“Doctor, Is This Part of the 30 Percent That Is Waste?”
I was recently part of a discussion breakout at an Institute of Medicine (IOM) meeting. Any reader of this column could have contributed to this brainstorm: our job was to explore the patient and community roles in transforming care. Each participant, in part, assumed the role of the patients we sometimes are.
As talk turned to roles for empowered patients, I shared something I have done three times in recent years when consulting with specialists on an eye issue related to a basketball injury from 20 years ago. Treatment choices for my eye fall within a semi-elective gray zone relative to potential surgery. My behavior as a patient, however, has been informed by my professional work—I wonder if all patients should use the same gambit.
Three years ago I came upon a 2008 editorial in the Journal of the American Medical Association called “From Waste to Value in Health Care.” The authors stated that 30 to 50 percent of healthcare spending is waste. A 2012 report from the IOM provided confirmation when it estimated waste at 30 percent. Since medical cascades are ripe with adverse effects, we know that much of that unnecessary spending is harmful to patients (read: morbidities and mortalities).
It’s difficult to take in the magnitude of this data point: 30 to 50 percent means between $1 trillion and $1.5 trillion a year wasted. (The latter is the United States’ military budget, two times over.) Think of how many schools, roads, teachers, retirements, and parks are dumped in the garbage. Think of the “opportunity costs”— all the things we can’t do—because the medical industry is flourishing via overtreatment.
Personalizing this data point is tougher yet. Here is a rough analogy: A good hitter in baseball might average .300—three hits in 10 at-bats. The chance of such a player getting a hit is the same chance that wasteful medicine will be practiced on you.
The higher you go up the medical industry’s economic food chain (which culminates in ultra-expensive specialty practices), the greater the risk. The meetings with my own series of ophthalmologists regarding a potential eye surgery inhabit this risky space: “Well, what we could do is …” or “You need to see my colleague who is really one of the best …”
Perhaps that gorgeous, high-towered, and big-viewed office room in which one waits is nothing more than a well-glossed sheen, covering the fact that you are actually sitting in a landfill?
This is not comforting. Speaking like this also feels mean-spirited. Mainly, we like our doctors. I like the ophthalmologist I’ve consulted with for 20 years. I have taken a liking to most of the others from whom I’ve sought additional perspectives or treatment following a geographic relocation and some aggravation in the eye. Yet the fact glares back as bold as the big E on an eye chart: a 30 to 50 percent chance of waste—on me.
Two May 2013 articles in the British Medical Journal won’t make you feel any better. One is called “Marketing vaccines by marketing disease.” The author argues that campaigns to get everyone to take the influenza vaccination are based on trumped-up evidence and fearmongering. (read: waste and potential harm).
The generalized practice of such marketing was the subject of an earlier piece entitled “A Call to Challenge the ‘Selling of Sickness.’” Medicine is characterized as snake oil salesmen on the back of Conestoga wagons with terms like: “unscrupulous,” “dubious remedies,” “out of control,” “research suppressed and distorted for commercial gain,” and worse. Then: “Patients experience well-documented harms as more and more financial imperatives are allowed to trump clinical judgment.”
The editorial focused on an international meeting entitled “Call to Action of the Selling of Sickness.” After noting that past campaigns have failed, the writers name new efforts underway to combat the practices. One is the exceptional “Choosing Wisely” campaign. Some medical specialties are working with Consumer Reports to first name then publicize over-performed procedures of their own discipline. This is an exceptional program. Check out the site at choosingwisely.org.
The journal’s own “Too Much Medicine” campaign is a second example. The “Triple Aim” effort in this country led by Donald Berwick, MD, is another effort. This campaign seeks to replace financial gain as the base of US medicine with values of: 1) patient experience, 2) population health, and 3) lower costs.
These are not abstract public health issues. They are personal, and should deeply discomfort you and me. And not just for the unfathomable opportunities lost to our public and private investment when over $1 trillion a year goes down a drain. We each need to be concerned that what our trusted doctors suggest is, well, potentially damaging and unnecessary.
So when I sit down with a specialist to consider a recommended procedure or surgery, at a certain point I give them a chance to share my discomfort. I say: “From my work I’ve learned that the Institute of Medicine has concluded that 30 to 50 percent of what is done in medicine is waste. They say that much of it is harmful. I have to assume that includes what happens inside these walls. Is your recommendation part of that 30 percent?”
John Weeks is the editor of “The Integrator Blog News and Reports” (theintegratorblog.com), a leadership-oriented news, networking, and organizing journal for the integrative medicine community, and a columnist for Integrative Medicine: A Clinician’s Journal.