Some tests and procedures lead to worse—rather than better—health
With all the high-tech—and expensive—medical care available in the US, you may assume that Americans are among the healthiest people in the world. But that’s not true.
Troubling fact: The US spends more than any other country (about 17% of its gross domestic product) on health care but ranks 12th (among 13 industrialized nations) in measures of overall health, such as life expectancy.
For an insider’s perspective on what’s wrong with our medical system—and advice on how we can protect ourselves—Bottom Line/Health spoke with Dennis Gottfried, MD, who has extensively researched this subject and worked as a general practice physician for more than 25 years.
Why is the US health-care system in such bad shape? Medical practices and hospitals are designed to care for patients, but they’re also businesses. Doctors are reimbursed by insurers for such services as medical procedures and surgeries that the doctors themselves recommend and order. As a result, many doctors order too many tests, perform too many procedures and prescribe too many medications. Some doctors also provide excessive medical care to protect themselves against malpractice lawsuits. Much of this is not in the best interests of the patient.
What role do patients play? Often, patients go to their doctors asking for specific treatments they’ve heard about from friends, read about on the Internet or seen in a drug company or advocacy group ad on TV or in a magazine. Doctors want happy customers, so after a while it’s easier to acquiesce than to argue. Americans are conditioned to believe that more is better, but that’s not always the case. Sometimes it’s worse.
How so? All medical procedures and even some tests carry risks for side effects or complications. For example, angioplasty, which uses a catheter and balloon to open a narrowed artery—and is sometimes followed by the placement of a stent (a tube to keep it open)—carries risks for heart attack, blood clots, kidney problems or stroke.
Similarly, some degree of brain damage (loss of cognitive functions, such as memory or judgment, that can last up to 12 months) can occur with coronary bypass surgery.
Yet many of these patients’ symptoms, especially those with stable angina (chest pain), could have been treated with medication that has far less risk for side effects. In many cases, patients don’t really need the stent or the surgery.
Then why were these procedures performed? To a large degree, doctors create their own demand. For example, Miami has a lot more cardiologists than the Minneapolis area. And recent research found that annual Medicare spending on health care for Miami seniors was nearly two-and-a-half times higher than it was for statistically matched older adults in Minneapolis. The Miami health-care costs included six-and-a-half times more visits to specialists, compared with Minneapolis health-care expenditures.
Do doctors create their own demand in other areas of medicine? In general, more specialists mean more expensive health care—and poorer health.
We need specialists to have a good health-care system. But based on several studies, including research by investigators at Dartmouth Medical School, regions in the US that have a greater proportion of primary care physicians (such as family physicians and general internists) than specialists provide better care at lower costs.
However, in the US, medical students want to be specialists because they make more money and usually can arrange less demanding schedules than generalists. And there’s more prestige—brain surgeons are referred to often for their intellectual abilities, but you never hear that about pediatricians, for example.
But don’t specialists provide better care when treating serious conditions? Not necessarily. Studies by Dartmouth Medical School researchers and others show that as you increase the number of specialists, health care improves—up to a point. Increasing the availability of primary care doctors is associated with lower costs and better health-care quality.
This occurs perhaps because the extra procedures specialists perform increase the odds that something will go wrong. Primary care doctors more often follow a “watchful waiting” philosophy. They put more emphasis on preventive medicine and may know the patient well enough to recognize when stress or other medical conditions are worsening symptoms.
Should we avoid consulting specialists? Certainly not. Just don’t see them unless you have to. Go to your primary care doctor first and rely on his/her judgment as to whether specialist care is needed.
When you do go to a specialist, choose a busy one. Because they typically have enough medically indicated work to do, they are less likely to recommend marginal or unnecessary procedures.
And whenever any doctor—generalist or specialist—recommends a procedure, don’t be shy about asking, “Is it really necessary?”
This query is particularly important when elective procedures that may carry risks, such as most orthopedic surgery or elective cardiac surgery, are recommended. If you’re not convinced, get another opinion.
Does the same advice apply to medication? Yes. Medication can be effective and even lifesaving. For example, drugs for elevated cholesterol and high blood pressure have played a substantial role in preventing heart disease and stroke. If you need them, take them.
But just make sure you really need them. In general, weight loss, salt reduction and exercise should be given a chance before using drugs to reduce blood pressure. Type 2 diabetes is often treatable with diet and exercise alone, but doctors frequently skip this step.
Even if you take medication for a chronic illness, such as high blood pressure, heart disease or diabetes, you need to maintain a healthy lifestyle. Patients have responsibility for their own health. However, when doctors prescribe a medication, they don’t always choose wisely among available drugs.
What do you mean? Because drug companies market new drugs heavily to patients and doctors, many physicians opt for these expensive medications when older, cheaper generic alternatives would do just as well—if not better.
Only 10% of new drugs are really new—the rest are molecular variations on existing ones, which are more profitable for the manufacturers but no more effective.
One of my patients with gastroesophageal reflux disease (GERD) recently came in and asked for “the little purple pill” she saw advertised on TV. I explained that the generic heartburn drug I had prescribed was nearly identical, but she insisted. She was sufficiently impressed by the flashy graphics on the TV ad to pay substantially—out of pocket—for the medication.
Shouldn’t patients have access to newer drugs if that’s what they want? Yes, but they need to understand that when a drug is approved, it has generally been tested on several thousand people. Serious problems often aren’t discovered until it’s been prescribed hundreds of thousands of times.
That’s why the cholesterol drug cerivastatin (Baycol)…the diabetes medication troglitazone (Rezulin)…and the heartburn drug cisapride (Propulsid) are no longer available. Serious—sometimes deadly—side effects were discovered after the medications had been on the market for a while. Such side effects are unlikely with drugs that have been around for several years.
Cheaper drugs are sometimes more effective, too. Several large studies have shown that diuretics (“water pills”)—among the oldest and cheapest drugs for high blood pressure—reduce heart failure and stroke more effectively than newer compounds.
If you have high blood pressure and your doctor isn’t prescribing a diuretic, ask why. If you need two or more drugs (about 70% of the time, that’s necessary), a diuretic usually should be one of them.