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What is Just Too Much

Posted 5/8/2015

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  What is just too much? What is overkill? And can these judgments, hard enough to make in totally other arenas, expand to include consideration of medical care?  Easy, not health-related examples, include housing and jewelry. When are McMansions too much or how many is too many bracelets? Different people surely have different opinions; I was raised with the old WASP rule of getting dressed and then taking off one piece of jewelry (never to include the sturdy watch or plain wedding band). If we can't agree on how many square feet are in the ideal house for a family of four or how much gold should enhance our style, we surely are not going to find it easy to share judgments about medical care.

  I have written before about the crisis in our country about health care costs, and most of you are aware of the national Choosing Wisely campaign, initially spearheaded by the American Board of Internal Medicine (ABIM). If you don't know about this, you should educate yourself:

  This is surely relevant to all of us, anyone who is interested in cancer care. There are some new cancer drugs with a monthly co-pay of tens of thousands of dollars. This, I think, is clearly nuts--especially since some of these medications may (if they work as hoped) extend life for only a few weeks. As a social worker and as an individual, I strongly believe in personal choice and freedom to make one's own decisions. However, there is clearly a flip side here related to what we as a country can afford as well as what any one family can manage.Do we want to spend some of our national healthy budget on keeping a few people alive a little bit longer or on pre-natal care or routine and vital pediatric care for poor children It is hard to talk about this, but we must begin and continue to conversation.

  For your week-end reading, I propose this excellent article from The New Yorker by Atal Guwande. Pour yourself a cup of coffee or make a cup of tea and read it. Here is the start and a link to read more:

An avalanche of unnecessary medical care is harming patients physically and financially. What can we
do about it?


Millions of Americans get tests,
drugs, and operations that won’t
make them better, may cause harm,
and cost billions.

 It was lunchtime before my afternoon surgery clinic, which
meant that I was at my desk, eating a ham-and-cheese
sandwich and clicking through medical articles. Among those
which caught my eye: a British case report on the first
3-D-printed hip implanted in a human being, a Canadian analysis
of the rising volume of emergency-room visits by children who have
ingested magnets, and a Colorado study finding that the percentage
of fatal motor-vehicle accidents involving marijuana had doubled
since its commercial distribution became legal. The one that got me
thinking, however, was a study of more than a million Medicare
patients. It suggested that a huge proportion had received care that was simply a waste.
The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is
unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.
Could pointless medical care really be that widespread?


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