Sunday, 21 October 2012

Book review: Overtreated


Title: Overtreated: why too much medicine is making us sicker and poorer (2009)
Author: Shannon Brownlee
Publisher: Bloomsbury

There appears to be many books on the topic of overtreatment, overdiagnosis, medicalization, medical error and what’s wrong with modern medicine in general. This book covers all of those topics, but focuses on the simple theme that more medicine does not lead to better health. Instead, it leads to higher costs and worse health.

This book targets the general public, health care providers and policy makers, because they are all part of the problem and can also be part of the solution. They just need to have the problem explained to them.

Brownlee walks us through the problems, starting with the work of John Wennberg, whose initial work on regional practice variation was initially based on the assumption that some people were missing out on healthcare and that there was a need for more. This assumption has led to regulators throwing more doctors at the problem, something that has led to increased costs, increased healthcare, and increased complexity, and worse health. On an individual basis, the assumption that more tests and more treatment are better continues to be the ‘practice style’ that junior doctors are absorbing.

The message is punctuated with reports of individual encounters with the health system. I feel that the over-reliance on case reports and under-reliance on numbers (hard data) makes the case weaker, but it probably makes it more readable.

The book is also entirely US focussed. Some international comparisons would be helpful, but I found the history of medical care in the US  (such as the AMA’s campaign against ‘socialized medicine’) interesting. I can speak from experience that many of the problems flagged in this book are not isolated to the US. I see similar problems here in Australia, and they are occurring in countries like Germany, Japan and even China.

Ascribing causes for overtreatment is not as simple as blaming the doctors; the patients, industry, hospitals and government also contribute. Underlying much of this is the perverse incentives of a system that pays for care, not health. Brownlee reminds us that there are many forces driving increased care (many of them financial) and there is little pushback to stop them: “Doing what’s best for patients is bad for business”. The financial incentives driving industry practice are well known, but I find the influence of financial incentives on expert medical panels particularly worrying – they are the people we are supposed to trust.

The usual areas of overtreatment are targeted, such as spine fusion, cardiac stents, anti-depressants. Interesting to those who are not aware of the problem, but well known to readers of similar books.

Brownlee offers solutions, and takes us through some systems that deliver better health with less ‘medicine’ already exist. The advice for planning future health systems and the patient advice are reasonable and are often based on current working systems.

This book broadly covers what I consider to be the biggest problem in healthcare today, but despite the publication of this book and others like it, the message is slow to penetrate the psyche of the public and the health care providers. Shannon Brownlee is continuing to push her message, beyond this book, and she is one of many who will change medicine for the better.

11 comments:

  1. Dear Dr. Skeptic,

    Thanks for your kind words about Overtreated. When it was published, in 2007, there were a lot of doctors and patients who looked at me as if my hair were on fire or I needed my dose of Thorazine, because I was clearly crazy to be talking about overtreatment when everybody in America knew the problem with our health care system was undertreatment due to lack of insurance. Times have changed a bit, and I'm pleased to see the attention that overtreatment and overdiagnosis ("overuse" as I think we should probably call it) are getting in the popular press and within the medical community. We now have the "Choosing Wisely"campaign here in the U.S. http://choosingwisely.org/wp-content/uploads/2012/04/5things_12_factsheet_Amer_Coll_Cardio.pdf
    and we have campaigns against overdiagnosis in the U.S., Australia http://www.bond.edu.au/about-bond/news-and-events/news/BD3_021794 and other countries.

    Will these projects shift the culture of "more is better"? Maybe a little. I think it is going to take a much more concerted, coordinated effort to transform the way both patients and clinicians think about overuse. I think it has to begin with clinicians, who must confront overuse not so much as a financial drain (though it is), but rather as an ethical issue. Overuse harms patients. Knowingly or unknowingly delivering a test or treatment a patient doesn't need is unethical, regardless of the motive behind it.

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    1. Thanks Shannon,

      I like the term 'overuse'. Maybe we could create another diagnosis: 'Medical overuse syndrome'. Trouble is, we would have to devise some tests and treatment, preferably an operation.

      Seriously though, I agree that things are looking up and I know that there are people here in Australia who are trying to change our way of thinking about health and healthcare.

      Keep up the good work.

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  2. "the message is slow to penetrate the psyche of the public and the health care providers".

    Naturally, when the faintest sniff of a trial of a new drug that might do something - no matter how unlikely, no matter how far in the future - gets front page in the media.

    The public in Australia still has a belief that if something is wrong, you go to a doctor and walk out with a pill or a referral for a 'procedure'.

    I recently presented with apparent bursitis. The doc agreed that it might be bursitis, but opined that maybe it wasn't. "Let's see how it goes". It went away. A happy customer (the word 'customer' carefully chosen).

    I recently told him that I had myalgia above and below the knee, and the beginning of Achilles tendinitis. I'm a runner. I suspected statins and intended to cessate their use. He agreed, but said with a wry grin "I agree, at your cholesterol level you don't need statins, and I don't subscribe to their alleged cardiac 'magic power', but keep in mind that if you have a heart attack, your cardiologist will say 'it's because you went off statins". Which, of course, he would.

    And so it goes ...

    Thanks for the book review.

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  3. PS Overtreated was the first book published in the U.S to focus on the problem of overtreatment. Maggie Mahar's Money-Driven Medicine, published the same year, got a piece of the puzzle from a financial perspective, but Overtreatment was the first book of its kind for a popular audience here in the U.S.

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    1. Thanks again. It would be remiss of me not to mention Nortin Hadler's books. They are also recommended for anyone interested in this field.

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    2. I too was remiss in not mentioning Nortin's books! His are a little tough going for the average reader, but he's been a clear and forceful voice on this topic for many years.

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  4. Thanks for the review. I'm reading her book now.

    Here's a great presentation by Ms. Brownlee and some others who discuss over-testing, diagnosis, and treatment.

    http://bit.ly/XsrpIC

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    1. Thanks Ken,

      Here is a link to a recent video put out via the BMJ, on overtreatment, featuring Shannon Brownlee: http://www.youtube.com/watch?v=uJ6NufAb2qc

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    2. Ken and Dr. S,

      The fact that the BMJ has devoted so much real estate to this issue is a very promising sign that the problem of overuse is finally getting some traction in the medical community. If you look at the medical literature, there's a large volume of work on the problem of underuse (which is just the flip side of the coin of a profit-driven system). There's remarkably little on overuse, though that has certainly begun to change in the last few years. Now we have the Archives of Internal Medicine devoting a special section to the subject (see the Journal's "Less is More" section), and BMJ may well follow suit.

      So keep up your great work, Dr. Skeptic! It's making a difference.

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    3. Thanks Shannon,

      As you probably know, this is thankless unpaid work, and as a practicing doctor, going against the flow is definitely harder than falling into line. I believe that the tide is changing, but we have a long way to go before we can reverse the thinking amongst practitioners and (especially) the public.

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  5. Dr. S, Not thankless! You are appreciated by many, including me. But you are a salmon swimming upstream, that's for sure. I hope you are already connected to others in Australia who are swimming in the same direction -- Ray Moynihan, for instance. There is an international cadre of clinicians who are concerned about this issue, and my colleague, Dr. Vikas Saini, and I are working to bring them together.

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