The Medicalization of America

September 16, 2009

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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