House to get the “worse” choice installed at all costs has people trying to stay ahead of Big Brother instead of honestly addressing the real existing problems.

  2. Tesh,

    Exactly! But the problem is of course that most people don’t understand the causes of the problem. Until they do they really can’t be for anything. They are simply against and often this is losing position.

  3. James D says:

    The only reform that will come will be worse. There are too many people and institutions with their fingers in the pie who don’t want their livelihood messed with. There is no vision for what healthcare should look like that is realistic in any meaningful fashion. When people point to Europe, they see that everyone gets some level of care. What they don’t hear about is the finance ministers getting together to say that their current levels of social spending are unsustainable. When people see that not enough Americans have access to primary care, they ignore a system with penalizes those who are in primary care to the point where they choose to become specialists as well.
    A friend once complained that something always seemed to be wrong with his car, and that it always seemed to need to go back to the mechanic. I told him as long as he keeps paying them to fix things, they’ll keep coming up with things to fix.
    Same thing in medicine. So long as pay-for-procedure reigns, we won’t take care of ourselves, we’ll look to doctors to fix things for us, because the system pays them to take care of us, not keep us healthy. Healthy people generally don’t have to spend much on health care. We need to find a system that rewards the least amount of medical care required. Then we’ll have something truly new. Anything else is just stirring the pot.

  4. Jim,

    Thank you for your thoughtful ideas. Exactly as you say “same thing in medicine” and very much to the detriment of good health.

  5. Medicare is in the news so often these days you might suspect he is running for office. In most of the articles and comments, the words diet, stress management and exercise are not mentioned even once. The word “prevention” is mentioned sometimes but usually inappropriately. What the press and the public are calling prevention is actually early detection. This would include mammograms, blood tests and prostate exams. If you already have breast or prostate cancer, or your high cholesterol and blood pressure have caused arteriosclerosis, your doctor can detect it and then treat it with pills or send you to a specialist. True “prevention” should have begun years or decades earlier.
    Diabetes classes are disease management programs. How can you “prevent” diabetes if you already have it and are going to classes to help control it? A “free annual wellness exam” is often touted but not defined. If you are talking about Medicare patients, the likelihood of any of them being “well”, that is completely disease and thus medication free, at an annual visit is pretty remote. Such a patient if identified should at least get his picture in the local paper, and if older than 70 perhaps a ticker tape parade too. It is a very poor choice of words to call the drug coverage gap the “doughnut hole”. You know there must be some seniors that, when they reach this gap, think they can make up for not taking all of their prescriptions by eating more doughnuts!
    We learn that Obama has been busy, when not hyping Chicago as the perfect site for the 2016 Olympics, creating a basic “health care safety net” for working Americans. Here would be the perfect place to suggest “healthy diet, stress management and exercise” as an integral part of that safety net. In fact without those vital components, any such purported safety net is going to be full of large holes. Large enough indeed to allow even the fattest Americans to fall through and hit the floor.
    We hear that “nearly one in five Medicare patients lands back in the hospital within a month of getting out”, costing billions of dollars annually. To combat this, Social Workers help arrange rides to doctors and make sure seniors can afford their medicines. Monitoring their dietary choices and joining the seniors on daily brisk walks would seem to be a better use of their time. The Social Workers would get some benefit themselves and might be able to reduce their own prescription drug expenses. Let’s come up with new mantra: “Healthy habits, like the swine flu are contagious.” Your choice. Both are covered by your insurance.
    One article mentioned a 75 year old retired businessman who can’t find a doctor who will take care of his chronic knee problem, presumably osteoarthritis from nearly 8 decades of walking on it. Can you imagine a doctor so obsessed with money and an opulent lifestyle she would turn away a fellow citizen who likely defended America from its enemies when he was a much younger man? Hippocrates would be rolling over in his grave.
    We hear that rarely does the Primary Care Physician take charge of her patient’s care from start to finish of a health problem. As it is now, the PCP usually asks the patient, ‘What did the specialist say? Proposals in the House and Senate would set up pilot programs to better coordinate primary and specialty care with the goals of saving money and improving quality. How about having a goal of reducing the need for expensive specialists and their multiple high tech tests and prescriptions? Why not double the doctor’s reimbursements if she convinces her patients to lose weight, swear off “Supersize Me” and the like, stop using elevators (except in the Empire State Building), really get into Yoga, walk a rescued dog daily and go fishing once in a while. Now that would be the most effective way of taking charge of her patient’s care and giving the “bird” to all those fat cat specialists. And perhaps save our beloved America from imminent bankruptcy.

  6. Dr. Bennett,

    I appreciate your wisdom and all the work that you do to educate Americans about what prevention truly means!

  7. Thanks for your appreciation. I have been a doctor for 50 years. The practice of medicine in 2009 is unrecognizable with my 1960s eyes. Now retired from being a hospital based doc, I am spending my retirement money promoting health diets and lifestyles at nomoremedicines.com, and at any public gathering in Austin TX that will have me. Our only hope is for large numbers of Americans to take better care of themselves. At age 75 I do walk the talk. That’s why I made it to 75 despite a family history of men dying young. I tell my patients and audiences “If I can do it so can you’.

  8. Dr. Bennett,

    One day the kind of ideas that you promote will be practiced by most Americans. Our current system is simply not sustainable. Unfortunately, first it may take a collapse of the current health-care system for the basic beliefs of health-care consumers to shift in sufficient numbers. The educational work you do may help to prevent that collapse.

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