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Voices in the Wilderness (The Treatment Trap, Chapter 1)

Author: Rosemary Gibson and Janardan Prasad Singh

It was 1998, and the truth was coming out. In Washington, D.C., the Institute of Medicine of the National Academy of Sciences convened a prestigious group of physicians, nurses, and consumers who acknowledged a uniquely American characteristic of our healthcare system. They called the phenomenon "overuse" and said it occurs when the potential for harm of a health-care service exceeds the possible benefit.

What exactly is overuse? It happens when people have surgery even though their medical condition does not warrant it. It is the revolving door of seemingly benign yet unnecessary tests and office visits that can stir an avalanche of still more tests and procedures. It is the rendering of treatment when no evidence exists that it will yield a benefit.

The phenomenon began to be noticed in the 1970s when Dr. John Wennberg, a physician and pioneer in research on differences in health-care use among communities around the country, observed an epidemic of tonsillectomies in Vermont. His research showed that in the town of Stowe, 70 percent of the children had their tonsils removed by the time they were fifteen years old, compared with only 20 percent of children in Waterbury. Wennberg wrote, "For half a century, the tonsil has been the target of a large-scale, uncontrolled surgical experiment tonsillectomy."

Wennberg discovered another epidemic, affecting men in Maine. Sixty percent of men who lived in certain communities had their prostates removed by the time they were age eighty, while only 20 percent of men had the surgery if they lived elsewhere in the state.

In the U.S. Congress in 1974 the House Committee on Interstate and Foreign Commerce held hearings on unnecessary surgery. Experts testified that nearly 18 percent of surgeries they studied might not have been necessary. In 1976 a House Subcommittee on Oversight and Investigations heard evidence and concluded that 2.4 million unnecessary surgeries were performed annually, resulting in 11,900 deaths. The annual cost of these surgeries was estimated at $3.9 billion. Since 1976, no new estimate of overuse has been calculated.

In the 1980s and 1990s the Rand Corporation and other researchers studied the overuse of selected medical procedures and found that many people had surgeries and tests they did not need. One of the procedures they examined was endoscopy, a most unpleasant examination in which the patient swallows a thin, flexible, lighted tube, called an endoscope, which then transmits a picture of the esophagus and stomach from the inside. Seventeen percent of endoscopies were performed for clearly inappropriate reasons.

The term "overuse" was first coined in 1991 by Dr. Mark Chassin, a physician and researcher, and now president of the Joint Commission, the Chicago-based organization that accredits and certifies sixteen thousand health-care organizations. In an article in the Journal of the American Medical Association, he defined it as providing a treatment when its risk of harm exceeds its potential benefit. At last a growing phenomenon in American health care had a name.

Although there was ample evidence of too much medicine, it did not arouse concern among the public, the medical establishment, or policymakers. "I feel as if I am a voice in the wilderness," says Dr. James Weinstein of Dartmouth, who has conducted extensive research on unnecessary back surgery. "Theres a Latin phrase for it, 'Vox clamantis in deserto,' a voice shouting in the desert or wilderness."

In recent years, however, overuse has gained media attention. Wall Street Journal front-page headline reported new studies that "hint at overuse" of stents to open clogged arteries. The New York Times reported on Elyria, Ohio, where the number of angioplasty procedures performed to open clogged arteries was four times the national average.

When Jane Brody, the veteran personal health columnist for the Times, described her painful experience with knee surgery, an orthopedic surgeon responded that his boss at his hospital complained that he didn't perform enough surgeries to bring in sufficient revenue. Brody wrote, "This is outrageous and just reveals the monetary motivation behind much of modern medicine. The patient be damned; just bring in the bucks."

Local newspapers provide a hometown flavor about overuse. In Hilton Head, South Carolina, the Island Packet reported on a whistle-blower lawsuit filed by a physician at Hilton Head Regional Medical Center accusing a physician colleague of performing hundreds of unnecessary heart catheterizations. The accused physician reportedly fled the country, possibly to Canada or Saudi Arabia.

The Miami Herald reported on a whistle-blower case brought by an anesthesiologist in which a neurosurgeon was prosecuted by the U.S. attorney for performing more than 150 unnecessary back surgeries. The Minot (North Dakota) Daily News described a lawsuit filed by a woman who accused a physician of performing an unnecessary lung surgery. That same month the Victoria (Texas) Advocate published an article, "Are Doctor's Morals for Sale?" quoting local doctors who claimed that their peers were performing excessive and needless tests and procedures "simply to make a buck." The newspaper alleged that "insured Victorians are being fleeced."

Consumer advocacy organizations have joined the voices in the wilderness to forge a path toward a more reasonable use of medical care. Debra Ness, president of the National Partnership for Women and Families, a Washington, D.C.-based nonprofit group that advocates for better health care, told a U.S. Senate committee, "Unnecessary care is rampant."

What lies beneath the news reports, congressional testimony, and health statistics? What happens to the people? A closer look reveals the untold human story.

DMU Timestamp: April 11, 2011 12:47

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